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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. Disclosure.

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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 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
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?

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


  • 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)

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

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

  • 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

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).

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, mindfulnessand values

Summary 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

  • Low Program Engagement/Satisfaction for ACT-CL Flexibility

    • 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 Flexibility

    • 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
    Thank You! Flexibility