Acceptance and Commitment Therapy for the Inpatient Treatment of Psychosis

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.

Inclusion Criteria:

Inclusion criteria for the patient sample, used to establish feasibility, acceptability,
safety, and efficacy of the experimental treatment, will be:

- hospitalized with current psychosis symptoms (hallucinations and/or delusions);

- DSM-IV-TR (APA, 2000) diagnosis of a psychotic disorder (i.e., schizophrenia,
schizoaffective disorder, schizophreniform disorder, delusional disorder, brief
psychotic disorder, psychotic disorder not otherwise specified) or a mood disorder
with psychotic features (major depression, bipolar I disorder) that requires
hospitalization;

- ability to provide informed consent ;

- conversational in English; and

- patient stay on the unit estimated in advance to be greater than one week.

Inclusion criteria for the staff sample, used to identify barriers and facilitators to the
implementation of the experimental treatment, will be

- ability to provide informed consent and

- conversational in English.

Exclusion Criteria: