Acceptance and commitment therapy for late-life treatment-resistant generalised anxiety disorder: a feasibility study

The effectiveness of the DNA-V program on reducing anxiety among Chinese adolescents: Outcomes of the face-to-face and web-based versions

Many studies have indicated an alarming prevalence of anxiety among Chinese adolescents, highlighting the critical need for prevention protocols. DNA-V (Discoverer, Noticer, Advisor-Values model) is an adapted version of Acceptance and Commitment Therapy designed to prevent mental health problems in adolescents. This study investigated the effects and underlying mechanisms of DNA-V. The DNA-V prevention program was culturally adapted and optimized in both content and form specifically for Chinese adolescents, with the aim of reducing anxiety levels. A total of 139 participants (59 females) from six eighth-grade classes at an average middle school in Beijing were randomly assigned to one of three groups consisting of the DNA-V face-to-face group (two classes), the DNA-V web-based group (two classes), or the active control group (two classes). Adolescents' anxiety and cognitive fusion were measured before (Time 1), immediately after (Time 2), and 2 months after (Time 3) the program using the Chinese Secondary School Students Anxiety Scale (CSSSAS) and Cognitive Fusion Questionnaire (CFQ). Results showed that in the DNA-V face-to-face group, the anxiety score at Time 3 was significantly lower than the scores at Time 1 (p < .001, Cohen's drm = 0.56) and Time 2 (p = .043, Cohen's drm = 0.24). The cognitive fusion score at Time 3 was significantly lower than the scores at Time 1 (p = .001, Cohen's drm = 0.51) and Time 2 (p = .003, Cohen's drm = 0.37). The results of the study suggest that the DNA-V prevention program could serve as an effective tool for reducing anxiety in adolescents.

Cognitive behavioural therapy and third-wave approaches for anxiety and related disorders in older people

BACKGROUND

Cognitive behavioural therapy (CBT) is the most researched psychological therapy for anxiety disorders in adults, and known to be effective in this population. However, it remains unclear whether these results apply to older adults, as most studies include participants between 18 and 55 years of age. This systematic review aims to provide a comprehensive and up-to-date synthesis of the available evidence on CBT and third wave approaches for older adults with anxiety and related disorders.

OBJECTIVES

To assess the effects of Cognitive Behavioural Therapy (CT, BT, CBT and third-wave CBT interventions) on severity of anxiety symptoms compared with minimal management (not providing therapy) for anxiety and related disorders in older adults, aged 55 years or over. To assess the effects of CBT and related therapies on severity of anxiety symptoms compared with other psychological therapies for anxiety and related disorders in older adults, aged 55 years or over.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled studies Register (CCMDCTR), CENTRAL, Ovid MEDLINE, Ovid Embase and Ovid PsycINFO to 21 July 2022. These searches were updated on 2 February 2024. We also searched the international studies registries, including Clinicalstudies.gov and the WHO International Clinical Trials Registry Platform (ICTRP), to identify additional ongoing and unpublished studies. These sources were manually searched for studies up to 12 February 2024.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in older adults (≥ 55 years) with an anxiety disorder, or a related disorder, including obsessive compulsive disorder (OCD), acute stress disorder and post-traumatic stress disorder (PTSD), that compared CBT to either minimal management or an active (non-CBT) psychological therapy. Eligible studies had to have an anxiety-related outcome.

DATA COLLECTION AND ANALYSIS

Several authors independently screened all titles identified by the searches. All full texts were screened for eligibility according to our prespecified selection criteria. Data were extracted and the risk of bias was assessed using the Cochrane tool for RCTs. The certainty of evidence was evaluated using GRADE. Meta-analyses were performed for outcomes with quantitative data from more than one study.

MAIN RESULTS

We included 21 RCTs on 1234 older people allocated to either CBT or control conditions. Ten studies focused on generalised anxiety disorder; others mostly included a mix of clinical diagnoses. Nineteen studies focused on the comparison between CBT and minimal management. Key issues relating to risk of bias were lack of blinding of participants and personnel, and participants dropping out of studies, potentially due to treatment preference and allocation. CBT may result in a small-to-moderate reduction of anxiety post-treatment (SMD -0.51, 95% CI -0.66 to -0.36, low-certainty evidence). However, compared to this benefit with CBT immediately after treatment, at three to six months post-treatment, there was little to no difference between CBT and minimal management (SMD -0.29, 95% CI -0.59 to 0.01, low-certainty evidence). CBT may have little or no effect on clinical recovery/ improvement post-treatment compared to minimal management, but the evidence is very uncertain (RR 1.56, 95% CI 1.20 to 2.03, very low-certainty evidence). Results indicate that five people would need to receive treatment for one additional person to benefit (NNTB = 5). Compared to minimal management, CBT may result in a reduction of comorbid depression symptoms post-treatment (SMD -0.57, 95% CI -0.74 to -0.40, low-certainty evidence). There was no difference in dropout rates post-treatment, although the certainty of the evidence was low (RR 1.19, 95% CI 0.80 to 1.78). Two studies reported adverse events, both of which related to medication in the control groups (very low-certainty evidence, no quantitative estimate). Only two studies compared CBT to other psychological therapies, both of which only included participants with post-traumatic stress disorder. Low-certainty evidence showed no difference in anxiety severity post-treatment and at four to six months post-treatment, symptoms of depression post-treatment, and dropout rates post-treatment. Other outcomes and time points are reported in the results section of the manuscript.

AUTHORS' CONCLUSIONS

CBT may be more effective than minimal management in reducing anxiety and symptoms of worry and depression post-treatment in older adults with anxiety disorders. The evidence is less certain longer-term and for other outcomes including clinical recovery/improvement. There is not enough evidence to determine whether CBT is more effective than alternative psychological therapies for anxiety in older adults.

Psychometric Properties of the Acceptance and Action Questionnaire-II (AAQ-II) in Older Adult Primary Care Patients

OBJECTIVES

Considering that the examination of psychological flexibility measures among older adults is scant, this study explores the psychometric properties of the Acceptance and Action Questionnaire-II (AAQ-II) among outpatient geriatrics primary care clinic patients in a university-affiliated medical center in the Deep South.

METHODS

On average, patients who consented to participate in research (N = 119) were 75.42 (SD = 9.14) years old. Approximately 74% were women, 91% were non-Hispanic white, and 86% lived in urban areas. Measures included psychological inflexibility, subjective health literacy, depression, anxiety, and global cognitive functioning.

RESULTS

The AAQ-II demonstrated adequate internal reliability, Cronbach's α = 0.79, and good test-retest reliability, r(28) = .84, p < .001. With the removal of item 4, confirmatory factor analysis demonstrated adequate construct validity for the use of AAQ-II with older adults. As predicted, the AAQ-II exhibited concurrent, predictive, discriminant, and incremental validity within this older adult sample.

CONCLUSIONS

These results demonstrate meaningful scientific and clinical implications. This is the first study to examine the psychometric properties of the Acceptance and Action Questionnaire-II (AAQ-II) in an older adult sample.

CLINICAL IMPLICATIONS

The AAQ-II is a psychometrically sound measurement that can be clinically used on older adults.

Usability and Acceptability of a Videoconference Program for the Treatment of Depression in Adults With Peripheral Neuropathy

Peripheral neuropathy is a debilitating neurological disorder affecting 13% to 14% of the US population. Estimates for co-occurring mood disorders in individuals with neuropathy range from 30% to 47%, but sparse evidence exists regarding depression treatment for adults with neuropathy. A cognitive-behavioral treatment, Acceptance and commitment therapy, is known to reduce depression in people with chronic pain, but little is known about its effectiveness in adults with neuropathy, particularly when the treatment is provided via videoconference. Acceptability and usability of this therapeutic treatment provided via videoconference was assessed in participants with peripheral neuropathy and symptoms of depression. Participants completed pre- and post-self-report outcome measures: the nine-item depression scale of the Patient Health Questionnaire and the 36-item Short-Form Health Survey. They also completed the Acceptability e-Scale and Post-Study System Usability Questionnaire after treatment. Depression decreased significantly, with scores declining from an average of 9.2 to 5.1 on the Patient Health Questionnaire ( P < .05). The Short-Form Health Survey indicated significant improvement post-treatment on the "Energy/Fatigue" and "Emotional Well Being" subscales. The intervention was rated by participants as acceptable and demonstrated high usability. This initial therapeutic treatment via videoconference offers promise to treat depression in older adults with neuropathy.

Effects of acceptance and commitment therapy on cognitive function: A systematic review

Cognitive function is essential for daily activities. Acceptance and commitment therapy (ACT) may improve cognitive function by enhancing psychological flexibility, but the underlying mechanism is unknown. This systematic review evaluated the effectiveness of ACT on cognitive function. Seven research databases (PubMed, ProQuest Dissertations and Theses, Web of Science, EBSCOhost, CNKI, Scopus, Wanfang) were searched to collect articles with trials published in English and Chinese. After applying inclusion and exclusion criteria, we identified 12 studies published between 1994 and 2022 that included a combined total of 904 participants. Among the included studies were within-group (N = 3) and randomized controlled trial (RCT, N = 9) study designs. Outcome measures included cognitive scales and behavioral measurements. Of the 12 articles, 10 studies showed improvements in certain domains of cognitive function due indirectly to ACT intervention. We found that the ability of ACT intervention to promote psychological flexibility is due to its transdiagnostic nature. Also, the effects of the ACT intervention were observed in multiple cognitive domains: attention, subjective cognitive function, executive function, and memory. In conclusion, cognitive trainers could consider practicing ACT as part of their strategy to enhance an individual's psychological flexibility and cognitive function.

Update on treatments for anxiety-related disorders

PURPOSE OF REVIEW

This review examines recent evidence that informs the treatment of anxiety-related disorders.

RECENT FINDINGS

In addition to selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and benzodiazepines, agomelatine has demonstrated efficacy in treating generalized anxiety disorder (GAD). Other novel products, such as ketamine, psilocybin and cannabidiol, are in the process of gathering evidence in support of the treatment of anxiety disorders. In psychological therapy, various psychological treatments for anxiety disorders, such as mindfulness-based intervention, acceptance and commitment therapy, psychodynamic therapy, emotion-focused therapy and dialectical behavioural therapy, have been tried. Still, most therapies have not proven superior to cognitive behavioural therapy (CBT). In very preliminary findings: Repetitive transcranial magnetic stimulation (rTMS) was effective in GAD; transcranial direct current stimulation (tDCS) was effective for social anxiety disorder (SAD) and GAD and augmented exposure therapy for specific fears. Internet and mobile-based interventions have comparable efficacy to face-to-face therapy.

SUMMARY

Pharmacotherapy of anxiety disorders is expanding to novel products. Despite trying other psychological therapies for anxiety disorders, most therapies were comparable to but not superior to CBT. rTMS and tDCS were also used and show early promise for GAD, but further studies are needed. Most internet or mobile app based psychological therapies were based on CBT, and some can be considered as alternatives to in-person face-to-face therapy.

Psychological flexibility in older adulthood: a scoping review

OBJECTIVES

Psychological flexibility/inflexibility (PF/PI) is a core component of the acceptance and commitment therapy (ACT) model, which is gaining more attention in the geropsychological literature. This scoping review examines the size and scope of the research on PF/PI in older adulthood related to age differences between older adult and younger samples, correlates relevant to psychological health, and changes with ACT.

METHODS

A systematic literature search was conducted using PubMed, CINAHL, and PsycINFO. Peer-reviewed articles available in English were included that: had a mean age ≥65 and a minimum age ≥60; and reported self-report measures of PF/PI. We categorized PF/PI into three domains: open, aware, and engaged.

RESULTS

Forty-six articles were included. Most studies measured open or aware domains; few measured the engaged domain. Older adults evidenced greater awareness compared to younger adults (9 of 13 analyses were significant). Openness and awareness consistently yielded medium to large correlations with anxiety and depression. PF/PI did not relate with positive affect and inconsistently correlated with quality of life measures.

CONCLUSION

Despite emerging trends, variability and limitations were evident in the literature. Specifically, measurement issues, lack of conceptual clarity, and the omission of values and behavioral measures require future attention.

Internet-delivered guided self-help acceptance and commitment therapy for family carers of people with dementia (iACT4CARERS): a feasibility study

OBJECTIVES

The feasibility of research into internet-delivered guided self-help Acceptance and Commitment Therapy (ACT) for family carers of people with dementia is not known. This study assessed this in an uncontrolled feasibility study.

METHOD

Family carers of people with dementia with mild to moderate anxiety or depression were recruited from primary and secondary healthcare services in the UK. Participants were offered eight, guided, self-help online ACT sessions adapted for the needs of family carers of people with dementia with optional online peer support groups. Pre-defined primary indicators of success included recruitment of 30 eligible carers over 6 months and ≥70% completing at least two online sessions.

RESULTS

Thirty-three participants (110% of the target sample) were recruited over 6 months and 30 participants (91%) completed two or more sessions, and thus both indicators of success were met. Further, 70% of participants completed seven or all eight sessions, and 27% of participants were lost to follow-up, but none of the reasons for early withdrawal were related to the intervention.

CONCLUSION

This study supports the feasibility, including recruitment and treatment completion. A full-scale trial to assess the clinical- and cost-effectiveness of the intervention including its long-term effects is warranted.

The effectiveness of mindfulness-based meditation treatments for late life anxiety: a systematic review of randomized controlled trials

OBJECTIVE

Older adults are interested in mindfulness-based interventions with a meditation component for late life anxiety. This review examined the effectiveness of existing mindfulness-based interventions with a meditation component.

METHODS

This systematic review was registered with the Joanna Briggs Institute on 2021-05-17, was guided by Joanna Briggs Institute methodology and followed the PRISMA framework. Peer-reviewed randomized control trials were reviewed. A systematic literature search was conducted, using the following databases: MEDLINE (Ovid), Embase, Cochrane Database of Systematic Reviews, PsycINFO, CINAHL (EBSCO), and AMED.

RESULTS

Of 2709 studies screened, seven eligible randomized controlled trials were included representing 355 participants. Sample sizes ranged from 36 to 141. Mindfulness-based meditation interventions used varied. Regardless of the mindfulness-based meditation intervention used, a reduction in symptoms of anxiety in participants was reported post-intervention. Results are reported through narrative summary and tables.

CONCLUSIONS

Based on the emerging literature of randomized controlled trials, mindfulness-based interventions with a meditation component appear to be promising in reducing symptoms of anxiety in older adults. These findings demonstrate a need for further randomized controlled trials to guide clinical practice.

Thinking of Me or Thinking of You? Behavioral Correlates of Self vs. Other Centered Worry and Reappraisal in Late-Life

Psychotherapeutic approaches in late-life anxiety have limited effect on reducing worry severity. The self-referential processing of worry contents (self- vs. other-focused worry) and reappraisal styles (internal vs. external locus of control) are important elements in psychotherapy, but little is known about these processes in late-life. We aimed to characterize severe worry from a self-referential processing perspective. We recruited 104 older adults with various levels of worry and used a personalized task to induce and reappraise worry. We analyzed the association between (1) worry severity/frequency for worry content (self- or other-focused) and (2) for reappraisal style (internal vs. external locus of control) with clinical inventories measuring anxiety, worry, depression, rumination, neuroticism, emotion regulation strategies, perceived stress, and physical illness burden. Higher self-worry severity was associated with higher scores of clinical inventories of worry, depression, perceived stress, and neuroticism, whereas other-worry severity did not show any association. Greater self-worry frequency was associated with higher medical burden. External locus of control in reappraisal statements was associated with lower worry severity in men. Overall, more severe and frequent self-focused worry was associated with a greater psychological and physiological burden. These results are useful in tailoring psychotherapy for older adults with severe worry.

Is acceptance and commitment therapy helpful in reducing anxiety symptomatology in people aged 65 or over? A systematic review

Anxiety-related mental health problems constitute a health challenge, especially in the elderly population. At present, there are few psychological treatments to reduce anxiety adapted to this group. The aim of this study was to conduct a systematic review of the literature to determine the therapeutic effects of Acceptance and Commitment Therapy (ACT) on anxiety in older adults, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Two blinded reviewers participated in the search, selection and methodological quality assessment processes; reaching satisfactory levels of agreement between reviewers (κ > 0.70). The search was performed in PubMed, Proquest Central, Scopus and Web of Science; making use of standardized terms for the construction of the algorithm. In the general search 348 studies were found. After applying the eligibility criteria and excluding duplicates, seven articles were extracted for qualitative analysis. The total number of subjects was 633, with an average age of 68.89 years (68.94% women). The analysis of methodological rigor showed moderate indices on average. The publications focused primarily on samples with a diagnosis of generalized anxiety disorder, proposing a variety of assessment tests for related dependent variables, especially depressive symptoms and psychological flexibility. Critical analysis of the findings provides evidence for the efficacy of ACT in reducing anxious and depressive symptoms in older adults. This study proposes the use of this procedure as a non-pharmacological alternative for a group usually underrepresented in the scientific literature on this topic.

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.