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Efficacy of an early intervention based on acceptance and commitment therapy for adults with depressive symptomatology: Evaluation in a randomized controlled trial

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Abstract

Objective

The current study examined the efficacy of an early intervention based on acceptance and commitment therapy (ACT) for depressive symptomatology. The ACT intervention is aimed at increasing the acceptance of negative thoughts and emotions and living a mindful and value-based life.

Method

Adults with mild to moderate depressive symptomatology were randomly assigned to the ACT intervention (n = 49) or to a waiting list (n = 44). The mean age of the participants was 49 years. The majority of the participants was female and of Dutch origin. All the participants completed measures before and after the intervention, as well as three months later at follow-up to assess depression (CES-D), anxiety (HADS-A), fatigue (CIS), alcohol use and acceptance (AAQ-II).

Results

The ACT intervention led to statistically significant reduction in depressive symptomatology (Cohen’s d = .60). These reductions were maintained at the three-month follow-up. Also significant reductions in anxiety and fatigue were observed. Moreover, mediational analysis showed that the improvement of acceptance during the intervention mediated the effects of the intervention on depressive symptomatology at follow-up.

Conclusion

These findings suggest that an early intervention based on ACT, aimed at increasing acceptance, is effective in reducing depressive symptomatology.

Introduction

Depression makes a large contribution to the burden of disease worldwide and is the leading cause of the burden of disease in middle- and high-income countries (World Health Organization, 2008). Depression is also associated with high economic costs and increased use of health services (e.g., Cuijpers et al., 2007, Von Korff et al., 1992). In the last decades many effective treatments for depression have been developed (Cuijpers, Van Straten, Smit, Mihalopoulos, & Beekman, 2008). However, even when the current evidence-based treatments would be optimally implemented, only 40% of the burden of depression will be avoided (Andrews, Issakidis, Sanderson, Corry, & Lapsley, 2004). Pro-actively offering preventive interventions to people in the community is therefore a necessary complementary strategy for decreasing the burden of disease (Hosman, Jane-Llopis, & Saxena, 2005). Particularly indicated preventive or early interventions are promising (Cuijpers et al., 2007, Cuijpers et al., 2008, Smit et al., 2006). These interventions aim at people who suffer from clinically relevant symptoms but who do not meet the criteria of a clinical disorder (Mrazek & Haggerty, 1994). The presence of depressive symptomatology can be seen as the most important risk factor for developing a clinical depression (Cuijpers & Smit, 2004). Early interventions in the form of workshops, courses or self-help can be attractive for people who are not in need of psychotherapy or medical treatment as yet (Jorm & Griffiths, 2006).

In the last years several early interventions have been developed (e.g. Lynch et al., 1997, Willemse et al., 2004). Most interventions are based on cognitive behavior therapy and on the ‘Coping with Depression’ course in particular (Lewinsohn, Antonucci, Breckenridge, & Munoz, 1984). In this 12-week group course psycho-education is combined with several mood management techniques. Cuijpers, Smit, and Van Straten (2007) found a mean effect size of .42 of seven interventions on depressive symptoms.

For early interventions to be effective, a clear model of risk factors and mechanisms in the development of psychopathology is needed (Rapee, 2008). There is growing evidence that in addition to symptoms of depression, experiential avoidance (EA) is such a mechanism involved in depression and other psychopathology. EA has been defined as the unwillingness to remain in contact with experiences such as feelings, thoughts, and bodily sensations, as an attempted means of behavioral regulation (Hayes et al., 2004). A meta-analysis of 32 studies examining the relationship between EA and psychopathology (e.g., anxiety, posttraumatic stress disorder, pain, depression) found a weighted effect size of r = .42 (95% CI: .40–.44) (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Additionally, EA has been found to mediate the effects of maladaptive coping behavior on psychopathology and positive mental health (Fledderus et al., 2010, Kashdan et al., 2006).

So, early interventions targeting EA and clinically relevant symptoms of depression are warranted from a public mental health perspective (Biglan, Hayes, & Pistorello, 2008). One intervention that has been specifically developed for targeting EA in patients with depression is acceptance and commitment therapy (ACT). ACT is a form a behavioral therapy that focuses on decreasing EA and increasing value-based behavior (Hayes, Strosahl, & Wilson, 1999). Several studies have shown medium to large effects of clinical ACT treatments on depression (e.g., Forman et al., 2007, Lappalainen et al., 2007).

However, to our knowledge, no studies have been conducted on the efficacy of ACT as an early community intervention for people with clinically relevant depressive symptoms. A group course based on ACT was developed, called “Living to the full” and was pro-actively offered to the general public. This paper presents the results of a randomized controlled trial with a waiting list as a control group, in which the efficacy of this ACT intervention was assessed for reducing depressive symptomatology. In addition, we were also interested in symptoms of anxiety and fatigue, and the degree of alcohol use. A secondary goal of this paper was to test the effects on EA as an important process factor of ACT.

Section snippets

Procedure and participants

The group intervention was designed as an early intervention for adults of 18 years and older with mild or moderate psychological distress. Study participants were recruited from March to May 2008 through press articles, leaflets and posters, and through psychologists at seven mental health institutions in the Netherlands. In these advertisements the target group of the intervention was described as people who want to live more fully but who are hindered by depressive symptoms. 140 individuals

Baseline characteristics

The means and standard deviations for the measures of depression (CES-D), anxiety (HADS-A), fatigue (CIS) and EA (AAQ-II) are presented in Table 2. There were no significant differences at baseline between the ACT group and the waiting-list group for any of the demographic variables or outcome measures, indicating a successful randomization.

The baseline scores of the participants on depression, anxiety and fatigue consistently show clinically relevant symptoms in at least two-thirds of the

Discussion

Depression is one of the most prevalent disorders in the world. In order to reduce this prevalence, a public mental health approach is needed in addition to effective treatment in clinical settings (Hosman et al., 2005). In this study it was found that a small-group course based on acceptance and commitment therapy (ACT) has beneficial effects on depressive symptoms and may be useful in such a public mental health approach. Among ACT participants the average level of depressive symptomatology

Acknowledgements

This study was funded by Innovation Fund Health Insurers (Innovatiefonds Zorgverzekeraars). Ethical principles in the country where the study was conducted (the Netherlands) were followed. The study was approved by the Medical-Ethical Review Board for Mental Health Care Institutes (METIGG; number 8203) which is recognized by the Central Committee for Research involving human participants (CCMO). Its activities fall under the Dutch law (WMO). The study has been registered in the “Nederlands

References (39)

  • P. Cuijpers et al.

    Economic costs of minor depression: a population-based study

    Acta Psychiatrica Scandinavica

    (2007)
  • P. Cuijpers et al.

    Psychological treatments of subthreshold depression: a meta-analytic review

    Acta Psychiatrica Scandinavica

    (2007)
  • P. Cuijpers et al.

    Preventing the onset of depressive disorders: a meta-analytic review of psychological interventions

    American Journal of Psychiatry

    (2008)
  • P. Cuijpers et al.

    Recruiting participants for intervention to prevent the onset of depressive disorders: possible ways to increase participation rates

    BMC Health Services Research

    (2010)
  • A.P. Dempster et al.

    Maximum likelihood from incomplete data via the EM algorithm

    Journal of the Royal Statistical Society

    (1977)
  • M. Fledderus et al.

    Does experiential avoidance mediate the effects of maladaptive coping styles on psychopathology and mental health?

    Behavior Modification

    (2010)
  • E.M. Forman et al.

    A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression

    Behavior Modification

    (2007)
  • R. Haringsma et al.

    The criterion validity of the Center for Epidemiological Studies Depression Scale (CES-D) in a sample of self-referred elders with depressive symptomatology

    International Journal of Geriatric Psychiatry

    (2004)
  • S.C. Hayes et al.

    Acceptance and commitment therapy: An experiential approach to behavior change

    (1999)
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