ACT Internet-based vs face-to-face? A randomized controlled trial of two ways to deliver Acceptance and Commitment Therapy for depressive symptoms: An 18-month follow-up
Introduction
Depression is one of the most common mental illnesses affecting 350 million people worldwide (WHO, 2012). In Western countries, depression may affect half of the population during their lifetime (Andrews, Poulton, & Skoog, 2005). Considering the significant economic costs and human suffering due to depression, it is important to improve access to psychological treatments and develop new, flexible and cost-effective therapies for those suffering from depression (e.g. Richards & Bower, 2011).
The ever-increasing use of Internet has created new opportunities to receive evidence-based psychological treatment. Internet-based interventions have been developed and tested for a wide range of health problems (Cuijpers, van Straten, & Andersson, 2008). Further, there are several protocols developed for depression and depressive symptoms (e.g. Andersson, 2006, Andersson et al., 2005, Christensen et al., 2004, Meyer et al., 2009, Van Straten et al., 2008, Vernmark et al., 2010).
Internet-delivered treatments differ in regard to the amount of therapist contact provided. Glasgow and Rosen (1978) have developed a taxonomy to classify the nature and type of support provided for CBT self-help. It distinguishes between three types of support: self-administered in which no support is provided; minimal contact in which a rationale with regular check-ins is provided; and guided self-help in which the clients receive an initial support session, a rationale and support sessions throughout the treatment program (see also Andersson, 2009). We know from previous research that treatments with therapist support are more effective than treatments without any therapist contact (e.g. Andersson and Cuijpers, 2009, Farrand and Woodford, 2013, Spek et al., 2007a, Spek et al., 2007b). Meta-analyses and reviews comparing untreated control conditions with Internet-based and other computerized treatments indicate effect sizes between d = 0.42 and 0.78 in favor of guided computerized and Internet-based treatments in which a therapist or a coach supports the client through the treatment program (Andersson and Cuijpers, 2009, Griffiths et al., 2010, Richards and Richardson, 2012). Self-administered or self-guided psychological treatments for depression without therapist support have shown lower effect sizes (d = 0.25–0.36; Andersson and Cuijpers, 2009, Cuijpers et al., 2011, Richards and Richardson, 2012). Meta-analysis comparing guided Internet-based interventions with face-to-face therapies for depression and anxiety indicated that both treatments were equally effective, with effect sizes varying from 0.02 to 0.09 (Andrews et al., 2010, Cuijpers et al., 2010).
Acceptance and Commitment Therapy is one of the third waves of behavioral therapies (Hayes, Strohsal & Wilson, 1999). Several studies and meta-analyses support its effectiveness across a range of psychological problems, including chronic pain, depression and anxiety disorders, substance abuse, smoking, psychosis, and workplace stress (Hayes et al., 2006, Powers et al., 2009, Ruiz, 2010). Available research offers limited evidence in support of ACT for treating depression and depressive symptoms. Nevertheless, reported studies indicate that ACT is effective in reducing depressive symptoms (Bohlmeijer et al., 2011, Powers et al., 2009), and might have an equal impact on depression when compared with traditional cognitive-behavioral treatments (Forman et al., 2007, Lappalainen et al., 2007, Zettle and Rains, 1989). A recent study where ACT was compared with Cognitive Therapy for treating depression reported that long-term treatment outcomes were slightly better maintained in the CT condition (Forman et al., 2012). Nevertheless, ACT is considered as an empirically supported treatment with modest effect on managing depression (American Psychological Association).
A number of self-help ACT-based treatments have been studied. Promising results have been found for bibliotherapy for chronic pain (Johnston, Foster, Shennan, Starkey, & Johnson, 2010), depression (Fledderus, Bohlmeijer, Pieterse, & Schreurs, 2012), Japanese students adjusting to university life in the United States (Muto, Hayes, & Jeffcoat, 2011), school teachers and other personnel (Jeffcoat & Hayes, 2012), and for guided Internet-delivered ACT for tinnitus distress (Hesser et al., 2012), and chronic pain (Buhrman et al., 2013). A brief telephone-based ACT intervention for smoking cessation has shown encouraging results (Bricker et al., 2010, Schimmel-Bristow et al., 2012), and an Internet-delivered ACT-based intervention for smoking cessation is under development (Heffner, Wyszynski, Comstock, Mercer, & Bricker, 2013). While these studies provide some support for the idea that Internet-based ACT interventions might be successful, we do not know of any published Internet-based depression studies with long-term follow-up data that purely focuses on ACT.
According to Andersson and Cuijpers (2009), there is a need to further test whether Internet-delivered treatment can be as effective as face-to-face treatments in depression. Identifying the gap, we decided to compare the effects of two short ACT-based interventions for the treatment of depressive symptoms delivered by student therapists: a six week face-to-face treatment (ACT) and a guided six week Internet-based treatment including two face-to-face assessment sessions (iACT). The support provided in the iACT group in this study can be characterized as guided self-help (Glasgow & Rosen, 1978). Both interventions were meant for outpatients who were experiencing at least mild depression as assessed by a telephone-based screening. The main objective of this study was to compare the effects of two parallel treatment groups. Both treatments were administred by the same therapist. We anticipated that both ACT-interventions would have similar effects in reducing depressive symptoms and psychological distress. Thus, the trial could be called as a non-inferiority trial that sought to determine whether the guided Internet-based ACT treatment (iACT) was as effective as the ACT-based face-to-face treatment (ACT).
Section snippets
Participants
Participants were recruited through an advertisement in a local newspaper in Jyväskylä, Finland. The advertisement explained that it was a university research project with an aim to investigate new psychotherapeutical methods in treating individuals who felt depressed. In response to the advertisement, 60 prospective participants contacted the clinic through email and telephone during the given time window (February 21–23, 2011), and were screened over the telephone using a structured
Participant adherence to the protocol and participant satisfaction
Data were available for 37 participants (drop-out rate 2.6%) at post-measurement, for 36 participants at 6-month follow-up (drop-out rate 5.3%) and for 35 participants (drop-out rate 7.9%) at 18-month follow-up.
Participant satisfaction was evaluated on a scale from 1 to 10 at post-measurement. Participants in the iACT group evaluated the intervention with 8.42 (SD = 1.35) compared with 8.83 (SD = 0.86; n = 18) in the ACT group. On a scale from 1 to 10, the mean for recommending this kind of
Discussion
The objective of this study was to investigate the effectiveness of a guided 6-week Internet-delivered ACT-based intervention (iACT) for depressive symptoms when compared with a 6-week ACT-based face-to-face intervention (ACT) when both treatments were administred by the same student therapist. Because earlier studies conclude that Internet-delivered CBT with the guidance of a therapist could be as effective as face-to-face treatment (Andersson and Cuijpers, 2009, Ruwaard et al., 2009, Titov,
Acknowledgments
All coworkers in the Good Life Compass – project are acknowledged for their help. We would also like to thank Jason Luoma and Joona Muotka for their assistance and valuable comments.
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