Evaluating Acceptance and Commitment Therapy Among Inpatients, Outpatients With Chronic Mental Disorders

Researchers identified improvements in well-being and functioning as well as a reduction of symptoms among patients treated with acceptance and commitment therapy in inpatient and outpatient care.

Among inpatients and outpatients with chronic mental disorders who are previously refractory to disease, transdiagnostic psychotherapy may be an effective treatment option, according to study findings published in Psychotherapy and Psychosomatics.

Comorbidity of common mental disorders is a frequent occurrence. Estimates suggest that as many as half of psychiatric patients are nonresponsive to first-line psychotherapy and pharmacotherapy. Researchers sought to investigate whether inpatients and outpatients with chronic mental disorders who do not respond to treatment could be treated effectively under real-world conditions using acceptance and commitment therapy (ACT). ACT, the investigators wrote, is a transdiagnostic treatment “that can effectively induce change in patients across many [psychopathologic] problems and with a long history of suffering” by helping patients “to reframe symptoms, emotions, and associated stress such that they are no longer barriers to living.”

The main study endpoints were symptoms (measured using the Brief Symptom Checklist [BSCL]), functioning (measured by the World Health Organization Disability Assessment Schedule [WHO-DAS]), and well-being (measured by the Mental Health Continuum-Short Form [MHC-SF]).

The researchers conducted a controlled, nonrandomized effectiveness trial, Choose Change, from May 2016 to May 2021 at 2 regional psychiatric clinics. Included in the trial were 200 patients at least 18 years of age, of whom 92 were outpatients (mean age, 36 years) and 108 were inpatients (mean age, 35 years). Among the outpatients, 57% were women, 60% had undergone previous psychotherapy, and 61% had previously received pharmacologic treatment. Among the inpatients, 47% were women, 92% had undergone previous psychotherapy, and 92% had previously received pharmacologic treatment.

Investigators explored whether the relationship between patients’ stress level and outcomes could be moderated by psychological flexibility.

The patients were treated by therapists for about 12 weeks with individualized and nonmanualized ACT. Inpatient treatment included 2 private therapy sessions per week plus daily group sessions presented by psychotherapists and nursing staff. Outpatient treatment included either 1 extended therapy session per week or 2 private therapy sessions per week, presented by a psychotherapist. Excluded from the trial were patients who had previous experience with ACT, active mania, acute substance dependence, or acute suicidal intent.

To assess the impact of continuity of care and treatment intensity, the researchers compared whether inpatients and outpatients achieved different outcomes from therapy. They also explored whether the relationship between patients’ stress level and outcomes could be moderated by psychologic flexibility. Patients, therapists, and assessors were blinded to the hypotheses.

Measuring the effectiveness of ACT, the researchers found decreases in symptomatology (d for BSCL=0.68) and increases in functioning (d for WHO-DAS=0.70) and well-being (d for MHC-SF=0.60) (all P <.001) for both inpatients and outpatients, with more improvement during treatment observed in the inpatients. They noted that at 1 year following treatment, there was no significant difference between groups and both maintained the initial gains. The impact of stress on outcomes was attenuated with psychologic flexibility.

In subgroup analysis, no differences were noted between patients with previous psychotherapy vs no previous psychotherapy, nor were differences noted between patients with previous pharmacotherapy vs no previous pharmacotherapy. The researchers also noted no difference over time for outpatients with minimally adequate previous treatment vs outpatients without previous treatment.

Overall response rates for symptoms using the BSCL showed 68% of patients with any improvement, 40% with statistically reliable improvement, and 32% with at least a 50% decrease in symptoms. The researchers reported that 17% of patients showed any increase in symptoms and 4% had a statistically reliable deterioration. Among completers, 80% of patients showed any improvement, 47% had statistically reliable improvement, and 37% had at least a 50% decrease in symptoms. Finally, 20% of patients showed any increase in symptoms and 5% with a statistically reliable deterioration.

Significant study limitations include the nonrandomized trial design, which limited the researchers’ ability to rule out spurious variables or covariates in causality; the absence of a control group with different treatment; and the response bias inherent in self-reported outcome questionnaires.

Psychotherapy as practiced under routine conditions is effective for a sample of patients with common mental disorders, a long history of treatment experience and burden of disease, in both inpatient and outpatient settings,” the researchers wrote. They concluded, “This clinically important result is also valuable for researchers, in that future research should continue to examine which psychological interventions and processes lead to increased well-being and reduced suffering in this common clinical group.”

This article originally appeared on Psychiatry Advisor


Gloster AT, Haller E, Villanueva J, et al. Psychotherapy for chronic in- and outpatients with common mental disorders: the “Choose Change” effectiveness trial. Psychother Psychosom. Published online April 6, 2023. doi:10.1159/000529411