Novel ACT-based eHealth psychoeducational intervention for students with mental distress: a study protocol for a mixed-methodology pilot trial

Darren J Edwards, Elinor Rainey, Vasiliki Boukouvala, Yasmin Wells, Paul Bennett, Jeremy Tree, Andrew H Kemp, Darren J Edwards, Elinor Rainey, Vasiliki Boukouvala, Yasmin Wells, Paul Bennett, Jeremy Tree, Andrew H Kemp

Abstract

Introduction: Recent studies have revealed a high prevalence of depression, anxiety and stress symptoms among university students, highlighting an urgent need for preventative measures at low cost to better support often overwhelmed support services.

Objective: Here we propose a protocol for assessing the feasibility of a randomised controlled trial (RCT) for an online transdiagnostic psychoeducational intervention called 'A Bite of ACT' compared with a waitlist control.

Methods and analysis: This is an RCT with crossover design involving baseline assessments and two follow-up periods. The primary outcome measure will be the Acceptance Checklist for Clinical Effectiveness Pilot Trials (ACCEPT) for measuring the feasibility of the trial design and methods. Secondary outcomes include measures of well-being, social connectedness, quality of life (EuroQol Five Dimensions), depression, anxiety and stress (Depression Anxiety Stress Scales-21), as well as the process measures: psychological flexibility (Acceptance and Action Questionnaire-Second Version and the Mindful Attention Awareness Scale) and heart rate variability. Analysis will involve calculating descriptive statistics, examining trial feasibility outcomes through ACCEPT, and determining effect size measures to determine the sample size needed in a future trial (if indicated). Qualitative interviews and preliminary health economics analysis will provide additional insights into the feasibility of the intervention and trial methods.

Ethics and dissemination: This study has been approved by the Department of Psychology Research Ethics Committee in the College of Human and Health Sciences at Swansea University. Dissemination will involve publication in international peer-reviewed journals, presentation of findings at relevant local, national and international conferences, and promotion of study outcomes using social media and other channels for disseminating findings to the wider community.

Trial registration number: NCT03810131; Pre-results.

Keywords: Ehealth; acceptance and commitment therapy; mental distress; psychoeducation; students.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
A CONSORT flow diagram with crossover design for a randomised controlled trial of ‘A Bite of ACT’ psychoeducation course with treatment group and waitlist control. CONSORT, Consolidated Standards of Reporting Trials; t1, preintervention and baseline; t2, after 2 weeks; t3, after 4 weeks.

References

    1. Centers for Disease Control. Division of Adolescent and School Health. 2016. .
    1. Kemp AH, Koenig J, Thayer JF. From psychological moments to mortality: a multidisciplinary synthesis on heart rate variability spanning the continuum of time. Neurosci Biobehav Rev 2017;83:547–67. 10.1016/j.neubiorev.2017.09.006
    1. Russ TC, Stamatakis E, Hamer M, et al. . Association between psychological distress and mortality: individual participant pooled analysis of 10 prospective cohort studies. BMJ 2012;345:e4933 10.1136/bmj.e4933
    1. Holt-Lunstad J, Smith TB, Baker M, et al. . Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci 2015;10:227–37. 10.1177/1745691614568352
    1. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med 2010;7:e1000316 10.1371/journal.pmed.1000316
    1. Ibrahim AK, Kelly SJ, Adams CE, et al. . A systematic review of studies of depression prevalence in university students. J Psychiatr Res 2013;47:391–400. 10.1016/j.jpsychires.2012.11.015
    1. Hope V, Henderson M. Medical student depression, anxiety and distress outside North America: a systematic review. Med Educ 2014;48:963–79. 10.1111/medu.12512
    1. Shiels C, Gabbay M, Exley D. Psychological distress in students registered at a university-based general practice. Primary Care and Community Psychiatry 2008;13:9–18.
    1. Twenge JM, Joiner TE, Rogers ML, et al. . Increases in depressive symptoms, suicide-related outcomes, and suicide rates among u.s. adolescents after 2010 and links to increased new media screen time. Clin Psychol Sci 2018;6:3–17. 10.1177/2167702617723376
    1. Beiter R, Nash R, McCrady M, et al. . The prevalence and correlates of depression, anxiety, and stress in a sample of college students. J Affect Disord 2015;173:90–6. 10.1016/j.jad.2014.10.054
    1. New J. Balancing response and treatment. 2017. .
    1. Novotney A. Students under pressure: college and university counseling centers are examining how best to serve the growing number of students seeking their services. 2014. .
    1. Centre for Collegiate Mental Health. 2015 annual report, Pennsylvania State University. 2015. .
    1. Bewick B, Koutsopoulou G, Miles J, et al. . Changes in undergraduate students’ psychological well‐being as they progress through university. Studies in Higher Education 2010;35:633–45. 10.1080/03075070903216643
    1. Newbury-Birch D, Lowry RJ, Kamali F. The changing patterns of drinking, illicit drug use, stress, anxiety and depression in dental students in a UK dental school: a longitudinal study. Br Dent J 2002;192:646–9. 10.1038/sj.bdj.4801448
    1. Adult Psychiatric Morbidity Survey. Adult psychiatric morbidity survey: survey of mental health and Wellbeing, England, 2014. 2016.
    1. Callender J. Mental health of students in higher education. London: Royal College of Psychiatrists, 2011.
    1. Brown P. The Invisible Problem?: improving students' mental health: Higher Education Policy Institute, 2016.
    1. Randall EM, Bewick BM. Exploration of counsellors' perceptions of the redesigned service pathways: a qualitative study of a UK university student counselling service. Br J Guid Counc 2016;44:86–98. 10.1080/03069885.2015.1017801
    1. Mair D. Short-term counselling in higher education: Context, theory and practice: Routledge, 2015.
    1. Sucala M, Schnur JB, Constantino MJ, et al. . The therapeutic relationship in e-therapy for mental health: a systematic review. J Med Internet Res 2012;14:e110 10.2196/jmir.2084
    1. Muto T, Hayes SC, Jeffcoat T. The effectiveness of acceptance and commitment therapy bibliotherapy for enhancing the psychological health of Japanese college students living abroad. Behav Ther 2011;42:323–35. 10.1016/j.beth.2010.08.009
    1. Daya Z, Hearn JH. Mindfulness interventions in medical education: a systematic review of their impact on medical student stress, depression, fatigue and burnout. Med Teach 2018;40:146–53. 10.1080/0142159X.2017.1394999
    1. Regehr C, Glancy D, Pitts A. Interventions to reduce stress in university students: a review and meta-analysis. J Affect Disord 2013;148:1–11. 10.1016/j.jad.2012.11.026
    1. Davies EB, Morriss R, Glazebrook C. Computer-delivered and web-based interventions to improve depression, anxiety, and psychological well-being of university students: a systematic review and meta-analysis. J Med Internet Res 2014;16:e130 10.2196/jmir.3142
    1. Forman EM, Herbert JD, Moitra E, et al. . A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behav Modif 2007;31:772–99. 10.1177/0145445507302202
    1. Ly KH, Asplund K, Andersson G. Stress management for middle managers via an acceptance and commitment-based smartphone application: a randomized controlled trial. Internet Interv 2014;1:95–101. 10.1016/j.invent.2014.06.003
    1. Wetherell JL, Afari N, Rutledge T, et al. . A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain 2011;152:2098–107. 10.1016/j.pain.2011.05.016
    1. Harris R. ACT made simple: An easy-to-read primer on acceptance and commitment therapy: New Harbinger Publications, 2009.
    1. Räsänen P, Lappalainen P, Muotka J, et al. . An online guided ACT intervention for enhancing the psychological wellbeing of university students: a randomized controlled clinical trial. Behav Res Ther 2016;78:30–42. 10.1016/j.brat.2016.01.001
    1. Levin ME, Pistorello J, Seeley JR, et al. . Feasibility of a prototype web-based acceptance and commitment therapy prevention program for college students. J Am Coll Health 2014;62:20–30. 10.1080/07448481.2013.843533
    1. Viskovich S, Pakenham KI. Pilot evaluation of a web-based acceptance and commitment therapy program to promote mental health skills in university students. J Clin Psychol 2018;74:2047–69. 10.1002/jclp.22656
    1. Levin ME, Haeger JA, Pierce BG, et al. . Web-based acceptance and commitment therapy for mental health problems in college students: a randomized controlled trial. Behav Modif 2017;41:141–62. 10.1177/0145445516659645
    1. Eustis EH, Hayes-Skelton SA, Orsillo SM, et al. . Surviving and thriving during stress: a randomized clinical trial comparing a brief web-based therapist-assisted acceptance-based behavioral intervention versus waitlist control for college students. Behav Ther 2018;49:889–903. 10.1016/j.beth.2018.05.009
    1. Beck JS. Cognitive behavior therapy: basics and beyond: Guilford press, 2011.
    1. Hayes S. Acceptance and commitment therapy: the process and practice of mindful change: Guilford Press, 2011.
    1. Strosahl K, Wilson K. Acceptance and commitment therapy: an experiential approach to behavior change. new york: Guilford Press, 1999.
    1. Seligman ME. Positive psychology in practice: John Wiley & Sons, 2012.
    1. Haslam C. The new psychology of health: Unlocking the social cure: Routledge, 2018.
    1. Kemp A. Fisher, social ties, health and wellbeing: a literature review and model, in Neuroscience and Social Science: Springer, 2017:397–427.
    1. Kashdan TB, Rottenberg J. Psychological flexibility as a fundamental aspect of health. Clin Psychol Rev 2010;30:865–78. 10.1016/j.cpr.2010.03.001
    1. Hayes. Get out of your mind and into your life: the new acceptance and commitment therapy: New Harbinger Publications, 2005.
    1. de Vente W, van Amsterdam JG, Olff M, et al. . Burnout is associated with reduced parasympathetic activity and reduced hpa axis responsiveness, predominantly in males. Biomed Res Int 2015;2015:1–13. 10.1155/2015/431725
    1. Gorman JM, Sloan RP. Heart rate variability in depressive and anxiety disorders. Am Heart J 2000;140:S77–S83. 10.1067/mhj.2000.109981
    1. Porges S. The Norton series on interpersonal neurobiology. The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York, NY, US: WW Norton & Co, 2011.
    1. Kok BE, Coffey KA, Cohn MA, et al. . How positive emotions build physical health: perceived positive social connections account for the upward spiral between positive emotions and vagal tone. Psychol Sci 2013;24:1123–32. 10.1177/0956797612470827
    1. Boehm JK, Lyubomirsky S. The promise of sustainable happiness. 2009.
    1. Scheier MF, Matthews KA, Owens JF, et al. . Dispositional optimism and recovery from coronary artery bypass surgery: the beneficial effects on physical and psychological well-being. J Pers Soc Psychol 1989;57:1024–40. 10.1037/0022-3514.57.6.1024
    1. Marks GN, Fleming N. Influences and consequences of well-being among Australian young people: 1980–1995. Soc Indic Res 1997;46:301–23. 10.1023/A:1006928507272
    1. Boehm JK, Kubzansky LD. The heart’s content: the association between positive psychological well-being and cardiovascular health. Psychol Bull 2012;138:655–91. 10.1037/a0027448
    1. Dubois CM, Beach SR, Kashdan TB, et al. . Positive psychological attributes and cardiac outcomes: associations, mechanisms, and interventions. Psychosomatics 2012;53:303–18. 10.1016/j.psym.2012.04.004
    1. Policy and Implementation Guidance. Psychological Therapies in Wales. Cardiff: Welsh Government, 2018.
    1. Tang NKY. Treating anxiety and stress: a group psycho-educational approach using brief CBT Jim White West Sussex, UK: Wiley, 2000. Pp. 246. ISBN: 0-471-49306-6. Behav Cogn Psychother 2002;30:375–80. 10.1017/S1352465802213132
    1. Burns P, Kellett S, Donohoe G. "Stress Control" as a large group psychoeducational intervention at step 2 of IAPT services: acceptability of the approach and moderators of effectiveness. Behav Cogn Psychother 2016;44:431–43. 10.1017/S1352465815000491
    1. Cartwright J, Hooper N. Evaluating a transdiagnostic acceptance and commitment therapy psychoeducation intervention. The Cognitive Behaviour Therapist 2017;10–10. 10.1017/S1754470X17000125
    1. National Institute for Health and Clinical Excellence. Common mental health problems: identification and pathways to care. 2011. (20 Feb 2018).
    1. O’Connor M, Munnelly A, Whelan R, et al. . The efficacy and acceptability of third-wave behavioral and cognitive ehealth treatments: a systematic review and meta-analysis of randomized controlled trials. Behav Ther 2018;49 10.1016/j.beth.2017.07.007
    1. Charlesworth G, Burnell K, Hoe J, et al. . Acceptance checklist for clinical effectiveness pilot trials: a systematic approach. BMC Med Res Methodol 2013;13:78 10.1186/1471-2288-13-78
    1. Bond FW, Bunce D. Mediators of change in emotion-focused and problem-focused worksite stress management interventions. J Occup Health Psychol 2000;5:156–63. 10.1037/1076-8998.5.1.156
    1. Hayes SC, Bissett R, Roget N, et al. . The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behav Ther 2004;35:821–35. 10.1016/S0005-7894(04)80022-4
    1. Hayes SC, Luoma JB, Bond FW, et al. . Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther 2006;44:1–25. 10.1016/j.brat.2005.06.006
    1. Gaudiano BA, Herbert JD. Believability of hallucinations as a potential mediator of their frequency and associated distress in psychotic inpatients. Behav Cogn Psychother 2006;34:497–502. 10.1017/S1352465806003080
    1. Moher D, Chan AW. SPIRIT (standard protocol items: recommendations for interventional trials). Guidelines for Reporting Health Research: a user’s manual, 2014:56–67.
    1. Moher D, Hopewell S, Schulz KF, et al. . CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c869 10.1136/bmj.c869
    1. Schulz KF, Altman DG, Moher D. CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMC Med 2010;8:18 10.1186/1741-7015-8-18
    1. Eldridge SM, Chan CL, Campbell MJ, et al. . CONSORT 2010 statement: extension to randomised pilot and feasibility trials. Pilot Feasibility Stud 2016;2:64 10.1186/s40814-016-0105-8
    1. Craig P, Dieppe P, Macintyre S, et al. . Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud 2013;50:587–92. 10.1016/j.ijnurstu.2012.09.010
    1. Developing and evaluating complex interventions: Following considerable development in the field since 2006, MRC and NIHR have jointly commissioned an update of this guidance to be published in 2019. 2019. .
    1. Hoffmann TC, Glasziou PP, Boutron I, et al. . Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 2014;348:g1687 10.1136/bmj.g1687
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101. 10.1191/1478088706qp063oa
    1. Melville KM, Casey LM, Kavanagh DJ. Dropout from Internet-based treatment for psychological disorders. Br J Clin Psychol 2010;49:455–71. 10.1348/014466509X472138
    1. Carlsen B, Glenton C. What about N? A methodological study of sample-size reporting in focus group studies. BMC Med Res Methodol 2011;11:26 10.1186/1471-2288-11-26
    1. Laborde S, Mosley E, Thayer JF. Heart rate variability and cardiac vagal tone in psychophysiological research - recommendations for experiment planning, data analysis, and data reporting. Front Psychol 2017;8:213 10.3389/fpsyg.2017.00213
    1. Quintana DS, Alvares GA, Heathers JA. Guidelines for reporting articles on psychiatry and heart rate variability (GRAPH): recommendations to advance research communication. Transl Psychiatry 2016;6:e803 10.1038/tp.2016.73
    1. Heart rate variability: standards of measurement, physiological interpretation and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Circulation 1996;93:1043–65.
    1. Tarvainen MP, Niskanen JP, Lipponen JA, et al. . Kubios HRV--heart rate variability analysis software. Comput Methods Programs Biomed 2014;113:210–20. 10.1016/j.cmpb.2013.07.024
    1. Hooper N, Saunders J, McHugh L. The derived generalization of thought suppression. Learn Behav 2010;38:160–8. 10.3758/LB.38.2.160
    1. Clark L, Fairhurst C, Torgerson DJ. Allocation concealment in randomised controlled trials: are we getting better? BMJ 2016;355:355 10.1136/bmj.i5663
    1. Savović J, Jones HE, Altman DG, et al. . Influence of reported study design characteristics on intervention effect estimates from randomized, controlled trials. Ann Intern Med 2012;157:429–38. 10.7326/0003-4819-157-6-201209180-00537
    1. Hewitt C, Hahn S, Torgerson DJ, et al. . Adequacy and reporting of allocation concealment: review of recent trials published in four general medical journals. BMJ 2005;330:1057–8. 10.1136/
    1. Clark L, Fairhurst C, Hewitt CE, et al. . A methodological review of recent meta-analyses has found significant heterogeneity in age between randomized groups. J Clin Epidemiol 2014;67:1016–24. 10.1016/j.jclinepi.2014.04.007
    1. Tennant R, Hiller L, Fishwick R, et al. . The Warwick-Edinburgh mental well-being scale (WEMWBS): development and UK validation. Health Qual Life Outcomes 2007;5:63 10.1186/1477-7525-5-63
    1. Henry JD, Crawford JR. The short-form version of the depression anxiety stress scales (DASS-21): construct validity and normative data in a large non-clinical sample. Br J Clin Psychol 2005;44:227–39. 10.1348/014466505X29657
    1. Schrag A, Selai C, Jahanshahi M, et al. . The EQ-5D--a generic quality of life measure-is a useful instrument to measure quality of life in patients with Parkinson’s disease. J Neurol Neurosurg Psychiatry 2000;69:67–73. 10.1136/jnnp.69.1.67
    1. Gootzeit JH. ACT process measures: specificity and incremental value: The University of Iowa, 2014.
    1. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol 2003;84:822–48. 10.1037/0022-3514.84.4.822
    1. Frewen PA, Evans EM, Maraj N, et al. . Letting go: mindfulness and negative automatic thinking. Cognit Ther Res 2008;32:758–74. 10.1007/s10608-007-9142-1
    1. Bond FW, Hayes SC, Baer RA, et al. . Preliminary psychometric properties of the acceptance and action questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther 2011;42:676–88. 10.1016/j.beth.2011.03.007
    1. Saracutu M, Edwards DJ, Davies H, et al. . Protocol for a feasibility and acceptability study using a brief ACT-based intervention for people from Southwest Wales who live with persistent pain. BMJ Open 2018;8:e021866 10.1136/bmjopen-2018-021866
    1. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods 2006;5:80–92. 10.1177/160940690600500107

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