Raimo Lappalainens and colleagues talk "The impact of an ACT-based Internet Treatment for Depressive symptom"

1. UNIVERSITY OF JYVÄSKYLÄ
The impact of an ACT-based
Internet Treatment for
Depressive symptom
Raimo Lappalainen, Anna Granlund,
Pä ivi Lappalainen
Department of Psychology
University of Jyvä skylä , Finland

2. UNIVERSITY OF JYVÄSKYLÄ
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.

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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

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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

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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

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Procedure

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Participant Characteristics:
Face-to-Face Internet (n=19)
(n=19)
Sex
Female 13 (68.4 %) 13 (68.4 %)
Male 6 (31.6 %) 6 (31.6 %)
Age (M, SD) 46.95 (12.26) 42.26 (16.04)
Education
9 years 1 (5.3 %) 3 (15.8 %)
12 years 9 (47.4 %) 7 (36.8 %)
University 9 (47.4 %) 9 (47.4 %)
Working/studying
Yes 8 (42.1 %) 9 (47.4 %)
No 11 (57.9 %9 10 (52.6 %)
Diagnosis
Yes 8 (42.1 %) 10 (52.6 %)
No 10 (52.6 %) 8 (42.1 %)
Other than depression 1 (5.3 %) 1 (5.3 %)
Depression medication
Yes 6 (31.6 %) 7 (36.8 %)
No 13 (68.4 %) 12 (63.2 %)

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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

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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

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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

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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

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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)

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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).

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Results
BDI-II SCL-90 GHQ Life
satisfaction
(0-100)
Face-to-Face
(n=19)
Pre 23.1 1.05 19.4 45.6
Post 9.0 0.64 10.7 56.3
F-up 6 mo 13.3 0.77 14.5 54.0
d=1.30 d=.65 d=.79 d=.50
Internet
(n=19)
Pre 20.8 1.11 22.3 39.1
Post 10.3 0.58 10.1 63.4
F-up 6 mo 8.7* 0.62 10.5* 67.0*
d=1.48 d=1.20 d=2.17 d=1.63
Between (d=.60) (d=.35) (d=.70) (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: vertailuryhmä nä Espoon kaupungin työ ntekijä t, joiden tulos on 0.60
GHQ General Health Questionnaire http://www.thl.fi/toimia/tietokanta/mittariversio/102/

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d=.60

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d=.72

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Results
AAQ-II KIMS ATQ ATQ WBSI
Mindfulness Automatic Automatic Thought
Thoughts: Thoughts: Suppression
How often? How much
believe?
Face-to-Face
(n=19)
Pre 39.0 120.5 77.0 74.8 46.8
Post 49.3 125.4 57.6 61.5 46.4
F-up 47.8 123.3 62.7 58.3 44.6
d=.84 d=18 d=.72 d=.83 d=.17
Internet
(n= 19)
Pre 41.2 120.0 74.8 70.1 49.8
Post 47.5 126.0 53.6 51.0 43.2
F-up 50.3 129.3 54.1 54.3 39.5
d=.97 d=.50 d=.97 d=.67 d=.98
Between (d=.24) (d=.32) (d=.43) (d=.19) (d=.40)

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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).

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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

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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