PACT. A feasibility trial of Acceptance and Commitment Therapy for emotional recovery following psychosis
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1 Academic Unit for Mental Health and Wellbeing PACT A feasibility trial of Acceptance and Commitment Therapy for emotional recovery following psychosis Dr Ross White Clinical Research Fellow Academic Unit of Mental Health and Well-being University of Glasgow Ross.White@glasgow.ac.uk
2 Nothing fixes a thing so intensely in the memory as the wish to forget it Michel de Montaigne
3 Emotional Difficulties Following Psychosis Psychosis associated with appraisals of loss, entrapment and humiliation (Birchwood et al., 2000) and feelings of fear (Shaw et al., 1997; 2002). Emotional difficulties lead to psychosis the experience of psychosis can lead to emotional difficulties. Rates of depression of 50% following a first episode of psychosis and 33% in established psychosis. (Whitehead et al., 2002) CBT for psychosis has limited effectiveness for treating depression following psychosis (Wykes et al., 2008) particularly when methodological quality was controlled for.
4 First Person Perspective...I was trying to think how I could describe the last 23 years of medication, and eh, hospitalisation, and you know, subsequent lifestyles that I ve become involved in and things like that, and I would have to say that basically it s been 23 years of physical, psychological and sexual abuse, and it s just going on and on and it never ends.
5 Aims of the PACT trial A feasibility study investigating: a) The acceptability of Acceptance and Commitment Therapy to individuals with psychosis. b) The appropriateness of primary and secondary outcomes for assessing distress associated with the experience of psychosis and relevant mechanisms of change. c) Whether a larger scale multi-centre randomised controlled trial is warranted.
6 Participants 27 individuals with psychosis took part: 6 females (22%) and 21 males (78%). Mean age of participants = years (range: 18-51). Recruited on the basis of being distressed by the experience of psychosis. Referred by NHS teams. Diagnosed with psychotic disorders. Recruited from community mental health teams, first episode services and medium secure forensic unit. Excluded if a score of 5 or above on individual items of the PANSS positive syndrome subscale.
7 Methodology Design: The study was a single-blind (rater) pilot randomized controlled trial comparing ACT plus treatment as usual (TAU) compared to TAU alone: 14 people got ACT 13 people got their usual treatment We compared changes in the two groups over a 3 month period: From randomisation to 3 months postrandomisation.
8 Intervention 10 sessions Kevin Polk s matrix used for formulation A CD incorporating a mindfulness exercise for psychosis (Paul Chadwick) and two defusion exercises (mind room, bubble wand). Using an extended metaphor/allegory to run alongside the treatment: See the wood for the trees.
9
10 Participants Diagnoses: Schizophrenia (F20) 13 Unspecified Non-organic Psychosis (F29) 7 Schizo-affective Disorder Manic Type (F25.0) 1 Schizo-affective Disorder Not Specified (F25.9) 2 Bipolar Disorder Mania and psychosis (F31.2) 1 Bipolar Disorder depression and psychosis (F31.5) 2 Recurrent depressive disorder, current episode severe with psychotic symptoms (F33.3) 1
11 Measures Outcome measures: Hospital Anxiety and Depression Scale PANSS Fear of Recurrence Scale Self-ratings of positive symptoms (frequency, believability, distress) ACT-specific measures: Acceptance and Action Questionnaire - II Kentucky Inventory of Mindfulness Skills Valued Living Questionnaire Therapeutic alliance: Working Alliance Inventory (short form revised)
12 Drop out from the study ACT (χ 2 = 4.79, p < 0.05) TAU
13 What service users thought of ACT The Working Alliance Inventory (Short Form Revised) measures therapeutic alliance. It assesses 3 aspects of the alliance: (a) agreement between client and therapist on the goals of therapy, (b) agreement between client and therapist on the tasks of therapy (c) the quality of the interpersonal bond between client and therapist.
14 What service users thought of ACT Goal Task Bond
15 Change in Depression Caseness (HADS depression subscale score 8) Baseline 0 3 Months ACT TAU (χ 2 = 4.67, p < 0.05) (effect size = 0.43)
16 Change in Depression In accordance with previous papers clinical change was defined as a decrease of 50% from baseline scores (Christodoulides, et al., 2008; Stojadinovic, et al., 2002). 75% of participants in the ACT group who were depressed at baseline achieved clinically significant decreases in levels of depression. None of the participants who received TAU and depressed at baseline achieved clinically significant decreases in levels of depression.
17 Change in Anxiety Caseness (HADS anxiety subscale score 8) Baseline Months ACT TAU (χ2 = 1.01, p = 0.314) (effect size = 0.03)
18 Crisis Contacts The crisis service works with people who are experiencing increased distress in terms of their mental health and are at risk of admission to a psychiatric hospital.
19 Mean Number of Crisis Contacts ACT TAU Z = -2.24, p < 0.05
20 Change in Positive Symptoms Baseline 0 3 Months ACT TAU (t = 0.24, df = 19, p = 0.81) (effect size = 0.05)
21 Change in Negative Symptoms ACT (t = -2.36, df = 19, p < 0.05) TAU Baseline 3 Months (effect size = 0.47)
22 Changes in AAQ-II Scores ACT Month Baseline (t = 0.60, df = 21, p = 0.56) (effect size = 0.13) TAU
23 Changes in Mindfulness Skills Baseline 100 ACT 3 Months (t = 2.66, df = 21, p < 0.05) (effect size = 0.50) TAU
24 Processes of Change? The change in Depression scores for the ACT group had a significant correlation with the change in mindfulness skills (ρ = -0.66, p < 0.05)
25 Conclusions ACT was acceptable to people recovering from psychosis. ACT lead to a significant decrease in the number of people who were depressed compared to treatment as usual. Changes in depression were related to changes in mindfulness. Those getting ACT had significantly less contact with crisis services. ACT had a significant impact on negative symptoms relative to treatment as usual.
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