A Brief Therapeutic approach for depression and disability in medical settings

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Acceptance and Commitment Training

• A Brief Therapeutic approach for depression and
  disability in medical settings
• Lilian Dindo, Ph.D.
• Iowa psychological association
• april 2015

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ACKNOWLEDGEMENTS

• NO DISCLOSURES
• Co-Investigators/Collaborators/Mentors
• James Marchman, PhD Carolyn Turvey, PhD
• Jess Fiedorowicz, MD Mike OHara, PhD
• Ana Recober, MD
• Funding
• NIH KL2RR024980
• NCCR UL1RR024979

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Chronic Medical Conditions

• Often require active participation in ones care
• Making significant changes to ones lifestyle
• eating healthfully
• exercising regularly
• self-monitoring of blood glucose
• Adhering to treatment recommendations that might
  be challenging
• taking medications correctly

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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.

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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

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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

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A question..

• If we are to implement psychological treatment
• What would we want to treat?

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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

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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.

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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

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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

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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

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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

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Evidence Supporting ACT
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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) Depression CT BDI 21 12 0.53 .75 (8) ATQ-B
Lappalainen (2007) Anx-Depr CBT SCL-90 28 10 0.62 .47 (24) AAQ
Forman (2007) Anx-Depr CT GAF 101 15 0.08   AAQ, KIMS
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) Math Anxiety S. Desens. Math anxiety 18 6 -0.55 - .12 (8) Initial AAQ
Montesinos (2006) 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
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First Author Problem Comparison Measure N Sessions Post F-up weeks Processes
Dahl (2004) Chronic pain TAU Sick days 19 4 1.17 1.0 (24) ---
Greco (submitted) Chronic pain --- FDI 15 12-14 1.28 1.48 (4) ---
McCracken (2005) Chronic pain --- Pain intensity 108 3-4 weeks .95 .61 (12) CPAQ
Wicksell (2006) Chronic pain --- Pain intensity 15 16 1.25 2.11 ---
McCracken (2007) Chronic pain --- Pain intensity 54 3 weeks .75 --- ---
Vowles (2007) Chronic pain --- Pain intensity 252 3-4 weeks .49 .47 CPAQ
Vowles (2008) Chronic pain --- Pain intensity 114 3-4 weeks .65 .56 (12) ---
Vowles (2009) Chronic pain --- MGPQ 11 8 1.28 --- ---
Vowles (2009) Chronic pain --- MGPQ 11 4 .77 --- ---
Wicksell (2008) Chronic pain Wait-list PDI 21 10 .96 .68 (16) ---
Wicksell (2009) Chronic pain TAU Pain intensity 32 10 .53 .38 (26) ---
Gifford (2004) Smoking Nicotine Repl. Abstinence 62 14 .06 .57 (48) Smoking AAQ
Hernandez Lopez (2009) Smoking CBT Abstinence 81 7 .46 .58 (48) ---
Gregg (2007) Diabetes Psychoed. HbA1C 78 7 h. --- .15 (12) Diabetes AAQ
Lundgren (2007) Epilepsy Placcebo att. Seizures 27 9 h. 1.43 1.23 Epilepsy AAQ
Lundren (2008) Epilepsy --- Seizures 9 12 h. --- 1.3 (48) ---
Sanchez (2006) Multiple sclerosis TAU Valued areas 7 4 ? ? ---
Branstetter (2004) Cancer CBT Distress 31 12 .9 --- Mental disengagement
Montesinos (2005) Cancer Wait-list Worries interf 12 1 --- 2.53 (12) ---
Paez (2007) Cancer CBT Valued areas 12 8 .53 1.78 (48) ---
Fernandez (subm.) Postsurgical TAU Days recovery 13 1 1.42 --- ---
Gutierrez (2006) HIV prevention Information Risk HIV 45 1 ? ? (24) ---
Lillis (2009) Obesity stigma Control WSQ 84 6 h. --- 1.07 (12) Weight AAQ
Tapper (2009) Weight loss Control BMI 47 8 h. --- .20 (24) Binge eating
Forman (2009) Weight loss --- Bodily mass 29 12 .42 .58 (24) Food AAQ
Quirosa (2009) Lupus Wait-list ? 17 11 h. -- -- (24) ---
Hesser (2009) Tinnitus --- Distress 19 10 --- .91 (24) Defusion acceptance
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First Author Problem Comparison Measure N Sessions Post F-up Processes
Fernandez (2004) 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) Worksite stress Wait list GHQ-12 60 9 h. .72 .7 AAQ
Blackedge (2006) 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
Varra (2008) Use validated treatments Education Use of treatments 57 6 h. --- 1.03 (12) AAQ believability
Luoma (2007) Use validated treatments Control Use of treatments 30 8 --- 1.45 (16) ---
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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 Natl Registry of
  Evidence-Based Programs and Practice
• Has shown preliminary efficacy as a 1-day
  treatment

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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

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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

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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

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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

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ACT Principles

• DO NOT HAVE TO WAIT TO FEEL BETTER
• BEFORE DOING SOMETHING
• I can do something I dont 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

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Fairy Tales... What do they tell us?

• Myth 1 Happiness is the natural state of all
  humans
• Myth 2 If youre not happy youre 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.

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The Model
An ACT Model of Treatment/Health
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Be here now
Open
Aware
Active
Know what matters
Open up
Watch your thinking
Do what works
Perspective Taking
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Be here now
Open
Know what matters
Open up
Watch your thinking
Do what works
Perspective Taking
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Acceptance and Defusion
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Acceptance/Willingness

• Alternative to Control/Struggle Acceptance
• Imagine you are stuck in quicksand.
• What is your first reaction?

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Pain versus Suffering
PAIN Physical Sensations of Headache SUFFERING
THIS IS AWFUL I CANT 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.
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Pain and Suffering
Suffering
Pain Non-Acceptance (struggling)
Pain
Pain Acceptance
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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 wont
  remove the feelings, but it will create a center
  of calm within you.

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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 dont want or like them. Acknowledge the
  thoughts and sensations, as if nodding to them,
  without giving into them.

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• Imagine youre walking in the rain

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Cognitive Fusion

• Thoughts are Reality, the truth, important,
  orders, wise.
• When a thought, belief, or story organizes a
  persons behavior in a limiting and unhelpful way
  
• Fusion with thoughts limits ones ability to be
  present and flexibly responsive

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Identifying Fusion

• Rules (e.g., shoulds, must)
• Reasons (e.g., Im too busy, tired, etc.)
• Judgments (e.g. Im bad, anxiety is awful)
• Past (rumination)
• Future (worry)
• Self (e.g., I am weak, I cant cope, I dont need
  help)

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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 ones
actions. It is discriminating between the product
(words or thoughts) and the process (generating
thoughts).
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Defusion

• Defusion does not aim to change content of
  thoughts. Aims to change the way one relates to
  their thoughts.
• (not getting rid ofchanging relationship to)
• Seeing our thoughts vs. being our thoughts

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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

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Be here now
Aware
Know what matters
Open up
Watch your thinking
Do what works
Perspective Taking
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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.

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Mindfulness
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What day is it? Its today, squeaked
Piglet. My favorite day, said Pooh. -A.A.
Milne  
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Awareness
Distant Past
Distant Future
Near Future
Present Moment
Recent past
Question What percentage of time were your
thoughts simply in Present Moment?   Question W
hich place on the timeline do you notice that you
tend to visit when you are not simply in the
Present Moment?  
Strosahl, Robinson, Gould
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Perspective Taking

• Perspective Taking requires.
• Ability to step back and become an observer of
  events.
• Ability to imagine the point of view of someone
  else

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You are the SKY, not the CLOUDS
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Perspective-Taking
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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?

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(No Transcript)
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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 isnt struggling
  with it anymore see it?
• What actions would each of these people be able
  to take?

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Be here now
Active
Know what matters
Open up
Watch your thinking
Do what works
Perspective Taking
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Values The key question

• How do you want to live your life?

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Values

• Your hearts 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?

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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.

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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
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Values-Based Goals

• Dont want Dead Man Goals
• Chocolate, Depressed, Panic attacks
• Living Person Goals
• So lets suppose that happens, what would you do
  differently? Do more of? How would you behave
  different towards friends/family?
• If you werent yelling at your kids, how would
  you be interacting with them?
• If you werent having panic attacks, what would
  you be doing differently with your life?
• Magic Wand ? No longer a problem for you

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Committed ACTion Doing What Matters
Activity w/w/w/w Obstacles Solutions to Obstacles Outcome
Go out to eat with mom Call mom from home on Monday at 6pm to see if she wants to go out for dinner this week. May forget to call   She might not have time this week Write a note to remind self to call   If mom is busy this week, suggest lunch or dinner next week Went out to dinner with mom on Wednesday night.

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THE WORLD INSIDE / YOUR MIND
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Depression/Migraine Study
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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.

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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

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2-Step Screening

• Online via web survey or by phone
• 4-12 Migraines in Previous Month
• 3 gt ID Migraine PPV 93.3. False positive rate
  19.
• 10 gt PHQ-8
• Exclusion Patients with serious psychiatric
  illness, brain injury leading to headache, new
  medication in previous 4 weeks.

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Intake Assessment (in-person)

• Interview to Confirm Presence of Depression
• SCID Depression Module
• HAM-D (gt17)
• 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

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Participant Flow
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Intervention

• 930 am 330 pm on a Saturday
• 6-10 participants of all ages
• 5 Hours Acceptance and Commitment Training
• 1 hour of Illness Management

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Structured Clinical Interview for DSM Disorders
(SCID) at 12-Week Follow-Up
Major Depression No Yes
Condition ACT-IM WL
29 9
2 19
N 60 Fishers Exact plt.0001Number Needed to
Treat 1.5 (Dindo et al., 2012)
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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
ModelCondition F.69, p.40Time F 59.26, p lt
.01Time Condition F14.71, p lt.01Effect
Size 1.0 (Dindo et al. 2012)
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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 PointsCondition F11.16, p
lt.001Time F19.2, p lt .001Condition Time
F2.96, p lt .05Effect Size .71
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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 PointsCondition F1.42, p
.22Time F27.92, p lt .01Condition Time
F4.88, plt.01Effect Size .84 (Dindo et al.
2012)
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HAM-D Recovery Rate

• GLIMMIX For Binary Variables (not normally
  distributed)
• Model
• Condition F11.25, p lt.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)
• (not depressed)

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Results
Headaches
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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) Disability Work Leisure 1,2,3,or 4(see below) Saw a healthcare provider? Y/N
1              
2              
3              
4              
5              
6              
7              
8              
9              
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Headache Frequency Headache Severity(Dindo
et al., 2014)
74
Leisure Disabilityand Work Disability(Dindo
et al., 2014)
75
Medication Usage Visits to
Healthcare ProviderDindo et al., 2014
76

• Role of Pain Acceptance Values-Based Behavior
  in Prediction of Depression/Disability
• N93

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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) t4.1 (plt.01) d1.05
Values-Based Behavior 2.40 (.81) 3.25 (.76) t3.8 (plt.01) d1.05
Headache Disability 67.43 (18.8) 48.4 (19.7) t3.6 (plt.01) d1.0
WHO-DAS 35.7 (14.2) 20 (14.5) t3.9 (plt.01) d1.1
(Dindo et al., 2014)
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Hierarchical Regression Analyses
(Dindo et al., 2014)
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Chronic Pain Acceptance Questionnaire

1. Keeping my pain level under control takes first
   priority whenever Im doing something.
2. Before I can make any serious plans, I have to
   get some control over my pain.
3. I avoid putting myself in situations where my
   pain might increase.
4. My worries and fears about what pain will do to
   me are true.
5. I need to concentrate on getting rid of my pain.
6. I lead a full life even though I have chronic
   pain.

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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

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Primary Care Effectiveness Study
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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.
83
Primary Care Patient Study

• Randomized treatment trial for patients with
• High Cholesterol, Diabetes, Hypertension,
  Obesity, Heart Attack, Stroke, Metabolic Syndrome
• Depression or Anxiety (10 gt 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

84
Completed Screening (N827)

• Excluded (n685)
• Low PHQ/GAD (n635)
• New Med (n28)
• No Vascular Risk Factor(n22)

Enrollment
Eligible at screening (N142)

• Not scheduled (n95)
• Could not reach (n58)
• Declined (n22)
• Could not make workshop date (n15)

Initial Assessment (N47)

• Ineligible after first interview (n3)
• No vascular risk factor (n1)
• Active Suicidal Ideation (n1)
• TBI (n1)

Randomized (N44)
ACT/IM (N30)
TAU/WL (N14)
Allocation
Intent to Treat (N4) Did not Attend Workshop
Attended Workshop (N26)
Week 2 (n26) Week 6 (n26) Week 12
(n26) Week 24 (n26)
Week 2 (n14) Week 6 (n14) Week 12
(n14) Week 24 (n13)
Week 2 (n3) Week 6 (n3) Week 12 (n3) Week
24 (n3)
Follow-Up
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Demographic Variables ACT-IM TAU
(N26) (N14)
Age (mean/SD) 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)

Note. ACT-IM Acceptance and Commitment Training plus Illness Management TAU Treatment as Usual. Note. ACT-IM Acceptance and Commitment Training plus Illness Management TAU Treatment as Usual. Note. ACT-IM Acceptance and Commitment Training plus Illness Management TAU Treatment as Usual.
86
Hamilton Rating Scale for Depression
Diff btwn Baseline and Wk 24 Mean
(SD)Trt 11.7(1.4)WL 0.8 (2.0)Mixed
ModelTime Condition F9.4, p lt.01Effect
Size 1.4
87
HAM-D Recovery Rate at 24-wk
Recovery Dropped 50 or more in score. 77
in ACT-IM21 in TAU?2 11.5,df1, p lt 0.01
88
Self-Rated Depression
Diff btwn Baseline and Wk 24 Mean
(SE)Trt 16.7 (2.2)WL 1.7 (3.1)Mixed
ModelTime Condition F8.5, p lt.01Effect
Size 1.3
89
Hamilton Rating Scale for Anxiety
Diff btwn Baseline and Wk 24 Mean
(SD)Trt 12.2 (1.6)WL 2.8 (2.3)Mixed
ModelTime Condition F9.4, p lt.01Effect
Size 1.5
90
HAM-A Recovery Rate at 24-wk
Recovery Dropped 50 or more in score. 65
in ACT-IM7 in TAU?2 12.5, p lt .01
91
Psychological Flexibility Measure (EQ)
1 2 3 4 5
never rarely sometimes often all the time
I am better able to accept myself as I am. I am better able to accept myself as I am. I am better able to accept myself as I am. I am better able to accept myself as I am. I am better able to accept myself as I am.
2. I can observe unpleasant feelings without being drawn into them. 2. I can observe unpleasant feelings without being drawn into them. 2. I can observe unpleasant feelings without being drawn into them. 2. I can observe unpleasant feelings without being drawn into them. 2. I can observe unpleasant feelings without being drawn into them.
I notice that I dont take difficulties so personally. I notice that I dont take difficulties so personally. I notice that I dont take difficulties so personally. I notice that I dont take difficulties so personally. I notice that I dont take difficulties so personally.
I can treat myself kindly. I can treat myself kindly. I can treat myself kindly. I can treat myself kindly. I can treat myself kindly.
I can separate myself from my thoughts and feelings. I can separate myself from my thoughts and feelings. I can separate myself from my thoughts and feelings. I can separate myself from my thoughts and feelings. I can separate myself from my thoughts and feelings.
I can slow my thinking in times of stress. I can slow my thinking in times of stress. I can slow my thinking in times of stress. I can slow my thinking in times of stress. I can slow my thinking in times of stress.
I can see that I am not my thoughts. I can see that I am not my thoughts. I can see that I am not my thoughts. I can see that I am not my thoughts. I can see that I am not my thoughts.
8. I view things from a wider perspective. 8. I view things from a wider perspective. 8. I view things from a wider perspective. 8. I view things from a wider perspective. 8. I view things from a wider perspective.
9. I can take time to respond to difficulties. 9. I can take time to respond to difficulties. 9. I can take time to respond to difficulties. 9. I can take time to respond to difficulties. 9. I can take time to respond to difficulties.
92
Psychological Flexibility (EQ)
93
0.54 0.001 (0.44) 0.002
0.29 0.06
0.47 0.002 (0.34) 0.01
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.
94
Psychological Inflexibility (AAQ)
1 2 3 4 5 6 6 6 6 6 7 7 7 7
never true very seldom true seldom true sometimes true frequently true almost always true almost always true almost always true almost always true almost always true always true always true always true always true
                           
My painful experiences and memories make it difficult for me to live a life that I would value. My painful experiences and memories make it difficult for me to live a life that I would value. My painful experiences and memories make it difficult for me to live a life that I would value. My painful experiences and memories make it difficult for me to live a life that I would value. My painful experiences and memories make it difficult for me to live a life that I would value. My painful experiences and memories make it difficult for me to live a life that I would value. 1 2 3 4 4 5 6 7
2. Im afraid of my feelings. 2. Im afraid of my feelings. 2. Im afraid of my feelings. 2. Im afraid of my feelings. 2. Im afraid of my feelings. 2. Im afraid of my feelings. 1 2 3 4 4 5 6 7
I worry about not being able to control my worries and feelings. I worry about not being able to control my worries and feelings. I worry about not being able to control my worries and feelings. I worry about not being able to control my worries and feelings. I worry about not being able to control my worries and feelings. I worry about not being able to control my worries and feelings. 1 2 3 4 4 5 6 7
My painful memories prevent me from having a fulfilling life. My painful memories prevent me from having a fulfilling life. My painful memories prevent me from having a fulfilling life. My painful memories prevent me from having a fulfilling life. My painful memories prevent me from having a fulfilling life. My painful memories prevent me from having a fulfilling life. 1 2 3 4 4 5 6 7
Emotions cause problems in my life. Emotions cause problems in my life. Emotions cause problems in my life. Emotions cause problems in my life. Emotions cause problems in my life. Emotions cause problems in my life. 1 2 3 4 4 5 6 7
It seems like most people are handling their lives better than I am. It seems like most people are handling their lives better than I am. It seems like most people are handling their lives better than I am. It seems like most people are handling their lives better than I am. It seems like most people are handling their lives better than I am. It seems like most people are handling their lives better than I am. 1 2 3 4 4 5 6 7
Worries get in the way of my success. Worries get in the way of my success. Worries get in the way of my success. Worries get in the way of my success. Worries get in the way of my success. Worries get in the way of my success. 1 2 3 4 4 5 6 7
95
Psychological Inflexibility Distress

• PHQ-GAD r.75 (p lt .01)
• PHQ-AAQ r.66 (p lt .01)
• GAD-AAQ r .71 (p lt .01)
• N919 (SCREENING)

96
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.

97
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.

98
Questions?