acceptance and commitment therapy: end state functioning dr matthew smout centre for treatment of...
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Acceptance and Commitment Therapy: End state functioningDr Matthew SmoutCentre for Treatment of Anxiety and DepressionSouth Australia
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
Bench-markingTypical 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
Clinical significance End-state functioning measured by clinical significance
Jacobson & Truax (1991) criteria: > 2 SDs improvement on pre-test mean < 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).
OCD Studies
0
5
10
15
20
25
30
35
40
Foa et al(2005)
vanOppen et
al(1995a)
Lindsayet al
(1997)
Cottrauxet al
(2001)
McLeanet al
(2001)
Franklinet al
(2000)
Tw ohiget al
(2010)
Study
Y-B
OC
S
Pre YBOCS M
Post YBOCS M
Non-clinical
“recovered”
Error bars = 1 SD
OCD Studies: RCI analysis
0%10%20%30%40%50%60%70%80%90%
100%
Foa et al(2005)
vanOppen et
al(1995a)
Lindsayet al
(1997)
Cottrauxet al
(2001)
McLeanet al
(2001)
Franklinet al
(2000)
Tw ohig etal (2010)
Study
Perc
enta
ges
Reliably Improved
Recovered
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 M=14.9
(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
OCD study sample characteristics
Social Phobia studies using SPAI
0
20
40
60
80
100
120
140
160
180
Clark et al(2006)
Gruber(2001)
Newman(1994)
Stangier(2003)
Turner(1994)
Dalrymple& Herbert
(2007)
Ossmanet al
(2006)
Study
SP
AI (
0-19
2)
Pre
Post
CT CBT EX EXCT
ACT ACT
ACT studies
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 < 19%
Education 59% > HS
31% < HS
NR NR 32% > HS
66% < HS
NR NR 89% > HS
Employed 81% NR NR NR NR NR 54%
Duration 13.13(11.15)
NR NR 56% > 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%
Social phobia study sample characteristicsACT studies
ACT for GAD benchmarking CBT: PSWQ
01020304050607080
Roemer et (2008) Arch et (2012) Wetherall et (2011) CBT aggregated
Study
PSW
Q (1
6-80
)
Pre
Post
• Arch study: only 25% sample primary GAD
• Error bars = SD
Benchmarking ACT for GAD against CBT: PSWQ Reliable change
0
20
40
60
80
100
Arch et (2012) Roemer et (2008) Wetherall et(2011)
Weighted averageCBT
Study
%
Reliably Improved
Recovered
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
ACT for depression studies pre-post benchmarked against CBT: BDI
0
5
10
15
20
25
30
35
Zettle &Rains(1989):
Forman et(2007)
Forman et(2012)
Peterson &Zettle (2009)
Folke et al(2012)
WeightedaverageCBT:
Study
BD
I (0
-63)
Pre
Post
• CBT studies from Thoma et al (2012) meta-regression where trial quality score > 24 (55 Tx arms in 33 studies)
• error bars: SEM
Severe
Recovered
ACT studies
ACT for depression in adults: benchmarked against CBT reliable change analysis self-report
0%
10%
20%
30%
40%
50%
60%
70%
Fledderuset al
(2011)Max Email
+ SH
Fledderuset al
(2011)Min Email
+ SH
Forman et(2007)
Forman et(2012)
Zettle &Rains(1989)
Folke et(2012)
CBTweightedaverage
Study
Pe
rce
nta
ge
(0
-10
0%
)
reliably improved
recovered
ACT for depression effect sizes benchmarked: BDI
0
0.5
1
1.5
2
2.5
TreatmentEfficacy ITT
TreatmentEfficacy
Completers
NaturalHistory
Zettle &Rains
(1989) CD
Forman et al(2007)
Forman et al(2012)
Peterson &Zettle(2009)
Folke et al(2012)
Study
Co
hen
's d
Aggregated benchmarks calculated by Minami et al (2007)
Efficacy > RCT benchmarks
NB: Below lower red dotted line: No better than natural remission
Aggregated benchmarks calculated by Minami et al (2007)
NB: Below lower red dotted line: No better than natural remission
ACT for depression effect sizes benchmarked: HRSD
0
0.5
1
1.5
2
2.5
3
TreatmentEfficacy ITT
TreatmentEfficacy
Completers
Natural History Zettle & Rains(1989) CD
Peterson &Zettle (2009)
Study
Eff
ect
size
(C
oh
en's
d) Efficacy > RCT benchmarks
ACT for pain: pain intensity effect sizes benchmarked
00.10.20.30.40.50.60.70.8
Ersek
(2008
)
Spinho
ven (2
004)
Leeu
w (200
8) E
XP
Leeu
w (200
8) G
A
Schm
idt (2
011)
Jens
en (2
001)
male
s
Jens
en (2
001)
fem
ales
Wick
sell (
2008
)
Wethe
rall (
2011)
Thors
ell (20
11)
John
ston
(201
0)
Mo't
amedi
(201
2)
Dahl (2
004)
Eff
ect
size
(C
oh
en's
d)
ACT studies
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
< 25% 80% NR 52.8% 74% 43.9%
Education 71% > 12 78% < 10 43.5% lo
44.7% mid
21% hi
42% mid
17% > 12
60% < 12
44.7% > 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
Demographics of ACT studies v CBT benchmarks pain
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
< 25% 80% NR 52.8% 74% 64.4%
Education 71% > 12 78% < 10 43.5% lo
44.7% mid
21% hi
42% mid
17% > 12
60% < 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
ACT study
Demographics of ACT studies v CBT benchmarks pain
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
< 25% 80% NR 52.8% 74% 64%
Education 71% > 12 78% < 10 43.5% lo
44.7% mid
21% hi
42% mid
17% > 12
60% < 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
ACT study
Pain disability: Reliable Improvement
0
5
10
15
20
25
30
35
40
45
50
ACT Other psychotherapy
Wei
gh
ted
ave
rag
e %
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)
ACT pain studies: meta-prevalence of reliable and clinically significant change
0
20
40
60
Depression Pain anxiety
Parameter
Aver
age
wei
ghte
d %
Reliably Improved
Recovered
McCracken et al (2007); Vowles et al (2008); Johnston et al (2010)
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%
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% > 12yrs
35% < 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
Psychosis study sample characteristicsACT studies
Error bars = SD
ACT for psychosis benchmarked against CBT: BPRS
18
38
58
78
98
118
Buchkremer (1997)[n=147]
Kemp (1998) [n=39] Pinto (1999) [n=19] Gaudiano (2006)[n=21]
Study
BPRS
(18-
126)
Pre
Post
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% >12
36%<12
11.7 NR 13.1 NR 14% > 12
68% <12
12.8
Employed 0% 19% 13.6% NR NR 3% 50%
Accommodation NR 51% indep
44% indep
NR 5.2% indep
NR <31% 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
Psychosis study sample characteristicsACT studies
ACT studies Psychosis benchmarked against CBT: PANSS-P
79
1113151719212325
White et(2011)[n=14]
Shawyer et(2012)[n=18]
Bechdolf et(2005)[n=40]
Cather(2005)[n=15]
Haddock(2009)[n=77]
Valmaggia(2005)[n=35]
Penn (2009)[n=32]
PANS
S-Po
sitive
(7-49
)
Pre
Post
Error bars = SD
ACT studies Psychosis benchmarked against CBT: PANSS-N
79
1113151719212325
White et(2011)[n=14]
Shawyer et(2012)n=18]
Bechdolf et(2005)[n=40]
Cather(2005)[n=15]
Haddock(2009)[n=77]
Valmaggia(2005)[n=35]
Penn (2009)[n=32]
PANS
S-N
(7-4
9)
Pre
Post
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.