Acceptance and Commitment Therapy for the Inpatient Treatment of Psychosis
Condition: Psychotic Disorders
MeSH terms: Psychotic Disorders; Mental Disorders
Study type: Interventional
Phase: Early Phase 1

Summary: 
      There is a substantial need for enhancing the efficacy and effectiveness of Veterans Health
      Administration (VHA) inpatient services for psychosis and tailoring them to support recovery.
      The proposed pilot study will explore whether Acceptance and Commitment Therapy (ACT), a
      recovery-oriented, evidence-based inpatient treatment, is a feasible, acceptable, safe, and
      effective adjunct for the inpatient treatment of Veterans with psychosis at a single VHA
      site. Additionally, an evaluation of barriers and facilitators to future implementation will
      be conducted. If promising, the data gained from the proposed study will support future
      evaluation, implementation and dissemination efforts that have the potential to improve
      inpatient treatment for psychosis and recovery, and thus, the lives of Veterans, while
      reducing costs for VHA.
    

Detailed description: 
      Within the Veterans Health Administration (VHA) in fiscal year 2011, patients with psychotic
      disorders represented approximately 4% of the total population, and received approximately
      14% of VHA's total expenditures (Blow et al., 2011). Patients with psychosis receive
      substantial, repeated, and costly inpatient treatment, and this is often the only chance to
      provide treatment due to gaps in mental health service utilization (Blow et al., 2011;
      McCarthy et al., 2007). Thus, there is an urgent need for enhancing the efficacy and
      effectiveness of VHA inpatient services and tailoring them to better support recovery.

      Acceptance and Commitment Therapy (ACT), a recovery-oriented, evidence-based adjunct to
      inpatient treatment for psychosis, is an excellent candidate for investigations within VHA
      inpatient settings. ACT for psychosis is considered an empirically supported treatment by the
      American Psychological Association (APA, 2012; Chambless et al., 1998). A consistent body of
      research has demonstrated the clinical effectiveness of ACT for treatment of psychosis,
      including well-designed randomized clinical trials of ACT on inpatient settings (Bach &
      Hayes, 2000; Gaudiano & Herbert, 2006). ACT is effective when provided in a flexible format
      of three to four sessions, and for patients with a range of chronic and severe psychotic and
      comorbid mental disorders.

      This proposed pilot study aims to explore ACT as an adjunct to inpatient treatment as usual
      (TAU) for psychosis among VHA patients at one VHA inpatient psychiatry unit. The project will
      use an effectiveness/ implementation Hybrid Type 1 design that incorporates a pilot RCT and
      semi-formative evaluation of barriers and facilitators to future implementation. Participants
      will be 80 VHA patients with current psychotic symptoms (hallucinations and/or delusions)
      related to a psychotic or mood disorder who are admitted to an inpatient psychiatry unit VA
      Palo Alto Health Care System (VAPAHCS). Participants will be randomly assigned to receive
      either TAU (n = 40), or TAU with plus 4-sessions of ACT (n = 40) individually provided during
      their stay on the inpatient unit. Aim 1 is to investigate the feasibility, acceptability, and
      safety of the treatment for VHA patients, as indexed by: (a) the ability to recruit and
      consent 2 eligible participants per week (for 40 weeks) to participate in the study and be
      randomized to ACT + TAU or TAU; (b) patient attendance of 3 ACT individual sessions (out of 4
      possible) on average; (c) patient and ACT Facilitator (provider of the intervention),
      reported ACT treatment satisfaction and alliance; and (d) the occurrence of zero serious
      adverse events attributable to the ACT treatment. Aim 2 is to investigate treatment effects
      of ACT on patient functioning (i.e., acceptance), symptomatology, distress, and affect. Aim 3
      is to obtain data from participating patients and unit staff regarding system-, clinician-
      and patient-level barriers and facilitators to implementing staff-delivered ACT services for
      psychosis at the participating VHA inpatient setting, including: (a) barriers that limit
      patients, staff, and site participation in ACT and how to address them; (b) provider and
      patient perceptions about why ACT is successful at achieving better outcomes; (c) site
      specific and general barriers to implementation of ACT and how to address them; and (d)
      perceived value of and how to sustain ACT in the absence of a funded project.

      This project is the first step in exploring a potentially sustainable and effective
      intervention that will improve inpatient psychosis treatment and recovery, and hence, the
      lives of VHA patients with psychosis, while reducing costs for VHA. If promising, study
      findings will support a HSR&D Investigator Initiated Research (IIR) Merit grant application
      that will propose to assess the effectiveness and cost of implementing the ACT intervention,
      and potential barriers and facilitators for implementation efforts at multiple VHA inpatient
      psychiatric units. The aims of this project align with the HSR&D research priority area of
      improving mental and behavioral interventions for individuals with serious mental illness by
      refining recovery-oriented treatment approaches related to evidence-based programs.
    

Intervention name(s): Acceptance and Commitment Therapy; Treatment as Usual (TAU)
Intervention type(s): Behavioral; Other
Intervention description(s): The goal of ACT is to help the patient increase psychological flexibility, a core component of mental health and well-being. ACT teaches clients to be mindfully aware but nonreactive to delusions/ hallucinations and to increase willingness to
experience associated distressing emotions while simultaneously engaging in meaningful behavioral actions.
Patients expand their repertoire of behaviors to live according to their values and to pursue valued goals, thereby increasing adaptive functioning and quality of life.; All patients admitted to the acute psychiatry unit are administered anti-psychotic and/or other psychotropic medication during their inpatient stay. Patients participate in standard milieu therapy on the unit (group and activities therapies, and individual therapy as needed). Therapy on the unit focuses on psycho-education about illness, symptom identification, mood management techniques, stress reduction, and relapse prevention. Patients also receive unstructured individual therapy and case management as appropriate.
Other intervention name(s): ACT
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Psychotic Disorders; Acceptance and Commitment Therapy; Inpatient psychiatry; Schizophrenia; Acute psychiatric disorder