Abstract
To the Editor
In spite of new advances in therapeutic options for major depression, there is a minority of people who continually fail to respond to repeated and adequate trials of treatment. Instead, they exhibit a chronic and at times deteriorating course of disease. In such individuals, persistent treatment is often not beneficial. Thus, realigning the aim of treatment from cure to maximization of quality of life and optimization of function in the context of limitations may provide a more realistic alternative (Berk et al., 2008; Berk et al., 2012).
In the service of this aim, the use of acceptance and commitment therapy (ACT) is an emerging option. ACT is one of the ‘new wave’ of approaches of cognitive behavioral therapy (Hofmann et al., 2010). ACT fosters acknowledgement and acceptance of negative thoughts and emotions and discourages experiential avoidance. The expectation is that once the patient’s struggle with unwanted thoughts and emotions has been reduced, it will be easier to focus on realistic plans and goals. ACT also aims to assist in setting goals and acting on these goals. With this, ACT endeavours to improve psychological flexibility – one’s ability to adaptively navigate across changing environmental conditions.
Accumulating evidence shows ACT to be effective in reducing depressive symptoms. We argue that it is conceptually viable as a treatment option specifically targeted to patients in the later stages of depression (Bohlmeijer et al., 2011; Forman et al., 2007). In this letter, we report the results of an audit performed on the effectiveness of ACT in a group of patients with treatment-resistant depression.
Nineteen patients were provided with a manualized ACT intervention within a group setting in a private psychiatric facility, the Geelong Clinic. While no formal inclusion and exclusion criteria were used in this audit, the intervention was targeted at individuals with treatment-refractory mood and anxiety disorders. The intervention consisted of four weekly sessions, each lasting 3 h, with an average of six patients in each group. Therapy was provided by trained licensed psychologists. The material covered the principles of fusion and defusion, mindfulness of breath, values and goal determination, and committed action (Harris, 2009).
A number of scales were routinely used to monitor the effectiveness of the treatment. The second version of the Acceptance and Action Questionnaire (AAQ-II) is a measure of psychological flexibility created by ACT therapists to verify the therapy’s effectiveness and is correlated with depressive symptoms (Hayes et al., 2004). The Self-Compassion scale is commonly used to measure the efficacy of therapies based on mindfulness and is also correlated with anxiety and depressive symptoms (Neff et al., 2007). Pre- and post-assessments were conducted separate to the therapy sessions.
A paired-sample Student’s t-test was conducted to compare patients’ scores on the AAQ-II and Self-Compassion scales pre- and post-ACT (Table 1). There was a significant increase (M diff = 5.79) in the AAQ-II scores post- compared to pre-treatment; t(18) = 3.866, p = 0.001. There was also a global increase in patients’ rating on the Self-Compassion scale post- compared to pre-treatment [M diff = 0.28, t(18) = −2.330, p = 0.032]. Specifically, improvements were seen on the Self-Kindness, Common Humanity and Mindfulness subscales (see Table 1).
Mean difference between pre- and post-assessments on the AAQ-II and Self-Compassion scales
Mean difference reflects post- and pre-assessment scores. bTwo-tailed.
P < 0.05; **P < 0.01. AAQ-II: Acceptance and Action Questionnaire (second version).
This audit suggests the potential benefits of ACT for patients with treatment-resistant depression. Improvements were most pronounced on the clinically relevant scales of Self-Kindness, Self-Compassion and Mindfulness. This provides support for the assertion that treatment garnered towards self-care and acceptance can achieve therapeutic gains for patients with persistent, ongoing depression (Berk et al., 2008; Berk et al., 2012). As a pilot study, it suggests the need for more comprehensive research into ACT as a stage-based therapy for treatment-resistant depression (Berk et al., 2007).