Adult Nursing field of practice

Answer

1. Nurs 2001 Assignment: Use of Internet-Based Act (iACT) Therapies in Treating and Preventing Depression and Anxiety

   Introduction

   Almost everyone in the world currently experiences stress in their everyday life, like work deadlines, being late for a job interview or appointment, family arguments/disagreements (Bohlmeijer et al. 2011; Wersebe et al. 2018). These stressors can cause a robust impact on the welfare of an individual (Bohlmeijer et al. 2015). One specific injurious kind of stress is associated with work. People who are working may experience a significant level of work-associated stress (Carmody & Baer 2008 Cohen & Janicki-Deverts 2012). In a United States report, 41% of all professionals revealed that their work is extremely or very stressful (Hayes et al. 2013). Work-associated stress is linked to minimized efficiency or effectiveness at work and absenteeism as well as large costs for community/society (Faber & Schlarb 2016; Fawzy & Hamed 2017; Flaxman & Bond 2010). Additionally, prolonged stress has been shown to have the ability of leading to stress-associated disorders (Frögéli et al. 2016; Gloster et al. 2015), besides being linked to a variety of diverse health results, like depression and anxiety (Bohlmeijer et al. 2011; Bohlmeijer et al. 2015), coronary disease (Baxter et al. 2013; Bluett et al. 2014), and sleep challenges (Dalrymple & Herbert 2014).  Depression is currently affecting several people in diverse ways. Depression was ranked by the Global Burden of Disease Study of the World Health Organization (WHO) as the single most onerous of troublesome disease globally in terms of total disability-modified years among individuals who are in their middle years of life (Roemer et al. 2008). Despite the fact that a number of approaches have been developed and employed in treating depression, efficacy for both psychological and pharmacological interventions is yet unsatisfactory (Ruiz 2010).

   According to Wersebe et al. (2018), depression is equally among the most highly recurrent disorders. Above 75% of people have been diagnosed with major depressive disorder (MDD) experience at least one time, usually substituting two years of recovery (Swain et al. 2013). Nat1onal Institute of Health and Clinical Excellence has recognized supplementary prevention as a crucial goal in the long term depression management (Fledderus et al. 2012). Depression’s high recurrence rate implies particular vulnerability factors that raise danger for experiencing MDD episodes (Cohen & Janicki-Deverts 2012).  Preventive approaches that help in identifying and ameliorating these factors could ostensibly minimize risk of MDD subsequent episodes (Carmody & Baer 2008). As such, to realize a detailed understanding of depression disorder along with its efficacious treatment, several angels and perspectives by be needful (Brinkborg et al. 2011; Faber & Schlarb 2016). Andersson and Titov (2014) proposed an extra unified depression model that integrates biological, evolutionary, and cognitive viewpoints for preventing and treating depression, and this approach is Acceptance and Commitment Therapy (ACT). ACT has been acknowledged as an effective treatment strategy for depression and has as well shown prospective outcomes in secondary depression prevention (Baxter et al. 2013; Hayes et al. 2013; Arnberg et al. 2014).

   However, to make mental treatment available to the larger population, researchers have successfully developed internet-based ACT interventions (iACT), a therapy that entails using the internet/websites to offer psychological health data and information and skill coaching online (Fawzy & Hamed 2017; Andersson et al. 2013; Brown et al. 2016). iACT has the ability of overcoming the attitudinal and structural limitations or hindrances of face-to-face treatment like shortages of therapist workers, geographical distance, social stigma, wait-list, work commitment, and financial costs (Brinkborg et al. 2011; Buhrman et al. 2013), which are very pronounced in rural regions (Carlbring et al. 2013). To this end, this paper assesses the impact of minimizing negative signs and symptoms in depression of iACT in adults. Due to many concerns that have been associated with treatment and prevention of depression, this report will identify two research pieces (one quantitative; one qualitative) exploring the impacts of iACT in depression’s treatment and prevention. A systematic search will be carried out in pertinent databases (MEDLINE, EMBASE, Scopus, ProQuest Central, Web of Science, and PsycINFO). Both research pieces will stringently be evaluated using Öst’s (2008) framework of critiquing. The researches’ contributions, limitations, and strengths to practice and theory will as well be discussed. The report will begin with an overview of ACT and iACT, then development of a literature research question, then literature search, then critiquing of the research pieces, and end with a conclusion followed by a list of reference. 

   Why This Topic Is Significant To Nursing Practice

   The focus of this paper is to assess the impact of minimizing negative signs and symptoms in depression of iACT in adults. The study is significant since it provides a detailed as well as up-to-date evaluation upon empirical status of ACT and iACT for depression. Additionally, the study is good since it bridges gaps in literature by providing information that can assist: (1) inform scholars, students, and researchers regarding what has so far been done, as well as where treatment gaps for depression or anxiety are present; (2) potentially guide the development, design, and empirical endorsement of ACT and iACT interventions either as adjunct or self-help to treatment as usual, and clarify what therapies or interventions hold the capability for efficacious, practical, and acceptable anxiety treatment.  

   ACT and iACT

   ACT has emerged as an increasingly famous therapeutic strategy and is regarded as the ‘thirdwave’ of cognitive-behavioural therapies (Fledderus et al. 2012: Fiorillo et al. 2017; Gershkovich et al. 2017).  As opposed to its predecessors, ACT concentrates upon a person’s behavior and thinking to achieve a meaningful and valued life, and therefore minimize psychological distress, as opposed to centering upon the removal and control of symptoms and signs of psychopathology in itself (Hesser et al. 2012). ACT’s key aim is to raise a person’s psychological flexibility (PF), which refers to the ability of present in the moment, seek crucial values, as well as select behavior aligned to the crucial values while simultaneously accepting the availability of unfriendly experiences (Hoffmann et al. 2018). ACT acknowledges six crucial processes that jointly work to realize PF: defusion, acceptance, contact with current moments (equally known as mindfulness), valuing, self-as-context, and committed action (Kelson et al. 2017). With substantial interception and overlap among the six crucial processes, a person’s mastery of the processes is essentially gauged by experiential circumvention as a substitution for PF (Levin et al. 2014).

   Evidently, ACT is a contemporary-behaviour therapy that combines mindfulness and acceptance processes, with behavior-change and commitment processes. Since ACT functions to foster PF, PF has been shown to be linked to higher life satisfaction, job performance, emotional wellbeing, and job satisfaction (Levin et al. 2015; Ljótsson et al. 2014; Molander et al. 2018; Pots et al. 2016). Levin et al. (2016) observe that experimental and correlational evidences show that experiential avoidance, as the opposite of acceptance, functions to contribute to the maintenance and development of various behavioural and psychological problems as supported by (Räsänen et al. 2016), Trompetter et al. (2015), and Viskovich and Pakenham (2018). ACT’s fundamental tenet is that by nurturing as well as developing an extra accepting as well as PF position, it is possible to remain in contact with sore experiences, while at the same time remaining focused upon what an individual wants their life to be both now and the future. Another process that contributes to PF that is addressed by ACT is the present-moment awareness. To some varying extent and through varying means, ACT procedures seek to buttress an individual’s mindfulness in a way.

   From the ACT’s viewpoint, depression is a secondary emotion that emerges from unproductive or ineffective determinations to experientially manage disappointment and sadness as an adaptive and normal reactions to life events that are distressing (Nayyereh et al. 2017). Sadness that psychologically unhealthy or not toxic per se, in effect, may be changed into medical depression (Gonzalez-Fernandez et al. 2018). As oppose to targeting transformations in the mind and thinking of people struggling with depression, ACT seeks to transform how those people respond, react, or relate to their individual thoughts. As opposed to changing a person’s thought, ACT via acceptance, defusion, and mindfulness strategies seeks to reduce its effects as a hindrance to PF. During depression, people often exhibit reduction in task-oriented and pleasurable activities (Davoudi et al. 2017; Witlox et al. 2018). From ACT’s viewpoint, it is not a rise in activity levels in someone that is most crucial, rather clarifying and exploring values, as well as exemplifying PF by dedicated actions that are coherent with values in several life areas (Lin et al. 2015). As aforementioned, to make mental treatment available to the larger population, researchers have successfully developed internet-based therapy interventions (iACT).

   Literature Search Question

   To achieve the aim of this study, the PIO (Population, Intervention, Outcome) system of developing literature search was employed. The PIO system was employed for this study it was more basic besides the fact that it was more pertinent for this research owing to the fact that it more easily accommodated both quantitative and qualitative studies (Baranoff et al. 2016). Therefore, the literature search question for this research was, ‘To what degree can Internet Acceptance and Commitment Therapy (iACT) minimize negative signs and symptoms and promote the wellbeing of clinically depressed adults?’

   Literature Search

   Search Strategy

   Various databases were search for literature on iACT. These included ProQuest Central, EMBASE, Scopus, MEDLINE, and PsycINFO. These databases were chosen since they are the widely used medicine, science, epidemiology, and public health databases (Ghomian & Shairi 2014). To identify and select the right literatures, various key words were employed, which were combined variedly. They included anxiety, ACT/acceptance and commitment therapy, iACT or internet acceptance and commitment therapy, or (internet or online or web-based) ACT, or etherapy. Others were depressed, depression, unipolar depression, depressive illness, and affective disorder. However, since the databases’ search engines only searched for exact word(s) that were typed in, it was necessary to use the various forms of the abovementioned keywords to ensure the research’s findings were not restricted (Beck & Bredemeier 2016). For that reason, words like depress* and affective disorder* were used to ensure that words that begin with ‘depress’ or ‘affective order’ were all captured. ‘*’ was used as well for other words that could have varied forms.

   Further, the literature search was restricted to peer reviewed literature that were published in English and between 2000 and March 2019. Other than databases, the ACBS (Association for Contextual Behavioural Science) website was equally surveyed for ACT or iACT research.  This website was surveyed since it is a global online research and learning community for ACT (Heydari et al. 2018).

   Article Selection

   Once duplicate citations had been removed, articles’ abstracts and titles were then appraised and screened independently in accordance with Hoseinaei et al.’s (2013) eligibility criteria. After the screening and appraisal, full text review was one more time carried out, and various perspectives were resolved via mutual agreement and discussion between the researchers.

   Data Extraction

   Data from the selected literatures were extracted into a standard coding sheet before they could be checked by another researcher for purposes of validity and eligibility.  Data items that were extracted for synthesis of the literatures are as follows:

   1. Reference source: publication year and first author’s surname
   2. Efficacy: anxiety measures, study quality ranking, and effect sizes.
   3. Anxiety-associated disorder or problem under examination
   4. Population: participants, country, age, sample size, and gender breakdown.
   5. Adherence: treatment satisfaction, attrition rate, and intention-to-treat assessment.
   6. Study design: measurement points, methodology, and comparator test arms.
   7. ACT or iACT intervention details: manual protocol, intervention name, treatment length, number of modules, educational content, and therapist guidance.

   Quality Assessment

   To evaluate the quality of the selected literatures, psychotherapy outcome study methodology rating form (POMRF) was employed. POMRF is a 22-item questionnaire addressing the crucial methodological aspects relevant to psychotherapy intervention researches, like psychotherapy implementation, statistical analyses, research design, user adherence, clinical significance, participant details, and therapist characteristics ().POMRF is employed in assessing quality across many research designs, with each of its items rated on a three-point scale varying between 2 (good) and 0 (poor) and its total score computed as the total sum of all points (). Total score for any study can vary between 0 and 44 points, with lower scores signifying lower general methodological quality.

   In this review, ACT and iACT studies that were included were assessed independently against POMRF items by two researchers who individually computed the general POMRF scores. Upon completion, the scores were compared between the researchers, and the differences resolved through mutual agreement and discussion.

   Narrative Synthesis

   A narrative synthesis methodology was employed for this review owing to the paucity of ACT and iACT literatures along with the heterogeneity that was found between the literatures, like designs, populations, comparators, as well as depression or anxiety results. Results are as presented here below.

   Results

   Literature Selection

   The literature search generated 571 articles. A total 201 articles remained after duplicates were removed. Of these, 20 articles attained the eligibility criteria as shown in the figure 1 in the appendix. Out of the 20 articles that remained after the literature research process two articles were chosen for analysis. They are Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review by Kelson, Rollin, Ridout, and Campbell (2019) (qualitative) and Internet-delivered acceptance-based behaviour therapy for generalized anxiety disorder: A pilot study by Dahlin, Ryberg, Vernmark, Annas, Carlbring and Andersson (2016) (quantitative).

   1. Kelson et al. 2019, ‘Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review’, Journal of Medical Internet Research, vol. 21, no. 1, p. 27

   The aim of this study was well spelt out by the researchers. The aim of the study by Kelson et al. (2019) was to examine the therapeutic effect of iACT upon all kinds of depression or anxiety. According to the paper, depression and anxiety conditions are prevalent and debilitating globally. This study is important because it adds to the fact that ACT is an effective strategy of preventing and treating depression. Nonetheless, the study acknowledges that there are barriers (geographical, attitudinal, and geographical) which prevent individuals from accessing ACT treatment. As such, the study recommends that to overcome the aforementioned barriers, internet-delivered ACT (iACT) therapy has been developed. According to the study, iACT intervention employs the internet and websites to provide ACT data and skill education exercises over the Web (Kelson et al. 2019). As such, the paper is important to this current study because it justifies that while ACT is appropriate for treating or addressing depressive and anxiety feelings, it is hindered by a number of factors that can only be bridged by iACT.

   To realize its objective, the study gives a very comprehensive methodology that was employed by the researchers, giving a detailed literature research, key words, and selection process. The researchers extracted information from MEDLINE, EMBASE, ProQuest Central, and Scopus, and obtained other data from Web of Science (Kelson et al. 2019). These databases were searched till 2018. Nevertheless, the number of databases that were searched were few and so the information that was gathered was limited to some extent. There are other several databases containing science, behavior, and medicine literature. Apart from databases, the researchers should have made use of data from recognized websites and organizations dealing with health, science, and behavior issues. 

   Out of the detailed methodology, a total of 20 studies were approved through the methodology’s inclusion criteria. Out of these, there were 11 RCTs and 9 uncontrolled pilot studies. 18 studies of the 20 indicated a substantial depression and anxiety minimization after the employment of iACT treatment (Kelson et al. 2019), a finding that was noted in studies that provided iACT without (n=5) or with (n=13) therapist guidance. Across all the studies that were included, the average attrition rate during the active iACT therapy sage was 19.19%. Out of the 20 studies, 13 that evaluated treatment satisfaction, respondents averaged their iACT experience with more than high treatment gratification (Kelson et al. 2019).

   The study is important to this current one since it concludes that iACT is an effective and acceptable therapy and treatment for adults with generalized anxiety disorder (GAD) as well as general anxiety signs and symptoms. The paper acknowledged that more RCT studies should be conducted to help corroborate iACT findings by use of empirical treatments in active control cohorts. The study would possibly validate the prospective outcomes for social anxiety disorder (SAD) and illness anxiety disorder (IAD) along with a full spectrum of depression and anxiety disorders.

   Despite its high degree of comprehensiveness in terms of discussion, methodology, data analysis, and the precise and informative findings, the study was not void of limitations. First, the study highlighted that as at the time the study was done, there was substantial need for testing iACT interventions upon all depression-associated challenges. This was hinged upon then fact that there were no studies on iACT regarding separation anxiety disorder, specific phobia, selective mutism, agoraphobia, depression disorders as a result of medical conditions, panic disorder, or medication/medication-induced depression disorder (Kelson et al. 2019). Additionally, the study underscored that there were still questions regarding the iACT’s capacity to enact therapeutic changes in people’s veins of proven treatments, recommending that further examination into the effect of personal ACT-based modules, without or with therapist guidance, using RCT (Kelson et al. 2019). This way, it could be possible to pinpoint maximal time lengths of treatment, clarify content quality, and elucidate the use of unguided therapy controls.

   Further, the study only included English publicized literatures. However, there are possibilities of more depression iACT articles in the global domain in other formats (like conference proceedings) or languages (). Moreover, even among the English language-based articles reviewed, there articles that were found to have met the study’s inclusion criteria, yet they were not self-described as iACT.  For instance, some studies employed “values-based behavior therapy” or “acceptance-based” in their titles. There are possibilities that a study was overlooked as a result obscure nomenclature. Additionally, the review only concentrated upon web-based intervention therapy and never included in its coverage other online modalities, like mobile phone applications, virtual reality systems, and social media. There were also no sub-group assessments performed regarding the effect of iACT on depression, implying that insight was lacking regarding the applicability of iACT to individuals with particular demographic features, like education level, age, or gender.

   Taking note of the weaknesses, further studies ought to take into consideration quality assessment when designing iACT studies. This, according to (), would assist in addressing gaps in present literature, like concomitant therapy confounds, inadequate clinical importance reporting, as well as depression outcome sustainability  above one year. Similarly, since most of the iACT initiatives were assessed, there is a need for an independent assessment to be done to help clarify external findings.

   2. Dahlin et al. 2016, ‘Internet-delivered acceptance-based behavior therapy for generalized anxiety disorder: A pilot study’, Internet Interventions, vol. 6, pp. 16–21.

   The aim of the study by Dahlin et al. (2016) was to test the effects of therapist-guided iACT on signs and symptoms of GAD as well as quality of life. The researchers also employed audio CD with mindfulness and accetance exercises along with a separate workbook in the treatment of depression patients. The reserchers randomly allocated participants who were diagnossed with GAD to immediate therapist-guided iACT or to a waiting-list-control status. The study found out that the follow-up cohort data showed maintained impacts. Whereas there was a 20% rate of droup out, sensitivity assessmenet revealed that dropouts remained similar in their exchange degree during the period of treatment (Dahlin et al. 2016). The findings of the study indicated that iACT can be effective in minimizing GAD’s sings and sympoms. Generally, the study is significant and contributes to current literature by indicating that iACT is effective in treating depression.

   From the analysis of the document, the strength of the study are that the authors of the same have no conflict of interst and that the authors have keenly checked the correctness of the findings. Conversely, the study had three main weaknesses. First, the researchers employed an individual-recruited sample and the education level was very high (most of the parrticipants were had university education). Additionally, despite the fact that GAD is common among females, there were few males in the study’s trial. Second, the researchers employed a waiting-list control cohort and whereas they did not gather weekly ratings from all their participants, an active control cohort of participants with a credible control therapy would have responded to the questions of relative merits of iACT therapy. Third, the researchers mainly self-reported findings and comorbidity was merely partly evaluated (depression).

   Notwithstanding the above mentioned limitations, the study by () adds to extant and growing literature regarding internet/online/web-based treatments for GAD, indicating prospective outcomes. Comparisons and larger replications against other treatments and formats are required to further gauge the plausibility and feasibility of thee treatment and therapeutic approach. Further study equally needs to address the quality of life, both with regard to how it is gauged and if result should be bettered. Generally, iACT therapy has the prospective of minimizing GAD’s signs and symptoms and, therefore, serve as a supplement to existing treatments.

   Conclusion

   To wrap it up, this study aimed at answering the question: To what degree can Internet Acceptance and Commitment Therapy (iACT) minimize negative signs and symptoms and promote the wellbeing of clinically depressed adults? To answer the same, the study assessed the impact of minimizing negative signs and symptoms in depression of iACT in adults. From the analysis, it can be deduced that ACT and iACT are effective therapies for people with depression and anxiety disorders, and are prospective therapies for the treatment of the same. Despite the success of this study, further studies are needed to take into consideration non-English published articles and formats (like conference recordings) and more information from various databases and organizations’ websites.