Efficacy of Acceptance and Commitment Therapy in Daily Life in Early Psychosis: Results from the Multi-Center INTERACT Randomized Controlled Trial

Abstract

<b><i>Introduction/Objective:</i></b> This study aimed to investigate efficacy of Acceptance and Commitment Therapy in Daily Life (ACT-DL), combining face-to-face therapy with an Ecological Momentary Intervention (EMI), in addition to treatment as usual (TAU) for psychotic distress, in comparison to TAU. <i>Methods</i>: Individuals aged 15–65 years with clinically established ultra-high risk or first episode of psychosis were randomly assigned to TAU or ACT-DL+TAU. ACT-DL+TAU consisted of 8 ACT-sessions augmented with an EMI-app. The primary outcome was psychotic distress assessed with the Comprehensive Assessment scale of At Risk Mental State (CAARMS) at post-intervention and 6- and 12-month follow-up. Secondary outcomes were functioning, symptom severity, and momentary psychotic distress. We performed multivariate mixed models according to intent-to-treat principles. <b><i>Results:</i></b> Between June 1, 2015 and December 31, 2018, 668 participants were referred, of whom 148 were randomized to ACT-DL+TAU (<i>n</i> = 71) or TAU (<i>n</i> = 77). One hundred and fifteen (78%) provided primary outcome data at least at one follow-up assessment. There was no evidence of greater reduction in the primary outcome measure CAARMS distress in ACT-DL+TAU compared to TAU (χ<sup>2</sup>(3) = 2.36; <i>p</i> = 0.50). However, out of the tested secondary outcomes, global functioning (χ<sup>2</sup>(3) = 9.05; <i>p</i> = 0.033), and negative symptoms (χ<sup>2</sup>(3) = 19.91; p<0.001) improved in ACT-DL+TAU compared to TAU, as did momentary psychotic distress (χ<sup>2</sup>(3) = 21.56; <i>p</i> < 0.001). <b><i>Conclusions:</i></b> INTERACT did not support a significant effect of ACT-DL over TAU on the primary outcome measure of psychotic distress as assessed with the CAARMS. Although significant improvements were found for some secondary outcome measures, further replication studies are needed to confirm the strength and specificity of these effects.

Acceptance and commitment therapy for psychosis: Current status, lingering questions and future directions

“…This has clearly been an obstacle to the dissemination and uptake of ACTp internationally relative to other evidence‐based therapies commonly offered to those with psychosis, such as CBTp and family interventions. This is despite evidence that ACT is a model showing cross‐cultural validity with many intervention studies conducted in non‐English speaking, low‐ and middle‐income countries (Association for Contextual Behavioral Science, 2023), and ACTp studies involving diverse samples in multiple countries and regions (e.g., Gaudiano & Herbert, 2006; Jeong et al, 2022; Johns et al, 2016; Jolley et al, 2020; Myin‐Germeys et al, 2022; Shi et al, 2023). ACTp has only recently begun to find its way into clinical practice guidelines as an evidence‐based treatment and much more work is needed to assemble all the pieces of research necessary to support strong recommendations for its use.…”

“…For example, Vilardaga et al (2020) reported that individuals with severe mental illness including psychosis ( n = 62) randomised to a mobile health app that included ACTp strategies showed reduced daily cigarette consumption compared with those receiving a standard smoking cessation app. Also, a study for people with early psychosis ( n = 148) reported that those randomised to ACT in Daily Life, which combined traditional therapy with a mobile intervention, produced greater improvements in global functioning, negative symptoms and momentary psychotic symptom distress compared with treatment as usual (Myin‐Germeys et al, 2022). Additionally, Wood et al (2021) described the implementation of a four‐session ACTp group for first episode psychosis patients delivered via telehealth, which had high adherence and client satisfaction.…”

Acceptance and Commitment Therapy for individuals at risk for psychosis or with a first psychotic episode: A qualitative study on patients' perspectives

“…Recruitment procedure and inclusion criteria for INTERACT have been described in detail elsewhere (Myin-Germeys et al, 2022). In Interviews were performed after verbal and written explanation and after written informed consent of the participant.…”

“…Therefore, 'ACT in Daily Life' (ACT-DL) was developed, a blended care intervention combining ACT-sessions with an app to add Ecological Momentary Intervention (Myin-Germeys et al, 2016) to enhance therapeutic effects in real life conditions in early psychosis (Vaessen et al, 2019). The INTERACT study (Myin-Germeys et al, 2022) quantitatively investigated ACT-DL and showed that adding ACT-DL to treatment as usual (TAU) significantly improved momentary psychotic distress, global functioning, and negative symptomatology, compared to only TAU, for participants with UHR and FEP.…”

Can digital tools improve clinical care in psychiatry?

“…We developed the app to augment the effects of the therapy in patients in the early phases of psychosis (11). In a randomized controlled trial, we found that ACT-DL was outperforming treatment-as-usual (including CBT) in improving negative symptoms and social functioning, two of the hardest-to-treat symptoms (12). Furthermore, we found that the intervention was feasible and accessible although it could further be optimized for use in this patient group (13).…”