Effectiveness of acceptance and commitment therapy for inpatients with psychosis: Implementation feasibility and acceptability from a pilot randomized controlled trial.

OBJECTIVE: Acceptance and Commitment Therapy for Inpatients (ACT-IN) with psychosis has been found to be efficacious in previous trials, but its effectiveness has not been studied when implemented by frontline clinicians in routine settings. METHOD: In this pilot randomized controlled effectiveness trial, inpatients with schizophrenia-spectrum disorders were randomized to ACT-IN plus treatment as usual (TAU) (n = 23) or a time/attention matched (TAM) supportive condition plus TAU (n = 23) delivered by routine hospital staff. Both conditions received individual and group therapy during inpatient care and completed follow-up phone sessions during the first month post-discharge. Patients were assessed through 4 months post-discharge (blinded to condition) to determine feasibility, acceptability, and preliminary effectiveness of ACT-IN. RESULTS: ACT-IN was feasible to deliver with fidelity by frontline staff when integrated into an acute care setting. At post-treatment, patients reported significantly greater treatment satisfaction in ACT-IN relative to TAM. Overall, results showed significant but similar improvements for both conditions through 4-month follow-up in psychiatric symptoms, functioning, and mindfulness. Only ACT-IN improved over time in distress. Furthermore, patients receiving TAM had a 3.76 times greater risk of rehospitalization over 4 months compared with ACT-IN. CONCLUSIONS: ACT-IN is feasible and acceptable for patients with psychosis, can be implemented by hospital staff when integrated into acute treatment, and may result in decreased rehospitalization compared to alternative therapies. A future full-scale randomized-controlled implementation trial is warranted. CLINICALTRIALS: gov Identifer: NCT02336581.

Yoga v. health education for attentional processes relevant to major depressive disorder.

OBJECTIVES: Research has shown that yoga may be an effective adjunctive treatment for persistent depression, the benefits of which may accumulate over time. The objectives of this study were to evaluate the following in a sample of persistently depressed individuals: whether yoga increases mindfulness and whether yoga attenuates rumination. Rumination and mindfulness both represent attentional processes relevant for onset and maintenance of depressive episodes. METHODS: One-hundred-ten individuals who were persistently depressed despite ongoing use of pharmacological treatment were recruited into an RCT comparing yoga with a health education class. Mindfulness and rumination were assessed at baseline and across 3 time points during the ten-week intervention. RESULTS: Findings demonstrate that, compared to health education, yoga was associated with higher mean levels of the observe facet of mindfulness relative to the control group during the intervention period (p =.004, d =0.38), and that yoga was associated with a faster rate of increase in levels of acting with awareness over the intervention period (p= .03, f2 =0.027). There were no differences between intervention groups with respect to rumination. CONCLUSIONS: Results suggest a small effect of yoga on components of mindfulness during a 10-week intervention period. Previous research suggests that continued assessment after the initial 10 weeks may reveal continued improvement. Future research may also examine moderators of the impact of yoga on mindfulness and rumination, including clinical factors such as depression severity or depression chronicity, or demographic factors such as age.

Weekly assessment of number of yoga classes and amount of yoga home practice: Agreement with daily diaries.

OBJECTIVE: To evaluate a weekly yoga practice assessment instrument designed to assess number of classes attended in the previous week, number of times engaged in formal home yoga practice, total number of minutes engaged in formal home yoga practice in the past week, and number of times engaged in informal home yoga practice. "Informal" practice was defined as "in the middle of other activities, you spent a few moments engaged in asanas/postures, focus on breath, body awareness, or very brief meditation, for less than 5 min at a time." We assessed agreement between this weekly assessment and a daily home practice log. DESIGN AND SETTING: Seventy-two community yoga practitioners completed online daily yoga logs for 28 days as well as the weekly yoga practice assessment four times over the 28 day period. RESULTS: We examined agreement between the two methods on the four indices of amount of weekly yoga practice. We found acceptable agreement between the two methods for number of classes, number of times engaged in formal home practice, and total number of minutes engaged in formal home practice. Agreement was lower for number of times engaged in informal practice. CONCLUSIONS: These data provide support for use of a weekly yoga practice assessment to assess number of classes attended and amount of formal but not informal home practice.

Development of a Storytelling Video Self-Help Intervention Based on Acceptance and Commitment Therapy for Major Depression: Open Trial Results.

This study involved the initial development and testing of a video self-help intervention called LifeStories, which features real patients describing their use of coping strategies for depression based on Acceptance and Commitment Therapy. We conducted a baseline-controlled open trial (AB design) of 11 individuals diagnosed with major depressive disorder. Participants reported high levels of satisfaction and transportation (i.e., engagement) after watching LifeStories. No significant changes were observed during the 4-week baseline period in terms of interviewer-rated depression severity (primary outcome), but a significant and large effect size improvement was observed at Week 8 postintervention. The majority of participants (54.5%) showed a reliable and clinically significant posttreatment response. Significant improvements also were observed during the intervention period only for self-reported depressive symptoms and aspects of mindfulness (nonreactivity). Qualitative data analysis of participant interviews identified additional areas for improvement and refinement. Future testing in a randomized trial is warranted based on these encouraging results.

Treatment credibility, expectancy, and preference: Prediction of treatment engagement and outcome in a randomized clinical trial of hatha yoga vs. health education as adjunct treatments for depression.

BACKGROUND: Hatha yoga may be helpful for alleviating depression symptoms. The purpose of this analysis is to determine whether treatment program preference, credibility, or expectancy predict engagement in depression interventions (yoga or a control class) or depression symptom severity over time. METHODS: This is a secondary analysis of a randomized controlled trial (RCT) of hatha yoga vs. a health education control group for treatment of depression. Depressed participants (n = 122) attended up to 20 classes over a period of 10 weeks, and then completed additional assessments after 3 and 6 months. We assessed treatment preference prior to randomization, and treatment credibility and expectancy after participants attended their first class. Treatment "concordance" indicated that treatment preference matched assigned treatment. RESULTS: Treatment credibility, expectancy, and concordance were not associated with treatment engagement. Treatment expectancy moderated the association between treatment group and depression. Depression severity over time differed by expectancy level for the yoga group but not for the health education group. Controlling for baseline depression, participants in the yoga group with an average or high expectancy for improvement showed lower depression symptoms across the acute intervention and follow-up period than those with a low expectancy for improvement. There was a trend for a similar pattern for credibility. Concordance was not associated with treatment outcome. LIMITATIONS: This is a secondary, post-hoc analysis and should be considered hypothesis-generating. CONCLUSIONS: Results suggest that expectancy improves the likelihood of success only for a intervention thought to actively target depression (yoga) and not a control intervention.

Perceptions of hatha yoga amongst persistently depressed individuals enrolled in a trial of yoga for depression.

OBJECTIVES: To understand depressed individuals' experiences in a 10-week hatha yoga program. DESIGN: In a randomized controlled trial, participants were assigned to either 10 weeks of hatha yoga classes or a health education control group. This report includes responses from participants in yoga classes. At the start of classes, average depression symptom severity level was moderate. MAIN OUTCOME MEASURES: After 10 weeks of yoga classes, we asked participants (n=50) to provide written responses to open-ended questions about what they liked about classes, what they did not like or did not find helpful, and what they learned. We analyzed qualitative data using thematic analysis. RESULTS AND CONCLUSIONS: Elements of yoga classes that may increase acceptability for depressed individuals include having instructors who promote a non-competitive and non-judgmental atmosphere, who are knowledgeable and able to provide individualized attention, and who are kind and warm. Including depression-related themes in classes, teaching mindfulness, teaching breathing exercises, and providing guidance for translating class into home practice may help to make yoga effective for targeting depression. Participants' comments reinforced the importance of aspects of mindfulness, such as attention to the present moment and acceptance of one's self and one's experience, as potential mechanisms of action. Other potential mechanisms include use of breathing practices in everyday life and the biological mechanisms that underlie the positive impact of yogic breathing. The most serious concern highlighted by a few participants was the concern that the yoga classes were too difficult given their physical abilities.

Acceptance and Commitment Therapy for Inpatients with Psychosis (the REACH Study): Protocol for Treatment Development and Pilot Testing.

Patients with schizophrenia-spectrum disorders frequently require treatment at inpatient hospitals during periods of acute illness for crisis management and stabilization. Acceptance and Commitment Therapy (ACT), a "third wave" cognitive-behavioral intervention that employs innovative mindfulness-based strategies, has shown initial efficacy in randomized controlled trials for improving acute and post-discharge outcomes in patients with psychosis when studied in acute-care psychiatric hospitals in the U.S. However, the intervention has not been widely adopted in its current form because of its use of an individual-only format and delivery by doctoral-level research therapists with extensive prior experience using ACT. The aim of the Researching the Effectiveness of Acceptance-based Coping during Hospitalization (REACH) Study is to adapt a promising acute-care psychosocial treatment for inpatients with psychosis, and to pilot test its effectiveness in a routine inpatient setting. More specifically, we describe our plans to: (a) further develop and refine the treatment and training protocols, (b) conduct an open trial and make further modifications based on the experience gained, and

Investigating the Role of Acceptance, Mindfulness, and Values in Patients with Psychosis in the Context of Depression.

BACKGROUND: Emerging research suggests that interventions incorporating acceptance, mindfulness, and values clarification elements are efficacious when treating patients experiencing major depression with psychotic features. However, there is little research on how these psychological constructs relate to symptoms and functioning in this population to guide future intervention efforts. METHODS: Patients with psychotic symptoms (hallucinations and/or delusions) occurring in the context of a major depressive episode (N = 29) were recruited primarily during a psychiatric hospitalization and assessed using a battery of self-report and interviewer-rated measures. RESULTS: Psychological acceptance was correlated with hallucination severity, behavioral activation, and family functioning; mindfulness was correlated with depression severity and behavioral activation; and values-action consistency was correlated with family functioning. Significant associations between acceptance, mindfulness, and values remained in most cases in multivariate analyses after controlling for the presence of the other variables and accounted for large amounts of variance. CONCLUSIONS: Although requiring future replication due to the sample size, findings support the conclusion that acceptance, mindfulness, and values appear to have meaningful and somewhat unique associations with important aspects of symptoms and functioning in individuals with psychotic depression. Potential treatment targets and mechanisms of psychosocial interventions are discussed.

A pilot randomized controlled trial comparing prenatal yoga to perinatal health education for antenatal depression.

We conducted a pilot randomized controlled trial (RCT) comparing a prenatal yoga intervention to perinatal-focused health education in pregnant women with depression. Findings document acceptability and feasibility of the yoga intervention: no yoga-related injuries were observed, instructors showed fidelity to the yoga manual, and women rated interventions as acceptable. Although improvements in depression were not statistically different between groups, they favored yoga. This study provides support for a larger scale RCT examining prenatal yoga to improve mood during pregnancy.

Acceptance-based Behavior Therapy for Depression With Psychosis: Results From a Pilot Feasibility Randomized Controlled Trial.

Acceptance-based depression and psychosis therapy (ADAPT), a mindfulness/acceptance-based behavioral activation treatment, showed clinically significant effects in the treatment of depression with psychosis in a previous open trial. The goal of the current study was to further test the feasibility of ADAPT to determine the utility of testing it in a future clinical trial, following a stage model of treatment development. Feasibility was determined by randomizing a small number of patients (N=13) with comorbid depression and psychosis to medication treatment as usual plus enhanced assessment and monitoring versus ADAPT for 4 months of outpatient treatment. Both conditions were deemed acceptable by patients. Differences in between-subjects effect sizes favored ADAPT posttreatment and were in the medium to large range for depression, psychosocial functioning, and experiential avoidance (ie, the target mechanism). Thus ADAPT shows promise for improving outcomes compared with medications alone and requires testing in a fully powered randomized trial.

Potential for prenatal yoga to serve as an intervention to treat depression during pregnancy.

BACKGROUND: When left untreated, antenatal depression can have a serious negative impact on maternal, and infant outcomes. Many affected women do not obtain treatment for depression owing to difficulties accessing care or because they do not find standard antidepressant treatments to be acceptable during pregnancy. This study examined the acceptability and feasibility of a gentle prenatal yoga intervention, as a strategy for treating depression during pregnancy. METHODS: We developed a 10-week prenatal yoga program for antenatal depression and an accompanying yoga instructors' manual, and enrolled 34 depressed pregnant women from the community into an open pilot trial. We measured change in maternal depression severity from before to after the intervention. RESULTS: Results suggested that the prenatal yoga intervention was feasible to administer and acceptable to the women enrolled. No study-related injuries or other safety issues were observed during the trial. On average, participants' depression severity decreased significantly by the end of the intervention based on both observed-rated and self-report depression assessment measures. CONCLUSION: The current study suggests that prenatal yoga may be a viable approach to addressing antenatal depression, one that may have advantages in terms of greater acceptability than standard depression treatments. Research and policy implications are discussed.

An open trial of a new acceptance-based behavioral treatment for major depression with psychotic features.

Research suggests that cognitive and behavioral therapies produce significant benefits over medications alone in the treatment of severe, nonpsychotic major depression or primary psychotic disorders such as schizophrenia. However, previous research has not demonstrated the efficacy of psychotherapy for major depression with psychotic features. In this initial treatment development study, we conducted an open trial of a new behavioral intervention that combines elements of behavioral activation and acceptance and commitment therapy for depression and psychosis. Fourteen patients with major depressive disorder with psychotic features were provided with up to 6 months of Acceptance-Based Depression and Psychosis Therapy (ADAPT) in combination with pharmacotherapy. Patients reported a high degree of treatment credibility and acceptability. Results showed that patients achieved clinically significant and sustained improvements through posttreatment follow-up in depressive and psychotic symptoms, as well as psychosocial functioning. In addition, the processes targeted by the intervention (e.g., acceptance, mindfulness, values) improved significantly over the course of treatment, and changes in processes were correlated with changes in symptoms. Results suggest that ADAPT combined with pharmacotherapy is a promising treatment approach for psychotic depression that should be tested in a future randomized trial.

A randomized controlled trial of cognitive-behavioral treatment for depression versus relaxation training for alcohol-dependent individuals with elevated depressive symptoms.

OBJECTIVE: A previous pilot study found positive outcomes among alcohol-dependent individuals with elevated depressive symptoms who received cognitive-behavioral treatment for depression (CBT-D; n = 19) compared with a relaxation training control (RTC; n = 16). The current study represents a replication of this pilot study using a larger sample size and a longer follow-up assessment period. METHOD: Patients entering a partial hospital drug and alcohol treatment program who met criteria for alcohol dependence and elevated depressive symptoms (Beck Depression Inventory score ≥ 15) were recruited and randomly assigned to receive eight individual sessions of CBT-D (n = 81) or RTC (n = 84). RESULTS: There were significant improvements in depressive and alcohol use outcomes over time for all participants.Compared with RTC, the CBT-D condition had significantly lower levels of depressive symptoms, as measured by the Beck Depression Inventory, at the 6-week follow-up. However, this effect was inconsistent because there were no differences in the Modified Hamilton Rating Scale for Depression between conditions at that time point and there were no significant differences at any other follow-up. No significant between-group differences on alcohol use outcomes were found. CONCLUSIONS: The current findings did not replicate the positive outcomes observed in the CBT-D condition in our previous pilot study. Possible explanations for why these findings were not replicated are discussed, as are theoretical and clinical implications of using CBT-D in alcohol treatment.

Investigating the similarities and differences between practitioners of second- and third-wave cognitive-behavioral therapies.

There has been much discussion in the literature recently regarding the conceptual and technical differences between so-called second- (e.g., Beckian cognitive therapy) and third-wave (e.g., acceptance and commitment therapy) behavioral therapies. Previous research has not addressed the potential similarities and differences among the practitioners of these types of approaches. The current study examined possible differences in the characteristics of second-wave (n = 55) and third-wave cognitive-behavioral therapists (n = 33) using an Internet-based survey. There were differences found at the technical level between the two groups. As expected, third-wave therapists reported greater use of mindfulness/acceptance techniques. Also, third-wave therapists reported greater use of exposure techniques and second-wave therapists reported greater use of cognitive restructuring and relaxation techniques. In general, third-wave clinicians were more eclectic at the technical level and demonstrated significantly greater use of family systems techniques, existential/humanistic techniques, and the total number of techniques. No significant differences were found on the attitudinal measures administered, including reliance on an intuitive thinking style, acceptance of complementary and alternative therapies and related health beliefs, or most attitudes toward evidence-based practices. The authors did not identify many differences between second-wave and third-wave therapists other than in terms of the techniques they employ. The clinical and research implications for these findings are discussed.

Factors associated with critical thinking abilities in psychotherapists.

Critical thinking is assumed to be an important factor in the promotion of evidence-based treatment practices. However, little is known about attitudinal and other dispositional factors that may influence critical thinking in psychotherapists specifically. The aim of the current study was to identify factors associated with critical thinking abilities in psychotherapists. A total of 143 licensed psychotherapists completed an Internet-based survey that assessed their critical thinking ability. Hierarchical regression analyses indicated that critical thinking ability was associated with theoretical orientation, reliance on intuition in decision-making, and endorsement of erroneous beliefs about health. Implications for improving critical thinking skills in psychotherapists are discussed.

Open trial of Vinyasa yoga for persistently depressed individuals: evidence of feasibility and acceptability.

The aim of this study was to assess the acceptability and feasibility of Vinyasa yoga as an adjunctive treatment for depressed patients who were not responding adequately to antidepressant medication. The authors also planned to ask participants for qualitative feedback on their experience of the class and to assess change over time in depression and in possible mediating variables. The authors recruited 11 participants in 1 month for an 8-week open trial of yoga classes. They found that 10 participants completed follow-up assessments, 9 of 10 were positive about their experience, and all provided feedback about what was and was not helpful about yoga, as well as barriers to class attendance. Over the 2-month period, participants exhibited significant decreases in depression symptoms and significant increases in an aspect of mindfulness and in behavior activation. This pilot study provided support for continuing to investigate Vinyasa yoga as an adjunct treatment for depression. The next step required is a rigorous randomized clinical trial.

Hatha yoga for depression: critical review of the evidence for efficacy, plausible mechanisms of action, and directions for future research.

BACKGROUND: The purpose of this article is to review the evidence for the efficacy of hatha yoga for depression and possible mechanisms by which yoga may have an impact on depression, and to outline directions for future research. METHODS: Literature review and synthesis. RESULTS AND CONCLUSIONS: A literature search for clinical trials examining yoga for depression uncovered eight trials: 5 including individuals with clinical depression, and 3 for individuals with elevated depression symptoms. Although results from these trials are encouraging, they should be viewed as very preliminary because the trials, as a group, suffered from substantial methodological limitations. We would argue, however, that there are several reasons to consider constructing careful research on yoga for depression. First, current strategies for treating depression are not sufficient for many individuals, and patients have several concerns about existing treatments. Yoga may be an attractive alternative to or a good way to augment current depression treatment strategies. Second, aspects of yoga-including mindfulness promotion and exercise-are thought to be "active ingredients" of other successful treatments for depression. Third, there are plausible biological, psychological, and behavioral mechanisms by which yoga may have an impact on depression. We provide suggestions for the next steps in the study of yoga as a treatment for depression.