Effectiveness of group acceptance and commitment therapy in treating depression for acute stroke patients

Abstract Objectives To date, the effectiveness of acceptance and commitment therapy (ACT) for acute stroke patients has not been well recognized. The study aimed to discover the effectiveness of group‐based ACT in treating depression for acute stroke patients. Methods We conducted a randomized controlled trial with 140 acute stroke patients with depression. The ACT intervention comprised seven sessions, of 45–60 min over 4 weeks. Data were collected pre‐ and post‐intervention and at 3‐month follow‐up, assessing depression, health‐related quality of life (HRQoL), psychological flexibility, cognitive fusion, sleep quality, and confidence. Results Overall, 99.3% of the included patients were assessed as having mild depression. The ACT intervention significantly reduced depression in acute stroke patients in comparison with the control group post‐intervention and at 3 months (partial η2=.306). Additionally ACT significantly improved HRQoL‐mental component summary, sleep quality, psychological flexibility, cognitive fusion, and confidence compared with control group. Conclusions ACT is effective in treating acute stroke patients with depression, and the efficacy was maintained at 3‐month follow‐up.

LIU ET AL. stroke patients (Kowalska et al., 2020).But only 5%-11% of those with PSD are recognized early and treated in a timely manner in hospital or other clinical settings (Muller et al., 2021;Swartz et al., 2016).
Recent research has reinforced that PSD remains underdiagnosed and undertreated (Bhattacharjee et al., 2018).Thus, it is important and desirable to recognize and treat depression in acute stroke patients appropriately.
Psychological interventions to build mental wellbeing can have a vital role in reducing the pressure and burden of illness (Slade, 2009).
van Agteren et al. (2021) review included 419 randomized controlled trials (RCTs) from clinical and nonclinical populations (n = 53,288) and found that acceptance and commitment therapy (ACT) was one of the impactful interventions.There is a growing body of RCTs in support of ACT to treat depression across a wide variety of patients, and ACT has been reported to be able to treat depression and improve quality of life (Bai et al., 2020).ACT proposes that depression is an indication that life is unbalanced, and it is a natural aspect of human experience.The core of ACT is behavioral change enabling living according to one's chosen values (A-Tjak et al., 2018).ACT has many characteristics indicating that it is suitable for stroke patients, such as a focus on an acceptance of unpleasant feelings, because many stroke patients may have disability for many years with accompanying psychological effects (Majumdar & Morris, 2019).
To date, three RCTs have reported the effectiveness of ACT for stroke patients, and both showed benefits.Firstly, Majumdar and Morris (2019) performed an RCT which compared regular treatments for stroke survivors (without the inclusion criterion of depression and the times since the most recent stroke averaged at 13.6 months) with group-based ACT (G-ACT) comprising four 2-h instructional Power-Point sessions.The results showed a significant reduction in depression and increased self-assessed health rating and hopefulness for the G-ACT intervention patients.However, there were no differences identified relating to quality of life, and the sample size was too small to yield conclusive results with only 56 participants and there was not inclusion criterion for depression in this study.
Secondly, Niu et al. (2021) included 104 acute ischemic stroke patients (having the first ever stroke attack, with the onset of less than a week) with those in the intervention group being given G-ACT treatment (five sessions, 45-55 min/session).The depression scores of those in the intervention group were significantly lower than those of the control group at 1 month (p = .018)and 3 months follow-up (p = .001);however, there were no differences in the other two outcomes including degree of neurological deficits and activities of daily living between the two groups.Additionally, the intervention comprised five sessions which has no scientific basis.Again, there was no inclusion criterion for depression in this study.
Thirdly, Wang et al. (2022) included 100 acute cerebral infarction patients (the times since the most recent stroke was not documented) suffering from insomnia, anxiety, and depression, with those in the observation group being given ACT psychological nursing (seven units, the time for each unit was not clear).After 1 month of nursing, the scores of depression were significantly decreased in the observation group (p = .001);however, the intervention integrated ACT into nurs-ing measures, and the study aimed to improve insomnia, anxiety, and depression, rather than depression only.
These three RCTs suggest that ACT may have efficacy in reducing depression following stroke.This study aims to test the effectiveness of ACT in a large hospital by implementing G-ACT for acute stroke patients with depression and to evaluate changes in the quality of life, and sleep quality.To our knowledge, this is the first large trial in an acute stroke sample testing G-ACT as the treatment of depressive symptoms following stroke.

Design
This was an RCT with a pretest-posttest design and two arms, in which a 4-week G-ACT intervention was compared to usual care.The primary and secondary outcomes were collected using interviews before the intervention and immediately after the intervention in hospital, and then again 3 months later (follow-up assessment) over the telephone, at the outpatient clinic, or during a home visit.The study was approved by the Ethics Committee of PLA Rocket Force Characteristic Medical Center (KY2018005).

Setting
This study was conducted at the PLA Rocket Force Characteristic Medical Center, which is a large hospital with acute stroke in-patient treatment.

Randomization
One hundred and forty patients gave written informed consent for this study, based on the Declaration of Helsinki, and were randomly assigned to one of two groups: G-ACT or control group.Two independent researchers who did not participate in assessing patients took charge of the randomization using the lottery method.Once a number has been selected, that particular number was struck off from the draw box.Sequentially numbered, opaque, sealed, and stapled envelopes were used to store the assignment results.The allocation process was concealed from other researchers who were responsible for assessing participants.The envelopes were opened only after the corresponding patient had completed the baseline assessment.

Intervention
The patients included to the control group received usual care support in hospital, and the patients included to the intervention group received G-ACT and usual care support.Based on the Hayes and Wilson (1994) and after expert consultation, the G-ACT treatment in this study comprised seven sessions of 45-60 min and was administered throughout the course of the 4-week long trial.The ACT sessions were generally held twice a week with each group enrolling 4-8 patients.A patient was excluded from the study if he/she was absent for three sessions, as this was half or less of the full treatment protocol (Johnsen & Friborg, 2015).The ACT in this study was adapted for acute stroke in collaboration with hospitalized patients and caregivers, including reducing the duration of each session, increasing the number of sessions per week, simplifying the language, and the inclusion of stroke-specific examples.The session-by-session outline is set out in Table 1.Prior to the study, the two nurses delivered three whole G-ACT intervention sessions with stroke survivors by themselves with supervision by one of the two clinical psychologists, and the results showed good interventional outcome.

Depression
The HAMD or HDRS (Hamilton, 1986) is the most common, standard, and classic depression rating scale in clinical research and has been used worldwide by researchers and clinicians due to its high reliability and validity in measuring depressive symptoms in stroke patients (Gao et al., 2012;Robinson et al., 1984).The Chinese version (Zheng et al., 1988) has good reliability and validity.We utilized the 24 item HAMD scale to measure the severity of depression symptoms.Each item is scored from 0 to 2 or 0 to 4; if the total score was less than 8, it would not be considered depression; if the total score was greater than 8, mild depression would be considered; if the total score was greater than 20, moderate depression would be considered; and if the total score exceeds 35, it would be considered severe depression.

2.7.1
Health-related quality of life (HRQoL) Health-related quality of life (HRQoL) was assessed using the Short Form Survey Version 2 (SF-12v2) (Ware et al., 1996) HRQoL.The SF-12v2 has been found to be a valid and reliable substitute for the SF-36 (Lam et al., 2013).It takes less than 2 min to complete SF-12 and has been widely used with stroke patients, and studies have shown that the Chinese version has good reliability and validity (Liao et al., 2016;Yu et al., 2012).

Psychological flexibility
The Acceptance and Action Questionnaire II (AAQ-II) (Bond et al., 2011) is a seven-item questionnaire measuring psychological flexibility.
The items are scored on a 7-point Likert scale and the total score ranges from 7 to 49 with a higher score indicating less psychological flexibility.

Cognitive fusion
The Cognitive Fusion Questionnaire (CFQ) (Gillanders et al., 2014) is a 9-item questionnaire measuring cognitive fusion on a 7-point Likert scale, scores range from 0 to 63 with a higher score indicating that a person is more fused one with one's thoughts.The Chinese version (Zhang et al., 2014) has good internal consistency (Cronbach's α = .92).

Sleep quality
The Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989) is a 19item questionnaire evaluating subjective sleep quality over the past month.The items are scored on a scale of 0 to 3, with total scores ranging from 0 to 21 and higher scores indicating poorer sleep quality.The TA B L E 1 Session-by-session outline of acceptance and commitment therapy course.

Session Content
First Getting to know stroke, from a broader perspective Familiarity and creating therapeutic communication.Encourage patients to share their views about stroke, ask the patients to share where they get their information about stroke, health education, including the risk factors, outcome, and rehabilitation, creating the distinction between actions that are under our control and actions that are controlled by our mind

Second
Embrace everyday life, be content with the present Encourage the patients to express their feelings and thoughts, normalization of negative thoughts, strengthen the positive thoughts, focus on acceptance of unpleasant feelings without trying to avoid or suppress them Third Observe yourself and understand yourself By using self-portrait, labeling, tearing off the label to teach the patients learn to observe and understand themselves, and recognize that "I'm who I am" Fourth Be aware of the present moment and embrace it Guide the patients to be aware of the present moment, and encourage them to describe their current feelings and embrace them, and reinforce positive beliefs

Confidence
The confidence was assessed using the confidence after stroke measure (CaSM) (Horne et al., 2017), which is a 27-item questionnaire on a 4-point Likert type scale with total scores ranging from 0 to 81 and higher scores representing higher confidence.The Chinese version (Hu et al., 2018) has good internal consistency (Cronbach's α = .974).If the total score was below 36, low confidence was considered; if the total score was lower than 28, very low confidence was considered.
The posttest and follow-up assessment were administered by a trained research assistant who was unaware of each patient's treatment allocation, and the patients were asked not to reveal to her the types of treatment that they received.

Statistical analyses
SPSS software version 20 was used for data analysis.Pearson χ 2 and independent samples t tests analyses were used as the statistical methods for comparisons between groups.Repeated measure ANOVA was used for the comparison of the changes of depression before, immediately after and 3 months after the intervention and, considering its significance, the least significant difference post hoc test was used.

RESULTS
One patient in the control group declined to complete the second assessment before discharge.Of the patients in the intervention group, 9 (12.9%)patients participated in 5 sessions, 21 (30%) patients participated in 6 sessions, and 40 (57.1%)patients participated in all sessions.

Primary outcome
There was no significant statistical difference regarding the score of HAMD at pre-intervention between the two groups (p > .05,Table 3).
The results demonstrated that the lengthening of time between intervention and follow-up resulted in a decrease of HAMD scores for both study groups with the ACT group having significantly lower scores compared to the control group at post-intervention (p < .001)

TA B L E 2
The demographic and clinical characteristics of the subjects (N = 139).Note: T1, pre-intervention; T2, post-intervention; T3, 3-month follow-up.Abbreviations: AAQ, the Acceptance and Action Questionnaire; CaSM, the confidence after stroke measure; CFQ, the Cognitive Fusion Questionnaire; MCS, mental component summary; PCS, physical component summary; PSQI, the Pittsburgh Sleep Quality Index.and 3-month follow-up (p < .001,Table 3), suggesting a reduction of depressive symptoms after the intervention.A mixed-design repeatedmeasures ANOVA found a significant time × group interaction for depression, in favor of G-ACT (Table 4).The partial  2 for this effect was .306,which indicates that G-ACT had an effect on reducing depression, and the effect was still significant over time.

Secondary outcomes
There were no significant statistical differences regarding the score of MCS, PSQI, AAQ, CFQ, and CaSM at pre-intervention between the two groups (p > .05,Table 5).There were significant differences across all the scores at post-intervention and at 3-month follow-up between the two groups (p < .001),indicating that G-ACT significantly improved HRQoL-MCS, sleep quality, psychological flexibility, cognitive fusion, and confidence compared with control group.However, there was no significant difference in the scores of PCS between the two groups at any time point (p > .05,Table 5).

DISCUSSION
This study found that the G-ACT intervention significantly reduced depression in acute stroke patients when compared with the control group at post-intervention and this difference persisted at 3 months, which echoes the findings of RCTs using G-ACT with acute stroke patients (Niu et al., 2021) and stroke survivors (Majumdar & Morris, 2019).However, both studies had small samples and neither included stroke patients with a diagnosis of depression.Although Rauwenhoff et al. ( 2019) published a protocol of ACT for depressive stroke patients, the results related to that trial have yet to be published.As stroke patients experience both physical and emotional changes in the acute phase, it is very important to provide timely emotional support for them (Niu et al., 2021).Our study testified the efficacy of G-ACT in reducing the depressive symptoms in patients with acute stroke, which has important implications for researchers and clinical staff.
Most of the included patients were assessed as having mild depression with those having severe psychotic symptoms and who may need individual therapy or more specialized psychiatric treatments excluded from our study.The promising results suggested that G-ACT was effective in patients with mild depression, which is similar to other reported findings (Bai et al., 2020).Its effectiveness for patients with major depression requires further study as does the suitability of G-ACT delivered by clinical professionals, including nurses, for patients with major or moderate depression.
This study also found that significant G-ACT intervention effects were observed for HRQoL-MCS at post-intervention which persisted at 3 months in acute stroke patients.However, there was no outstanding difference in the PCS scores between the two groups at any time point.The lack of effect of G-ACT on PCS in our study was similar to Dewhurst et al. (2015) finding for epilepsy patients but contrary to Lundgren et al.'s (2008) study showing significant improvements in quality of life following a short-term ACT treatment in epilepsy patients.The process of ACT represents psychological flexibility which has been shown to be important in improving psychological health (Kashdan & Rottenberg, 2010).The lack of effect of G-ACT on PCS found in our study may due to ACT being primarily focused on emotional, interpersonal, and cognitive difficulties and is, therefore, more effective in improving the mental well-being aspects of HRQoL rather than physical functioning (Dewhurst et al., 2015).Furthermore, the 3month time frame of the follow-up might have been too short a time gap for such life changes to become observable as a response to the intervention.
This study assessed an ACT intervention change in psychological flexibility, and the findings indicated that G-ACT could improve psychological flexibility significantly over time, which was similar to a review (Graham et al., 2016) where all six different studies observed significant pre-to-post intervention improvements following ACT measures of psychological flexibility with AAQ.The overall purpose of ACT is to increase psychological flexibility, which is the ability to be mindful of experiences in the present moment, in an open and neutral manner, while being with one's values (Levin et al., 2014).This study applied interactive, discursive, and more empirical acceptance-based strategies that are found within traditional ACT group formats, including encouraging patients to share their views about stroke and discussing it with the other patients or their family, inviting previous patients whom had benefited from ACT and would love to share successful experi-ences with those new to ACT, and using self-portrait, labeling, tearing off the labels to teach patients to observe and understand themselves, and recognize that "I'm who I am" which may be a particularly good fit for stroke patient groups because it enables the individual to move forward with life and accept their neurocognitive and physical limitations.
The ACT focus on value-driven strategies may be especially useful in this situation.More studies need to test its efficacy on a wider range of stroke patients.

Strengths and limitations
To our knowledge, this is the first large-scale trial which focused on testing the effectiveness of G-ACT in treating depression for acute stroke patients.The results showed that G-ACT could reduce depression, and the effect was still significant over time (partial  2 = .306).
The G-ACT in this study was adapted for the acute stroke scenario in This study has several limitations.The study was conducted in one center with mainly hospitalized patients with acute stroke whose length of hospitalization was mostly less than 1 month.Although the study increased the occurrences of G-ACT per week, there were still some patients who were unable to complete all seven sessions at the hospital.Participation in the study was voluntary and excluded patients using psychiatric drugs including antidepressants or sedatives so that the sample may not have been representative of the overall population, and a single site limits the generalizability of the findings.Most of the included patients were assessed as having mild depression, and it might be expected that their mental health would improve along with the recovery of neurological function compared with those with severe or moderate depression (Niu et al., 2021).

CONCLUSION
This study found that G-ACT could significantly reduce depressive symptoms in patients with acute stroke, and the interventional efficacy was maintained at 3-month follow-up (partial  2 for this effect was The group training sessions were performed and administered by two research nurses.Prior to the study, the 2 nurses completed an online ACT training course including 16 classes in Meilihua eHealth University, and received supervision from 2 clinical psychologists, who had 5 years of experience in ACT therapy and who participated in designing the intervention sessions as primary researchers in the study.
collaboration with hospitalized patients and caregivers.The changes included reducing the duration of each session, increasing times per week, simplifying the language, and the inclusion of stroke specific examples.The group training sessions in this study were performed by two research nurses with appropriate training and support suggesting the potential of nurses and other clinical professionals as deliverers of G-ACT.The study had a high response rate which may reflect the maintenance of good relationships between the researchers and sample.

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306), with similar benefits being observed for HRQoL-MCS, sleep quality, psychological flexibility, cognitive fusion, and confidence, and that G-ACT can be performed well by clinical nurses with sufficient training and support.The study findings suggest that G-ACT is an acceptable and promising intervention following acute stroke.The next logical step for future research in this field would be to test the efficacy of ACT interventions against alternative, suitably "active" treatments, including traditional CBT and pharmacotherapy, and to measure both of the variability of depression and stroke severity in the long term.AUTHOR CONTRIBUTIONS Yun-E.Liu: Supervision; writing-original draft.Jin Lv: Conceptualization.Fangzhen Sun: Data curation; investigation.Jingjing Liang: Investigation.Ying-Ying Zhang: Formal analysis.Jie Chen: Funding acquisition; project administration.Weijian Jiang: Methodology; project administration.
FifthIdentification of individual values Help the patient identify individual values at present and establish a positive attitude to face the current situation Sixth Set goals and commit to action Help the patient develop specific goals based on value orientation, and identify targets in line with their current situation and commit to action Seventh Learn how to relax, improve sleep quality By using abdominal breathing, relaxing music, soft, and slow language to let the patient relax, help them learn the relaxation technique and can practice it by themselves (Lu et al., 2014)f PSQI(Lu et al., 2014)has good internal consistency (Cronbach's α = .845)and test-retest reliability (α = .994).If the total score was lower than 5, it would be considered very good sleep quality; if the total score was greater than 6, it would be considered good sleep quality; if the total score was greater than 11, it would be considered moderate sleep quality; and if the total score exceeds 16, it would be considered poor sleep quality.
Estimated means of primary outcome across time by treatment condition.Repeated measurement analysis of variance of depression across time by treatment condition.< .001indicates acceptance and commitment therapy has effect on reducing depression, and the effect is still significant over time.Estimated means of secondary outcome across time by treatment condition.