Development and evaluation of an 1-day Acceptance and Commitment Therapy workshop for Veterans with comorbid chronic pain, TBI, and psychological distress: Outcomes from a pilot study

Ten Priorities for Research Addressing the Intersections of Brain Injury, Mental Health and Addictions: A Stakeholder-Driven Priority-Setting Study

OBJECTIVES

The purpose of this study was to engage key stakeholders in a health research priority-setting process to identify, prioritize and produce a community-driven list of research questions addressing intersectional issues on mental health and addictions (MHA) in acquired brain injury (ABI).

METHODS

A multiphasic health research priority-setting process was co-designed and executed with community-based stakeholders, including researchers, health professionals, clinicians, service providers, representatives from brain injury associations, policy makers and people with lived experience of ABI and MHA, including patients and their family members. Stakeholders' ideas led to the generation of research questions, which were prioritized at a 1-day workshop.

RESULTS

Fifty-nine stakeholders participated in the priority-setting activity during the workshop, which resulted in a rank-ordered list of the top 10 questions for research addressing the intersections of ABI and MHA. Questions identified touched on several pressing issues (e.g., opioid crisis, homelessness), encompassed multiple subtypes of ABI (e.g., hypoxic-ischaemic, mild traumatic), and involved different domains (e.g., identification, intervention) of health research.

CONCLUSIONS

This community-driven health research priority-setting study identified and prioritized research questions addressing the intersections of ABI and MHA. Researchers and funding agencies should use this list to inform their agendas and address stakeholders' most urgent needs, fostering meaningful improvements to clinical services.

PATIENT OR PUBLIC CONTRIBUTION

An 11-person working group comprised of people with lived experience, service providers, researchers, healthcare professionals and other key stakeholders collaboratively developed and informed the scope, design, methodology and interpretation of this study. Over 50 community-based stakeholders contributed to the research priority-setting activity. One co-author is a person with lived experience.

How completely are randomized controlled trials of non-pharmacological interventions following concussion reported? A systematic review

PURPOSE

The study aimed to examine the reporting completeness of randomized controlled trials (RCTs) of non-pharmacological interventions following concussion.

METHODS

We searched MEDLINE, Embase, PsycInfo, CINAHL, and Web of Science up to May 2022. Two reviewers independently screened studies and assessed reporting completeness using the Template for Intervention Description and Replication (TIDieR), Consensus on Exercise Reporting Template (CERT), and international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) checklists. Additional information was sought my study authors where reporting was incomplete. Risk of bias (ROB) was assessed with the Cochrane ROB-2 Tool. RCTs examining non-pharmacological interventions following concussion.

RESULTS

We included 89 RCTs (n = 53 high ROB) examining 11 different interventions for concussion: sub-symptom threshold aerobic exercise, cervicovestibular therapy, physical/cognitive rest, vision therapy, education, psychotherapy, hyperbaric oxygen therapy, transcranial magnetic stimulation, blue light therapy, osteopathic manipulation, and head/neck cooling. Median scores were: TIDieR 9/12 (75%; interquartile range (IQR) = 5; range: 5-12), CERT 17/19 (89%; IQR = 2; range: 10-19), and i-CONTENT 6/7 (86%; IQR = 1; range: 5-7). Percentage of studies completely reporting all items was TIDieR 35% (31/89), CERT 24% (5/21), and i-CONTENT 10% (2/21). Studies were more completely reported after publication of TIDieR (t87 = 2.08; p = 0.04) and CERT (t19 = 2.72; p = 0.01). Reporting completeness was not strongly associated with journal impact factor (TIDieR: rs = 0.27; p = 0.01; CERT: rs = -0.44; p = 0.06; i-CONTENT: rs = -0.17; p = 0.48) or ROB (TIDieR: rs = 0.11; p = 0.31; CERT: rs = 0.04; p = 0.86; i-CONTENT: rs = 0.12; p = 0.60).

CONCLUSION

RCTs of non-pharmacological interventions following concussion demonstrate moderate to good reporting completeness, but are often missing key components, particularly modifications, motivational strategies, and qualified supervisor. Reporting completeness improved after TIDieR and CERT publication, but publication in highly cited journals and low ROB do not guarantee reporting completeness.

Demystifying the virtualization process: A call for standard reporting of virtual modifications to evidence-based psychotherapies, using the FRAME model

The sudden onset of the coronavirus disease led to a rapid expansion of video telehealth to deliver mental healthcare. Although video telehealth was not a new clinical practice, there was limited guidance on how best to modify evidence-based psychotherapies (EBPs) for virtual delivery (a process also referred to as virtualization). The virtualization process for EBPs remains unclear as newly emerging reports on this topic do not consistently report modification decisions. This commentary calls attention to the need to improve documentation practices to allow a greater understanding of modifications needed to maximize the positive effects of EBPs transported to a virtual format. We used the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to capture details about the nature, process, and outcomes of intervention modifications across a given clinical setting or population. To illustrate the use of the FRAME, we present a case example describing our experiences with transporting a 1-day in-person Acceptance and Commitment Therapy group workshop to a virtual format. Workshop modifications primarily involved changes to the delivery format, administration procedures, and content. The case example walks through how, why, and by whom specific modifications were made as well as the degree to which fidelity was maintained. In the wake of the telemedicine revolution, further investigation into the virtualization process for EBPs is warranted. Improving reporting practices by using the FRAME or a similar adaptation framework will promote a more rigorous study of virtual modifications to EBPs that inform future guidelines and best practices.

The Effectiveness of Interventions for Improving Chronic Pain Symptoms Among People With Mental Illness: A Systematic Review

Chronic pain (CP) and mental illness (MI) are leading causes of years lived with disability and commonly co-occur. However, it remains unclear if available interventions are effective in improving pain outcomes in patients with co-existing CP and MI. This systematic review synthesised evidence for the effectiveness of interventions to improve pain outcomes for people with comorbid CP and clinically diagnosed MI. Ten electronic databases were searched from inception until May 2023. Randomised controlled trials (RCTs) were included if they evaluated interventions for CP-related outcomes among people with comorbid CP and clinically diagnosed MI. Pain-related and mental health outcomes were reported as primary and secondary outcomes, respectively. 26 RCTs (2,311 participants) were included. Four trials evaluated the effectiveness of cognitive-behavioural therapy, 6 mindfulness-based interventions, 1 interpersonal psychotherapy, 5 body-based interventions, 5 multi-component interventions, and 5 examined pharmacological-based interventions. Overall, there was considerable heterogeneity in sample characteristics and interventions, and included studies were generally of poor quality with insufficient trial details being reported. Despite the inconsistency in results, preliminary evidence suggests interventions demonstrating a positive effect on CP may include cognitive-behavioural therapy for patients with depression (with a small to medium effect size) and multi-component intervention for people with substance use disorders (with a small effect size). Despite the high occurrence/burden of CP and MI, there is a relative paucity of RCTs investigating interventions and none in people with severe MI. More rigorously designed RCTs are needed to further support our findings. PERSPECTIVE: This systematic review presents current evidence evaluating interventions for CP-related and MH outcomes for people with comorbid CP and clinically diagnosed MI. Our findings could potentially help clinicians identify the most effective treatments to manage these symptoms for this vulnerable patient group.

Acceptance and commitment therapy for co-occurring gambling disorder and posttraumatic stress disorder in veterans: a narrative review

Background: PTSD and gambling disorder (GD) are frequently comorbid. Gambling may provide escape-based coping for the emotions experienced by PTSD sufferers. Military personnel may be at increased risk of PTSD and/or GD. Acceptance and Commitment Therapy (ACT) has been found to improve both PTSD and GD outcomes, yet research into the potential effectiveness of ACT for PTSD and/GD in veterans is scarce.Objective: This review aimed to systematically assess and describe the evidence relating to the use of ACT and acceptance-based therapy for military populations with PTSD and/or GD.Method: Six databases were searched. Selection criteria included studies that featured the armed forces/military, delivered ACT/acceptance-based therapy, and aimed to improve PTSD and/or GD outcomes. A narrative synthesis approach was adopted.Results: From 1,117 results, 39 studies were fully screened and 14 met inclusion criteria. All studies originated from the USA and 9 were associated with United States Department of Veterans Affairs. Therapy use within each study produced an improvement in PTSD and/or GD, yet only one study examined GD and no studies considered comorbid PTSD/GD. The broad range of study designs made it difficult to compare the findings or make generalisations from the collective results. It is unclear which method of ACT delivery is superior (app-based, telehealth, face-to-face, groups, one-to-one, manualised, or unstructured), or what the true effect size is of ACT for PTSD and/or GD.Conclusions: These preliminary findings are promising, yet more research is needed on the delivery format and content of ACT sessions, and whether findings generalise beyond USA-recruited military samples. The cost-effectiveness of remote-based ACT also warrants investigation.HIGHLIGHTS Among veterans, psychological interventions such as Acceptance and Commitment Therapy (ACT) may be effective for Post-Traumatic Stress Disorder (PTSD) and/or Gambling Disorder (GD).There is a paucity of evidence on ACT approaches for treating PTSD and GD in veterans.Further work is needed on context-specific delivery (in-person vs. group), method of ACT intervention (manualised vs unstructured, digital therapeutics) with non-US samples.

Efficacy and acceptability of mobile application-delivered acceptance and commitment therapy for posttraumatic stress disorder in China: A randomized controlled trial

Due to the COVID-19 pandemic and its extensive effects, the incidence of posttraumatic stress disorder (PTSD) symptoms is rapidly increasing in China. This research aimed to assess the efficacy and acceptability of a mobile application delivering Acceptance and Commitment Therapy (ACT) in reducing PTSD symptoms. 221 Chinese individuals with elevated PTSD symptoms were randomly assigned to app-delivered ACT (ACT condition), app-delivered mindfulness (MI condition), or a waitlist (WL condition). Assessments were performed pre- and post-intervention. The results showed that participants in both the ACT and MI groups had significantly greater improvements across mental health outcomes compared to the WL group. No significant differences were observed between the ACT and MI groups except for psychological flexibility, which improved more in ACT than MI (d = -0.37). Compared to WL, the ACT group showed a greater improvement in PTSD symptoms (d = -0.79), anxiety (d = -0.62), depression (d = -0.51), posttraumatic growth (d = 0.46), and psychological flexibility (d = 0.76). The drop-out rates in the ACT and MI were 25.76% and 39.71%, respectively. Participants in the ACT condition reported medium program satisfaction. The study suggests app-delivered ACT is efficacious in reducing PTSD symptoms and improving overall mental health among Chinese adults.

Changes in State and Trait Anxiety Throughout Concussion Recovery in High School- and College-Aged Individuals

CONTEXT

Researchers have indicated that individuals may experience anxiety symptoms after concussion. A potential mechanism for these presentations is shifts in anxiety throughout recovery.

OBJECTIVE

To examine the levels of state and trait anxiety in individuals after concussion throughout recovery compared with the levels in individuals serving as uninjured matched control participants.

DESIGN

Prospective cohort study.

SETTING

University laboratory.

PATIENTS OR OTHER PARTICIPANTS

Seventy-eight high school- and college-aged individuals (concussion group = 39, age = 18.4 ± 2.3 years; matched control group = 39, age = 18.4 ± 2.3 years) were enrolled.

MAIN OUTCOME MEASURE(S)

The State-Trait Anxiety Inventory was administered within 72 hours of injury (day 0: first test session), 5 days (±1 day) after the first test session (day 5), and at the time of full medical clearance (+2 days). Separate 2 × 3 repeated-measures analyses of variance were used to investigate differences in state and trait anxiety for each group throughout recovery.

RESULTS

State and trait anxiety were higher in the concussion group than in the control group at day 0, day 5, and full medical clearance. For state anxiety, we observed a group × time interaction (F2,150 = 10.45, P < .001, ƞp2 = 0.12). For trait anxiety, we did not note an interaction (F1.74,150 = 1.5, P = .22, ƞp2 = 0.02) but did find main effects for time (F1.74,150 = 25.7, P < .001, ƞp2 = 0.3) and group (F1,75 = 7.23, P = .01, ƞp2 = 0.09).

CONCLUSIONS

Participants with concussion experienced higher levels of state anxiety throughout recovery than matched control individuals. Although trait anxiety was higher in the concussion group and decreased over time, no interaction was seen, demonstrating that concussion may not affect this aspect of personality. Postinjury anxiety may result from increased state anxiety, and clinicians should screen for and manage these symptoms throughout recovery.

Effectiveness of interventions for the improvement of mental health and well-being post-concussion: a systematic review

OBJECTIVE

To identify and assess the effectiveness and quality of interventions targeted at improving mental health, well-being, and psychosocial impairments post-concussion.

DATA SOURCES

EBSCOHost, SPORTSDiscus, PsychINFO, Medline (Web of Science), PubMed, and Embase databases.

REVIEW METHODS

This systematic review is reported in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement in exercise, rehabilitation, sport medicine and sports science (PERSiST). Articles were included if they: (1) were randomized controlled trials or repeated measures pre-posttest study designs, (2) reported mild traumatic brain injury (mTBI) or concussion injury, and (3) evaluated interventions targeting mental health, well-being, and psychosocial impairments post-injury.

RESULTS

Twenty-three studies were included which evaluated interventions targeting mental health, well-being, and psychosocial impairments post-concussion. Interventions included cognitive rehabilitation (n = 7), psychotherapy (n = 7), psychoeducational (n = 3), neurocognitive training (n = 4), neurocognitive training combined with cognitive rehabilitation (n = 1), and psychotherapy combined with cognitive rehabilitation (n = 1). The seven (100%) cognitive rehabilitation intervention studies and four of the five (80%) neurocognitive training intervention studies observed significant improvements in mental health and well-being outcomes.

CONCLUSIONS

Cognitive rehabilitation and neurocognitive training may be the most effective interventions for mental health and well-being impairments post-concussion. Researchers and clinicians should continue to explore the effectiveness of these interventions, specifically in populations most impacted by concussion (i.e. athletes).

An Online Acceptance and Mindfulness Intervention for Chronic Pain in Veterans: Development and Protocol for a Pilot Feasibility Randomized Controlled Trial

BACKGROUND

In the veteran community, chronic pain is particularly prevalent and often debilitating. Until recently, veterans with chronic pain were offered primarily pharmacological intervention options, which rarely suffice and can also have negative health consequences. To better address chronic pain in veterans, the Veterans Health Administration has invested in novel, nonpharmacological behavior interventions that target both pain management and chronic pain-related functional issues. One approach, acceptance and commitment therapy (ACT) for chronic pain, is supported by decades of efficacy evidence for improving pain outcomes; however, ACT can be difficult to obtain owing to issues such as a lack of trained therapists or veterans having difficulty committing to the time and resources needed for the full clinician-led ACT protocol. Given the strong ACT evidence base combined with access limitations, we set out to develop and evaluate Veteran ACT for Chronic Pain (VACT-CP), an online program guided by an embodied conversational agent to improve pain management and functioning.

OBJECTIVE

The aims of this study are to develop, iteratively refine, and then conduct a pilot feasibility randomized controlled trial (RCT) of a VACT-CP group (n=20) versus a waitlist and treatment-as-usual control group (n=20).

METHODS

This research project includes 3 phases. In phase 1, our research team consulted with pain and virtual care experts, developed the preliminary VACT-CP online program, and conducted interviews with providers to obtain their feedback on the intervention. In phase 2, we incorporated feedback from phase 1 into the VACT-CP program and completed initial usability testing with veterans with chronic pain. In phase 3, we are conducting a small pilot feasibility RCT, with the primary outcome being assessment of usability of the VACT-CP system.

RESULTS

This study is currently in phase 3; recruitment for the RCT began in April 2022 and is expected to continue through April 2023. Data collection is expected to be completed by October 2023, with full data analysis completed by late 2023.

CONCLUSIONS

The findings from this research project will provide information on the usability of the VACT-CP intervention, as well as secondary outcomes related to treatment satisfaction, pain outcomes (pain-related daily functioning and pain severity), ACT processes (pain acceptance, behavioral avoidance, and valued living), and mental and physical functioning.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03655132; https://clinicaltrials.gov/ct2/show/NCT03655132.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45887.

The efficacy of acceptance and commitment therapy for chronic pain: A three-level meta-analysis and a trial sequential analysis of randomized controlled trials

The current study included randomized controlled trials (RCTs) to assess the benefits of Acceptance and commitment therapy (ACT) for chronic pain. Searches were conducted in Web of Science, PsycINFO, PubMed, Scopus, Cochrane Library, and Embase from inception until September 30, 2022. Thirty-three RCTs, including 2293 participants, were included. Small to medium effect sizes for pain intensity/physical function favoring ACT were found both at post-treatment (pain intensity: g = 0.44; physical function: g = 0.59) and follow-up (pain intensity: g = 0.34; physical function: g = 0.56). The effect sizes on psychological outcomes were significant at post-treatment (depression: g = 0.43; anxiety: g = 0.43; quality of life: g = 0.45) and follow-up (depression: g = 0.43; anxiety: g = 0.35; quality of life: g = 0.43). The results of the trial sequential analyses indicated that pooled estimates were unlikely to be incidental findings, as effects of multiple testing were controlled and power was adequate. Face-to-face ACT yielded significantly larger effects on physical outcomes than internet-delivered ACT. Participants with chronic headache and fibromyalgia showed greater benefit from ACT compared to those with non-specific pain or mixed pain. In addition, the longer the follow-up duration, the smaller the effect sizes for pain intensity/physical function at follow-up. The present meta-analysis suggests sufficient evidence for the significant benefits of ACT for people with chronic pain.

Efficacy and mechanisms of mobile application-delivered Acceptance and Commitment Therapy for posttraumatic stress disorder in China: Study protocol for a randomized controlled trial

BACKGROUND

As a result of the COVID-19 pandemic and its far-reaching impact, the prevalence of posttraumatic stress disorder (PTSD) symptoms is increasing significantly in China. Yet access to reliable and effective psychological treatment is still limited during the pandemic. The widespread adoption of mobile technologies may provide a new way to address this gap. In this research we will develop an Acceptance and Commitment Therapy (ACT) based intervention delivered by mobile application and will test its usability, efficacy, and mechanism of its effects in relieving PTSD symptoms.

METHODS

A total of 147 Chinese participants with a diagnosis of PTSD according to the Clinician Administered PTSD Scale (CAPS-5) will be randomly assigned to an intervention group (app-delivered ACT), an active comparison group (app-delivered mindfulness), or a waitlist group. Participants in the intervention group or comparison group will use their respective apps for one month. Online self-report questionnaires will be used to assess the primary outcome of PTSD symptoms and the secondary outcomes symptoms of depression, symptoms of anxiety, and posttraumatic growth. The potential mediating variable to be tested is psychological flexibility and its components. These assessments will be conducted at baseline, at five times during treatment, at the end of treatment, and at 1- and 3-month follow-ups.

DISCUSSION

As far as we know, this study is the first randomized controlled trial to investigate the usability, efficacy, and mechanism of an app-delivered ACT intervention for PTSD. Furthermore, the research will assess the effect of treatment in reducing dropout rates, explore effective therapeutic components, and investigate mechanisms of symptom change, which will be valuable in improving the efficacy and usability of PTSD interventions.Trial registration: ChiCTR2200058408.

Exploring the relationships between resilience, mindfulness, and experiential avoidance after the use of a mindfulness- and acceptance-based mobile app for posttraumatic stress disorder

PURPOSE

This study used a mindfulness- and acceptance-based mobile app to examine the relationships between resilience, mindfulness, experiential avoidance, and posttraumatic stress disorder (PTSD) symptoms.

DESIGN AND METHODS

A quasi-experimental pre-posttest, single-group study design was used. A total of 23 college student veterans used the app for 4 weeks. Outcomes of resilience, mindfulness, experiential avoidance, and PTSD were measured at three time-points (baseline, end of Week 2, and end of Week 4).

FINDINGS

All outcomes significantly improved at postintervention. Improvements in resilience and PTSD significantly correlated with improvement in mindfulness.

PRACTICE IMPLICATIONS

Mindfulness- and acceptance-based mobile apps can be safely used by individuals with PTSD as a complementary approach to enhance resilient coping with PTSD.

New generation psychological treatments in chronic pain

Chronic pain conditions are common and have a considerable impact on health and wellbeing. This impact can be reduced by cognitive behavioral therapy (CBT), the most commonly applied psychological approach to chronic pain. At the same time, CBT continues to develop, and now includes what is sometimes called "third wave" CBT. In this review, we examine the evidence for application of acceptance and commitment therapy (ACT), a principal example of this new wave or latest generation of treatment approaches, in people with chronic pain. We identified 25 randomized controlled trials of ACT for adults with chronic pain. Across the included trials, small to large effect sizes favoring ACT were reported for key outcomes including pain interference, disability, depression, and quality of life. Evidence from three studies provided some support for the cost effectiveness of ACT for chronic pain. Evidence also supported the mediating role of theoretically consistent processes of change (psychological flexibility) in relation to treatment outcomes. Investigation of moderators and predictors of outcomes was limited and inconsistent. In future, a greater focus on process based treatments is recommended. This should include continued identification of evidence based processes of change, and research methods more suited to understanding the experience and needs of individual people.

The Process of Learning Mindfulness and Acceptance through the Use of a Mobile App Based on Acceptance and Commitment Therapy: A Grounded Theory Analysis

This study aimed to explore the process of how college student military veterans with posttraumatic stress disorder (PTSD) symptoms learn mindfulness and acceptance through the use of a mobile app based on acceptance and commitment therapy (ACT). Twenty-three college student veterans with PTSD symptoms participated in the 4-week ACT mobile app-based intervention and took part in three weekly semi-structured interviews. Results of the grounded theory data analysis reveal the core category of Mindful Scaffolding, a process indicating how student veterans cope with the interruptions and intrusions associated with learning mindfulness and acceptance through the use of the ACT-based app. The grounded theory provides a foundational theoretical framework for increasing adherence with using mindfulness- and acceptance-based mobile app interventions for PTSD.

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.

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.

Protocol for a Phase Two, Parallel Three-Armed Non-inferiority Randomized Controlled Trial of Acceptance and Commitment Therapy (ACT-Adjust) Comparing Face-to-Face and Video Conferencing Delivery to Individuals With Traumatic Brain Injury Experiencing Psychological Distress

Background: People with traumatic brain injury (TBI) face a range of mental health challenges during the adjustment process post-injury, but access to treatment can be difficult, particularly for those who live in regional and remote regions. eHealth provides the potential to improve access to evidence-based psychological therapy for people with a severe TBI. The aim of the current study is to assess the efficacy of a psychological intervention delivered via video consulting to reduce psychological distress in people with TBI.

Methods: This paper outlines the protocol for a multi-center, three-arm, parallel, non-inferiority randomized controlled trial (RCT) of an evidence-based manualized psychological intervention, ACT-Adjust. ACT-Adjust provides nine sessions for adults with a moderate to severe TBI experiencing clinical levels of psychological distress. Fifty-six participants referred from Brain Injury Rehabilitation Units across New South Wales (NSW) and the NSW icare scheme will be randomly allocated to three conditions; (1) video consulting (VC), (2) face-to-face (FtF) and, (3) a waitlist control (WL).

Discussion: This is the first RCT to evaluate the efficacy of a psychological therapy (ACT-Adjust) delivered via video consulting for individuals with a moderate to severe TBI.

Trial Registration:www.anzctr.org.au, Australian New Zealand Clinical Trials Registry ANZCTRN2619001602112.