Lappalainen depression

UNIVERSITY OF JYVÄSKYLÄ

The impact of an ACT-based Internet Treatment for Depressive

symptom

Raimo Lappalainen, Anna Granlund,

Päivi Lappalainen

Department of Psychology

University of Jyväskylä, Finland


Introduction

Depression is common, affecting about 121 million people worldwide

Depression is among the leading causes of disability worldwide.

Fewer than 25 % of those affected have access to effective treatments

There is a need to develop alternative approaches to help clients with depression.


Aim

We developed a web-based ACT-treatment program (6 weeks) for clients experiencing depressive symptoms, and compared it to a 6 week face-to-face ACT-based treatment


Method

We had an advertisement in the local newspaper seeking clients experiencing depressive symptoms

60 persons contacted the clinic and were interviewed in the telephone

38 participants were randomized to either a 6 week face-to-face or a 6 week Internet based ACT-treatment program

The treatment was delivered by 18 psychology students with no previous experience of ACT

Each student therapist had one face-to-face and one net client


Criteria for eligibility Depression: 3 questions about depression:

1) Have you experienced depressed mood most of the day, nearly every day (e.g., feels sad or irritable) without knowing why

2) Have you had periods with markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

3) Have you had periods of several days, when you have felt so depressed that nothing can make you feel better

No simultaneous attendance in another treatment Basic computer skills and access to the Internet


Procedure

UNIVERSITY OF JYVÄSKYLÄParticipant Characteristics:

Face-to-Face (n=19) Internet (n=19)

Sex Female Male

13 (68.4 %)6 (31.6 %)

13 (68.4 %)6 (31.6 %)

Age (M, SD) 46.95 (12.26) 42.26 (16.04)

Education 9 years 12 years University

1 (5.3 %)9 (47.4 %)9 (47.4 %)

3 (15.8 %)7 (36.8 %)9 (47.4 %)

Working/studying Yes No

8 (42.1 %)11 (57.9 %9

9 (47.4 %)10 (52.6 %)

Diagnosis Yes No Other than depression

8 (42.1 %)10 (52.6 %)1 (5.3 %)

10 (52.6 %)8 (42.1 %)1 (5.3 %)

Depression medication Yes No

6 (31.6 %)13 (68.4 %)

7 (36.8 %)12 (63.2 %)


Therapists

The study was conducted as a part the psychotherapy training given to master’s level students in psychology. In general, the students had no experience or very little experience in carrying out psychological treatment Each therapist was responsible for 2 clients in each group. The mean age of the 18 student therapists was 26.2 years (range 21-34).

All student therapists had received 13 hours training in Acceptance & Commitment Therapy

Used handbooks Supervision 3 hours/week, and student peer-group

meeting weekly


The web-based treatment program

Included 1 face-to-face sessions at the beginning and 1 at the end (measurements and case formulation) and weekly contact with the therapist (feedback on homework), approx. 40 min/week (20-90 min), the majority of the clients used less than 2 hours/weekly the web intervention


The web-based treatment program

Consisted of 6 modules (one module per week), mostly text (information, exercises, homework) pictures and a few taped exercises

Each module included homework each week which the clients completed and placed in their own folder in the treatment platform

The modules were based on the core processes of ACT: Values, value-based actions, acceptance, cognitive fusion, contact with the present moment and self-as-context


Face-to-face treatment

6 x 60 min during a 6 week period Individual behavioral analysis (case formulation) Value work: description of values, discussion of values

and BA, discussion of commitment to value based actions

Discussions about control and acceptance Experiential exercises, such as mindfulness exercises,

the observer exercise, metaphors Other exercises depending on the problems Homework assignments


Face-to-Face treatment

The student therapists used altogether 27 exercises and 31 metaphors during the sessions.

The clients completed on average 9.11 exercises (SD=3.69; range 2-15) and heard 6.50 metaphors (SD= 4.09; range 1-13) during the whole treatment (1 assessment + 5 intervention sessions)


Students confidence of the intervention

The student therapists were moderately confident both with functional analysis (M=6.78; SD= 1.06) and with ACT (M=6.89; SD=0.96) on a scale 0-10, whereas the acceptance of the principles and methods of ACT were rated higher (M= 8.28, SD= 0.83).


ResultsBDI-II

SCL-90 GHQ Life satisfaction(0-100)

Face-to-Face (n=19) Pre PostF-up 6 mo

23.19.013.3d=1.30

1.050.640.77d=.65

19.410.714.5d=.79

45.656.354.0d=.50

Internet (n=19) Pre PostF-up 6 mo

Between

20.810.38.7* d=1.48(d=.60)

1.110.580.62 d=1.20(d=.35)

22.310.110.5*d=2.17(d=.70)

39.163.467.0*d=1.63(d=.72)

Mittareista: BDI rajat:0–13: ei lainkaan masennusta; 14–19: lievä masennus; 20–28: keskivaikea masennus; 29–63: vakava masennus.SCL-90:, Symptom Check List-90: vertailuryhmänä Espoon kaupungin työntekijät, joiden tulos on 0.60GHQ General Health Questionnaire http://www.thl.fi/toimia/tietokanta/mittariversio/102/


d=.60


d=.72


ResultsAAQ-II KIMS

MindfulnessATQAutomatic Thoughts:How often?

ATQAutomatic Thoughts: How much believe?

WBSIThought Suppression

Face-to-Face (n=19)PrePostF-up

39.049.347.8d=.84

120.5125.4123.3d=18

77.057.662.7d=.72

74.861.558.3d=.83

46.846.444.6d=.17

Internet (n= 19)PrePostF-up

Between

41.247.550.3d=.97(d=.24)

120.0126.0129.3d=.50(d=.32)

74.853.654.1d=.97(d=.43)

70.151.054.3d=.67(d=.19)

49.843.239.5d=.98(d=.40)


Client’s experiences of the web-intervention

The Compass is great! And the materials are excellent! I have printed out all the texts, exercises and metaphors and I’m going to organize them into a folder. I really appreciate the treatment philosophy: one must take the responsibility and lead one’s life into valued direction. Years of going to therapy and talking about the problems didn’t help me at all but I found this very useful. Thanks for allowing me to participate (225).


Conclusions

A 6 week Internet-based ACT treatment including 2 (face-to-face) session was as effective as a face-to-face treatment

Indications that an internet-based treatment may have better treatment effect after the active treatment period than a face-to-face treatment

The student delivered ACT-based Internet treatment was well accepted by the clients


Limitations

Students as therapists Very limited training both in psychotherapy and in ACT All subjects did not have depression diagnoses Relatively small number of subjects Relatively short follow-up time

Lappalainen depression

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