Effectiveness of attentional bias modification training as add-on to regular treatment in alcohol and cannabis use disorder: A multicenter randomized control trial.

BACKGROUND: Attentional bias for substance-relevant cues has been found to contribute to the persistence of addiction. Attentional bias modification (ABM) interventions might, therefore, increase positive treatment outcome and reduce relapse rates. The current study investigated the effectiveness of a newly developed home-delivered, multi-session, internet-based ABM intervention, the Bouncing Image Training Task (BITT), as an add-on to treatment as usual (TAU). METHODS: Participants (N = 169), diagnosed with alcohol or cannabis use disorder, were randomly assigned to one of two conditions: the experimental ABM group (50%; TAU+ABM); or the control group (50%; split in two subgroups the TAU+placebo group and TAU-only group, 25% each). Participants completed baseline, post-test, and 6 and 12 months follow-up measures of substance use and craving allowing to assess long-term treatment success and relapse rates. In addition, attentional bias (both engagement and disengagement), as well as secondary physical and psychological complaints (depression, anxiety, and stress) were assessed. RESULTS: No significant differences were found between conditions with regard to substance use, craving, relapse rates, attentional bias, or physical and psychological complaints. CONCLUSIONS: The findings may reflect unsuccessful modification of attentional bias, the BITT not targeting the relevant process (engagement vs. disengagement bias), or may relate to the diverse treatment goals of the current sample (i.e., moderation or abstinence). The current findings provide no support for the efficacy of this ABM approach as an add-on to TAU in alcohol or cannabis use disorder. Future studies need to delineate the role of engagement and disengagement bias in the persistence of addiction, and the role of treatment goal in the effectiveness of ABM interventions.

Treatment of substance use disorders: Effects on patients with higher or lower levels of PTSD symptoms.

While guidelines advise integrated treatment of patients with substance use disorder (SUD) and posttraumatic stress disorder (PTSD), recent studies and reviews find no convincing evidence of different outcomes following treatment between non-trauma focused integrated programs and SUD treatment alone. In this study, we analyzed whether SUD patients with higher levels of PTSD symptoms receiving standard, non-integrated SUD treatment (N=145) differed in outcomes compared to patients with lower levels of PTSD symptoms (N=152). Patients with higher levels of PTSD symptoms showed no difference in days of substance use, but significantly more craving and psychiatric symptoms (depression, anxiety and stress) were measured at baseline. After 3 and 6months of SUD treatment, there was no difference between the groups in decreased days of substance use. After 6months of SUD treatment, depression, anxiety and stress were significantly diminished in both groups. However, those with higher levels of PTSD symptoms at the start of the SUD treatment still reported significantly higher scores on depression, anxiety and stress after 6months of SUD treatment. These findings corroborate earlier studies that SUD patients with PTSD symptoms do not necessarily have poorer addiction treatment outcomes. However, as anxiety and PTSD symptoms predict relapse, future research should note the effect of higher symptom levels on long-term SUD treatment results. Additionally, more research is needed to determine which patients need additional treatment in conjunction with or following SUD treatment.

Internet-based attentional bias modification training as add-on to regular treatment in alcohol and cannabis dependent outpatients: a study protocol of a randomized control trial.

BACKGROUND: The automatic tendency to attend to and focus on substance-related cues in the environment (attentional bias), has been found to contribute to the persistence of addiction. Attentional bias modification (ABM) interventions might, therefore, contribute to treatment outcome and the reduction of relapse rates. Based on some promising research findings, we designed a study to test the clinical relevance of ABM as an add-on component of regular intervention for alcohol and cannabis patients. DESIGN/METHODS: The current protocol describes a study which will investigate the effectiveness and cost-effectiveness of a newly developed home-delivered, multi-session, internet-based ABM (iABM) intervention as an add-on to treatment as usual (TAU). TAU consists of cognitive behavioural therapy-based treatment according to the Dutch guidelines for the treatment of addiction. Participants (N = 213) will be outpatients from specialized addiction care institutions diagnosed with alcohol or cannabis dependency who will be randomly assigned to one of three conditions: TAU + iABM; TAU + placebo condition; TAU-only. Primary outcome measures are substance use, craving, and rates of relapse. Changes in attentional bias will be measured to investigate whether changes in primary outcome measures can be attributed to the modification of attentional bias. Indices of cost-effectiveness and secondary physical and psychological complaints (depression, anxiety, and stress) are assessed as secondary outcome measures. DISCUSSION: This randomized control trial will be the first to investigate whether a home-delivered, multi-session iABM intervention is (cost-) effective in reducing relapse rates in alcohol and cannabis dependency as an add-on to TAU, compared with an active and a waiting list control group. If proven effective, this ABM intervention could be easily implemented as a home-delivered component of current TAU. TRIAL REGISTRATION: Netherlands Trial Register, NTR5497 , registered on 18th September 2015.

Acceptance and commitment therapy as a web-based intervention for depressive symptoms: randomised controlled trial.

BACKGROUND: Depression is a highly prevalent disorder, causing a large burden of disease and substantial economic costs. Web-based self-help interventions seem promising in promoting mental health. AIMS: To compare the efficacy of a guided web-based intervention based on acceptance and commitment therapy (ACT) with an active control (expressive writing) and a waiting-list control condition (Netherlands Trial Register NTR1296). METHOD: Adults with depressive symptoms from the general population were randomised to ACT (n = 82), expressive writing (n = 67) or waiting-list control (n = 87). The main outcome was reduction in depressive symptoms assessed with the Center for Epidemiological Studies - Depression scale. RESULTS: Significant reductions in depressive symptoms were found following the ACT intervention, compared with the control group (Cohen's d = 0.56) and the expressive writing intervention (d = 0.36). The effects were sustained at 6-month and 12-month follow-up. CONCLUSIONS: Acceptance and commitment therapy as a web-based public mental health intervention for adults with depressive symptoms can be effective and applicable.

Flourishing in people with depressive symptomatology increases with Acceptance and Commitment Therapy. Post-hoc analyses of a randomized controlled trial.

Mental health is more than the absence of mental illness. Rather, both well-being (positive mental health) and mental illness are actually two related continua, with higher levels of well-being defined as "flourishing." This two-continua model and existing studies about the impact of flourishing on psychopathology underscore the need for interventions that enhance flourishing and well-being. Acceptance and Commitment Therapy (ACT) is a model of cognitive behavioral therapy that aims not only to reduce psychopathology but also to promote flourishing as well. This is the first study to evaluate the impact of ACT on flourishing. A post-analysis was conducted on an earlier randomized controlled trial of a sample of adults with depressive symptomatology who participated in a guided self-help ACT intervention. This post-analysis showed a 5%-28% increase of flourishing by the participants. In addition, the effects on flourishing were maintained at the three-month follow-up. When compared to participants in a control group, the flourishing of the ACT-trained participants increased from 5% to about 14% after nine weeks. In addition to levels of positive mental health at baseline, an increase of psychological flexibility during the intervention was a significant predictor of flourishing at the three-month follow-up.

Development and Pilot Evaluation of an Online Relapse-Prevention Program Based on Acceptance and Commitment Therapy for Chronic Pain Patients.

BACKGROUND: A significant number of chronic pain patients experience a decline in therapeutic effects after rehabilitation. As face-to-face contacts with health care professionals are not always feasible after treatment, new, innovative, fully automated relapse-prevention programs are highly needed. OBJECTIVE: In this study an online, automated relapse-prevention program based on acceptance and commitment therapy (ACT)-both as a website and as a mobile app-was developed and evaluated. At each step of the development, end users (ie, chronic pain patients) were consulted in order to fully address their needs. METHODS: In a step-by-step process, a contextual inquiry, requirement specification, and design were executed with chronic pain patients by conducting, respectively, a focus group (n=10), interviews with rapid prototyping (n=28), and a user- and expert-based usability evaluation (n=14). Furthermore, a pilot evaluation was conducted with 14 chronic pain or fatigue patients who had received the online relapse-prevention program following a multidisciplinary ACT treatment. They were interviewed about their usage and the usefulness of the program in supporting them to maintain changed behaviors and prevent relapses in avoidance and pain control behaviors. RESULTS: The three stages provided information about the expected needs of end users, comments about the usefulness of the proposed features, and feedback about the design and usability of the program. This resulted in a fully operational, online relapse-prevention program. Results from the pilot evaluation showed that 9 patients used the online program after treatment, 5 of whom indicated that the program supported them after treatment. Of all the patients, 4 of them indicated that the program did not support them because they wanted more social interaction with other users. CONCLUSIONS: This study showed that an innovative, automated, online program that is user friendly can be developed by involving the end users in each step. The program was evaluated positively by some participants. The evaluation showed that the online relapse-prevention program has the potential to support chronic pain patients in maintaining their changed behaviors and preventing relapses in avoidance and pain control behaviors. TRIAL REGISTRATION: Nederlands Trial Register (NTR) Number: NTR4177; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4177 (Archived by WebCite at http://www.webcitation.org/6Ur6EFD1D).

Measuring values and committed action with the Engaged Living Scale (ELS): psychometric evaluation in a nonclinical sample and a chronic pain sample.

This article describes the development and evaluation of the Engaged Living Scale (ELS) as a new self-report, process-specific measure to assess an engaged response style as conceptualized in acceptance and commitment therapy (ACT). The psychometric properties of the ELS test scores were evaluated in both a nonclinical sample (N = 439) and a clinical sample consisting of chronic pain patients who participated in a study on the effects of an online ACT intervention (N = 238). Item analysis and exploratory factor analysis in the nonclinical sample suggested a 16-item version of the ELS with 2 subscales, Valued Living (10 items) and Life Fulfillment (6 items). A bifactor model with 2 specific factors and 1 general underlying factor showed the best fit in confirmatory factor analyses in the chronic pain sample. In both samples, the scores on the ELS and its subscales showed good internal consistency and construct validity by consistent patterns of relationships with theoretically related process and outcome variables, such as psychological well-being, anxiety/depression, acceptance, mindfulness, and pain interference in daily life. Furthermore, in the chronic pain sample, the ELS showed incremental validity in explaining anxiety and depression, positive mental health, and pain interference beyond both acceptance and mindfulness. This study suggests the ELS shows promise as a useful tool for the measurement of an engaged response style, enabling more comprehensive evaluation of working mechanisms of ACT.

The role of psychological flexibility in a self-help acceptance and commitment therapy intervention for psychological distress in a randomized controlled trial.

This study examined the role of psychological flexibility, as a risk factor and as a process of change, in a self-help Acceptance and Commitment Therapy (ACT) intervention for adults with mild to moderate depression and anxiety. Participants were randomized to the self-help programme with e-mail support (n=250), or to a waiting list control group (n=126). All participants completed measures before and after the intervention to assess depression, anxiety and psychological flexibility. Participants in the experimental condition also completed these measures during the intervention (after three and six weeks) and at a three-month follow-up. With multilevel modelling, it was shown that the effects of the intervention on psychological distress were stronger for participants with higher levels of psychological flexibility. Furthermore, our study showed that improved psychological flexibility mediated the effects of the ACT intervention. With a cross-lagged panel design, it was shown that especially improvements in psychological flexibility in the last three sessions of the intervention were important for further reductions in anxiety. To conclude, our study showed the importance of targeting psychological flexibility during an ACT intervention for a reduction in depressive and anxiety symptoms.

Further evaluation of the psychometric properties of the Acceptance and Action Questionnaire-II.

The Acceptance and Action Questionnaire-II (AAQ-II) is a self-report measure designed to assess experiential avoidance as conceptualized in acceptance and commitment therapy (ACT). The current study is the first to evaluate the psychometric properties of the AAQ-II in a large sample of adults (N = 376) with mild to moderate levels of depression and anxiety who participated in a study on the effects of an ACT intervention. The internal construct validity and local measurement precision were investigated by fitting the data to a unidimensional item response theory (IRT) model, and the incremental validity of the AAQ-II beyond mindfulness, as measured by the Five Facet Mindfulness Questionnaire, was assessed. Results of the IRT analyses suggest that the AAQ-II is a unidimensional measure of experiential avoidance and has satisfactory reliability for group comparisons in mild to moderately depressed and anxious populations. Item functioning was found to be independent of gender and slightly dependent on age in this sample. Furthermore, the AAQ-II showed incremental validity beyond 5 mindfulness facets in explaining depression, anxiety, and positive mental health. This study suggests the AAQ-II shows promise as a useful tool for the measurement of experiential avoidance in mild to moderately depressed and anxious populations.

Psychometric properties of the five facet mindfulness questionnaire in depressed adults and development of a short form.

In recent years, there has been a growing interest in therapies that include the learning of mindfulness skills. The 39-item Five Facet Mindfulness Questionnaire (FFMQ) has been developed as a reliable and valid comprehensive instrument for assessing different aspects of mindfulness in community and student samples. In this study, the psychometric properties of the Dutch FFMQ were assessed in a sample of 376 adults with clinically relevant symptoms of depression and anxiety. Construct validity was examined with confirmatory factor analyses and by relating the FFMQ to measures of psychological symptoms, well-being, experiential avoidance, and the personality factors neuroticism and openness to experience. In addition, a 24-item short form of the FFMQ (FFMQ-SF) was developed and assessed in the same sample and cross-validated in an independent sample of patients with fibromyalgia. Confirmatory factor analyses showed acceptable model fit for a correlated five-factor structure of the FFMQ and good model fit for the structure of the FFMQ-SF. The replicability of the five-factor structure of the FFMQ-SF was confirmed in the fibromyalgia sample. Both instruments proved highly sensitive to change. It is concluded that both the FFMQ and the FFMQ-SF are reliable and valid instruments for use in adults with clinically relevant symptoms of depression and anxiety.

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

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.

Mental health promotion as a new goal in public mental health care: a randomized controlled trial of an intervention enhancing psychological flexibility.

OBJECTIVES: We assessed whether an intervention based on acceptance and commitment therapy (ACT) and mindfulness was successful in promoting positive mental health by enhancing psychological flexibility. METHODS: Participants were 93 adults with mild to moderate psychological distress. They were randomly assigned to the group intervention (n = 49) or to a waiting-list control group (n = 44). Participants completed measures before and after the intervention as well as 3 months later at follow-up to assess mental health in terms of emotional, psychological, and social well-being (Mental Health Continuum-Short Form) as well as psychological flexibility (i.e., acceptance of present experiences and value-based behavior, Acceptance and Action Questionnaire-II). RESULTS: Regression analyses showed that compared with the participants on the waiting list, participants in the ACT and mindfulness intervention had greater emotional and psychological well-being after the intervention and also greater psychological flexibility at follow-up. Mediational analyses showed that the enhancement of psychological flexibility during the intervention mediated the effects of the intervention on positive mental health. CONCLUSIONS: The intervention is effective in improving positive mental health by stimulating skills of acceptance and value-based action.

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

Experiential avoidance (EA) is considered a risk factor for psychopathology.This study explores whether EA mediates the relationship between maladaptive coping styles (palliative, avoidance, and passive coping) and psychopathology and positive mental health. A total of 93 adults with mild to moderate psychological distress completed measures assessing coping styles, psychopathology (depression, anxiety, and alcohol use), and mental health (emotional, psychological, and social well-being). Results showed that EA mediated the effects of passive coping on both increased anxiety and depression and decreased emotional and psychological well-being. These results suggest that a person who is prone to use EA or has learned EA in stressful situations has a higher risk of developing psychopathology and lower mental health.This indicates that early interventions that aim at people with high levels of EA are highly relevant.