A systematic review of the use of Acceptance and Commitment Therapy (ACT) in chronic disease and long-term conditions

Does Integrating Cognitive and Psychological Interventions Enhance Wellbeing After Acquired Brain Injury? Study Protocol for a Phase II Randomized Controlled Trial of the VaLiANT (Valued Living After Neurological Trauma) Group Program

Background and Objectives

Cognitive and emotional changes affect the majority of individuals with acquired brain injury (ABI) and are associated with poorer outcomes. The evidence for “siloed” rehabilitation approaches targeting cognition and mood separately remains mixed. Valued living (i.e., acting consistently with personal values) is associated with better psychological functioning and participation in work and other productive activities. Rehabilitation interventions that concurrently address cognitive and emotional barriers to valued living may therefore result in improved outcomes. VaLiANT (Valued Living After Neurological Trauma) is an 8-week group intervention developed by our team, which uniquely combines cognitive rehabilitation and psychological therapy to improve wellbeing and meaningful participation (i.e., valued living) following ABI.

Method

This protocol describes the design and implementation of a Phase II parallel-group randomized controlled trial with blinded outcome assessors, to evaluate the potential efficacy of VaLiANT and the feasibility of a Phase III trial. Participants are adults with a history of ABI at least 3 months prior to study entry, who experience cognitive and/or emotional difficulties and associated reduced participation in valued activities. Random allocation to the treatment condition (8-week VaLiANT group program) or a usual care waitlist control condition occurs at a 2:1 treatment: control ratio. The primary outcome is wellbeing, measured by the Warwick-Edinburgh Mental Wellbeing Scale. Secondary outcomes include measures of valued living, mood, cognitive complaints, quality of life, community participation, post-traumatic growth, and self-efficacy. All measures are collected across three time points by blinded assessors (baseline, 8-week follow-up, 16-week follow-up). Trial feasibility will be evaluated against recruitment rates, drop-out rates, intervention acceptability, and treatment fidelity (manual adherence and therapist competence).

Discussion

This trial will extend current knowledge on how to improve long-term outcomes following ABI by evaluating an innovative integrated, multi-domain approach to rehabilitation concurrently addressing cognitive and emotional barriers to participation in meaningful life roles.

Technology-supported Acceptance and Commitment Therapy for chronic health conditions: A systematic review and meta-analysis

Chronic health conditions (CHCs) are common and associated with functional limitations. Acceptance and commitment therapy (ACT) shows promise in improving functioning, quality of life, and distress across several CHCs. The purpose of this study was to conduct a systematic review of technology-supported ACT for CHCs and perform a meta-analysis on functioning and ACT process outcomes. Multiple databases were systematically searched for randomized controlled trials. A total of 20 unique studies with 2,430 randomized participants were included. CHCs addressed in these studies were chronic pain (k = 9), obesity/overweight (k = 4), cancer (k = 3), hearing loss (k = 1), HIV (k = 1), multiple sclerosis (k = 1), and tinnitus (k = 1). Internet and telephone were the most used technology platforms. All studies included therapist contact with considerable heterogeneity between studies. Random effects meta-analyses found medium effect sizes showing technology-supported ACT outperformed comparator groups on measures of function at post-treatment (Hedges' g = -0.49; p = 0.002) and follow-up (Hedges' g = -0.52; p = 0.02), as well as ACT process outcomes at post-treatment (Hedges' g = 0.48; p < 0.001) and follow-up (Hedges' g = 0.44; p < 0.001). Technology-supported ACT shows promise for improving function and ACT process outcomes across a range of CHCs. Recommendations are provided to optimize technology-supported ACT for CHCs. PROSPERO registration number: CRD42020200230.

Multidisciplinary Care for Adults With Chronic Pancreatitis: Incorporating Psychological Therapies to Optimize Outcomes

ABSTRACT

Chronic pancreatitis (CP) is associated with a high disease burden, extensive negative impact on quality of life, increased rates of depression and anxiety, and significant health care utilization and expenditures. Pain is a hallmark feature of CP, present in up to 90% of patients with this condition, and can lead to high rates of disability, hospitalization, and opioid medication use. Current perspectives on the management of CP have evolved to advocate a multidisciplinary approach which offers new pathways for helping patients manage symptoms. Psychologists play an important role in a multidisciplinary team effort by applying scientifically based psychological principles and techniques to improve pain and adaptation to chronic illness. This review will detail the fundamentals of delivering psychological interventions for adults with CP managed in an outpatient setting. Recommendations for integrating psychological care in multidisciplinary management of CP will be offered. Future directions for psychological care in CP multidisciplinary teams are also discussed.

Investigating the needs and concerns of older adults with multimorbidity and their healthcare professionals for conceivable digital psychotherapeutic interventions

Multimorbidity, defined as the concurrent experience of more than one chronic health condition in an individual, affects ∼65% of people over 65 and 85% of those over 85 years old with 30% of those also experiencing mental health concerns. This can lead to reduced quality of life and functioning as well as poorer outcomes in terms of condition management, adherence to treatment, and ultimately disease prognosis and progression. Digital health interventions offer a viable means of condition self-management, as well as psychological support, particularly for those who may have difficulty accessing in-person services. To best meet the needs of older adults with multimorbidity, deeper insights are needed into their specific concerns and issues around condition management, particularly with regard to distress in relation to managing one's condition. The present study aimed to explore this using one-to-one qualitative interviews and focus groups with people with chronic health conditions and healthcare professionals. Participants were 11 older adults with multimorbidity (4 males; mean age: M = 72.7 years) and 14 healthcare professionals including five clinical nurse specialists, four pharmacists, two general practitioners, one occupational therapist, one speech and language therapist and one dietician. Thematic analysis was used to identify key themes, which included: patient feelings of anxiety or worry leading to an unwillingness to access essential information; the various mental health challenges faced by those with multimorbidity; the importance of personal values in providing motivation; and the importance of social support. Findings are discussed in relation to the potential development of transdiagnostically applicable digital interventions for the management of distress in those with multimorbidity.

The Experience of Self-conscious Emotions in Inflammatory Bowel Disease: A Thematic Analysis

Few studies have investigated emotional experiences in people living with inflammatory bowel disease (IBD). However, self-conscious emotions, including embarrassment and shame, are indicated as a key factor in delayed help-seeking for bowel symptoms, which can result in poorer health outcomes. This study aimed to explore experiences of self-conscious emotions among people with IBD. Fifteen participants were recruited from outpatient IBD clinics and patient groups, and engaged in semi-structured interviews about their experiences of IBD-related self-consciousness. Data were analysed using thematic analysis following an inductive, semantic approach and conducted from a critical realist position. The analysis generated two themes, each with three sub-themes, which captured self-conscious emotions in relation to experiences which threatened participants' preferred identities. The first theme, 'Lack of control' encapsulated participants' distress relating to fundamental alteration in self-perception, and their attempts to mitigate this. The second, 'Lack of understanding' captured distress associated with awareness of being unfairly judged by other people. Clinical implications are identified, including consideration of therapeutic approaches which target self-conscious emotions such as shame, and continued societal efforts to educate others about invisible disabilities such as IBD. Experiences which threatened participants' identities were implicated in the generation of self-conscious emotions; these should be considered in work with clients with IBD. Future research should target further investigation of these constructs.

Online Acceptance and Commitment Therapy (ACT) interventions for chronic pain: A systematic literature review

BACKGROUND

We systematically reviewed all literature concerning online Acceptance and Commitment Therapy (ACT) interventions for chronic pain to evaluate their (1) ACT content, (2) design characteristics, (3) design rationales, and (4) adherence.

MATERIAL AND METHODS

A systematic search was performed on July 9th, 2020 in; PubMed, PsycINFO, CINAHL, and Web of Science. Search terms related to: Acceptance and Commitment Therapy, chronic pain, and eHealth. Extracted data concerned ACT content, design characteristics, adherence, and design rationales.

RESULTS

20 articles, in which 14 interventions were described, met all inclusion criteria. Adherence and design rationales were described to a limited extent in the included studies. In total, the majority provided an overview of the included ACT processes. In 10 articles it was described that the intervention was delivered via a dedicated website (n = 10), which was sometimes combined with an app (n = 3). Guidance was included in most studies (n = 19). Studies including RCT's (n = 8) reported online ACT interventions to be effective.

CONCLUSION

Online ACT interventions for chronic pain have been shown to be effective and have generally been constructed in line with ACT theory. However, the majority of studies does not provide information about the choices to optimize the fit between task, technology, and user. Considerations behind the choices for intervention features as well as design rationales could help to optimize future online ACT interventions. Additionally, consistent attention should be paid to measurement and operationalization of adherence, since this is a crucial link between content, design and effectiveness.

The effects of acceptance and commitment therapy on psychosocial impact and adherence of MDR-TB patients

Background: The Worldwide resistance prevalence of the first-line tuberculosis drug, rifampicin, in 2017 was 7.4 per 100,000 population, and 82% of them experienced multidrugresistant tuberculosis (MDR-TB). Indonesia is the top 20 country with an MDR-TB burden, and its prevalence is 8.8 per 100,000 population. MDR-TB requires a long-time treatment and has accompanying side effects: biological and psychosocial effects. However, efforts to overcome the psychosocial impacts have not been conducted. This study aims to determine the effect of acceptance and commitment therapy (ACT) on anxiety, depression, suicidal ideation, and treatment adherence in MDR-TB patients.

Design and methods: This research employed a quasi-experimental design with a pre-test three post-tests using total sampling. The pre-test was conducted before the standard nursing intervention, post-test 1 was after the standard nursing intervention, posttest 2 was after ACT session 1, and post-test 3 was after ACT session 2. Data were collected by the Hamilton Rating Scale for Anxiety, Beck Hopelessness Scale, a Scale for Suicide Ideation, and Morisky Medication Adherence Scale.

Results: The standard nursing action and ACT reduce anxiety (p=0.002), reduced depression (p=0.0001), reduced suicidal ideation (p=0.008), and increased treatment adherence (p=0.0001).

Conclusions: The standard nursing action and ACT reduce anxiety, depression, and suicidal ideation. They increase treatment adherence recommended for use in MDR-TB patients.

Group-based acceptance and commitment therapy interventions for improving general distress and work-related distress in healthcare professionals: A systematic review and meta-analysis

BACKGROUND

A large proportion of the healthcare workforce reports significant distress and burnout, which can lead to poor patient care. Several psychological interventions, such as Acceptance and Commitment Therapy (ACT), have been applied to improve general distress and work-related distress in healthcare professionals (HCPs). However, the overall efficacy of ACT in this context is unknown. This review and meta-analysis aimed to: 1) test the pooled efficacy of ACT trials for improving general distress and reducing work-related distress in HCPs; 2) evaluate the overall study quality and risk of bias; and 3) investigate potential moderators of intervention effectiveness.

METHOD

Four databases (Ovid MEDLINE, EMBASE, PsycINFO, CINHAL) were searched, with 22 pre-post design and randomised controlled trial (RCTs) studies meeting the inclusion criteria. 10 RCTs studies were included in the meta-analysis.

RESULTS

Two random effects meta-analyses on general distress and work-related distress found that ACT outperformed pooled control conditions with a small effect size for general distress at post-intervention (g = 0.394, CIs [.040; .748]) and for work-related distress (g = 0.301, CIs [.122; .480]) at follow-up. However, ACT was more effective than controls. The number of treatment sessions was a moderator of intervention efficacy for general distress. ACT process measures (psychological flexibility) did not show significantly greater improvements in those who received the intervention.

LIMITATIONS

The methodological quality of studies was poor and needs to be improved.

CONCLUSIONS

Overall, ACT interventions are effective in improving general distress and work-related distress in HCPs. These findings have implications for policymakers, healthcare organisations and clinicians.

Patient and health care professional co-development of an Acceptance and Commitment Therapy intervention to support hormone therapy decision-making and well-being in women with breast cancer

OBJECTIVES

The aim of this work was to co-develop an Acceptance and Commitment Therapy (ACT) intervention to support medication adherence and quality of life in breast cancer survivors (BCSs). The research approach was intervention co-development.

METHODS

The sample consisted of BCS focus groups (n = 24), health care provider (HCP) interviews (n = 10), and a co-development workshop (BCSs, n = 12; HCPs, n = 9).We conducted 6 BCS focus groups and 10 HCP interviews to understand the acceptability of ACT. We co-designed the intervention in a workshop.

RESULTS

Participants reported high acceptability of an ACT intervention. BCSs preferred ACT exercises focused on values and self-compassion. Both groups recommended face-to-face intervention delivery, by a clinical psychologist, with a mixture of individual and group sessions. BCSs requested advice on side-effect management.

CONCLUSIONS

We effectively used patient and HCP co-design to configure an ACT intervention to support medication adherence and quality of life for BCSs. If feasible and efficacious, this ACT-based intervention could support breast cancer survivorship.

Using patient feedback to adapt intervention materials based on acceptance and commitment therapy for people receiving renal dialysis

Background

Theory-based intervention materials must be carefully adapted to meet the needs of users with specific physical conditions. Acceptance and Commitment Therapy (ACT) has been adapted successfully for cancer, chronic pain, diabetes, irritable bowel syndrome, multiple sclerosis, and a range of other conditions, but not so far for people receiving renal haemodialysis. This paper presents findings from a study to adapt ACT-based intervention materials specifically for renal dialysis.

Methods

Draft written materials consisting of four stories depicting fictitious individuals who used ACT-related techniques to help overcome different challenges and difficulties related to dialysis were adapted using a systematic patient consultation process. The participants were 18 people aged 19–80 years, with chronic kidney disease and receiving renal dialysis. Individual, semi-structured interviews were conducted to elicit participants’ views about how the content of the draft materials should be adapted to make them more realistic and relevant for people receiving renal dialysis and about how the materials should be presented and delivered to people receiving renal dialysis. The interview transcripts were analysed using a qualitative adaptation of the Delphi method in which themes are used as a framework for translating feedback into proposals for modifications.

Results

The analysis of patient feedback supported the use of patient stories but suggested they should be presented by video and narrated by real dialysis patients. They also indicated specific adaptations to make the stories more credible and realistic. Participant feedback was translated into proposals for change that were considered along with clinical, ethical and theoretical factors. The outcome was a design for a video-based intervention that separated the stories about individuals from the explanations of the specific ACT techniques and provided greater structure, with material organised into smaller chunks. This intervention is adapted specifically for people receiving renal dialysis while retaining the distinctive theoretical principles of ACT.

Conclusions

The study shows the value of consulting patients in the development of intervention materials and illustrates a process for integrating patient feedback with theoretical, clinical and practical considerations in intervention design.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-021-00921-5.

Cross-cultural adaptation, reliability, and validity of the Chinese version of the Acceptance and Action Questionnaire-Adult Hearing Loss

OBJECTIVE

Few mental health assessment tools are available for people with hearing loss (HL) in China. The Acceptance and Action Questionnaire-Adult Hearing Loss (AAQ-AHL) has been specifically designed to assess psychological inflexibility in adults with HL and may help assess mental health status promptly for targeted psychological interventions. The study aimed to investigate the cross-cultural validity and reliability of the Chinese version of the AAQ-AHL to assess its applicability to teenagers and adults with HL in China.

DESIGN

A descriptive and correlational study of a convenience sample of students aged above 12 years. All participants were invited to complete an online questionnaire.

STUDY SAMPLES

Participants included 402 students with HL.

RESULTS

The Chinese version of the AAQ-AHL was shown to be an excellent, reliable, and valid instrument that can be used to assess psychological inflexibility in teenagers and adults with HL by clinicians working with Mandarin-speaking populations.

CONCLUSION

Although the AAQ-AHL showed very good psychometric properties in hearing-impaired students aged above 12 years, further testing is needed to validate the measure across other age groups and validate its feasibility and utility in clinical applications.

Acceptance and Commitment Training for Veterans with polytrauma: A randomized controlled trial protocol

BACKGROUND

Mild traumatic brain injury (mTBI) is a signature wound of Veterans of operations in Iraq and Afghanistan (i.e., OIF/OEF/OND). Most Veterans with mTBI also experience stress-based psychopathology (e.g., depression, posttraumatic stress disorder) and chronic pain. This combination - referred to as polytrauma - results in detrimental long-term effects on social, occupational, and community reintegration. This study will compare the efficacy of a one-day Acceptance and Commitment Training plus Education, Resources, and Support (ACT+ERS) workshop to a one-day active control group (ERS) on symptoms of distress and social, occupational, and community reintegration. We will also examine mediators and moderators of treatment response.

METHODS

This is an ongoing randomized clinical trial. 212 OIF/OEF/OND Veterans with polytrauma are being recruited. Veterans are randomly assigned to a one-day ACT+ERS or a one-day ERS workshop with two individualized booster sessions approximately two- and four-weeks post-workshop. Veterans complete assessments prior to the workshop and again at six weeks, three months, and six months post-workshop. Of note, workshops were converted to a virtual format due to the COVID-19 pandemic.

RESULTS

The primary outcomes are symptoms of distress and reintegration; secondary outcomes are post-traumatic stress disorder symptoms and pain interference. Secondary analyses will assess whether changes in avoidance at three months mediate changes in distress and reintegration at six months.

CONCLUSION

Facilitating the psychological adjustment and reintegration of Veterans with polytrauma is critical. The results of this study will provide important information about the impact of a brief intervention for Veterans with these concerns.

Acceptance and Commitment Therapy in a Low-Income Country in Sub-Saharan Africa: A Call for Further Research

A worsening trend of critical shortages in senior health care workers across low- and middle-income countries (LMICs) in sub-Saharan Africa has been documented for decades. This is especially the case in Ethiopia that has severe shortage of mental health professionals. Consistent with the WHO recommended approach of task sharing for mental health care in LMICs, Acceptance and Commitment Therapy (ACT), which is an empirically validated psychological intervention aimed at increasing psychological flexibility, may be delivered by trained laypersons who have a grassroots presence. In this paper, we discuss the need for and potential role of ACT to be delivered by health extension workers (HEWs) to address mental health care needs across Ethiopia. To this end, we also reviewed previous studies that have examined the effectiveness of ACT-based interventions in African countries including in Nigeria, Sierra Leone, Uganda, and South Africa. All studies revealed significant improvements of various mental health-related outcome measures such as decreased psychological distress and depressive symptoms, or increased subjective wellbeing and life satisfaction in the groups that received an ACT-based intervention. However, to date, there is no study that applied ACT in Ethiopia. Thus, more research is warranted to examine the effectiveness and, if proven successful, to scale up a task sharing approach of an ACT-based intervention being delivered by trained HEWs at a grassroots level, possibly paving the way for an innovative, sustainable mental health service in Ethiopia as well as other African LMICs.

The impact of the COVID-19 pandemic on mental health and well-being of people living with a long-term physical health condition: a qualitative study

BACKGROUND

The COVID-19 pandemic and associated restrictions caused major global disruption. Individuals with long-term physical health conditions (LTCs) are at higher risk of severe illness and often subject to the strictest pandemic guidance, so may be disproportionally affected. The aim of this study was to qualitatively explore how living with a LTC during the COVID-19 pandemic affected people's mental health and wellbeing.

METHODS

Participants were people living with LTCs who participated in telephone/video call interviews based on a semi-structured topic guide. Key themes and subthemes were determined using deductive and inductive thematic analysis.

RESULTS

The sample included 32 participants with LTCs (most commonly cancer, respiratory conditions or cardiovascular diseases), mean age 57 (SD 13) years, 66% female and 72% white British. There were four overarching themes specific to living with a LTC. These were 1) high levels of fear and anxiety related to perceived consequences of catching COVID-19, 2) impact of shielding/isolation on mental health and wellbeing, 3) experience of healthcare during the pandemic and 4) anxiety created by uncertainty about the future. Fourteen subthemes were identified, including concerns about accessing essential supplies and the importance of social support. Individuals who lived alone and were advised to shield could be profoundly negatively affected.

CONCLUSIONS

This study found that there were a number of aspects of living with a LTC during the pandemic that had a significant impact on mental health and well-being. There should be focus on how best to provide practical and social support to people with LTCs during a pandemic, particularly if they have to shield or isolate.

A longitudinal study exploring the evolution of pain during pregnancy and after delivery: does worry matter?

The aim of this study is to evaluate the evolution of pain through pregnancy until after delivery, as well as to explore the mediating role of pregnancy worries in this evolution of pain. We conducted a longitudinal cohort study. The convenience sample was evaluated on four separate occasions: in the first trimester of pregnancy (pain), during the third trimester (pain and worry), during labor (pain), and after birth (< 24 h; pain). The final sample included 120 pregnant women with a mean age of 31.29 years (SD = 4.9; range = [22, 42 years]). The results evidenced changes in pain over time (F = 13.31, p < .001). Pain severity increased in the third trimester compared to the first trimester (t =  - 4.60; 95% CI = [- 1.31, - 0.52]; p < .001), while pain during the third trimester and pain after delivery were comparable (t =  - 0.94; 95% CI = [- 1.02, 0.36]; p = .35). Pain during labor was uncorrelated with all other pain measures, so it was not included in the model. The results of the mediation analyses indicated a total effect of pain during pregnancy (first and third trimester) and worry on pain severity after delivery (B = 0.35; SE = 0.14; t = 2.43; 95% CI = [0.06, 0.65]; p = .017). Pregnancy worries (B = 0.14; SE = 0.07; 95% CI = [0.06, 0.29]), but not pain during the third trimester (B = 0.03; SE = 0.12; 95% CI = [- 0.17, 0.31]) mediated the relationship between pain during the first trimester and pain after delivery. These results support the need to reduce worry in pregnant mothers, especially when pain during the first trimester is high, to reduce the risk of pain after delivery.

Qualitative study of the acceptability and feasibility of acceptance and commitment therapy for adolescents with chronic fatigue syndrome

Background

Paediatric chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is disabling and relatively common. Although evidenced-based treatments are available, at least 15% of children remain symptomatic after one year of treatment. Acceptance and commitment therapy (ACT) is an alternative therapy option; however, little is known about whether it is an acceptable treatment approach. Our aim was to find out if adolescents who remain symptomatic with CFS/ME after 12 months of treatment would find ACT acceptable, to inform a randomised controlled trial (RCT) of ACT.

Methods

We recruited adolescents (diagnosed with CFS/ME; not recovered after one year of treatment; aged 11-17 years), their parent/carer and healthcare professionals (HCPs) from one specialist UK paediatric CFS/ME service. We conducted semi-structured interviews to explore barriers to recovery; views on current treatments; acceptability of ACT; and feasibility of an effectiveness RCT. Thematic analysis was used to identify patterns in data.

Results

Twelve adolescents, eleven parents and seven HCPs were interviewed. All participants thought ACT was acceptable. Participants identified reasons why ACT might be efficacious: pragmatism, acceptance and compassion are valued in chronic illness; values-focussed treatment provides motivation and direction; psychological and physical needs are addressed; normalising difficulties is a useful life-skill. Some adolescents preferred ACT to cognitive behavioural therapy as it encouraged accepting (rather than challenging) thoughts. Most adolescents would consent to an RCT of ACT but a barrier to recruitment was reluctance to randomisation. All HCPs deemed ACT feasible to deliver. Some were concerned patients might confuse 'acceptance' with 'giving up' and called for clear explanations. All participants thought the timing of ACT should be individualised.

Conclusions

All adolescents with CFS/ME, parents and HCPs thought ACT was acceptable, and most adolescents were willing to try ACT. An RCT needs to solve issues around randomisation and timing of the intervention.

Acceptance and commitment therapy for older people with treatment-resistant generalised anxiety disorder: the FACTOID feasibility study

BACKGROUND

Generalised anxiety disorder, characterised by excessive anxiety and worry, is the most common anxiety disorder among older people. It is a condition that may persist for decades and is associated with numerous negative outcomes. Front-line treatments include pharmacological and psychological therapy, but many older people do not find these treatments effective. Guidance on managing treatment-resistant generalised anxiety disorder in older people is lacking.

OBJECTIVES

To assess whether or not a study to examine the clinical effectiveness and cost-effectiveness of acceptance and commitment therapy for older people with treatment-resistant generalised anxiety disorder is feasible, we developed an intervention based on acceptance and commitment therapy for this population, assessed its acceptability and feasibility in an uncontrolled feasibility study and clarified key study design parameters.

DESIGN

Phase 1 involved qualitative interviews to develop and optimise an intervention as well as a survey of service users and clinicians to clarify usual care. Phase 2 involved an uncontrolled feasibility study and qualitative interviews to refine the intervention.

SETTING

Participants were recruited from general practices, Improving Access to Psychological Therapies services, Community Mental Health Teams and the community.

PARTICIPANTS

Participants were people aged ≥ 65 years with treatment-resistant generalised anxiety disorder.

INTERVENTION

Participants received up to 16 one-to-one sessions of acceptance and commitment therapy, adapted for older people with treatment-resistant generalised anxiety disorder, in addition to usual care. Sessions were delivered by therapists based in primary and secondary care services, either in the clinic or at participants' homes. Sessions were weekly for the first 14 sessions and fortnightly thereafter.

MAIN OUTCOME MEASURES

The co-primary outcome measures for phase 2 were acceptability (session attendance and satisfaction with therapy) and feasibility (recruitment and retention). Secondary outcome measures included additional measures of acceptability and feasibility and self-reported measures of anxiety, worry, depression and psychological flexibility. Self-reported outcomes were assessed at 0 weeks (baseline) and 20 weeks (follow-up). Health economic outcomes included intervention and resource use costs and health-related quality of life.

RESULTS

Fifteen older people with treatment-resistant generalised anxiety disorder participated in phase 1 and 37 participated in phase 2. A high level of feasibility was demonstrated by a recruitment rate of 93% and a retention rate of 81%. A high level of acceptability was found with respect to session attendance (70% of participants attended ≥ 10 sessions) and satisfaction with therapy was adequate (60% of participants scored ≥ 21 out of 30 points on the Satisfaction with Therapy subscale of the Satisfaction with Therapy and Therapist Scale-Revised, although 80% of participants had not finished receiving therapy at the time of rating). Secondary outcome measures and qualitative data further supported the feasibility and acceptability of the intervention. Health economic data supported the feasibility of examining cost-effectiveness in a future randomised controlled trial. Although the study was not powered to examine clinical effectiveness, there was indicative evidence of improvements in scores for anxiety, depression and psychological flexibility.

LIMITATIONS

Non-specific therapeutic factors were not controlled for, and recruitment in phase 2 was limited to London.

CONCLUSIONS

There was evidence of high levels of feasibility and acceptability and indicative evidence of improvements in symptoms of anxiety, depression and psychological flexibility. The results of this study suggest that a larger-scale randomised controlled trial would be feasible to conduct and is warranted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12268776.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 54. See the NIHR Journals Library website for further project information.

Implementation of an Internet-Based Acceptance and Commitment Therapy for Promoting Mental Health Among Migrant Live-in Caregivers in Canada: Protocol

Background

Psychological distress, isolation, feelings of powerlessness, and limited social support are realities faced by temporary migrant live-in caregivers in Canada. Furthermore, they experience multiple barriers in accessing mental health services due to their long work hours, limited knowledge of health resources, precarious employment, and immigration status.

Objective

The Women Empowerment - Caregiver Acceptance & Resilience E-Learning (WE2CARE) project is a pilot intervention research project that aims to promote the mental well-being and resiliency of migrant live-in caregivers. The objectives include exploring the effectiveness of this program in achieving the following: (1) reducing psychological distress (depression, anxiety, and stress); (2) promoting committed actions of self-care; and (3) building mutual support social networks. Further, participants’ satisfaction with the intervention and their perceived barriers to and facilitators of practicing the self-care strategies embedded in WE2CARE will be examined.

Methods

A total of 36 live-in caregivers residing in the Greater Toronto Area will be recruited and randomly assigned to either the intervention or waitlist control group. The intervention group will receive a 6-week web-based psychosocial intervention that will be based on Acceptance and Commitment Therapy (ACT). Standardized self-reported surveys will be administered online preintervention, postintervention, and at 6 weeks postintervention to assess mental distress (Depression, Anxiety and Stress Scale), psychological flexibility (Acceptance and Action Questionnaire), mindfulness (Cognitive and Affective Mindfulness Scale – Revised), and resilience (Multi-System Model of Resilience Inventory). In addition, two focus groups will be held with a subset of participants to explore their feedback on the utility of the WE2CARE program.

Results

WE2CARE was funded in January 2019 for a year. The protocol was approved by the research ethics boards of Ryerson University (REB 2019-036) and the University of Toronto (RIS37623) in February and May 2019, respectively. Data collection started upon ethics approval and was completed by May 2020. A total of 29 caregivers completed the study and 20 participated in the focus groups. Data analyses are in progress and results will be published in 2021.

Conclusions

WE2CARE could be a promising approach to reducing stress, promoting resilience, and providing a virtual space for peer emotional support and collaborative learning among socially isolated and marginalized women. The results of this pilot study will inform the adaptation of an ACT-based psychological intervention for online delivery and determine its utility in promoting mental health among disadvantaged and vulnerable populations.

International Registered Report Identifier (IRRID)

DERR1-10.2196/31211

La Terapia de Aceptación y Compromiso (ACT) en tres víctimas del conflicto armado en Colombia

Los daños psicológicos ocasionados por el conflicto sociopolítico de hace más de 60 años en Colombia justifican la evaluación de intervenciones psicológicas que contribuyan a su disminución. El objetivo del trabajo fue evaluar el efecto de la Terapia de Aceptación y Compromiso (ACT) en los problemas identificados en víctimas de este conflicto armado. Se utilizó un diseño AB con seguimiento, con tres víctimas, dos hombres y una mujer, con edades entre 37 y 52 años. Se realizó un análisis funcional de cada caso para ajustar la intervención a las necesidades individuales, y se aplicaron el Cuestionario de Aceptación y Acción (AAQ II), el Índice de bienestar psicológico de Dupuy, listas de chequeo y autorregistros. Los resultados mostraron a la evitación experiencial como patrón de conducta en función de las condiciones contextuales relacionadas con la historia de aprendizaje y la experiencia del conflicto. En los tres participantes, la intervención ACT tuvo un efecto favorable. Varias de las respuestas de las víctimas fueron indicadores asociados al diagnóstico de trastorno de estrés postraumático (TEPT), y la evitación experiencial fue la estrategia psicológica para afrontarlos. Se recomienda evaluar ACT con poblaciones de niños y jóvenes afectados por el conflicto armado y evaluar formatos grupales.

Patient and family engagement strategies for children and adolescents with chronic diseases: A review of systematic reviews

OBJECTIVE

Patient and family engagement is important for family-centered care, particularly for children and adolescents with chronic disease. We aimed to 1) identify available evidence from systematic reviews on engagement strategies used to help children, adolescents, and their caregivers manage chronic conditions, and 2) identify gaps in the literature.

METHODS

We searched PubMed and CINAHL from January 2015 to January 2020 for systematic reviews on patient and family engagement strategies in the pediatrics population (<18 years). Strategies were categorized by direct patient care, health system, and community policy levels. We excluded reviews if interventions were unidirectional or without comparison.

RESULTS

We identified 25 systematic reviews. Twenty-two evaluated direct patient care, with 14 (279 unique studies) exclusively in pediatrics and 8 (24 unique studies) that included pediatric results with adults. Three reviews (9 unique studies) evaluated health system strategies. Direct patient care reviews focused on self-management support (n = 16) and shared decisionmaking (n = 6). Asthma was the most frequently evaluated condition (n = 14).

CONCLUSIONS AND PRACTICE IMPLICATIONS

Engagement strategies for children and adolescents with chronic disease are focused on direct patient care, particularly for asthma. More research is needed to address engagement for broader populations, expanded outcomes, and at health system and community levels.

"Comprehensive Assessment of ACT Processes CompACT. Romanian Adaptation and Short Form Validation"

"The current paper presents the translation and validation for Romanian non-clinical population of Comprehensive Assessment of ACT Processes – CompACT (Francis et al., 2016), an instrument that evaluates three dimensions of psychological flexibility: openness to experience, present moment awareness (mindfulness) and valued action. The psychometric properties of the Romanian version of the instrument were investigated, convergent validity in relation with AQQ-II and concurrent validity in relation with DASS-21 (with comparable results with ones reported for the original instrument). Considering modest model fit with theoretical factor structure of the instrument, current paper proposes a shorter, more stable Romanian Version, and tests its psychometric properties."

Unmet supportive care needs, anxiety and depression in haematology patients during watch-and-wait

OBJECTIVE

There is growing evidence and awareness of the psychological impact of watch-and-wait in patients with indolent haematological malignancy. However, the need for supportive care is unknown. The aims of this study were to investigate prevalence of unmet needs, their psychological associates, and prevalence of anxiety and depressive symptomatology.

METHODS

Adult patients with indolent haematological malignancy, during watch-and-wait (n = 122) were included in this cross-sectional single-centre study. Participants filled out questionnaires on anxiety (Generalised Anxiety Disorder), depression (Patient Health Questionnaire), coping (Acceptance and Action Questionnaire II), distress (distress thermometer), disease-specific quality of life (The European Organisation for Research and Treatment of Cancer quality of life questionnaire) and supportive care needs (Supportive care needs survey - Dutch short version). Multiple linear regression analyses were performed to identify patient-factors associated with unmet needs.

RESULTS

The prevalence of anxiety and depressive symptomatology were both 7.3%. Unmet needs were reported by 35% (n = 43) of patients. After controlling for covariates, higher levels of distress (β = 0.23, p = 0.05), depression (β = 0.41, p = 0.001), poorer coping (β = 0.35, p = 0.002) and younger age (β = -0.16, p = 0.05) were independently associated with more supportive care needs. The highest unmet needs were reported in domain health system, information & patient support (mean = 23.6 ± 23.0) and psychological domain (mean = 18.7 ± 21.8).

CONCLUSIONS

One third of indolent haematology patients during watch-and-wait report unmet supportive care needs. Screening for unmet needs and design of interventions is required. A joint approach focused on psychological care, especially on improving psychological flexibility, should be combined with promoting accessibility to health-services and optimising disease education.

A single-case experimental evaluation of a new group-based intervention to enhance adjustment to life with acquired brain injury: VaLiANT (valued living after neurological trauma)

Adjustment to life with acquired brain injury (ABI) requires self-identity and behaviour to be updated, incorporating injury-related changes. Identifying and enabling new values-consistent behaviours could facilitate this process. We evaluated the feasibility, acceptability, and preliminary efficacy of VaLiANT, a new group intervention that aims to enhance "valued living" following ABI. We used a non-concurrent multiple baseline single-case experimental design (SCED) with an 8-week follow-up phase and randomization to multiple baseline lengths (5-7 weeks). Eight participants (50% women, aged 26-65; 4 Stroke, 3 Traumatic Brain Injury, 1 Epilepsy) attended eight group sessions with assessments before, during, and after the group. Target behaviour was valued living, assessed weekly by the Valued Living Questionnaire. Secondary outcomes included measures of wellbeing, mood, psychological acceptance, self-efficacy regarding ABI consequences, cognitive complaints, and intervention acceptability. Target behaviour was analysed through visual and statistical analysis while secondary outcome data were analysed via reliable change indices and descriptive statistics. Target behaviour data displayed no convincing patterns of improvement. Reliable improvements were found for most participants on secondary outcomes, particularly subjective wellbeing and anxiety. Intervention delivery was feasible with high acceptability ratings. Further investigation of VaLiANT is warranted, based on the feasibility and acceptability of intervention delivery and signals of efficacy identified across adjustment-related secondary outcomes.

The Relationship between Diabetes Family Conflict and Parental Conflict on Problem Recognition in Illness Self-Management among Individuals with Type 1 Diabetes Mellitus

We investigated the relationship between diabetes family conflict and parental conflict on problem recognition in illness self-management (PRISM) among individuals with type 1 diabetes mellitus (T1DM). We employed a descriptive research design. Participants were 243 individuals with T1DM who completed online questionnaires. Data were analyzed with descriptive statistics, correlations, and multiple regression analyses. Results revealed that barriers were felt in all areas (understanding and organizing care, regimen pain and bother, healthcare team interaction, family interaction, and peer interaction), especially peer interaction. The significant influencing factors in the regression model for the total PRISM score of individuals with T1DM were conflict behavior toward mothers (t = 4.44, p < 0.001), diabetes family conflict (t = 5.77, p < 0.001), conflict behavior toward fathers (t = 2.58, p = 0.011), women (t = 2.67, p = 0.008), non-religious (t = -2.33, p = 0.020), and diabetic complications (t = 2.17, p = 0.031). The explanatory power of the constructed regression model for PRISM was 42.0% (F = 30.12, p < 0.001). To promote self-management among individuals with T1DM, the development of interventions that promote improved peer interactions, a family-centered approach, and a program that can minimize conflicts between families and parents are required.

Systematic Review and Meta-Analysis of Effectiveness of Acceptance and Commitment Therapy in Patients With Breast Cancer

BACKGROUND

The physical and psychological well-being of patients with breast cancer is an important global issue. Acceptance and commitment therapy (ACT) aims to equip patients with the skills to respond and adapt to difficult circumstances. However, the extent of the physical and psychological outcomes of this therapy in patients with breast cancer remains unclear.

OBJECTIVES

The aim of the study was to summarize available evidence and assess the efficacy of ACT on physiological and psychological outcomes in patients with breast cancer.

METHODS

Published randomized controlled studies were identified in MEDLINE, PsycInfo, Embase, Web of Science, CINAHL, and CNKI from inception to December 2019 and Cochrane Library, AMED, and Clinical trials.gov from inception to September 2020. Methodological rigor was assessed by two reviewers using the Cochrane Handbook for Systematic Review of Interventions. Sufficient data were statistically pooled with review manager; otherwise, a narrative summary was used.

RESULTS

Thirteen trials were included in the review. Methodological quality varied across the studies. Meta-analyses demonstrated that ACT had moderate to large effects on reducing anxiety, depression, and stress and improving hope. Sensitivity analyses reached results similar to those of the meta-analyses. However, the effects of ACT on the physiological symptoms, fear of cancer recurrence, and psychological flexibility of patients with breast cancer remain inconclusive.

DISCUSSION

ACT has beneficial effects on the anxiety, depression, stress, and hope of patients with breast cancer. The evidence of ACT on physiological symptoms, fear of cancer recurrence, and psychological flexibility needs to be treated with caution. Further studies are needed and should consider different delivery forms and also explore the mechanisms of each component of ACT under different cultural contexts.

Therapeutic assessment and the art of feedback: A model for integrating evidence-based assessment and therapy techniques in neurological rehabilitation

BACKGROUND

Therapeutic assessment involves the integration of evidence-based approaches and humanistic principles, and there is empirical support for the use of this approach in the context of neuropsychological assessment broadly.

OBJECTIVE

We propose that therapeutic assessment (TA) and collaborative therapeutic neuropsychological assessment (CTNA) principles are appropriate and effective for application within a neurological rehabilitation population specifically.

METHODS

We review TA and CTNA principles and propose a model for their application to a neurological rehabilitation population, with an emphasis on describing the strengths of the collaborative approach, guidelines and principles for maximizing the efficacy of feedback, and transitioning the patient into psychotherapy services to further address their personal goals. A case example of a neurologically injured individual engaged in CTNA and subsequent intervention is shared to highlight the principles discussed.

RESULTS AND CONCLUSION

The proposed model and case study demonstrate the clinical utility of TA and CTNA principles with a neurological rehabilitation population.

Acceptance and commitment therapy for individuals having attention deficit hyperactivity disorder (ADHD): A scoping review

OBJECTIVES

Acceptance and commitment therapy (ACT) has accumulated increasing evidence-base for a broad range of mental health issues. Considering that ACT encourages broad and flexible patterns of behaviour and neutralizes the pervasive psychological processes proposed to be caused by most individuals' distress, such a modality may be effective for ADHD. This review aimed to give a synthesis of the studies, so far, focusing on the usefulness of ACT approaches among individuals having ADHD.

DESIGN/METHODS

This scoping review searched studies exploring the effectiveness of ACT approaches for individuals with ADHD across eight electronic databases (Medline, Embase, PsycInfo, ScienceDirect, PubMed, Emcare, Scopus, and Google Scholar). This review was based on a total of two quasi-experimental and four experimental studies.

RESULTS

A thematic analysis was suggested based on the PRISMA guidelines. Overall, the review presented preliminary evidence demonstrating the use of ACT among individuals with ADHD. It was found that the ACT was used to treat a variety of behavioural and psychosocial outcomes, which included reducing ADHD symptoms (e.g., impulsivity, inattention, inflexibility, etc.) and other sequelae related to the ADHD diagnosis such as poor quality of life, academic procrastination, depression and anxiety symptoms, and psychological maladjustment.

CONCLUSIONS

This review revealed that ACT was a flexible approach that could be adapted to deliver both targeted treatment of ADHD symptomatology and more general psychosocial issues. It could also be delivered in group or individual formats. Nevertheless, although the findings of the present scoping review indicate promising results, more research is needed.

The Role of Acceptance and Commitment Therapy in Cardiovascular and Diabetes Healthcare: A Scoping Review

Acceptance and commitment therapy (ACT) is an adapted form of cognitive behavioural therapy. ACT focuses on how thinking affects behaviour and promotes psychological flexibility. The prevalence of psychological distress among people living with cardiovascular disease (CVD) and/or type 2 diabetes mellitus (T2DM) is high, and ACT may offer an alternative treatment approach. This scoping review explored the use of ACT as an intervention to support adults living with CVD and/or T2DM. A systematic search of the literature resulted in the inclusion of 15 studies. Studies were reviewed using the Joanna Briggs Institute approach to conducting scoping reviews. Most studies (n = 13) related to people living with T2DM, and most (n = 10) used a pre-post design, four studies were randomised controlled trials, and one was a qualitative study. Eight studies reported an improvement in the outcome(s) assessed post-intervention, suggesting that ACT was an acceptable and valid intervention to support people living with CVD or T2DM. However, studies were underpowered and only limited studies involved people living with CVD. ACT was assessed as a valuable approach to improve a range of patient-reported outcomes for those living with CVD or T2DM, and further research involving robust study designs and larger cohorts are warranted.

A pilot randomized controlled trial of online acceptance and commitment therapy versus compassion-focused therapy for chronic illness

Literature suggests that acceptance and commitment therapy (ACT) is effective in improving well-being and in reducing psychopathological symptoms commonly experienced by people with chronic illness (CI). Compassion-focused therapy (CFT) reduces psychological distress, especially in individuals with high levels of shame and self-criticism, but few studies have explored CFT in CI. Additionally, studies almost exclusively compared ACT and CFT with inactive controls (wait-list; treatment as usual). Also, there is an interest in developing cost-effective mental health solutions, such as low-intensity online psychological interventions. This randomized controlled trial (RCT) aimed to assess the acceptability and compare the efficacy of four-session online ACT (n = 25) and CFT (n = 24) interventions in a sample of people with CI. Results showed both interventions were acceptable, with attrition rates at post-intervention comparable to those found in similar studies (around 50%). Intention-to-treat analyses showed that participants presented significantly less illness-related shame, less uncompassionate self-responding and more valued living after the intervention, although no difference was found between conditions. Results were sustained at 3- and 6-month follow-up. Results did not find statistical differences between conditions through reliable change index (RCI). Correlation between demographics and RCI showed that, at post-intervention, younger participants presented more behavioural awareness, men presented more valued action, and participants with CI for shorter periods presented less uncompassionate self-responding and less anxiety. Results suggest that low-intensity (four sessions) online ACT and CFT are cost-effective approaches to promote mental health of individuals with CI. Results and limitations are thoroughly discussed.

Acceptance and commitment therapy meets peer-support. Development of a supportive self-care intervention for patients with rare diseases: a multistage development process

OBJECTIVE

We aimed at developing a patient-centred self-help programme, tailored to the needs of patients with rare chronic diseases.

DESIGN

Multistage, multimethod development process including a survey with validated self-report scales and open-ended questions (phase 1) and focus groups (phase 2) for needs assessment and, consolidating the first phases and the literature, the intervention development (phase 3).

SETTING

Phase 1: nationwide online survey in Germany, phase 2: four separate and diagnostically homogeneous focus groups. The focus groups took place at a university medical centre in Germany.

PARTICIPANTS

Target group were patients with rare diseases that occur at a prevalence <1:2000. Phase 1: n=300 participants with different rare diseases. Phase 2: Individuals with neurofibromatosis type 1 (n=4), primary sclerosing cholangitis (n=5), pulmonary arterial hypertension (n=4) and Marfan syndrome (n=5).

RESULTS

The central results of phases 1 and 2 were requests for more information about the disease and contact with other affected persons. Patients also expressed support needs in dealing with difficult emotions and identified acceptance of the disease as a turning point for quality of life. In phase 3, we identified acceptance and commitment therapy (ACT) as a suitable therapeutic approach and determined details about implementation and execution of self-management programmes. A 6-week self-help concept led by peer counsellors was developed, which includes disease-specific information and ACT-based exercises.

CONCLUSION

Based on a multistage needs assessment, we developed a peer-guided self-help intervention for patients with rare chronic diseases. Combining self-management, peer-counselling and ACT may help living with a rare condition. Further research needs to test the programme's efficacy.

TRIAL REGISTRATION NUMBER

ISRCTN13738704.

A tailored intervention for illness acceptance improves adherence and quality of life in adults with haemophilia using prophylaxis

INTRODUCTION

Adherence to prophylactic treatment (prophylaxis) in persons with haemophilia is challenging and has been reported at only ±50%. Acceptance problems are one of the main reasons for non-adherence in haemophilia. An evidence-based intervention was developed based on an acceptance and commitment therapy (ACT) approach.

AIM

To evaluate a tailored intervention focused on illness acceptance in adults with haemophilia who were prescribed prophylaxis.

METHODS

A pre-post study was executed in adults with haemophilia who were prescribed prophylaxis. A series of 8 2-hour group trainings were held, including 3-8 participants/series. Adherence (VERITAS-Pro, optimum 0), health-related quality of life (HRQoL, SF-36, optimum 100) and illness perception (BIPQ, optimum 0) were measured at start, after six months and 12 months and analysed using Wilcoxon signed-rank test.

RESULTS

Twenty-four patients (median age 47 years, range 27-74) were included. After 12 months, adherence improved in 68% of patients, quality of life in 48% and illness perception in 31%. Adherence (total score) improved from 35 to 25 (P<0.01). HRQoL showed clinically relevant improvement in domains of social-functioning (P = 0.04), role-emotional, physical-functioning, role-physical and bodily pain. Illness perception improved statistically significant on domains of affect (P = 0.01), concern (P = 0.01) and understanding (P = 0.04). Patients evaluated the training useful, an eye-opener, a personal enrichment and insightful.

CONCLUSION

The tailored group intervention resulted in significant improvement of adherence, quality of life and illness perception. Based on our current experience, we have implemented it in clinical practice and collaborate with the patient association to make it available for all Dutch people with haemophilia.

Systematic Review of Acceptance and Commitment Therapy in Individuals with Neurodevelopmental Disorders, Caregivers, and Staff

The purpose of this review was to quantitatively synthesize studies using acceptance and commitment therapy (ACT) with individuals with neurodevelopmental disorders (NNDs), their parents, and staff members that support them. Thirty studies published in peer-reviewed journals between 2006 and 2020 met inclusion criteria. They were reviewed and coded on variables associated with participants' characteristics, settings, dropouts, design type, ACT procedures and measures, social validity, treatment integrity, and main findings. The What Works Clearinghouse (WWC), the revised Cochrane risk-of-bias tool for randomized trials (RoB2) and the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) were applied to evaluate the quality of the studies. Results indicated that 20 studies used group designs and 10 studies used single-case designs. Participants with NNDs consisted predominantly of those with autism spectrum disorder, attention deficit hyperactivity disorder, and learning disabilities. Group studies reported process and outcome measures exclusively; whereas, single-case studies also incorporated behavioral/direct measures. Overall, results showed mixed improvements across studies using indirect and direct measures. Lastly, quality assessment for group studies presented moderate or serious risk of bias and two single-case studies did not meet WWC evidence of effectiveness. Directions for future research and practice are discussed.

Acceptance of Illness Among Patients Pursuing Transplantation or Left Ventricular Assist Device

Acceptance of illness is related to better mental health among patients with chronic illness; however, this construct has not been evaluated as part of routine transplantation evaluations. The purpose of this study was to create a brief measure of acceptance of illness for patients pursuing organ transplantation and examine how acceptance is related to distress. Retrospective medical record reviews were conducted for 290 patients who completed a routine psychosocial evaluation prior to transplant listing which included the Illness Acceptance Scale (IAS). Internal consistency for the IAS was excellent (Cronbach's alpha = .92). Illness acceptance was negatively correlated with depression, anxiety, and catastrophizing and was not related to health literacy or health numeracy. The IAS is a reliable and valid measure for patients who are pursuing thoracic transplant or left ventricular assist device. Clinicians may want to screen transplant candidates for illness acceptance and refer those with lower levels to psychological interventions.

Acceptance and commitment therapy for young brain tumour survivors: study protocol for an acceptability and feasibility trial

INTRODUCTION

Survivors of childhood brain tumours have the poorest health-related quality of life of all cancer survivors due to the multiple physical and psychological sequelae of brain tumours and their treatment. Remotely delivered acceptance and commitment therapy (ACT) may be a suitable and accessible psychological intervention to support young people who have survived brain tumours. This study aims to assess the feasibility and acceptability of remotely delivered ACT to improve quality of life among these young survivors.

METHODS AND ANALYSIS

This study is a two-arm, parallel group, randomised controlled trial comparing ACT with waitlist control at 12-week follow-up as the primary endpoint. Seventy-two participants will be recruited, who are aged 11-24 and have completed brain tumour treatment. Participants will be randomised to receive 12 weeks of ACT either immediately or after a 12-week wait. The DNA-v model of ACT will be employed, which is a developmentally appropriate model for young people. Feasibility will be assessed using the proportion of those showing interest who consent to the trial and complete the intervention. Acceptability will be assessed using participant evaluations of the intervention, alongside qualitative interviews and treatment diaries analysed thematically. A range of clinical outcome measures will also assess physical and mental health, everyday functioning, quality of life and service usage at 12-week follow-up. The durability of treatment effects will be assessed by further follow-up assessments at 24 weeks, 36 weeks and 48 weeks.

ETHICS AND DISSEMINATION

Ethical approval was given by East Midlands, Nottingham 1 Research Ethics Committee (Reference: 20/EM/0237). Study results will be disseminated in peer-reviewed journals, through public events and relevant third sector organisations.

TRIAL REGISTRATION

ISRCTN10903290; NCT04722237.

Efficacy of a Brief, Peer-Delivered Self-management Intervention for Patients With Rare Chronic Diseases: A Randomized Clinical Trial

IMPORTANCE

Patients coping with rare diseases need psychosocial support.

OBJECTIVE

To evaluate the efficacy of a brief, transdiagnostic, peer-delivered intervention for patients with rare diseases in addition to care as usual (CAU) compared with CAU only.

DESIGN, SETTING, AND PARTICIPANTS

In this 2-group randomized clinical trial conducted from October 5, 2017, to July 12, 2019, patients were recruited via specialized clinics and patient organizations across Germany and participated from home. The study included consecutive adult patients with neurofibromatosis type 1, Marfan syndrome, primary sclerosing cholangitis, and pulmonary arterial hypertension who have limited functionality because of the disease. Exclusion criteria were a life-threatening health status and ongoing psychotherapeutic treatment. Of 143 patients screened for eligibility with a semistructured telephone interview, 54 were excluded, and 89 were randomized: 45 patients were randomly allocated to the peer-delivered intervention group, and 44 to the control group; 87 patients (98%) completed the 6-month follow-up assessment. The analysis was performed using an intention-to-treat principle. Data cleansing and analysis were conducted between April 25, 2019, and February 13, 2020.

INTERVENTIONS

The 6-week intervention consisted of a self-help book and telephone-based peer counseling in addition to CAU. The control group received CAU alone. Peer counselors received training, structured consultation guidelines, and supervision.

MAIN OUTCOMES AND MEASURES

The primary outcome was acceptance of the disease as assessed using the Illness Cognition Questionnaire (ICQ; mean sum scores range from 0 to 18, with higher values representing more acceptance) 6 months after the intervention. Secondary outcomes included self-reported coping strategies (Health Education Impact Questionnaire), illness cognition (ICQ and Illness Perception Questionnaire), depression severity (Patient Health Questionnaire 9-item depression scale), anxiety severity (Generalized Anxiety Disorder Scale), quality of life (12-Item Short-Form Health Survey), and social support (Social Support Questionnaire). Outcomes were assessed before the intervention, after the intervention, and at a 6-month follow-up.

RESULTS

The mean (SD) age of the 89 participating patients was 46.3 (14.9) years; 59 (66%) were women. There were no group differences regarding baseline variables. All patients allocated to the intervention group completed the intervention. Six months after the intervention, but not directly after completing the program, the intervention group had significantly higher rates of acceptance (ICQ) of the disease (primary outcome) compared with the CAU group. Mean (SD) baseline ICQ scores were 9.61 (3.79) in the control group and 9.86 (3.40) in the intervention group. Mean (SE) ICQ scores at 6 months were 10.32 (0.42) for the control group and 11.79 (0.42) for the intervention group, with a significant mean difference of -1.47 (95% CI, -2.63 to -0.31; P = .01). Several secondary outcomes, including different coping strategies, social support, and mental quality of life, were significantly higher after the intervention compared with the control group.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, a self-help and peer counseling intervention improved patients' acceptance of their rare chronic diseases. Self-management and peer support can efficiently address the unique care needs of patients with rare diseases.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN13738704.

Experiences of Using Positive Airway Pressure for Treatment of Obstructive Sleep Apnoea: A Systematic Review and Thematic Synthesis

STUDY OBJECTIVES

Sub-optimal use of positive airway pressure (PAP) to treat obstructive sleep apnoea (OSA) continues to be a major challenge to effective treatment. Meanwhile, the individual and societal impacts of untreated OSA make effective treatment a priority. Although extensive research has been conducted into factors that impact PAP use, it is estimated that at least half of users do not use it as prescribed. However, the voice of users is notably minimal in the literature. A systematic review and qualitative metasynthesis of PAP user experience was conducted to contribute to understandings of how PAP is experienced and to inform how usage could be improved.

METHODS

PsycINFO, MEDLINE, CINAHL and EMBASE databases were systematically searched. Primary research findings of adult experiences using PAP that had been inductively analysed were included. Papers were critically appraised using the CASP qualitative checklist to generate a "hierarchy of evidence". Thematic synthesis was then conducted to generate analytical themes. Results were presented in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).

RESULTS

25 papers reporting on over 398 people's experiences were analysed to generate 4 themes: Journey to PAP, Discomfort from and around PAP, Adapting to and using PAP, and Benefits from PAP. Author reflexivity and vulnerability to bias is acknowledged.

CONCLUSIONS

The findings highlight the applicability of a biopsychosocial understanding to PAP use. This metasynthesis gave voice to user experiences, revealing barriers to PAP use at a healthcare service level across the world, and suggests ways services can address these barriers.

Young adults with epilepsy: Relationships between psychosocial variables and anxiety, depression, and suicidality

BACKGROUND

People with epilepsy (PWE) are at an increased risk of anxiety, depression, and suicidality. Young adulthood is a critical developmental period which can be complicated by the unique challenges of having epilepsy. The risk factors of mental health difficulties in young adults with epilepsy (YAWE) have not been investigated.

AIMS

To examine the relationships between psychosocial variables (coping strategies and sources of social support) and mental health outcomes in YAWE, and determine whether these psychosocial variables independently predict mental health outcomes after controlling for sociodemographic and epilepsy-related factors.

METHOD

An online survey was completed by 144 YAWE (18-25-year-olds), which measured sociodemographic and epilepsy-related factors, coping strategies, sources of social support, and current mental health symptoms (anxiety, depression, and suicidality).

RESULTS

Avoidant-focused coping was positively correlated, and problem-focused coping and meaning-focused coping were negatively correlated, with symptoms of anxiety, depression, and suicidality. Social support from family, friends, and a special person all negatively correlated with mental health outcomes. Using multiple regression analyses, greater use of avoidant-focused coping strategies independently predicted higher symptoms of anxiety, depression, and suicidality. Greater support from friends independently predicted significantly lower anxiety and depression, whereas greater support from family independently predicted significantly lower suicidality.

CLINICAL IMPLICATIONS

These findings have implications for clinical practice in YAWE and suggest that screening for mental health symptoms and psychosocial variables to identify those at risk would be beneficial. Access to tailored psychological support is also needed.

Does the Rural Environment Influence Symptomatology and Optimize the Effectiveness of Disease Acceptance? A Study Among Women With Fibromyalgia

The present study aims to explore whether the symptoms associated with fibromyalgia are contextually influenced by the area of residence (rural/urban). Furthermore, it is analyzed whether the effect of the acceptance of the disease on the emotional, cognitive and physical symptoms is moderated by the patients' place of residence. Using a cross-sectional design, a total of 234 women with fibromyalgia (mean age = 56.91 years; SD = 8.94) were surveyed, of which 55.13% resided in rural areas and 44.87% in urban areas. Self-reported questionnaires were used to assess pain severity, anxiety and depression, functional limitation, physical and mental fatigue and acceptance of the disease. The results show significant differences in acceptance (p = 0.040), pain (p < 0.001), and physical and mental fatigue (p = 0.003 and p = 0.004, respectively) between patients from rural and urban areas. The rural area patients presented higher levels of acceptance and pain and lesser levels of physical and mental fatigue compared to the urban area. The moderation analysis add that, only in patients from the rural area, the variables of physical symptoms (pain, functional limitation, and physical fatigue) were significantly and negatively associated with acceptance. This study addresses for the first time the role of the place of residence in suffering from fibromyalgia, suggesting that the rural or urban environment plays a relevant role in the severity and/or management of symptoms in fibromyalgia women. Limitations and practical implications are also discussed.

Treatment of Major Depressive Disorder with Autism Spectrum Disorder by Acceptance and Commitment Therapy Matrix

Autism spectrum disorder (ASD) is known to increase a variety of psychiatric disorders, including major depressive disorder (MDD). Acceptance and commitment therapy (ACT) has been reported to be an effective psychotherapy for MDD. However, this is not the case with ASD. In this case study, based on the hypothesis that it is effective in treating MDD with ASD, we adapted the ACT Matrix, a tool for visualizing an individual's experiences in the context of ACT, and administered 15 sessions to a woman with MDD with ASD following the onset of photo dermatosis. By the end of the final session, there was an increase in value-based behaviors and significant changes in depressive symptoms as well as significant changes in process measures such as experience avoidance, mindfulness, and progress toward a valued life. Six months after the end of the session, the improvement in symptoms was even stronger and the process measure of obstruction to a valued life was significantly improved. The ACT Matrix may thus ameliorate MDD in patients with ASD.

Can psychological flexibility and prosociality mitigate illness perceptions toward COVID-19 on mental health? A cross-sectional study among Hong Kong adults

BACKGROUND

The negative impact of COVID-19 pandemic on public mental health can be persistent and substantial over a long period of time, but little is known regarding what psychological factors or processes can buffer such impact. The present study aimed to examine the mediating roles of coping, psychological flexibility and prosociality in the impacts of perceived illness threats toward COVID-19 on mental health.

METHOD

Five-hundred and fourteen Hong Kong citizens (18 years or above) completed an online survey to measure illness perceptions toward COVID-19, coping, psychological flexibility, prosociality, and mental health, together with their socio-demographic variables. Structural equation modelling was used to explore the explanatory model that was the best-fit to illustrate the relationships between these constructs.

RESULTS

Serial mediation structural equation model showed that only psychological flexibility (unstandardised beta coefficient, β = - 0.12, 95% CI [- 0.20, - 0.02], p = 0.031) and prosociality (unstandardised β = 0.04, 95% CI [0.01, 0.08], p = 0.001) fully mediated the relationship between illness perceptions toward COVID-19 and mental health. In addition, psychological flexibility exerted a direct effect on prosociality (standardised β = 0.22, 95% CI [0.12, 0.32], p < 0.001). This best-fit model explained 62% of the variance of mental health.

CONCLUSIONS

Fostering psychological flexibility and prosocial behaviour may play significant roles in mitigating the adverse effects of COVID-19 and its perceived threats on public mental health.

A systematic review of the use of acceptance and commitment therapy in supporting parents

OBJECTIVES

Acceptance and commitment therapy (ACT) has accrued a growing evidence-base for a wide variety of psychological difficulties. Given that ACT promotes broad and flexible repertoires of behaviour as well as neutralizing the ubiquitous psychological processes theorized to be responsible for much human suffering, such an approach may hold promise. The use of ACT-informed parenting interventions offers another alternative to solely behavioural approaches but it remains relatively understudied and in need of further exploration.

DESIGN

The current systematic review, which searched four databases, aimed to collate all ACT interventions that included parental therapeutic components in the treatment of various child presenting difficulties. The review also rated the methodological rigour of the ACT evidence-base for this type of treatment format.

RESULTS

Twenty-seven individual studies covering a broad spectrum of presenting problems were included, comprising of 1,155 participants. A large proportion of studies were within-group designs with a smaller number using randomized controlled trials. The majority of studies reported improvements on either parent report symptoms regarding child physical or psychological functioning as well as parent-reported measures of stress, depression, and anxiety. Similar improvements were noted on a number of ACT mechanisms of change outcomes, including mindfulness, acceptance, and cognitive fusing. These gains were evident for parents of children with neurodevelopmental disorders, chronic pain, and significant physical health difficulties. Maintenance or further treatment gains were often reported at follow-up. These positive findings are tempered by low levels of methodological rigour common in some of the studies included.

CONCLUSIONS

Despite these limitations, ACT holds promise as a transdiagnostic intervention that can help with the parenting of children with a range of psychological and physical difficulties.

PRACTITIONER POINTS

ACT has accrued a relatively strong evidence base for a range of psychological difficulties. Despite some methodological shortcomings, ACT shows promise as an intervention to help parents manage stress and difficulties especially in relation to children with autism, chronic pain, and physical health needs. Further research is required in comparing ACT to more established treatments and helping consolidate initial positive findings.

Single-Session Acceptance and Commitment Therapy (ACT) Interventions for Patients with Chronic Health Conditions: A Systematic Review and Meta-Analysis

RATIONALE

Chronic health conditions (CHCs) are costly and difficult to manage. Patients often struggle with behavioral adherence to complex treatment regimens and experience psychiatric distress. Acceptance and Commitment Therapy (ACT) is a transdiagnostic behavioral approach that aims to improve functioning and quality of life (QoL), which are important treatment outcomes for this population. Preliminary efficacy of multi-session ACT in patients with CHCs has been demonstrated, and single-session ACT interventions have since been developed to increase feasibility, acceptability, and accessibility. The purpose of this systematic review and meta-analysis was to describe the literature on single-session ACT intervention studies in CHC populations with regards to (1) study design and methodology, (2) patient characteristics and conditions targeted, and (3) efficacy for outcomes across various domains, using narrative and quantitative methods.

METHODS

PsycINFO, PubMed, and Web of Science were systematically searched in August 2020. Studies of single-session ACT interventions in adult patients with CHCs that reported quantitative outcomes in any of the following domains were included: (a) functioning and related domains (e.g., disability, QoL, well-being); (b) mental health; (c) physical health; (d) ACT processes. Both controlled and uncontrolled studies were included. Study quality was assessed using the Psychotherapy Outcome Study Methodology Rating Scale (POMRF). Between-group random effects meta-analysis was conducted on general functioning outcomes.

RESULTS

Fourteen manuscripts reporting outcomes from 13 studies (N = 793) met inclusion criteria. Ten studies were identified by their authors as pilot or feasibility trials. Eight studies used comparison or control groups. Twelve studies delivered the ACT content in workshop format. Studies recruited for a variety of conditions. Narrative review found that between- and within-group effect sizes showed generally positive results favoring single-session ACT overall (69%), especially for measures of functioning and related domains (88%), mental health (67%), and ACT processes (73%). Meta-analysis found that ACT did not significantly outperform comparison groups on measures of general functioning (Hedges' g: -0.51, 95% confidence interval: [-1.19, 0.16]; I 2 = 86%; K = 5) despite a medium-sized pooled effect.

DISCUSSION

Use of single-session ACT interventions in CHC populations is an emergent field. There is preliminary evidence for the acceptability, feasibility, and efficacy of these interventions, which provides support for further testing in fully-powered RCTs. Additional RCTs will enable larger meta-analyses and stronger conclusions about efficacy. Recommendations for future trials are provided.

Effects of mindfulness- and acceptance-based interventions on diabetes distress and glycaemic level in people with type 2 diabetes: Systematic review and meta-analysis

AIM

For people with type 2 diabetes, self management and fear of disease complication often cause psychological distress. Mindfulness and acceptance might be beneficial for reducing diabetes-related distress and glycaemic level. We systematically review the effects of mindfulness- and acceptance-based interventions on diabetes distress and glycaemic level in community-dwelling adults with type 2 diabetes.

METHODS

Seven electronic databases (English and Chinese) were searched comprehensively from inception to June 2020. Data extraction and methodological quality assessment were independently performed by two reviewers using Grading of Recommendations, Assessment, Development and Evaluations criteria.

RESULTS

Nine RCTs (801 participants) examining the effects of acceptance and commitment therapy, mindfulness-based cognitive therapy, mindfulness-based stress reduction and self-directed mindfulness practice were included. In the reviewed RCTs, the majority of participants (mean age: 50-66 years, average disease duration: 4-10 years) had suboptimal diabetes control (HbA_1c >7.0%, 53 mmol/mol). Compared with controls, the interventions significantly reduced diabetes distress (standardised mean difference, SMD = -0.37, 95% confidence intervals, CI: -0.63, -0.12; p < 0.01) and HbA_1c (mean difference, MD = -0.35, 95% CI: -0.67, -0.04; p = 0.03) up to 1-month post-intervention. However, the underpowered studies may have led to overestimation, the interventions for diabetes distress and HbA_1c were heterogeneous.

CONCLUSIONS

Within evidenced-based diabetes education programmes, mindfulness- and acceptance-based approaches may reduce distress and HbA_1c levels and promote self care in people with type 2 diabetes. Further controlled trials are recommended to examine the clinical effectiveness of such programmes for people with type 2 diabetes of diverse clinical, cultural and socio-demographic backgrounds.