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PII: S0165-1781(16)31288-4
DOI: http://dx.doi.org/10.1016/j.psychres.2017.07.030
Reference: PSY10664
To appear in: Psychiatry Research
Received date: 5 August 2016
Revised date: 4 July 2017
Accepted date: 14 July 2017
Cite this article as: Mohammad Ahmadpanah, Tayebe Akbari, Amineh Akhondi,
Mohammad Haghighi, Leila Jahangard, Dena Sadeghi Bahmani, Hafez Bajoghli,
Edith Holsboer-Trachsler and Serge Brand, Detached mindfulness reduced both
depression and anxiety in elderly women with major depressive disorders,
Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2017.07.030
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Detached mindfulness reduced both depression and anxiety in elderly women with major
depressive disorders
a
Behavioral Disorders and Substances Abuse Research Center. Hamadan University of
Medical Sciences, Hamadan, Iran
b
White Jasmine Adult Nursing Home. Hamadan, Iran
c
Hamadan Educational Organization, Ministry of Education. Hamadan, Iran
d
Psychiatric Clinics of the University of Basel, Center for Affective, Stress und Sleep
Disorders, University of Basel, Basel, Switzerland
e
Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical
Sciences, Tehran, Iran
f
Department of Sport, Exercise and Health, Division of Sport and Psychosocial Health,
University of Basel, Basel, Switzerland
g
Sleep Disorders Research Center, Kermanshah University of Medical Sciences (KUMS),
Kermanshah, Iran
*Corresponding address. Serge Brand, PhD, University of Basel, Psychiatric Clinics (UPK),
Center for Affective, Stress and Sleep Disorders (ZASS), Wilhelm Klein-Strasse 27, 4012
Basel – Switzerland, +4161 32 55 114 (voice), +4161 32 55 513 (fax), serge.brand@upkbs.ch
1
Abstract
We investigated the influence of detached mindfulness (DM) in treating symptoms of
depression and anxiety among elderly women. Thirty-four elderly females (mean age: 69.23
years) suffering from moderate major depressive disorders (MDD) and treated with a standard
condition (DM; group treatment, twice weekly) or to a control condition (with leisure
activities, twice weekly). At baseline (BL), four weeks later at study completion (SC), and
four weeks after that at follow-up (FU), participants completed ratings for symptoms of
depression and anxiety; experts blind to patients’ group assignments rated patients’ symptoms
of depression. Symptoms of depression (self and experts’ ratings) and anxiety declined
significantly over time in the DM, but not in the control condition. Effects remained stable at
FU. The pattern of results suggests that, compared to a control condition, a specific
2
1. Introduction
Major depressive disorders (MDD) are unsurprisingly among the most common of
psychiatric disorders. Moreover, Murray and Lopez (1997) have calculated that MDDs are
responsible for the second highest number of years lost due to premature death or disability,
with chronic lifelong risk for recurrent relapse, and high morbidity, co-morbidity and
mortality (Culpepper et al., 2015; Gonda et al., 2015; Lockwood et al., 2015;, Kennedy and
Paykel, 2004; Fava and Ruini, 2002). Accordingly, adequate treatment and care of patients
suffering from MDD is highly desirable for both clinical and economic reasons. However,
several studies indicate that the efficacy of antidepressants is limited; a therapeutic effect is
achieved at most in 60-70% of patients suffering from major depressive disorders (Castren,
2005), with maximum adherence of 50% four weeks after starting treatment (Cassano and
Fava, 2002), probably due to an antidepressant effect time lag of two or more weeks (Castren,
2005), and to various adverse side-effects such as weight gain, dry mouth, and sexual
The first-line options in the treatment of severe MDD are antidepressants. In treating
mild to moderate MDD, psychotherapeutic interventions (e.g. Cuijpers et al., 2011a,b) and
physical activity (Kvam et al., 2016; Josefsson et al., 2014) are valuable options both by
themselves and in combination with antidepressants or ECT (Salehi et al. , 2016). Schuch et al.
(2016) concluded from their meta-analysis that physical activity is a valid treatment option
older adults.
2). Metacognitive interventions or detached mindfulness (Solem et al., 2017, 2015) focus on
thinking about one’s own thinking; more specifically, metacognitive interventions ask to what
3
extent one’s own thoughts are helpful in becoming aware (‘mindful’) of mental processes
such as thoughts and feelings, and to increase the capacity to disrupt (or ‘detach’) the relation
between thoughts and reactions to thoughts (Wells, 2006). Specifically, detached mindfulness
aims to strengthen the belief that thoughts are nothing more than inner events separate from
the control of action. Or to put it another way, detached mindfulness helps to achieve
awareness of negative thoughts, to identify and isolate them as mere mental processes, and to
avoid turning these (negative) thoughts into action. Detached mindfulness (DM) has been
disorders, and major depressive disorders (Wells et al., 2012; Spada et al., 2010, Wells, 2006;
Matthews and Wells, 2000), and also with patients suffering from hypertension (Ahmadpanah
et al., 2016a).
Given these encouraging results, and given the standardized, economic and time-
influence of DM concomitantly on both depression and anxiety among elderly patients with
MDD. Such a procedure is justified given numerous observations of the high comorbidity of
MDD and anxiety disorders among adolescents, young adults (Melton et al., 2016; Coplan et
al., 2015; Leventhal and Zvolensky, 2015; Quante, 2015), and the elderly (Beattie et al., 2010;
Flood and Buckwalter, 2009; Devanand, 2002; Lenze et al., 2002). Furthermore, Cuijpers et
al. (2011a, b) have shown in a systematic review and meta-analyses that psychological
interventions to treat patients with major depressive disorders are superior to control
conditions, though concomitant effects on anxiety have not been investigated (Hollon and
Ponniah, 2010), nor has the focus of previous studies been on older populations.
Specifically, Laidlaw (2013) also pointed out that findings regarding the
psychotherapeutic treatment of depression and anxiety have often been based on studies of
younger adults or older adults with symptoms of depression and anxiety, though without
diagnosed MDD (see also Klainin-Yobas et al., 2015). To counter this, the first aim of the
4
present study was to compare the influence of DM and a control condition on elderly female
patients diagnosed with MDD. To our knowledge, there has been no research into the longer-
et al., 2016). The second aim of the present study, therefore, was to investigate whether MDM
has an effect four weeks after study completion and if so the scale of such an effect. Third,
given the substantial overlap between symptoms of depression and of anxiety among the
elderly (Beattie et al., 2010; Flood and Buckwalter, 2009; Devanand, 2002; Lenze et al. 2002),
the present study also aimed to investigate the influence of DM on both sets of symptoms
Two hypotheses and two research questions were formulated. First, following Wells
(Wells et al., 2012; Wells, 2006), Ahmadpanah et al. (2016a), Spada et al. (2010), and Hollon
rated by patients and experts, in the intervention condition, but not in the control condition. .
Second, following Karyotaki et al. (2016), we anticipated that the influence of DM would
persist for four weeks after intervention completion. We treated as exploratory research
questions whether and under which of the two condition participants would show a response
2. Method
2.1. Procedure
Eligible participants were recruited from the Retirement Home Center of Habib Ibn
Mazaher (Hamadan, Iran). Participants were fully informed about the aims and the procedure
of the study. Furthermore, they were informed about the anonymous data analysis, and that
5
questionnaires relating respectively to depression and anxiety (see below). Next, they were
randomly assigned either to the intervention or to the control group (see below for details).
The intervention lasted four weeks (study completion [SC]), and assessments were repeated
four weeks later (follow-up [FU]). In parallel, experts blind to participants’ group allocation
rated the latter’s level of depression at baseline, at study completion and at follow-up.
The study was approved by the ethics committee of the University of Hamadan
(Hamadan, Iran) and conducted in accordance with the rules laid down in the Declaration of
2.2. Sample
A total of 34 elderly women (mean age: M = 69.23 years, SD = 4.35) diagnosed with
MDD took part in the study. Inclusion criteria were as follows: 1. Age between 65 and 85
psychologist not otherwise involved in the study, and based on a clinical psychiatric interview
with the Structured Clinical Interview for DSM Disorders (SCID; First et al., 1997; Farsi
Geriatric Depression Scale (five or more points; see description below). 4. Symptoms of
symptoms of anxiety, as self-reported on the Beck Anxiety Inventory (BAI; Beck et al., 1988;
16 or more points; see description below). 6. Monotherapy with a standard SSRI (citalopram)
at therapeutic levels. 7. Written informed consent. 8. Able and willing to complete self-rating
questionnaires. 9. Mini Mental State Examination (MMSE, Folstein et al., 1975; 26 points or
Exclusion criteria were: 1. Not meeting the inclusion criteria (see above). 2. Suicidal
or psychotic state within the six months prior to study enrollment. 3. Other psychiatric
6
disorders, specifically addiction disorders. 4. Undergoing other treatments such as physical
were recruited, 19 being allocated to intervention condition, and 17 and to the control
condition. During the study, two participants dropped out of the intervention condition. While
36 participants completed the study, the statistical analysis was performed following the
Table 1 gives the descriptive and inferential statistics for the socio-demographic and
illness-related variables, separately for patients in the DM group and in the control group. No
significant differences were observed between the two study conditions. Accordingly, socio-
2.3. Randomization
not otherwise involved in the study prepared an opaque ballot box containing 2 x 20 chips in
two different colors. Each color represented a study condition. The chips were mixed, the
patient drew a chip and was assigned to the corresponding study condition.
7
2.4. Tools
depression such as feeling hopeless, lonely, and sad, social withdrawal, weight loss, or loss of
interest in usual pursuits. Answers are yes (= 1) or no (= 0), with higher scores reflecting a
higher level of depression (Cronbach’s alpha = 0.87). Categorization was made as follows
(Sheikh et al., 1991): 0–4 points: no depression; 5-9 points: mild to moderate depression; 10-
Depression Rating Scale (MADRS; original: Montgomery and Asberg, 1979; Farsi validation:
Ahmadpanah et al., 2016). The 10 items forming the scale assess the following symptoms: 1.
apparent sadness; 2. reported sadness; 3. inner tension; 4. reduced sleep; 5. reduced appetite; 6.
thoughts. Answers are given on a 6-point Likert scale ranging from 0 (= not at all) to 6 (=
definitely), with higher scores reflecting more severe symptoms (Cronbach’s alpha = 0.89).
Categorization was made as follows (Ahmadpanah et al., 2016b; Montgomery and Asberg,
1979): 0-6 points: no depression; 7-19 points: mild depression; 20-34 points: moderate
8
Symptoms of anxiety were assessed with the Beck Anxiety Inventory (BAI; Beck et al.
1988). Kaviani and Mosavi (2008) have reported robust and reliable psychometric properties
for the Farsi version of this inventory. The BAI consists of 21 items addressing typical
cognitive, emotional and bodily signs of anxiety such a fear of the worst happening,
numbness and tingling, or sweating not due to heat. Answers are given on 4-point rating
scales with the anchor points 0 (= not at all) and 3 (= severely/it bothered me a lot), and with
higher sum scores reflecting greater symptoms of anxiety (Cronbach’s alpha = 0.88).
Categorization was made as follows (Kaviani and Mousavi, 2008; Beck et al., 1988): 0-9:
minimal anxiety; 10-16: mild anxiety; 17-29: moderate anxiety; 30-63: severe anxiety.
2.5. Interventions
psychotherapeutic intervention aimed at learning how and where to guide one’s attention, and
to focus on thinking about thinking. More specifically, DM aims at becoming aware of one’s
negative thoughts, but recognizing them as mere mental processes without the need to follow
about 60-90min. Sessions took place twice a week as group therapy with 7 to 9 participants
per group, and lasted for four consecutive weeks. Table 2 describes the individual sessions.
Additionally, patients were asked to exercise individually at least three times per week.
9
2.5.2. Control condition
Participants in the control condition met twice a week in small groups to engage in
leisure activities together. These guided and supervised activities included walking through
the park and the woods, painting lessons, museum visits, handcrafts, and similar. The duration,
frequency and intensity of the ‘special program’ for the control condition were identical to the
intervention condition: four consecutive weeks, twice a week for 60-90min per session.
Follow-up (FU) took place four weeks after study completion (SC).
All patients were treated with citalopram (an SSRI) at therapeutic dosages. At least
four weeks before being enrolled in the study, patients started pharmacological treatment with
citalopram (40mg/d), which was maintained at this level until the follow-up (2*4 weeks).
With respect to the initial pharmacological intervention, patient-reported side effects included
2.6. Response
10
At baseline, there were no statistically or descriptively significant group differences
for age, symptom severity (depression: self- and experts’ ratings; self rated anxiety; see also
Table 2), mental status (Mini Mental Status Examination), number of previous depressive
episodes (see Table 1), or other inclusion and exclusion criteria. Accordingly, no covariates
Data were analyzed as intention-to-treat, with LOCF. Three ANOVAs for repeated
measures were performed with Group (intervention vs. control condition), Time (baseline,
study completion, follow-up), and the Group-by-Time interaction as independent factors and
the depression and anxiety scores as dependent variables. Post-hoc tests were performed with
Bonferroni-Holm corrections for p-values. To allow for deviations from sphericity, statistical
the paper the original degrees of freedom are reported with the relevant Greenhouse-Geisser
epsilon value (ε). To calculate whether the distribution of responders and remitters at SC and
FU differed between the intervention and the control condition, a series of odds-ratio
calculations were performed. The nominal level of significance was set at alpha < 0.05. All
statistics were performed with SPSS® 22.0 (IBM Corporation, Armonk NY, USA) for Apple
Mac®.
3. Results
Tables 3 and 4 give a descriptive and inferential statistical overview for symptoms of
depression as self- (GDS) and expert (MADRS) rated. Statistical indices are only reported in
11
the Tables. Figure 2 displays symptoms of depression over time and separately for the two
Symptoms of depression decreased over time, but more so in the treatment than in the
control condition (significant time by group interaction). Compared to the control condition,
analyses after Bonferroni-Holm corrections for p-values showed that at SC, depression scores
were significantly lower in the treatment than the control condition. Post-hoc analyses after
Bonferroni-Holm corrections for p-values showed that at FU depression scores were still
significantly lower in the treatment than the control condition (see also Figure 2).
Tables 3 and 4 also give a descriptive and inferential statistical overview for
symptoms of anxiety, as self-rated with the BAI. Statistical indices are reported only in the
Tables. Figure 3 shows the self-rated symptoms of anxiety over time and separately for the
two groups.
Symptoms of anxiety decreased over time, but more so in the treatment than in the
control condition (significant time by group interaction). Anxiety scores did not significantly
differ between the two groups. Post-hoc analyses after Bonferroni-Holm corrections for p-
values showed that at SC, anxiety scores were significantly lower and clinically relevant (cf.
Beck et al. 1988) in the treatment condition than in the control condition. Post-hoc analyses
12
after Bonferroni-Holm corrections for p-values showed that anxiety scores were still
significantly and clinically lower in the treatment condition than in the control condition at
With the first research question we explored whether and under which of the two
more was defined as response to treatment. Response to treatment was observed at SC and FU
in the DM condition but not in the control condition (symptoms of depression [self- and
With the second research question we explored whether and if so in which study
condition remissions were observed at SC and FU. The following remission criteria were
applied: Geriatric Depression scale (Sheikh et al., 1991; Sheikh, 1985): 0–4 points = no
and Asberg, 1979): 0-6 points: no depression; Beck Anxiety Inventory (Hossein and Mousavi,
13
As summarized in Table 6, the likelihood of a full remission from depression (self-
and experts’ ratings) was 7.65-15.53-fold higher in the intervention than in control group. No
4. Discussion
The key finding of the present study was that, compared to a control condition,
depression (self- and experts’-rated) and anxiety among elderly women diagnosed with major
depressive disorders and treated with a standard antidepressant. Furthermore, the present
study expanded upon the current literature in showing that the influence of DM persisted even
Two hypotheses and two research questions were formulated and each of these is
considered in turn.
Our first hypothesis was that the MDM intervention would have reduced symptoms of
depression (self- and experts’ rated) and anxiety by completion of the intervention program,
and this was confirmed (see Tables 3 and 4, and Figure 2). In this regard, the present findings
are in line with previous results (Ahmadpanah et al., 2016a; Wells et al., 2012; Spada et al.,
2010; Wells, 2006; Hollon and Ponniah, 2010). However, the present findings also expand
upon previous research in filling a gap in psychotherapeutic research that has largely focused
Moreover, we confirmed that DM had the potential to reduce symptoms of depression and
anxiety among older people (Klainin-Yobas et al., 2015; Cuijpers et al., 2011a, 2011b). Given
the substantial overlap between symptoms of depression and of anxiety that also exists among
the elderly (Beattie et al., 2010; Flood and Buckwalter, 2009; Devanand, 2002; Lenze et al.,
2002), this result was to be expected. It is also noteworthy that symptoms of depression were
14
assessed both by participants and by experts blind to participants’ group allocation; we
believe this further confirms the reliability and validity of the intervention effect and its
clinical relevance.
Our second hypothesis was that, four weeks after the intervention, symptoms of
depression and anxiety would remain stable, and this was confirmed. As shown in Tables 3
depression and anxiety remained low, a finding in line with previous research (Karyotaki et
al., 2016). On the other hand, symptoms of depression and anxiety also remained unchanged
in the control condition; that is to say, there were no improvements, but also no deterioration
Our research questions concerned whether and if so in which group response and
remission would be observed. As reported in the text and in Table 5 and 6, response and
remission in depression (self- and experts’ ratings) were observed in the intervention but not
in the control condition. Notably, the odds of remission with respect to depression were 8 to
15-fold higher in the treatment than in the control condition. We believe this outcome is an
levels.
Remitter- and odds-ratio calculations (Table 6) also showed that remission was
generally not achieved as regards anxiety. This result is at odds with the observed
improvements in anxiety (see Tables 3 and 4 and Figure 3), though it is possible that the
The question remains as to why detached mindfulness should have a positive and
enduring impact on patients’ symptoms of depression and anxiety. The data available to us
15
elaborated elsewhere (Ahmadpanah et al., 2016a), the following would appear to be possible
explanations.
system and information processing by focusing on breathing and attention to the body and to
the present (“here and now”). Furthermore, the impact of DM on anxiety in a group therapy
setting can be explained as follows: patients are over-sensitized to concerns and anxieties and
are more inclined to misinterpret psychological symptoms and bodily sensations as symptoms
emotional concepts of what might be more or less fearful could have led to a decrease in their
levels of anxiety.
On the other hand, techniques such as DM cause changes in the attitudes and
cognitions of patients such that they accept their current physical and psychological state,
engage with its mental consequences, and learn that emotions and negative thoughts are
nothing more than transient inner processes carrying no requirement that these be translated
into action.
Despite the positive findings of this study, several limitations warrant against
overgeneralization. First, in Iran, wards and health care units are gender-segregated;
study only females were assessed. Thus, it remains unclear to what extent the present findings
would generalize to male patients. Second, sleep was not assessed, though several studies
have shown poor sleep to be causally related to poor mental health (Lovato and Gradisar,
2014), and that, compared to males, females complain more about insomnia (Zhang and Wing,
2006). Third, the present pattern of results might have emerged due to further latent but
perceived peer acceptance and rejection), which might have biased two or more variables in
the same or opposite directions. Fourth, we applied statistical procedures, which by definition
16
assumed linear associations. However, a more fine-grained day-by-day analysis would have
allowed for the exploration of non-linear processes, with possible accelerated improvements
at the beginning of the treatment and continuous deceleration. Such a microanalysis would
allow for the fine-tuning of interventions in terms of frequency, duration and intensity.
Further, it would also have permitted a clearer understanding as to why for patients in the
control condition the impact of the social setting was apparently zero, or at least not aversive.
However, this observation does not support the so-called social deprivation hypothesis, which
explains the emergence and maintenance of symptoms of depression in terms of low social
interaction rates (Lewinsohn, 1974). Rather, as regards the control group, the pattern of
results suggested that the cognitive-emotional content of social contacts rather than the mere
fact of social contact seems to be of particular importance. Fifth, as regards the control
condition, we observed that the psychopharmacologic treatment with SSRIs had no beneficial
(and no detrimental) effects. We believe this pattern of results is consistent with that from a
recent study among primiparae with postpartum depression (Ahmadpanah et al., in press):
While both Detached Mindfulness and Stress Management Training reduced symptoms of
depression after eight to sixteen weeks, no substantive changes were observed in the control
group treated with a standard SSRI (citalopram). Sixth, a major limitation of the study is the
cognitive-emotional concepts if any were modified, and why? Furthermore, while the DM
intervention had effects that persisted for at least four weeks beyond completion of the
program, we do not know what cognitive-emotional processes might have been responsible
for this effect. Accordingly, we believe that future studies should focus more directly on the
especially important as Driessen et al. (2015) have shown that a publication bias might inflate
the apparent efficacy of psychological treatments for MDDs (as is also the case for
pharmacotherapy).
17
5. Conclusion
Compared to a control condition reproducing very similar social conditions, detached
mindfulness (DM) reduced symptoms of depression and anxiety in elderly female patients
with major depressive disorders (MDD), both over the course of a four week intervention and
external funding.
Acknowledgements
We thank Nick Emler (University of Surrey, Surrey UK) for proofreading the
manuscript.
18
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Groups Statistics
Detached Control
Mindfulness condition
condition
N 17 17
Age (years) 68.28 (5.28) 70.18 (6.56) t(32) = 0.98, p = 0.33
Mini Mental Status 27.83 (1.07) 28.18 (0.89) t(32) = 1.05, p = 0.30
22
Examination
Civil status (single- 11/6 9/8 X2(N = 34; df = 1) =
widowed/married) 0.49, p = 0.49)
23
Table 3 Descriptive overview of symptoms of depression (self- and experts’ ratings) and anxiety
(self-rating), separately for Time (baseline, on study completion, and 4 weeks later at follow-up),
and separately for the two groups (detached mindfulness DM; controls CG)
Groups
completion up completion up
(BL) (BL)
N 19 17
Geriatric Depression 8.12 4.00 (2.69) 4.30 8.53 8.65 (2.69) 9.06
24
Table 4 Inferential statistical overview of symptoms of depression (self- and experts’ ratings)
and anxiety (self-rating), separately for Time (pre-test, on completion of the study (post-test),
and 4 weeks later at follow-up), Group (metacognitive detached mindfulness MDM; controls CG),
and the Time by Group interaction
Factors
interaction
epsilon
Scale (GDS;
self-rating)
Beck Anxiety 0.12 75.70*** 41.67*** 0.895 MDM < CG MDM <
self-rating)
ratings;
MADSR)
25
Table 5 Response rates at study completion four weeks later, and at follow-up four weeks
after study completion.
Time points
Beck Anxiety Inventory 3/16 1/16 X2(1, 36) 4/15 5/12 X2(1, 36)
(BAI; self-rating) = 3.29 = 4.53*
Table 6 Remission rates at baseline, at study completion four weeks later, and at follow-
up four weeks after study completion.
Time points
OR = OR =
15.53, 11.34,
CI = CI =
0.14- 0.35-
0.64 0.83
Montgomer 0/1 0/1 - 10/ 0/1 X2(1, 9/1 0/1 X2(1,
y-Asberg 9 7 9 7 36) = 0 7 36) =
Depression 10.46** 8.82**
26
Rating *
Scale OR =
(MADRS; OR = 8.43, CI
experts’ 7.65, CI = 0.41-
rating) = 0.34- 0.88
0.83
Beck 0/1 0/1 - 2/1 1/1 X2(1, 4/1 2/1 X2(1,
Anxiety 9 7 7 6 36) = 5 5 36) =
Inventory 1.12 3.65
(BAI; self-
rating) OR = OR =
1.4, CI 2.54 CI
= 0.48- = 0.82-
5.65 7.65
Highlights
· Detached mindfulness (DM) was employed to treat symptoms of depression and anxiety
· Participants were elderly women (mean age: 69 years) with major depressive disorders
· Compared to the control condition, in he DM condition, but not in the control condition
27
Enrollment Assessed for eligibility (n= 85)
Allocation
Allocated to active intervention (n= 19) Allocated to control condition (n= 17)
¨ Received allocated intervention (n= 19) ¨ Received allocated intervention (n= 17)
¨ Did not receive allocated intervention (n= 0) ¨ Did not receive allocated intervention (give
reasons) (n= 0)
Follow-Up
Lost to follow-up (n= 2) Lost to follow-up (n= 0)
Analysis
Analysed (n= 19) = intention-to-treat-analysis Analysed (n= 17)
Figure 2
Beck Anxiety scores (self-rating) did not decrease over time (F = 0.12), though anxiety scores decreased
over time in the Detached Mindfulness group (DM), compared to the control condition (CC) (F = 41.67,
p < 0.001). Compared to the control condition, anxiety scores were significantly lower in the Detached
Mindfulness group (F = 75.70, p < 0.001). After study completion, scores remained unaltered in both
groups. Points are means and bars are standard deviations. For visual clarity, standard deviations are
represented only in one direction.