Acceptance and Commitment Therapy: End state functioning

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Acceptance and Commitment Therapy End state
functioning

• Dr Matthew Smout
• Centre for Treatment of Anxiety and Depression
• South Australia

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Aims

• Overview how healthy ACT recipients are at the
  end of treatment
• Put this in the context of end-state functioning
  typically achieved by other CBTs

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Bench-marking

• Typical use
• Once efficacy established in tightly controlled
  RCTs
• Evaluation of an EBT in real-world community
  setting (some inclusion criteria relaxed)
• Model RCTs are selected either individually or
  aggregated to serve as benchmark
• Comparison informal

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Clinical significance

• End-state functioning measured by clinical
  significance
• Jacobson Truax (1991) criteria
• gt 2 SDs improvement on pre-test mean
• lt 2 SDs of functional population post-test
• Post-test closer to functional than dysfunctional
  mean
• Pre-determined reduction in Sx (e.g., 50)
• Composite or selection of outcome measures
• Even large effect sizes are not necessarily
  clinically significant
• 16/62 ACT RCTs included this information (Smout
  et al., 2012)
• A further 3 ACT non-RCTs provided info (Scopus
  search on ACT in Title, 1/6/13).

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recovered
Non-clinical
Error bars 1 SD
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OCD study sample characteristics
Study/ Variable Foa et al (2005) Van Oppen et al (1995a) Lindsay et al (1997) Cottraux et al (2001) McLean et al (2001) Franklin et al (2000) Twohig et al (2010)
Female 62 52 44 64 48 47 61
Age 33.8(8.9) 35.3(10.1) 31.6(8.9) 34.8(11.4) 35 34.2(13.1) 37(15.5)
Married/ Cohabitating 28 38 44 NR NR 31 33
Education NR 31 low 24 hi 22 low 45 hi NR 5 low, 73 hi 46 uni M14.9 (2.0) yrs
Employed NR NR NR NR NR 39 NR
Duration 14.4(11.5) 14.4(11.7) 9.0(8.7) 11.4(8.7) NR NR 20.5(17.1)
Using Medication No No 27 ?Hypnotics 63 60 40
Comorbid Axis I NR NR NR 31.2 50 54 51
Comorbid Axis II NR NR NR 34 OCPD NR 17 NR
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ACT studies
CT
CT
CBT
EX
EX
ACT
ACT
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ACT studies
Social phobia study sample characteristics
Study/ Variable Clark et al (2006) Gruber et al (2001) Newman et al (1994) Stangier et al (2003) Turner et al (1994) Ossman et al (2006) Dalrymple Herbert (2007)
Female 44 52 50 49 61 50 53
Age 31.95(8.6) 41.7(8.2) 46.57(9.4) 38.8(10.5) 35.4 42.4 31(10)
Married/ Cohabitating 36 NR NR NR NR NR lt 19
Education 59 gt HS 31 lt HS NR NR 32 gt HS 66 lt HS NR NR 89 gt HS
Employed 81 NR NR NR NR NR 54
Duration 13.13(11.15) NR NR 56 gt 15y 19.2 38.7 NR
Using Medication 28 16 Excluded 6 0 NR 16
Comorbid Axis I 21 current NR NR 75 NR NR 48.6
Comorbid Axis II 56 NR NR 35 NR NR 59.5
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• Arch study only 25 sample primary GAD
• Error bars SD

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Demographics of ACT studies v CBT benchmarks
depression
Study/ Variable Unweighted CBT average Zettle Rains (1989) Forman et al (2007) Forman et al (2012) Peterson Zettle (2009) Folke et al (2012)
Female 69 (14.3) 100 76 79.5 42 94.4
Age 43.8 yrs (12.1) 41.3 27.9 26.7 (6.4) 36.7 (11.5) 40.6 yrs (10.14)
Married/ Cohabitating 53.8 (23.5) NR 34.7 49.3 8.3 83.3
Education 13.5 yrs (1.3) 14.1yrs NR NR 11.9 yrs (2.7) NR
Employed 53.4 (28.8) NR NR NR NR 0
Duration 8.8 yrs (5.6) NR NR NR NR NR
Using Medication 38.3 (21.7) NR NR 16.7 NR 77.8
Comorbid Axis I 28.4 (16.1) NR NR NB 34.8 DD NR NR
Comorbid Axis II 37.5 (25) NR NR NR NR NR
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ACT studies
Severe
Recovered

• CBT studies from Thoma et al (2012)
  meta-regression where trial quality score gt 24
  (55 Tx arms in 33 studies)
• error bars SEM

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Efficacy gt RCT benchmarks
Aggregated benchmarks calculated by Minami et al
(2007)
NB Below lower red dotted line No better than
natural remission
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Efficacy gt RCT benchmarks
Aggregated benchmarks calculated by Minami et al
(2007)
NB Below lower red dotted line No better than
natural remission
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ACT studies
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Demographics of ACT studies v CBT benchmarks pain
Study/ Variable Ersek et (2008) Spinhoven (2004) Leeuw (2008) Schmidt (2011) Jensen (2001) Wetherall (2011)
Female 87.2 64 48.2 100 45 50.9
Age 81.9 39.8 45.3 53.4 43.8 54.9
Married/ Cohabitating lt 25 80 NR 52.8 74 43.9
Education 71 gt 12 78 lt 10 43.5 lo 44.7 mid 21 hi 42 mid 17 gt 12 60 lt 12 44.7 gt 15
Employed NR 79 disability comp 36 emp 26 DSP 36 emp 38 retire 86 emp 29.8 emp 47.4 DSP
Duration NR 9.8 9.0 14.5 1.8 15.0
Using Medication NR NR 72 NR NR 95.6
Main Pain sites Legs, back, hips/buttock Lower back Lower back Fibro- myalgia Spinal pain Lower extremity, lower back, upper ext
n 114 130 42 53 49 57
ACT study
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Demographics of ACT studies v CBT benchmarks pain
ACT study
Study/ Variable Ersek et (2008) Spinhoven (2004) Leeuw (2008) Schmidt (2011) Jensen (2001) Thorsell et (2011)
Female 87.2 64 48.2 100 45 64.4
Age 81.9 39.8 45.3 53.4 43.8 46
Married/ Cohabitating lt 25 80 NR 52.8 74 64.4
Education 71 gt 12 78 lt 10 43.5 lo 44.7 mid 21 hi 42 mid 17 gt 12 60 lt 12 NR
Employed NR 79 disability comp 36 emp 26 DSP 36 emp 38 retire 86 emp 22 emp 62.2 S/L
Duration NR 9.8 9.0 14.5 1.8 NR
Using Medication NR NR 72 NR NR NR
Main Pain sites Legs, back, hips/buttock Lower back Lower back Fibro- myalgia Spinal pain NR
n 114 130 42 53 49 12
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Demographics of ACT studies v CBT benchmarks pain
ACT study
Study/ Variable Ersek et (2008) Spinhoven (2004) Leeuw (2008) Schmidt (2011) Jensen (2001) Wicksell et (2008)
Female 87.2 64 48.2 100 45 82
Age 81.9 39.8 45.3 53.4 43.8 48.2
Married/ Cohabitating lt 25 80 NR 52.8 74 64
Education 71 gt 12 78 lt 10 43.5 lo 44.7 mid 21 hi 42 mid 17 gt 12 60 lt 12 NR
Employed NR 79 disability comp 36 emp 26 DSP 36 emp 38 retire 86 emp 27 emp
Duration NR 9.8 9.0 14.5 1.8 7.0
Using Medication NR NR 72 NR NR NR
Main Pain sites Legs, back, hips/buttock Lower back Lower back Fibro- myalgia Spinal pain Neck
n 114 130 42 53 49 11
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ACT studies McCracken et al (2007) Vowles et al
(2008) Other 8 Tx groups from 4 studies (Leuw et
al, 2008 Ersek et al., 2008 Smeets et al.,
2008 Schmidt et al., 2011)
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McCracken et al (2007) Vowles et al (2008)
Johnston et al (2010)
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ACT for psychosis in context
Rehospitalisation CBT Control
Drury (2000) - 4 yrs FU 1.2 (1.4) 1.2 (1.4) ns
Bechdolf (2005) 2yrs FU 37.5 59.3 ns
Buchkremer (1999) 2yrs FU 38 50 ns
Penn et (2009) 1yr FU 18 11 ns
Jackson et (2008) 40 29.6 ns
Gaudiano Herbert (2006) ACT 28 45 ns
Bach et al (2012) 1yr FU ACT 40 TAU 80
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ACT studies
Psychosis study sample characteristics
Study/ Variable Buchkremer (1997) Kemp (1998) Pinto (1999) Guadiano (2006)
Female 42 48.7 70 36
Age 31.3 34 33.9 40
Married/ Cohabitating NR NR NR 12
Education NR NR 9.2 17 gt 12yrs 35 lt 12yrs
Employed NR NR NR 13 employed
Accommodation NR NR NR 29 homeless 12 own home
Duration of illness 8.4 8.5 11.6 NR
Chlorpromazine eq 4639 NR 735 NR
Hospitalisations 4.7 4.4 4.3 NR
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Error bars SD
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Psychosis study sample characteristics
ACT studies
Study/ Variable White et (2011) Shawyer et (2012) Bechdolf et (2005) Cather (2005) Haddock (2009) Valmaggia (2005) Penn (2009)
Female 29 29 46 25 14 23 47
Age 33.6 40 31.8 45.9 35.7 35.4 41.7
Married/ Cohabitating 7.1 NR 11.4 NR 3.9 7 NR
Education 36 gt12 36lt12 11.7 NR 13.1 NR 14 gt 12 68 lt12 12.8
Employed 0 19 13.6 NR NR 3 50
Accommodation NR 51 indep 44 indep NR 5.2 indep NR lt31 indep
Duration of illness NR 14.2 NR 24.9 NR 10.4 14
Chlorpromazine eq NR 742.9 NR 433 400-1000 NR NR
Hospitalisations NR NR NR NR NR 3.8 7.6
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Error bars SD
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Conclusions

• ACT for most conditions achieves outcomes within
  the range of average CBT studies (neither
  exceptionally better not worse) ?exception of
  social phobia
• Larger samples of ACT participants would be
  needed to have more confidence in the point
  prevalence estimates
• ACT researchers could contribute to efficient
  bench-marking through consistent reporting of
  essential demographic information.