Within the Veterans Health Administration (VHA) in FY2013, patients with psychotic disorders represented approximately 4% of the total population, and received approximately 11% of VHA's total expenditures. Patients with psychosis receive substantial, repeated, and costly inpatient treatment, and this is often the only opportunity to provide treatment, due to gaps in mental health service utilization. There is an urgent need for enhancing VHA inpatient services and tailoring them to better support recovery. Acceptance and Commitment Therapy (ACT), a recovery-oriented, evidence-based adjunct to inpatient treatment for psychosis, is an excellent candidate to support recovery within VHA inpatient settings. ACT for psychosis is considered an empirically supported treatment by the American Psychological Association. Research, including RCTs in inpatient settings, has demonstrated the effectiveness of ACT for treatment of psychosis. ACT is effective when provided in a flexible format of three to four sessions, and for patients with a range of chronic and severe psychotic and comorbid mental disorders.
This pilot study examined ACT as an adjunct to treatment as usual (TAU) for psychosis among VHA patients at one inpatient psychiatry unit. Aim 1 investigated the feasibility, acceptability, and safety of the treatment, as indexed by: (a) the ability to recruit and consent 2 eligible participants per week (for 40 weeks) to participate and be randomized to ACT+TAU or TAU; (b) patient attendance of 3 ACT individual sessions (out of 4 possible) on average; (c) patient and ACT Facilitator (provider of the intervention) reported ACT treatment satisfaction and alliance; and (d) lack of adverse events attributable to ACT. Aim 2 investigated effects of ACT on patient acceptance, a hypothesized mechanism of change, symptomatology, distress, and affect. Aim 3 obtained data from participating unit staff regarding system-, clinician- and patient-level barriers and facilitators to implementing staff-delivered ACT services for psychosis at the participating unit. We were unable to address two exploratory aims, related to (1) the extent to which ACT Facilitators were adherent to ACT, and (2) the cost of ACT relative to TAU.
The project utilized an effectiveness/ implementation Hybrid Type 1 design that incorporates a pilot RCT and semi-formative evaluation of barriers and facilitators to future implementation. Participants for Aims 1 and 2 were VHA patients with current psychotic symptoms (hallucinations and/or delusions) related to a psychotic or psychotic-mood disorder who were admitted to an inpatient psychiatry unit at VA Palo Alto Health Care System (VAPAHCS). We reviewed charts for 429 admissions; 67 patients were approached because they potentially met study criteria; 29 provided informed consent and agreed to be comprehensively assessed for eligibility. Eighteen participants were randomly assigned to receive either TAU (n = 6), or ACT+TAU (n = 12). Sixteen consented participants were withdrawn from the study because they did not meet eligibility criteria or withdrew themselves at some time during the study. Participants were 100% male, middle-aged (M = 53.4, SD = 17.5), and Caucasian (38.5%), Hispanic/Latino (30.8%), Black/African-American (23.1%), and Asian/Asian-American (7.7%). Nine participants (TAU = 4; ACT+TAU = 5) completed all aspects of the study. Pre- and post-treatment assessments included measures of acceptance (Acceptance and Action Questionnaire - II), positive and negative affect (Positive and Negative Affect Scale), symptom severity (Brief Psychiatric Rating Scale), and distress related to and believability of delusions and hallucinations (Frequency, Believability, and Distress Symptom Scale). Measures of treatment satisfaction (Client Satisfaction Questionnaire - 8) and alliance (Working Alliance Inventory) were administered to patients and ACT Facilitators. Aim 3 was addressed by interviewing two staff psychologists and one nurse.
Findings regarding the feasibility and acceptability of ACT (Aim 1) were mixed. We were unable to recruit and randomize two eligible participants per week. However, patients assigned to ACT attended 3.0 sessions on average (SD = 1.6, Range = 0 to 4), and reported high levels of ACT satisfaction (M = 2.9 of 4, SD = 0.3) and alliance (M = 4.7 of 7, SD = 1.0). ACT was safe, as indicated by having no serious adverse events attributable to the treatment.
For Aim 2, patients randomized to ACT+TAU and TAU experienced similar increases, from treatment intake to discharge, in acceptance (ACT+TAU = 12.4%, TAU = 17.0%) and positive affect (ACT+TAU = 13.2%, TAU = 14.5%), and decreases in symptom severity (ACT+TAU = 6.8%, TAU = 8.6%). Patients randomized to ACT+TAU experienced smaller decreases in negative affect (ACT+TAU = 12.4%, TAU = 22.0%) and distress related to (ACT+TAU = 11.3%, TAU = 31.3%), and believability of (ACT+TAU = 13.8%, TAU = 31.3%), hallucinations and delusions, although the latter two comparisons are skewed by a single TAU participant reporting extremely large decreases (90.0%).
In regard to Aim 3, staff members consistently reported: (a) Strengths of ACT for inpatient psychosis included the focus on achievement of valued goals rather than symptoms; (b) Weaknesses of ACT included patients' symptoms (e.g., paranoia) and related sequela (e.g., cognitive impairment) may limit patients' abilities to fully understand it; (c) Facilitators to ACT implementation included a focus on building of trust with patients, offering ACT in a group format, being flexible in applications of the manual, engaging in more experiential exercises, and utilizing a team-based approach to apply ACT; (d) Barriers to implementation included difficulties involved in obtaining research evidence on an inpatient psychiatric unit, a manualized treatment being too rigid, and patients engaging in many activities and appointments, thus limiting their time and motivation.
This project was the first step in exploring a potentially sustainable and effective intervention that will potentially improve inpatient psychosis treatment and recovery and lives of VHA patients with psychosis, while reducing costs for VHA.
- Boden MT, Gaudiano BA, Walser RD, Timko C, Faustman W, Yasmin S, Cronkite RC, Bonn-Miller MO, McCarthy JF. Feasibility and challenges of inpatient psychotherapy for psychosis: lessons learned from a veterans health administration pilot randomized controlled trial. BMC research notes. 2016 Jul 30; 9(1):376.
- Boden MT. Feasibility of and Challenges to the Implementation of Acceptance and Commitment Therapy for the Inpatient Treatment of Psychosis at the Veterans Health Administration. Continuing Education course. ACT Mini Lecture Series, National Center for Posttraumatic Stress Disorder. 2015 Jul 22.
- Johnson JR, Babson KA, Boden MT, Bonn-Miller MO. The role of expressive suppression in terms of the relations between sleep quality and depression and anxiety symptoms among medical cannabis patients. Poster session presented at: Associated Professional Sleep Societies Annual Meeting (SLEEP); 2015 Jun 11; Seattle, WA.
- Johnson JR, Babson KA, Boden MT, Bonn-Miller MO. Sleep and expressive suppression: independent predictors of PTSD symptom severity in a sample of military Veterans engaged in residential treatment. Poster session presented at: Associated Professional Sleep Societies Annual Meeting (SLEEP); 2015 Jun 11; Seattle, WA.