Michael E. Levin,Utah State University
Steven C. Hayes, Jacqueline Pistorello,University of Nevada Reno
John Seeley,Oregon Research Institute
Preventing Mental Health Problems in College Students through Web-Based ACT
The ACT on College Life project is supported by a Small Business Innovation Research grant awarded to Contextual Change LLC National Institute of Mental Health - R43 MH085336 Intended to eventually lead to a commercial product
DISCLOSURE
Depression and anxiety disorders among college students are prevalent and costly
Effective prevention approaches have been developed, but are rarely implemented by colleges and universities
Challenges to implementation include Students are at risk for a range of disorders, but programs are
generally disorder-specific Costs of implementation, training, and supervision for face-to-face
interventions
Mental Health Challenges in the College Population
Blanco et al., 2008; Kessler et al., 2005
Transdiagnostic web-based prevention Target a range of disorders with a single program Easy and cost effective to implement
Psychological inflexibility is a common risk factor across disorders
Psychological inflexibility can be targeted with ACT to produce clinical improvements
Can ACT be used to target psychological inflexibility to prevent disorders from developing? And can it be done using a readily disseminable method?
ACT AS A TRANSDIAGNOSTIC WEB-BASED PREVENTION APPROACH
Lesson 1: Exploring your values Defining what values are Clarifying and reflecting on personal
values Defining effective and values-based goals Goal setting
Lesson 2: Dealing with barriers Exploring internal barriers to values-
based action The problem with control strategies Defining and practicing willingness Linking willingness to values-based action
ACT-CL Lesson Content
Pilot RCT with 76 first-year college studentsRandomized to ACT-CL or waitlist
ACT-CL was acceptable to usersACT-CL impacted ACT knowledge and values
processes But not psychological inflexibility
ACT-CL impacted depression and anxiety among distressed students
Failed to replicate effects with waitlist condition
Initial Pilot Results with ACT-CL
Levin, Pistorello, Hayes & Seeley, 2014
Feasibility RCT comparing ACT-CL to an active control website (mental health education)Replicating/extending testing of acceptability and
potential efficacy
Universal prevention approach with broad sample of undergraduate students
Current Study Overview
• 234 undergraduate college students from UNR• Eligible if undergraduate, fluent in English and 18 or older• Recruited through Psychology classes, flyers on campus, SONA
• Demographics• 77% Female• 76% White; 24% ethnic/racial minority• Median age of 20 (Range = 18 – 58)• Year in school: 29% first year student, 37% second or third year,
35% fourth year or higher
Measures completed at baseline, post, 1-month and 3-month follow up
Participants automatically randomized to condition after completing baseline assessment
Participants and Procedures
Outcome measures Depression, Anxiety, Stress Scale (DASS-21) Mental Health Continuum (MHC)
Process measures Avoidance and Fusion Questionnaire (AFQ) Personal Values Questionnaire (PVQ) Five Facet Mindfulness Questionnaire (FFMQ)
Acting with awareness and Nonreactivity subscales ACT Knowledge System Usability Scale (SUS)
Measures
Two core multimedia lessons and follow up emails Identical to the content included in the initial pilot trial
Web-based mindfulness resources Sent as a link after users completed each lesson Focused on targeting present moment awareness and defusion
Optional text messages Sent 3 and 6 days after users finished each lesson Focused on strengthening and generalizing ACT skills
Email and phone call reminders
ACT on College Life
MULTIMEDIA ELEMENTS
INTERACTIVE ELEMENTS
EXAMPLE: VALUES CARD SORT
EXAMPLE: VALUES CARD SORT
PROGRAM TAILORING
Basic educational information about depression and anxiety Symptoms, causes and prevalence of disorders Basic and brief information on coping strategies Lesson 1 – Depression Lesson 2 – Stress and Anxiety
Content taken from halfofus.com and ulifeline.com Excluded more active intervention content (i.e.,
celebrities describing experiences) and content targeting psychological flexibility processes
Primarily text-based with some illustrations and quizzes
Healthy Living: Active Control Website
Significantly lower program completion rates with ACT-CL compared to control condition and initial pilot trial
ACT-CL program usage Only 36.4% requested to receive text messages Only 16.4% accessed the mindfulness resources at least once
ACT-CL Control
Pilot ACT-CL
Lesson 1 completed
85% 100% 97%
Lesson 2 completed
55% 86% 92%
Relatively Poor Program Engagement in ACT-CL
Significantly higher rating for ACT-CL in the initial pilot
Single item satisfaction ratings were significantly lower in ACT-CL compared to control website on Overall satisfaction Willingness to use the program again Perceived helpfulness for students Whether would recommend the program to others
ACT-CL Control Pilot ACT-CLSUS M (SD) 73.41 (19.72) 72.63 (17.54) 84.97 (9.89)
Low Satisfaction Ratings with ACT-CL
Tested time by condition interaction effects in mixed model repeated measures ANOVAs
Greater pre to post improvements in ACT knowledge in the ACT-CL condition (p < .001, Cohen’s d = 1.23)
No other significant between group effects
Program Completer Analyses
Similar pattern of results except Greater pre to 3-month improvement in education values success
in the control condition (p = .088, Cohen’s d = .23)
Lower remission rates of severe depression/anxiety symptoms in ACT-CL among those with severe symptoms at baseline Higher rate of severe symptoms at post (χ2 = 3.80, p = .051,
Cohen’s d = .26) and 3-month follow up (χ2 = 2.79, p = .095, Cohen’s d = .22).Severe distress at
baselinePost 1-
month3-month
ACT-CL (n = 19) 79% 68% 63%Control (n = 24) 50% 46% 38%
Intent-To-Treat Analyses
Analyses conducted among the following subgroups: No, mild or high levels of distress Higher or lower psychological inflexibility First year or non-first year students Male or female Minority or non-minority
No consistent between group effects for any of the subgroups
Program satisfaction and engagement did not differ by subgroup
Subgroup Analyses
Pre to post AFQ improvements related to 1-month improvements in depression, anxiety, stress, positive mental health and values successPartial correlations (controlling for baseline outcome) coefficients
ranging between .15 and .28
Improvements in ACT knowledge related to 1-month improvements in inflexibility (r = .43) and mindfulness (r = .23)ACT-CL arm only
Testing the Psychological Flexibility Model
Time on Lessons Time on ACT-CL lesson 1 related to improvements at post on
inflexibility, values and mindfulness Time on control lessons not related to post improvements
Word CountValues writing word count related to post improvements on
mindfulness and valuesLesson 1 goal setting word count related to post improvements on
values Lesson 2 goal setting word count related to post improvements on
inflexibility, mindfulness, and values
Text messages Participants receiving text messages improved more at post on
inflexibility, mindfulness and values
Relationship Between Program Engagement and Changes in Flexibility
ACT-CL prototype had relatively low acceptability/usabilityNo consistent differences by subgroups on impact, usage or
acceptabilityTechnology failure for ACT-CL prototype Failure to differentially impact outcome or process measures May be due to the use of a limited prototype intervention, poor
program engagement and/or strong active condition
Support found for the psychological flexibility model Improvements in flexibility predicted improvements in outcomes
Engagement in ACT-CL predictive of improvements in psychological inflexibility
Summary
Surprisingly low engagement/satisfaction given sophistication and development resources with ACT-CL
Some users disliked these more sophisticated elements Particularly the tunneled format, use of audio narration, and the
program seeming targeted to a younger audience
Students appeared to like a text driven approach
Differences between current and pilot trial may be due to differences in degree of personal contact and compensation
Low Program Engagement/Satisfaction for ACT-CL
Further research is needed on how to transport ACT to web-based prevention and how to increase user engagement
Integrating text messaging and mobile app features
Incentivizing participation and promoting adherence
Balancing sophisticated elements with more simple, text-driven elements within a flexible user interface
Prototype testing and iterative design
Future Directions
Thank You!
