Acceptance and Commitment Training: A BRIEF THERAPEUTIC APPROACH FOR DEPRESSION AND DISABILITY IN MEDICAL SETTINGS LILIAN DINDO, PH.D. I O W A P S Y C H O L O G I C A L A S S O C I AT I O N APRIL 2015 ACKNOWLEDGEMENTS NO DISCLOSURES Co-Investigators/Collaborators/Mentors James Marchman, PhD Jess Fiedorowicz, MD Ana Recober, MD Funding NIH KL2RR024980 NCCR UL1RR024979 Carolyn Turvey, PhD Mike O’Hara, PhD Chronic Medical Conditions Often require active participation in one’s care Making significant changes to one’s lifestyle eating healthfully exercising regularly self-monitoring of blood glucose Adhering to treatment recommendations that might be challenging taking medications correctly Co-Occurrence of Depression & Anxiety Adherence become even more difficult when there is co- occurring depression or anxiety Interfere with motivation and drive Inflammation 20% of patients with chronic medical conditions suffer from major depressive or anxiety disorders Comorbidity adversely impacts quality of life, prognosis, and is associated with shortened life expectancy The causal relationship between medical and psychiatric conditions bidirectional. Why Target Distress In Medical Populations Highly prevalent Underdiagnosed & undertreated Lead to worse outcomes Economic burden of medical problem 2-4x when there is depression Negative Affect States Detrimental impact of depression and anxiety seen with other negative affect states: • Anger/hostility • Neuroticism/negative affectivity • Social inhibition • Type A Personality • Psychosocial distress A question….. If we are to implement psychological treatment… What would we want to treat? Coping strategies The way one copes with chronic illness and associated stress long-term effects Cognitive and behavioral avoidant coping strategies: avoiding reminders related to the medical condition, distraction techniques, mental disengagement, denial associated with poorer psychological and health outcomes Interventions that counter avoidance and encourage engagement in important activities improve health outcomes Example from Chronic Pain Natural response to pain: to resist and avoid pain and suffering “Its important to keep fighting this pain.” 92% of CP patients endorsed as “Always True” or “Almost Always True” (McCracken, Vowles, & Eccleston, 2004, Pain) However, struggling to change something that is uncontrollable/intractable leads to more harm than good. Pain and Disability Relationship between pain intensity and functioning: weak Pain (including migraine pain) does not per se lead to depression or impairment. Problems: Struggle with pain Preoccupation with avoiding unpleasant experiences (i.e., pain, fatigue, activities, places) Adaptive/reinforcing in short-term Long term decrease functioning, QOL (w/o decease in symptoms) depression The Impact of Frequent Struggling Struggling is best predictor of: Worse Pain Poorer Activity Greater Disability Worse Depression Greater Avoidance Attempt to suppress pain tends to increase it (Cioffi & Holloway, 1993) McCracken, Eccleston & Bell, 2005, Eur J Pain McCracken, Vowles, & Gauntlett-Gilbert, 2007, J Behavioral Medicine Vowles & McCracken, 2011 Pain Acceptance Acceptance-based coping associated with: less distress across chronic medical conditions reduced psychopathology enhanced physical and social functioning ↑ levels of pain-related acceptance (willingness): ↓ levels of catastrophizing , ↓ pain-related interference ↓ avoidance ↑ increased perceived control, ↑ Pain Tolerance, ↑ engagement in activities Unified Approach To Treat Comorbidity ACT provides a unified model of behaviour change applicable to human beings in general Transdiagnostic By targeting 6 core psychological processes that are related to diverse unhealthy behaviors. Acceptance/Mindfulness & Behavioral Change Evidence Supporting ACT August 2014: 104 ACT RCT’s N= 8,636 (avg: 84) 100 80 60 40 20 0 1985 1990 1995 2000 2005 2010 2014 First Author Problem Comparison Measure N Sessions Post F-up Processes Zettle (1986) Depression CT BDI 18 12 1.23 .92 (8) ATQ-B* Zettle (1989) Lappalainen (2007) Depression CT BDI 21 12 0.53 .75 (8) ATQ-B* Anx-Depr CBT SCL-90 28 10 0.62 .47 (24) AAQ Forman (2007) Anx-Depr CT GAF 101 15 0.08 Twohig (2006) OCD MBL OCI Distress 4 8 3.08 4.63 (12) AAQ Twohig (2007) OCD Relaxation Y-BOCS 34 8 ? ? (12) AAQ* Block (2002) Social Anxiety CBT Public speaking 26 6 0.49 --- Willingness Ossman (2006) Social Phobia --- SPAI-DIFF 12 10 0.86 --- AAQ, VLQ Dalrymple (2006) Social Phobia --- SPAI-SP 16 12 1.05 1.41 (12) AAQ* Kocovski (2009) Social Phobia --- LSAS 29 12 1 1 (12) --- Roemer (2007) GAD --- GAD-CSR 16 16 2.42 1.93 (12) Accep. and Roemer (2008) GAD Wait-list GAD-CSR 31 16 2.97 2.34 (36) values* Zettle (2003) Montesinos (2006) Math Anxiety S. Desens. Math anxiety 18 6 -0.55 - .12 (8) Initial AAQ Worries Control Fear Interference 20 1 0.33 1.38 (6) AAQ Twohig (2004) Trichotillomania MLB MGH-HS 6 7 30.5 2.91 (12) AAQ Woods (2006) Trichotillomania Wait List MGH-HS 25 10 2.22 .98 (12) AAQ Twohig (2006) Skin Picking MBL Skin picking 5 8 2.81 1.64 (12) AAQ Bach (2002) Psychotic S. TAU Rehospitalization 70 4 --- .45 (16) Believability Gaudiano (2006) Psychotic S. ETAU BPRS 29 3 1.19 --- Believability* Gratz (2006) BPD TAU DSHI 22 14 1.01 --- --- Hayes (2004) Poliadiction M. Methad. Analitic 51 48 0.41 .95 (24) ATQ-B Twohig (2007) Marijuana MLB Self-report 3 8 --- --- --- Gomez (subm.) Antisocial Beh. --- self-control 5 12 h. 1.29 --- --- Luciano (2009) High risk adol. --- Prob. behaviors 8 5 1.55 1.1 (16) Acceptance AAQ, KIMS First Author Dahl (2004) Greco (submitted) McCracken (2005) Wicksell (2006) McCracken (2007) Vowles (2007) Vowles (2008) Vowles (2009) Vowles (2009) Wicksell (2008) Wicksell (2009) Gifford (2004) Hernandez Lopez (2009) Gregg (2007) Lundgren (2007) Lundren (2008) Sanchez (2006) Branstetter (2004) Montesinos (2005) Paez (2007) Fernandez (subm.) Gutierrez (2006) Lillis (2009) Tapper (2009) Forman (2009) Quirosa (2009) Hesser (2009) Problem Comparison Measure Chronic pain Chronic pain Chronic pain Chronic pain Chronic pain Chronic pain Chronic pain Chronic pain Chronic pain Chronic pain Chronic pain Smoking TAU ----------------Wait-list TAU Nicotine Repl. Smoking CBT Abstinence Diabetes Epilepsy Epilepsy Multiple sclerosis Psychoed. Placcebo att. --- N Sessions Post F-up weeks Processes 4 12-14 3-4 weeks 16 3 weeks 3-4 weeks 3-4 weeks 8 4 10 10 14 1.17 1.28 .95 1.25 .75 .49 .65 1.28 .77 .96 .53 .06 1.0 (24) 1.48 (4) .61 (12) 2.11 --.47 .56 (12) ----.68 (16) .38 (26) .57 (48) ----CPAQ ----CPAQ ----------Smoking AAQ* 81 7 .46 .58 (48) --- HbA1C Seizures Seizures 78 27 9 7 h. 9 h. 12 h. --1.43 --- .15 (12) 1.23 1.3 (48) Diabetes AAQ* Epilepsy AAQ* --- TAU Valued areas 7 4 ? ? --- Cancer CBT Distress 31 12 .9 --- Mental disengagement* Cancer Wait-list 12 1 --- 2.53 (12) --- Cancer CBT 12 8 .53 1.78 (48) --- Postsurgical TAU 13 1 1.42 --- --- HIV prevention Obesity stigma Weight loss Weight loss Lupus Tinnitus Information Control Control --Wait-list --- 45 84 47 29 17 19 1 6 h. 8 h. 12 11 h. 10 ? ----.42 ---- ? (24) 1.07 (12) .20 (24) .58 (24) -- (24) .91 (24) --Weight AAQ* Binge eating* Food AAQ --Defusion & acceptance Sick days 19 FDI 15 Pain intensity 108 Pain intensity 15 Pain intensity 54 Pain intensity 252 Pain intensity 114 MGPQ 11 MGPQ 11 PDI 21 Pain intensity 32 Abstinence 62 Worries interf Valued areas Days recovery Risk HIV WSQ BMI Bodily mass ? Distress First Author Problem Comparison Measure N Sessions Post F-up Processes Canoeing Hypnosis Strength rowing 16 3 ? ? --- Ruiz (subm.) Chess performance Control ELO performance 10 4 h. --- .79 (28) Chess AAQ Ruiz (2009) Chess performance Control ELO performance 14 4 h. --- .52 (36) Chess AAQ Bond (2000) Worksite stress IPP GHQ-12 60 9 h. .8 .72 AAQ* Bond (2000) Blackedge (2006) Worksite stress Wait list GHQ-12 60 9 h. .72 .7 AAQ* Parents autism children --- GSI 20 14 h. 1.8 .81 (12) ATQ-B Hayes (2004) Stigma & Burnout Biological ed. MBI 64 6 h. .74 .61 (12) SAB* Hayes (2004) Stigma & Burnout Multicultural T. MBI 59 6 h. .26 .57 (12) SAB* Masuda (2007) Stigma (high AAQ) Education CAMI 24 2.5 h. .80 .88 (4) --- Masuda (2007) Stigma (mid AAQ) Education CAMI 61 2.5 h. -.13 -.37 (4) --- Luoma (2008) Adiction Stigma --- ISS 48 6 h. .66 --- AAQ Lillis (2007) Racial prejudice Education PBADAQ 32 1 ? ? (1) Acceptance* 57 6 h. --- 1.03 (12) AAQ & believability* 30 8 --- 1.45 (16) --- Fernandez (2004) Varra (2008) Luoma (2007) Use validated treatments Use validated treatments Education Control Use of treatments Use of treatments Research Support for ACT Research support American Psychological Assoc. ACT listed as Empirically supported treatment for depression, mixed anxiety, chronic pain, psychosis, and OCD. SAHMSHA ACT Listed on Nat’l Registry of Evidence-Based Programs and Practice Has shown preliminary efficacy as a 1-day treatment Why 1 Day? Why Group Workshop? Ensures treatment adherence and completion NIMH: Deployment Focused Interventions Research Pragmatic Clinical Trials (PCTs) More suitable for patients not presenting for psychiatric care Implemented more easily in primary care Less stigmatizing/threatening More accessible/feasible for: rural patients (1/4 US; ½ Iowa) functionally impaired individuals Cost effective Acceptance and Commitment Therapy (ACT) Incorporates acceptance and mindfulness strategies with behavioral change techniques. Promotes acceptance of what cannot be directly changed (private experiences such as thoughts, emotions, bodily sensations, pain) Thought & Emotion Suppression Literature (e.g., Wegner) Engagement in previously avoided situations Discussion of values and valued-based action Goal of ACT Goal is psychological flexibility Changing/Persisting in behavior in the service of important goals or values Awareness and willingness to experience unpleasant or unwanted internal stimuli Goal is not symptom reduction This is often a by-product ACT – Basic Principles We get to choose our actions – where we go, what we do with our hands and feet, what comes out of our mouth. We have relatively little choice about the memories, feelings (including pain), or thoughts that show up in a situation. So the most effective way to change our lives is to focus on changing our actions and learning new ways to deal with troubling memories, thoughts, and feelings ACT Principles: DO NOT HAVE TO WAIT TO FEEL BETTER BEFORE DOING SOMETHING I can do something I don’t want to do because doing it is important I can not do something I want to do because not doing it is important Work in Therapy: always placed within context of individual values Fairy Tales... What do they tell us? Myth 1: Happiness is the natural state of all humans Myth 2: If you’re not happy you’re defective Myth 3: To create a better life, we must get rid of negative feelings and thoughts Myth 4: You should be able to control what you think & feel. The Model Contact with the Present Moment Acceptance Values Psychological Flexibility Defusion Committed Action Self as Context Contact with the Present Moment Be here now Acceptance Values Know what matters Open up Open Psychological Flexibility Aware Defusion Active Committed Action Watch your thinking Do what works Self as Context Perspective Taking Contact with the Present Moment Be here now Acceptance Values Know what matters Open up Open Psychological Flexibility Defusion Committed Action Watch your thinking Do what works Self as Context Perspective Taking Acceptance and Defusion Acceptance/Willingness Alternative to Control/Struggle: Acceptance Imagine you are stuck in quicksand. What is your first reaction? Pain versus Suffering PAIN SUFFERING PAIN SUFFERING MORE SUFFERING PAIN = Physical Sensations of Headache SUFFERING = “THIS IS AWFUL; I CAN’T BEAR THIS” PAIN = Physical Sensations of Anxiety SUFFERING = “This is awful” Experience of distress exacerbated + person feels they have to do something to avoid this feeling. Pain and Suffering Pain + Non-Acceptance (struggling) Pain + Acceptance Suffering Pain Steps to Acceptance Ask yourself: What thoughts, feelings and sensations are you willing have to complete a goal? Step 1: Observe Notice what you are feeling and where. Look for the sensation that is bothering you the most. Focus your attention on it and observe it with curiosity Step 2: Breathe Breathe slowly and deeply. Imagine you are breathing directly into the sensation, making room for it. This won’t remove the feelings, but it will create a center of calm within you. Steps to Acceptance Step 3: Expand Make room for those feelings. Create some space for them. Step 4: Allow Allow the sensations to be there with you, even if you don’t want or like them. Acknowledge the thoughts and sensations, as if nodding to them, without giving into them. Imagine you’re walking in the rain Cognitive Fusion Thoughts are: Reality, the truth, important, orders, wise. When a thought, belief, or story organizes a person’s behavior in a limiting and unhelpful way Fusion with thoughts limits one’s ability to be present and flexibly responsive Identifying Fusion Rules (e.g., shoulds, must) Reasons (e.g., I’m too busy, tired, etc.) Judgments (e.g. I’m bad, anxiety is awful) Past (rumination) Future (worry) Self (e.g., I am weak, I can’t cope, I don’t need help) Fusion Defusion Defusion is the act of responding flexibly to thoughts, beliefs, conceptions, assumptions, and stories as thoughts, beliefs, conceptions, assumptions, and stories rather than taking them literally as truths that must guide one’s actions. It is discriminating between the product (words or thoughts) and the process (generating thoughts). Defusion Defusion does not aim to change content of thoughts. Aims to change the way one relates to their thoughts. (not getting rid of…changing relationship to…) Seeing our thoughts vs. being our thoughts Defusion Cues Able to let go of being right / looking good Disentangles from stories and reasons in the interest of effective action Evaluates thoughts primarily on the basis of workability rather than “truth” in a literal sense Thinking seems open, penetrable, and flexible Contact with the Present Moment Be here now Acceptance Values Know what matters Open up Psychological Flexibility Aware Defusion Committed Action Watch your thinking Do what works Self as Context Perspective Taking Present Moment Awareness Living Life While Paying Attention Being present promotes vitality, creativity and spontaneity. “How much do you find yourself thinking about the past or the future?” Flexible attention/focus, or ability to effectively shift focus of attention Skiing Metaphor: Adventure is in the journey, not the destination. How you get there matters. Mindfulness “What day is it?” “It’s today,” squeaked Piglet. “My favorite day,” said Pooh. -A.A. Milne Awareness Distant Past Recent past Present Moment Near Future Distant Future Question: What percentage of time were your thoughts simply in “Present Moment?” Question: Which place on the timeline do you notice that you tend to ‘visit’ when you are not simply in the “Present Moment?” Strosahl, Robinson, Gould Perspective Taking Perspective Taking requires…. o Ability to “step back” and become an observer of events. o Ability to imagine the point of view of someone else You are the SKY, not the CLOUDS ...JI , ,/J;( ...... I. Perspective-Taking Perspective-Taking Things change over time – this includes your body, your thoughts and your feelings. Changes will happen, due to the passage of time, gaining experience, and knowledge. When you think back in time, was there something you once thought was too hard, or too scary, yet now you do it? Can you think of anything you used to see one way, but now see another? Did this change just happen through time? Or did you do something, take some action? Perspective-Taking Think of a current situation you are struggling with: How would another person possibly see it? How would a younger/older version of you see it? How would a version of you who isn’t struggling with it anymore see it? What actions would each of these people be able to take? Contact with the Present Moment Be here now Acceptance Values Open up Know what matters Psychological Flexibility Defusion Active Committed Action Watch your thinking Do what works Self as Context Perspective Taking Values: The key question How do you want to live your life? Values Your heart’s deepest desires for how you want to behave as a human being. How you want to act on an ongoing basis. Questions: Deep down, what is most important to you? What sort of relationships do you want to build- with others and with yourself? If you could live your life, in any way you wanted, how would you be living it? In a world, where it could be about anything, what do you want your life to be about? Values Imagine you are 80 Years old and you have continued to live your life exactly as you do now: I spent too much time worrying about…. I spent too little time doing things such as ….. If I could go back in time, what I would do differently from today onward is…. Values-Based ACTions Actions directed towards personally meaningful purposes, rather than towards the elimination of unwanted experiences Step 1: Summarize your values Step 2: Set an immediate goal Step 3: Set a medium-range goals Step 4: Set a long-term goals “The Journey of 1,000 miles Begins with a Single Step” ~ Lao-tzu Values-Based Goals Don’t want “Dead Man Goals” Chocolate, Depressed, Panic attacks Living Person Goals So let’s suppose that happens, what would you do differently? Do more of? How would you behave different towards friends/family? If you weren’t yelling at your kids, how would you be interacting with them? If you weren’t having panic attacks, what would you be doing differently with your life? Magic Wand No longer a problem for you… Committed ACTion: Doing What Matters Activity Go out to eat with mom w/w/w/w Obstacles Call mom from home May forget to call on Monday at 6pm to see if she wants to go out for dinner this She might not have time this week week. Solutions to Obstacles Outcome Write a note to remind self to call Went out to dinner with mom on Wednesday night. If mom is busy this week, suggest lunch or dinner next week THE WORLD INSIDE / YOUR MIND Depression/Migraine Study Comorbid Migraine/Depression Depression 3-5 x more common in migraine than in general population. Decreased QOL, worse prognosis, increased risk for suicidality, medication overuse, and disability. Comorbid Migraine and Depression Study Quasi-randomized treatment trial Goals: 1. Evaluate the efficacy of 1-day ACT intervention, compared to TAU on: Depression General functioning. Migraine-related disability Headache 2. Examine process variables associated with depression and disability 2-Step Screening Online via web survey or by phone 4-12 Migraines in Previous Month 3 > ID Migraine: PPV 93.3%. False positive rate 19%. 10 > PHQ-8 Exclusion: Patients with serious psychiatric illness, brain injury leading to headache, new medication in previous 4 weeks. Intake Assessment (in-person) Interview to Confirm Presence of Depression: SCID Depression Module HAM-D (>17) Self-Report Inventory of Depression and Anxiety Symptoms (IDAS) World Health Organization Disability Assessment Schedule (WHO-DAS) Headache Disability Inventory (HDI) Process Measures Chronic Pain Acceptance Questionnaire Chronic Pain Values Inventory Participant Flow Screened for Eligibility N= 1284 Eligible at Screening N = 173 Enrolled (full intake) N = 93 Excluded (N=33) •Didn’t meet inclusion criteria (22) •Hospitalized/Suicidal (2) •Not interested (9) ACT-IM (N=38) Wait List (N=22) Week 2: N=37 Week 6: N=36 Week 12: N=37 9-Month: N=32 1-year: N=26 Week 2: N=22 Week 6: N=21 Week 12: N=21 9-Month: N=8 1-Year: N=6 Attended workshop = 7 Intervention 9:30 am – 3:30 pm on a Saturday 6-10 participants of all ages 5 Hours Acceptance and Commitment Training 1 hour of Illness Management Structured Clinical Interview for DSM Disorders (SCID) at 12-Week Follow-Up Major Depression No Yes Condition ACT-IM WL N= 60 29 2 9 19 Fisher’s Exact: p<.0001 Number Needed to Treat: =1.5 (Dindo et al., 2012) Hamilton Depression Rating Scale (HAM-D) Diff btwn Baseline and Wk 12 Mean (SD) Trt: 14.0 (1.5) WL: 4.7 (2.0) Mixed Model Condition F=.69, p=.40 Time F= 59.26, p < .01 Time * Condition F=14.71, p <.01 Effect Size= 1.0 (Dindo et al. 2012) IDAS: General Depression Diff Btwn Baseline and Wk 12 Mean (SD) Trt: 15.1 (2.1) WL: 6.1 (2.8) Mixed Model With 4 Time Points Condition F=11.16, p <.001 Time F=19.2, p < .001 Condition * Time F=2.96, p < .05 Effect Size= .71 Headache Disability Inventory Diff Btwn Baseline and Wk 12 Mean (SD) Trt: 25.1 (2.9) WL: 10.3 (3.8) Mixed Model With 3 Time Points Condition F=1.42, p = .22 Time F=27.92, p < .01 Condition * Time F=4.88, p<.01 Effect Size= .84 (Dindo et al. 2012) HAM-D: Recovery Rate 70% 66% GLIMMIX For Binary Variables (not normally distributed) 65% ACT-IM 60% 60% WL/TAU 50% 40% 33% 30% 36% 24% 20% Model Condition F=11.25, p <.01 Time F=.39, p = .67 Condition * Time F= .45, p =.64 ODDS RATIO 3Mo: 6.2 (1.3-28.8) ** 9Mo: 2.5 (.44-13.8) 12Mo: 4.8 (.5-45) * 10% (not depressed) 0% 3-Mo 9-Mo 12-Mo Results: Headaches Example of Headache Diary Sheet Headache (yes/no) Severity 1,2, or 3 (see below) Medication taken, if any Effect of medication Disability Work Leisure 1,2,3,or 4(see below) 1 2 3 4 5 6 7 8 9 Saw a healthcare provider? Y/N Headache Frequency Headache Severity (Dindo et al., 2014) Leisure Disability and Work Disability (Dindo et al., 2014) Medication Usage & Visits to Healthcare Provider Dindo et al., 2014 Role of Pain Acceptance & Values-Based Behavior in Prediction of Depression/Disability N=93 SCID Diagnosis of MDD Depressed Non-Depressed Mean (SD) Mean (SD) t-test Effect Size Pain Acceptance 57.05 (16.3) 73.8 (14.2) t=4.1 (p<.01) d=1.05 Values-Based Behavior 2.40 (.81) 3.25 (.76) t=3.8 (p<.01) d=1.05 Headache Disability 67.43 (18.8) 48.4 (19.7) t=3.6 (p<.01) d=1.0 WHO-DAS 35.7 (14.2) 20 (14.5) t=3.9 (p=<.01) d=1.1 (Dindo et al., 2014) Hierarchical Regression Analyses Δr2 Predictors R2 Headache Disability Inventory (HDI) 1. Depression (Self Report) 2. Pain Acceptance .22** .20** .42** 1. HRSD 2. Pain Acceptance .15* .25** .40** WHO-Disability Assessment Schedule (WHO-DAS) 1. Depression (Self Report) 2. Pain Acceptance .38** .10** .48** 1. HRSD 2. Pain Acceptance .24** .16** .40** (Dindo et al., 2014) Chronic Pain Acceptance Questionnaire 1. 2. 3. 4. 5. 6. Keeping my pain level under control takes first priority whenever I’m doing something. Before I can make any serious plans, I have to get some control over my pain. I avoid putting myself in situations where my pain might increase. My worries and fears about what pain will do to me are true. I need to concentrate on getting rid of my pain. I lead a full life even though I have chronic pain. Conclusions 1-day group treatment of ACT-IM can reduce depressive symptoms and headache frequency, and improve functioning. Targeting pain-acceptance may be particularly important Primary Care Effectiveness Study Vascular Disease/Mood Comorbidity World Mental Health Surveys: Risk of heart disease double in those with mood disorders (major depression and dysthymia). Ormel J et al. Gen Hosp Psych 2007. Primary Care Patient Study Randomized treatment trial for patients with High Cholesterol, Diabetes, Hypertension, Obesity, Heart Attack, Stroke, Metabolic Syndrome Depression or Anxiety (10 > PHQ-8 or GAD-7) Goals Establish Feasibility/Acceptability of Treatment, Randomization. Evaluate impact of 1-day ACT intervention on: Primary: Quality of Life/Functioning Secondary: Depression and Anxiety Completed Screening (N=827) Enrollment Excluded (n=685) •Low PHQ/GAD (n=635) •New Med (n=28) •No Vascular Risk Factor(n=22) Eligible at screening (N=142) Initial Assessment (N=47) Not scheduled (n=95) •Could not reach (n=58) •Declined (n=22) •Could not make workshop date Ineligible(n=15) after first interview (n=3) • No vascular risk factor (n=1) • Active Suicidal Ideation (n=1) • TBI (n=1) Follow-Up Allocation Randomized (N=44) ACT/IM (N=30) TAU/WL (N=14) Intent to Treat (N=4) Attended Workshop (N=26) Week 2: (n=26) Week 6: (n=26) Week 12: (n=26) Week 24: (n=26) Did not Attend Workshop Week 2: (n=3) Week 6: (n=3) Week 12: (n=3) Week 24: (n=3) Week 2: (n=14) Week 6: (n=14) Week 12: (n=14) Week 24: (n=13) Demographic Variables ACT-IM TAU (N=26) (N=14) 45.0 (11.4) 45.7 (13.1) Gender, N(%) female 18 (69%) 9 (64%) Race/Ethnicity, % Caucasian, Not Hispanic 18 (69%) 12 (86%) Education, % completed college 18 (69%) 10 (71%) Working or in school, % yes 22 (85%) 10 (71%) Currently on an antidepressant medication 12 (46%) 9 (64%) Age (mean/SD) Note. ACT-IM = Acceptance and Commitment Training plus Illness Management; TAU = Treatment as Usual. Hamilton Rating Scale for Depression Diff btwn Baseline and Wk 24 Mean (SD) Trt: 11.7(1.4) WL: 0.8 (2.0) HRSD Score 20 15 Mixed Model Time * Condition F=9.4, p <.01 10 ACT-IM Effect Size= 1.4 TAU 5 Baseline 12-Week FU 24-Week FU Time at Follow-Up % of participants with > 50% drop on HAM-D HAM-D: Recovery Rate at 24-wk 90% Recovery: Dropped 50% or more in score. 80% 70% 60% 50% 77% in ACT-IM 21% in TAU 40% 30% 20% χ2= 11.5,df=1, p < 0.01 10% 0% ACT-IM TAU Treatment Condition Self-Rated Depression Diff btwn Baseline and Wk 24 60 Mean (SE) Trt: 16.7 (2.2) WL: 1.7 (3.1) General Depression 55 50 Mixed Model 45 Time * Condition F=8.5, p <.01 40 Effect Size= 1.3 ACT-IM TAU 35 Baseline 12 Wk FU 24 Wk FU Time at Follow-Up Hamilton Rating Scale for Anxiety Diff btwn Baseline and Wk 24 Mean (SD) Trt: 12.2 (1.6) WL: 2.8 (2.3) HRSA Score 20 15 Mixed Model Time * Condition F=9.4, p <.01 10 ACT-IM Effect Size= 1.5 TAU 5 Baseline 12-Week FU 24-Week FU Time at Follow-Up HAM-A: Recovery Rate at 24-wk Recovery: Dropped 50% or more in score. % of participants with > 50% drop on HAM-A 70% 60% 50% 40% 65% in ACT-IM 7% in TAU 30% 20% χ2= 12.5, p < .01 10% 0% ACT-IM TAU Treatment Condition Psychological Flexibility Measure (EQ) 1 2 3 4 5 never rarely sometimes often all the time 1. I am better able to accept myself as I am. 2. I can observe unpleasant feelings without being drawn into them. 3. I notice that I dont take difficulties so personally. 4. I can treat myself kindly. 5. I can separate myself from my thoughts and feelings. 6. I can slow my thinking in times of stress. 7. I can see that I am not my thoughts. 8. I view things from a wider perspective. 9. I can take time to respond to difficulties. Psychological Flexibility (EQ) Change in Psychological Flexibility ACT Intervention 0.47 0.002 (0.34) 0.01 Change In HamD Standardized regression coefficients for the relationships between the ACT Intervention and Changes in Psychological Flexibility and Ham-D-17 at 24 weeks. The standardized beta for the Intervention and change in Ham-D-17 controlling for changes in psychological flexibility is in parentheses. p-value in superscript. Psychological Inflexibility (AAQ) 1 2 3 4 5 6 7 never very seldom seldom sometimes frequently almost always always true true true true true true true 1. My painful experiences and memories make it difficult for me to live a life that I would value. 1 2 3 4 5 6 7 2. I’m afraid of my feelings. 1 2 3 4 5 6 7 3. I worry about not being able to control my worries and feelings. 1 2 3 4 5 6 7 4. My painful memories prevent me from having a fulfilling life. 1 2 3 4 5 6 7 5. Emotions cause problems in my life. 1 2 3 4 5 6 7 6. It seems like most people are handling their lives better than I am. 1 2 3 4 5 6 7 7. Worries get in the way of my success. 1 2 3 4 5 6 7 Psychological Inflexibility & Distress PHQ-GAD: r=.75 (p < .01) PHQ-AAQ: r=.66 (p < .01) GAD-AAQ: r= .71 (p < .01) N=919 (SCREENING) Qualitative Feedback Ratio of didactic to experiential work was good People empowered by idea of acceptance of emotions (not fighting) & present-moment connectedness 2 Facilitators kept things engaging and variable 6-Hour span was adequate but a follow-up 1-3 months later would be good. Challenges/Lessons Learned Feasible, credible, acceptable, and possibly efficacious Randomization acceptable. Follow-Up retention rates are excellent. Recruiting people that may otherwise not get help Severe group. Questions?