Preventing Mental Health Problems in College Students through Web-Based ACT Michael E. Levin, Utah State University Steven C. Hayes, Jacqueline Pistorello, University of Nevada Reno John Seeley, Oregon Research Institute

Disclosure The ACT on College Life project is supported by a Small Business Innovation Research grant awarded to Contextual Change LLC National Institute of Mental Health - R43 MH085336 Intended to eventually lead to a commercial product

Mental Health Challenges in the College Population Depression and anxiety disorders among college students are prevalent and costly Effective prevention approaches have been developed, but are rarely implemented by colleges and universities Challenges to implementation include Students are at risk for a range of disorders, but programs are generally disorder-specific Costs of implementation, training, and supervision for face-to-face interventions Blanco et al., 2008; Kessler et al., 2005

ACT as a Transdiagnostic Web-Based Prevention Approach Target a range of disorders with a single program Easy and cost effective to implement Psychological inflexibility is a common risk factor across disorders Psychological inflexibility can be targeted with ACT to produce clinical improvements Can ACT be used to target psychological inflexibility to prevent disorders from developing? And can it be done using a readily disseminable method?

ACT-CL Lesson Content Lesson 1: Exploring your values Defining what values are Clarifying and reflecting on personal values Defining effective and values-based goals Goal setting Lesson 2: Dealing with barriers Exploring internal barriers to values-based action The problem with control strategies Defining and practicing willingness Linking willingness to values-based action

Initial Pilot Results with ACT-CL Pilot RCT with 76 first-year college students Randomized to ACT-CL or waitlist ACT-CL was acceptable to users ACT-CL impacted ACT knowledge and values processes But not psychological inflexibility ACT-CL impacted depression and anxiety among distressed students Failed to replicate effects with waitlist condition Levin, Pistorello, Hayes & Seeley, 2014

Current Study Overview Feasibility RCT comparing ACT-CL to an active control website (mental health education) Replicating/extending testing of acceptability and potential efficacy Universal prevention approach with broad sample of undergraduate students

Participants and Procedures 234 undergraduate college students from UNR Eligible if undergraduate, fluent in English and 18 or older Recruited through Psychology classes, flyers on campus, SONA Demographics 77% Female 76% White; 24% ethnic/racial minority Median age of 20 (Range = 18 – 58) Year in school: 29% first year student, 37% second or third year, 35% fourth year or higher Measures completed at baseline, post, 1-month and 3-month follow up Participants automatically randomized to condition after completing baseline assessment

Measures Outcome measures Process measures Depression, Anxiety, Stress Scale (DASS-21) Mental Health Continuum (MHC) Process measures Avoidance and Fusion Questionnaire (AFQ) Personal Values Questionnaire (PVQ) Five Facet Mindfulness Questionnaire (FFMQ) Acting with awareness and Nonreactivity subscales ACT Knowledge System Usability Scale (SUS)

ACT on College Life Two core multimedia lessons and follow up emails Identical to the content included in the initial pilot trial Web-based mindfulness resources Sent as a link after users completed each lesson Focused on targeting present moment awareness and defusion Optional text messages Sent 3 and 6 days after users finished each lesson Focused on strengthening and generalizing ACT skills Email and phone call reminders

Multimedia Elements

Interactive Elements

Example: Values Card Sort

Example: Values Card Sort

Program Tailoring

Healthy Living: Active Control Website Basic educational information about depression and anxiety Symptoms, causes and prevalence of disorders Basic and brief information on coping strategies Lesson 1 – Depression Lesson 2 – Stress and Anxiety Content taken from halfofus.com and ulifeline.com Excluded more active intervention content (i.e., celebrities describing experiences) and content targeting psychological flexibility processes Primarily text-based with some illustrations and quizzes

Relatively Poor Program Engagement in ACT-CL Control Pilot ACT-CL Lesson 1 completed 85% 100% 97% Lesson 2 completed 55% 86% 92% Significantly lower program completion rates with ACT-CL compared to control condition and initial pilot trial ACT-CL program usage Only 36.4% requested to receive text messages Only 16.4% accessed the mindfulness resources at least once

Low Satisfaction Ratings with ACT-CL Significantly higher rating for ACT-CL in the initial pilot Single item satisfaction ratings were significantly lower in ACT-CL compared to control website on Overall satisfaction Willingness to use the program again Perceived helpfulness for students Whether would recommend the program to others ACT-CL Control Pilot ACT-CL SUS M (SD) 73.41 (19.72) 72.63 (17.54) 84.97 (9.89)

Program Completer Analyses Tested time by condition interaction effects in mixed model repeated measures ANOVAs Greater pre to post improvements in ACT knowledge in the ACT-CL condition (p < .001, Cohen’s d = 1.23) No other significant between group effects

Intent-To-Treat Analyses Similar pattern of results except Greater pre to 3-month improvement in education values success in the control condition (p = .088, Cohen’s d = .23) Lower remission rates of severe depression/anxiety symptoms in ACT-CL among those with severe symptoms at baseline Higher rate of severe symptoms at post (χ2 = 3.80, p = .051, Cohen’s d = .26) and 3-month follow up (χ2 = 2.79, p = .095, Cohen’s d = .22). Severe distress at baseline Post 1-month 3-month ACT-CL (n = 19) 79% 68% 63% Control (n = 24) 50% 46% 38%

Subgroup Analyses Analyses conducted among the following subgroups: No, mild or high levels of distress Higher or lower psychological inflexibility First year or non-first year students Male or female Minority or non-minority No consistent between group effects for any of the subgroups Program satisfaction and engagement did not differ by subgroup

Testing the Psychological Flexibility Model Pre to post AFQ improvements related to 1-month improvements in depression, anxiety, stress, positive mental health and values success Partial correlations (controlling for baseline outcome) coefficients ranging between .15 and .28 Improvements in ACT knowledge related to 1-month improvements in inflexibility (r = .43) and mindfulness (r = .23) ACT-CL arm only

Relationship Between Program Engagement and Changes in Flexibility Time on Lessons Time on ACT-CL lesson 1 related to improvements at post on inflexibility, values and mindfulness Time on control lessons not related to post improvements Word Count Values writing word count related to post improvements on mindfulness and values Lesson 1 goal setting word count related to post improvements on values Lesson 2 goal setting word count related to post improvements on inflexibility, mindfulness, and values Text messages Participants receiving text messages improved more at post on inflexibility, mindfulness and values

Summary ACT-CL prototype had relatively low acceptability/usability No consistent differences by subgroups on impact, usage or acceptability Technology failure for ACT-CL prototype Failure to differentially impact outcome or process measures May be due to the use of a limited prototype intervention, poor program engagement and/or strong active condition Support found for the psychological flexibility model Improvements in flexibility predicted improvements in outcomes Engagement in ACT-CL predictive of improvements in psychological inflexibility

Low Program Engagement/Satisfaction for ACT-CL Surprisingly low engagement/satisfaction given sophistication and development resources with ACT-CL Some users disliked these more sophisticated elements Particularly the tunneled format, use of audio narration, and the program seeming targeted to a younger audience Students appeared to like a text driven approach Differences between current and pilot trial may be due to differences in degree of personal contact and compensation

Future Directions Further research is needed on how to transport ACT to web-based prevention and how to increase user engagement Integrating text messaging and mobile app features Incentivizing participation and promoting adherence Balancing sophisticated elements with more simple, text-driven elements within a flexible user interface Prototype testing and iterative design

Thank You!