Michael E. Levin, Utah State University Steven C. Hayes, Jacqueline Pistorello ,

1. 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

2. 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

3. 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

4. ACT as a TransdiagnosticWeb-Based Prevention Approach • 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?

6. 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

7. 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

8. 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

9. 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

10. Measures • 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)

11. 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

12. Multimedia Elements

13. Interactive Elements

14. Example: Values Card Sort

15. Example: Values Card Sort

16. Program Tailoring

17. 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

18. Relatively Poor Program Engagement in ACT-CL • 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

19. 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

20. 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

21. 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).

22. 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

23. 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

24. 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, mindfulnessand values

25. 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

26. 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

27. 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

28. Thank You!