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

 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 MH  Intended to eventually lead to a commercial product DISCLOSURE

 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 Mental Health Challenges in the College Population Blanco et al., 2008; Kessler et al., 2005

 Transdiagnostic web-based prevention  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 AS A TRANSDIAGNOSTIC WEB-BASED PREVENTION APPROACH

 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 ACT-CL Lesson Content

 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 Initial Pilot Results with ACT-CL Levin, Pistorello, Hayes & Seeley, 2014

 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 Current Study Overview

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 Participants and Procedures

 Outcome 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) Measures

 Two core multimedia lessons and follow up s  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  and phone call reminders ACT on College Life

MULTIMEDIA ELEMENTS

INTERACTIVE ELEMENTS

EXAMPLE: VALUES CARD SORT

PROGRAM TAILORING

 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 Healthy Living: Active Control Website

 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 ACT-CLControlPilot ACT-CL Lesson 1 completed 85%100%97% Lesson 2 completed 55%86%92% Relatively Poor Program Engagement in 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-CLControlPilot ACT-CL SUS M (SD)73.41 (19.72)72.63 (17.54)84.97 (9.89) Low Satisfaction Ratings with ACT-CL

 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 Program Completer 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 (χ 2 = 3.80, p =.051, Cohen’s d =.26) and 3-month follow up (χ 2 = 2.79, p =.095, Cohen’s d =.22). Severe distress at baselinePost1-month3-month ACT-CL (n = 19)79%68%63% Control (n = 24)50%46%38% Intent-To-Treat 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 Subgroup Analyses

 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 Testing the Psychological Flexibility Model

 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 Relationship Between Program Engagement and Changes in Flexibility

 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 Summary

 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 Low Program Engagement/Satisfaction for ACT-CL

 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 Future Directions

Thank You!