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Cited by 272Mindfulness and Compassion InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychotherapy Techniques and Applications

Acceptance and Commitment Therapy as a Treatment for Anxiety and Depression

Open access
Twohig, Michael P., Levin, Michael E.·2017·Psychiatric Clinics of North America
DOI 10.1016/j.psc.2017.08.009
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Abstract

Acceptance and commitment therapy (ACT) is a modern form of cognitive behavioral therapy based on a distinct philosophy and basic science of cognition. This article reviews the core features of ACT's theoretic model of psychopathology and treatment and its therapeutic approach. It provides a systematic review of randomized controlled trials (RCTs) evaluating ACT for depression and anxiety disorders. Summarizing 36 RCTs, ACT appears to be more efficacious than waitlist conditions and treatment-as-usual, with largely equivalent effects relative to traditional cognitive behavioral therapy. Evidence indicates that ACT treatment outcomes are mediated through increases in psychological flexibility, its theorized process of change. © 2017

AI snapshot

Written from the paper’s full text.

TL;DR

This review outlines acceptance and commitment therapy’s theoretical foundations and systematically examines randomized trials for anxiety and depression. Across 36 trials, ACT generally outperformed waitlist and treatment-as-usual conditions and was largely comparable to traditional cognitive behavioral therapy, with psychological flexibility often acting as a mediator.

Key findings

  • Across 36 randomized controlled trials, ACT was more effective than waitlist and treatment-as-usual for anxiety and depression, and largely equivalent to traditional cognitive behavioral therapy.
  • For depression, all 7 waitlist comparisons favored ACT up to 6-month follow-up (Cohen’s d = .32–1.18); 4 of 5 treatment-as-usual comparisons favored ACT up to 18 months (d = .38–1.45); among 5 CT/CBT comparisons, 4 of 5 found equivalent post-treatment effects, with mixed follow-up results.
  • Anxiety findings included panic disorder (between-group d = .72 for panic, d = .89 for general functioning; 70% response at post-treatment and 80% at 6-month follow-up), GAD (ABBT vs waitlist d = 1.02; 76% vs 16% no longer meeting GAD criteria at post), and mixed anxiety, social anxiety, OCD, and health anxiety trials showing generally positive outcomes.
  • Process analyses in several trials indicated that increases in psychological flexibility mediated ACT outcomes; for depression, 12 of 17 trials examined processes, and formal mediation supported psychological flexibility in three waitlist comparisons and cognitive defusion in one ACT-vs-CT comparison.

Methods

  • Narrative/systematic review of published randomized controlled trials of ACT for anxiety disorders and depression, alongside a conceptual review of contextual behavioral science, functional contextualism, relational frame theory, and the psychological flexibility model.
  • The abstract reports 36 RCTs total; tables organize trials by anxiety disorder and depression, including comparison conditions such as waitlist, treatment-as-usual, minimal/placebo conditions, and CT/CBT, as well as individual, group, self-help, online, and workshop formats.
  • Main analysis is qualitative synthesis of between-group effect sizes, response and recovery rates, quality-of-life outcomes, and mediation/process findings; no pooled meta-analytic effect estimate is reported.

Limitations

  • The paper states that many trials have small samples, that research is limited for panic disorder, health anxiety, and specific phobias, and that it remains unclear which clients benefit more from ACT versus traditional CBT or how to match treatments.
  • The paper states that ACT’s comparison with CBT for depression is unclear because of the number of trials and small samples, and that follow-up findings are mixed; it also notes inconsistent differential effects on psychological inflexibility relative to CT/CBT.
  • Evident from the text: this is a narrative review rather than a meta-analysis, effect sizes are not pooled, included studies vary in protocols, comparators, and outcome measures, and five depression RCTs were excluded because they were not available in English, which may limit generalizability.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.psc.2017.08.009

Cites

93 of 93 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

15 of 54 cited sources checked · 9 supported · 1 flagged · accuracy not yet measured

  • Findingcitation

    In a one-day workshop trial, 71% to 77% of ACT participants recovered from depression at 3-month follow-up.

    “71 and 77% recovered from depression in ACT at 3 month follow up after a one day workshop.68”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [68] Gaudiano, 2015, Acceptance-based behavior therapy for depression with psychosis: results from a pilot feasibility randomized controlled trial, J Psychiatr Pract source

      The Method section (page unavailable) describes a 16-session treatment over four months, not a one-day workshop. The Results report reliable improvement in depressive symptoms for 50% of ADAPT participants at posttreatment, not 71%–77% recovery at three months; the Discussion says the three-month sample was too small for definitive conclusions. (LLM, conf=0.88)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
  • Premisecitation

    ACT alters the context of relating to internal experiences so that they have less influence on behavior, a decoupling effect.

    “This is sometimes referred to as a “decoupling” effect 10 in that ACT alters the context of relating to internal experiences such that they have less influence on behavior (e.g., self-critical thoughts are noticed as just thoughts, while one chooses to engage in social activities).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [10] Levin, 2015, Decoupling as a mechanism of change in mindfulness and acceptance: a literature review, Behav Modif source
  • Premisecitation

    A web-based ACT intervention for college students with mixed issues successfully reduced anxiety.

    “Additionally, a web-based intervention for college students with mixed issues also showed that ACT successfully reduced anxiety.23”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [23] Levin, 2017, Web-based acceptance and commitment therapy for mental health problems in college students: a randomized controlled trial, Behav Modif source
  • Premisecitation

    A large well-controlled RCT showed ACT utility for mixed anxiety and depression.

    “in a large well-controlled RCT, 20”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [20] Arch, 2012, Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders, J Consult Clin Psychol source

      The Methods (Participants and Design; page unavailable) describe a randomized ACT-versus-CBT trial with 128 treatment starters, and the Discussion (Summary and conclusion; page unavailable) calls ACT a viable treatment for anxiety disorders. The trial enrolled people with anxiety disorders, not a mixed anxiety-and-depression sample; the Discussion (Secondary outcomes) reports reductions in co-occurring mood disorders but does not establish ACT’s utility for depression as a primary condition. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Findingcitation

    The tendency to relate to anxiety as bad predicts avoidance behavior.

    “Laboratory-based research has modeled this, demonstrating for example that the tendency to relate to anxiety as bad predicts avoidance behavior 12”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [12] Levin, 2017, Examining the role of implicit emotional judgments in social anxiety and experiential avoidance, Journal of Psychopathology and Behavioral Assessment source

      In “Do implicit emotional judgments interact with increases in heart rate?” (page unavailable), an “anxiety is bad” bias predicted shorter speech time—a measure of avoidance—only when heart rate increased during the speech. The “public speaking outcomes” results found no direct association between that bias and speech time or willingness to give another speech. The citing sentence omits this condition and presents the relationship as a general prediction. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
  • May combine two claims. 36
  • Classified as probably not a substantial claim. 12

  • May combine two claims.

    Premisecitation

    In an RCT of ACT vs waitlist for 43 adults who were nonresponders to previous panic treatments, between-group effect size was d=.72 for panic and d=.89 for general functioning.

    “A full RCT (ACT vs waitlist) was conducted with 43 adults who were nonresponders to previous treatments for panic disorder.35 The between group effect size was d=.72 for panic and d=.89 for general functioning.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [35] Gloster, 2015, Treating treatment-resistant patients with panic disorder and agoraphobia using psychotherapy: a randomized controlled switching trial, Psychother Psychosom source

  • May combine two claims.

    Findingcitation

    ACT has been tested in six randomized controlled trials using a group format, one of which was a single-day workshop.

    “ACT has also been evaluated in 6 RCTs in a group format, one of which used a single day workshop format.68”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [68] Gaudiano, 2015, Acceptance-based behavior therapy for depression with psychosis: results from a pilot feasibility randomized controlled trial, J Psychiatr Pract source

      The Introduction describes this paper’s pilot randomized trial of ADAPT and mentions another ACT-based pilot trial, but it does not count six group-format RCTs. The Methods describe a 16-session protocol, not a single-day workshop. Searches for group trials and a workshop found no passage supporting the cited claim; page numbers were unavailable in our copy. (LLM, conf=0.74)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Use of hierarchical frames may enhance the impact of ACT exercises focused on practicing psychological flexibility with cognitions.

    “such as research suggesting that the use of hierarchical frames (that one contains these experiences as part of an observing self) may enhance the impact of ACT exercises focused on practicing psychological flexibility with cognitions.14”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Foody, 2015, An empirical investigation of the role of self, hierarchy, and distinction in a common act exercise, Psychol Rec source

  • May combine two claims.

    Findingown data

    Across 36 randomized controlled trials, ACT is more efficacious than waitlist and treatment-as-usual for depression and anxiety.

    “Summarizing across a total of 36 RCTs, ACT appears to be more efficacious than waitlist conditions and treatment-as-usual, with largely equivalent effects relative to traditional cognitive behavioral therapy.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Online ACT outperformed expressive writing on depression at post-treatment, but the two conditions had equivalent positive effects at follow-up.

    “ACT delivered online also outperformed an active comparison condition of expressive writing at post, though both conditions had equivalent positive effects at depression at follow-up (Pots).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Pots

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Findingcitation

    In that trial, online ACT produced greater improvements at 6-month follow-up in depressive symptoms (g = .76) and life satisfaction (g = .75) than face-to-face ACT.

    “Participants receiving an online program actually demonstrated stronger improvements at 6-month follow up on depressive symptoms (g = .76)and life satisfaction (g = .75)relative to face-to-face ACT.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [76] Lappalainen, 2014, ACT Internet-based vs face-to-face? A randomized controlled trial of two ways to deliver Acceptance and Commitment Therapy for depressive symptoms: an 18-month follow-up, Behaviour Research and Therapy source

  • May combine two claims.

    Findingown data

    At follow-up, one study found ACT and CBT equivalent at 6 months, one found CT outperformed ACT at 18 months, and two found ACT outperformed CT at 2 months.

    “Results were more mixed at follow up, with one studying finding ACT and CBT were equivalent on depression at 6-month follow up, one study finding CT outperformed ACT on depression at 18-month follow up, and two studies finding ACT outperformed CT on depression at 2-month follow up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Two RCTs compared ACT to minimally active comparison conditions on depression; both found ACT outperformed at post but were equivalent at follow-up.

    “Two other RCTs compared ACT to minimally active comparison conditions (expressive writing and minimal support group) on depression.Both studies found ACT outperformed comparison conditions on depression at post, but were equivalent at follow up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Five RCTs compared ACT to TAU on depression, with 4 of 5 showing ACT improves depression more than TAU up to 18-month follow-up.

    “Five RCTs compared ACT to TAU on depression, with 4 out of 5 studies showing ACT improves depression more than TAU up to 18-month follow up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    ACT has been adopted internationally, demonstrated by the range of countries publishing RCTs on ACT for depression.

    “ACT has been adopted internationally, which is demonstrated by the range of countries that have published RCTs on ACT for depression (even when this review was restricted to English-language publications).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    ACT produced greater improvements in psychological flexibility than placebo conditions, with d .43 for expressive writing and d .77 for minimal support group.

    “and relative to placebo conditions (expressive writing d = .43,minimal support group d = .77).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Five RCTs compared ACT to CT or CBT on depression; at post, 4 of 5 found equivalence and the remaining found ACT led to greater improvements.

    “Finally, five RCTs compared ACT to CT or CBT on depression.At post, 4 out of 5 studies found ACT and CT/CBT were equivalent in improving depression, with the remaining study finding ACT led to greater improvements than CT.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Another RCT found equivalent effects for ACT relative to TAU among individuals with comorbid alcohol and depressive disorders, although ACT led to less required treatment prior to discharge.

    “Another RCT 72 found equivalent effects for ACT relative to TAU among individuals with comorbid alcohol and depressive disorders, although it is worth noting that the ACT condition led to less required treatment prior to discharge from the inpatient unit (i.e., greater treatment efficiency).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    ACT improved quality of life relative to waitlist in four of five trials, with effect sizes from d .39 to 1.03, up to 3-month follow-up.

    “ACT improved quality of life relative to waitlist in four out of five trials with Cohen's d effect sizes ranging between .39 and 1.03, up to 3-month follow up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    RCTs indicate ACT leads to greater improvements in depression relative to comparison conditions for depressed individuals with comorbid migraines, comorbid psychosis, caregivers of family members with dementia, and individuals on long-term sick leave.

    “RCTs indicate that ACT leads to greater improvements in depression relative to comparison conditions for depressed individuals with comorbid migraines, 68 with comorbid psychosis, 69 caregivers of family members with dementia, 70 and individuals on long-term sick leave.71”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Open trials found ACT produced improvements over time with depression in unique/complex samples including comorbid depression and social anxiety disorder, comorbid depression and obesity, and depressed veterans in the US.

    “Additional open trials have found ACT to produce improvements over time with depression in unique/complex samples including comorbid depression and social anxiety disorder, 73 comorbid depression and obesity, 74 and depressed veterans in the US (Walser et al., 2013).75”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Among studies reporting rates, ACT response rates ranged from 50% to 58% with depression recovery rates ranging from 24% to 82%.

    “Among studies reporting rates, ACT response rates ranged from 50% to 58% with depression recovery rates ranging from 24% to 82%.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    In group-format trials, ACT beat waitlist and treatment as usual, and its results were at least as good as cognitive therapy.

    “These studies similarly found ACT outperforms waitlist and TAU, with equivalent or greater outcomes relative to CT.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    Four randomized trials tested self-help ACT for depression: three delivered online and one used a self-help book with email support.

    “Four RCTs evaluated ACT in a self-help format for depression, with three using an online delivery format and one testing a self-help book with email support.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Seven RCTs compared ACT to waitlist on depression, and every study showed ACT improves depression relative to no treatment up to 6-month follow-up.

    “Seven RCTs compared ACT to waitlist conditions on depression, with every study showing that ACT improves depression relative to no treatment up to 6-month follow up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Only two of four trials found that ACT improved psychological flexibility relative to CT/CBT; the other two found equal improvements between conditions.

    “However, only two of four RCTs found that ACT improved psychological flexibility relative to CT/CBT, with the other two studies finding equal improvements between conditions.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    ACT response rates in self-help studies ranged from 25% to 54%, and one study found that 50% recovered from depression after an ACT self-help program.

    “Response rates from ACT varied between 25% and 54%, with one study finding that 50% recovered from depression following an ACT self-help program (Lappalainen).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Lappalainen

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Findingnone given

    Research on ACT for panic disorder and health anxiety is in its infancy, and very little exists for specific phobias.

    “The work in panic disorder and health anxiety is in its infancy; there has been very little with specific phobias.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In self-help trials for depression, ACT yielded significant improvements over no treatment at post-treatment and up to 6-month follow-up, with effect sizes from Cohen's d .32 to .98.

    “These studies almost exclusively compared ACT to waitlist, finding that ACT produces significant improvements in depression relative to no treatment at post and up to 6-month follow up with effect sizes ranging between Cohen's d of .32 and .98.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    These individual therapy studies found ACT outperforms waitlist, TAU, and a minimal support group, with largely equivalent effects relative to CT/CBT.

    “These studies found ACT outperforms waitlist, TAU, and a minimal support group, with largely equivalent effects relative to CT/CBT.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Functional contextualism defines truth by success in achieving its goals, which are prediction and influence of behavior.

    “Functional contextualism is a pragmatic world view in that it defines truth with regards to success in achieving stated goals, which in the case of functional contextualism are prediction and influence of behavior.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Hayes, 1988, Finding the philosophical core: a review of Stephen C. Pepper's World Hypotheses: a study in evidence, J Exp Anal Behav source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Relational frame theory focuses on arbitrarily applicable derived relational responding as a central component of language and cognition.

    “RFT focuses on the role of a specific type of behavior, arbitrarily applicable derived relational responding, as a central component of language and cognition.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [3] Hayes, 2001

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [5] Zettle, 2016 source

  • Classified as probably not a substantial claim.

    Premisenone given

    Humans can derive relations beyond their direct learning history.

    “However, humans also have the unique capacity to derive relations beyond direct learning history (e.g., learning a nickel is smaller than a dime and a dime is smaller than a quarter, and deriving a quarter is greater than a nickel).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The unit of analysis in functional contextualism is the organism interacting in and with a context, defined currently and historically.

    “The unit of analysis in functional contextualism is the organism interacting in and with a context (defined currently and historically).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [8] Hayes, 1988, Finding the philosophical core: a review of Stephen C. Pepper's World Hypotheses: a study in evidence, J Exp Anal Behav source
    • cites [9] Hayes, 2012, Contextual behavioral science: creating a science more adequate to the challenge of the human condition, J Contextual Behav Sci source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    ACT belongs to the larger research approach called Contextual Behavioral Sciences.

    “Acceptance and commitment therapy (ACT) 1 is part of a larger research approach called Contextual Behavioral Sciences (CBS).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Hayes, 2012 source

  • Classified as probably not a substantial claim.

    Premisereasoning

    Relational behavior can transform the functions of stimuli.

    “This last example highlights another key property of relational behavior, which is that they can transform the functions of stimuli.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    ACT is a contemporary cognitive behavioral therapy that rests on functional contextualism and relational frame theory.

    “Acceptance and commitment therapy (ACT) is a modern form of cognitive behavioral therapy based on a distinct philosophy (functional contextualism) and basic science of cognition (relational frame theory).”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [3] Hayes, 2001

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [5] Zettle, 2016 source
    • cites [8] Hayes, 1988, Finding the philosophical core: a review of Stephen C. Pepper's World Hypotheses: a study in evidence, J Exp Anal Behav source
    • cites [9] Hayes, 2012, Contextual behavioral science: creating a science more adequate to the challenge of the human condition, J Contextual Behav Sci source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Derived relational responding can be applied arbitrarily, allowing social cues to inform how one responds to stimuli.

    “Furthermore, derived relational responding can be applied arbitrarily, meaning social cues (instead of just physical properties of stimuli) can inform us of how to relationally respond to stimuli.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] De Houwer, 2013

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisereasoning

    RFT suggests that altering the literal context of thoughts can reduce their functions, which is cognitive defusion.

    “RFT suggests that the literal context of thoughts might be altered such that these relations do not have the same functions (cognitive defusion).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In an open trial of ACT-based exposure for panic disorder with 11 adults, panic disorder decreased significantly after 4 ACT sessions and additional significant gains followed 6 self-guided exposure sessions.

    “A significant decrease in panic disorder was seen after the first 4 sessions, with additional significant gains found in the following 6 sessions.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [34] Meuret, 2012, Brief acceptance and commitment therapy and exposure for panic disorder: a pilot study, Cogn Behav Pract source

  • May combine two claims.

    Interpretationreasoning

    ACT improves quality of life in addition to reducing symptom severity in depressed samples.

    “Overall, these results indicate that ACT improves quality of life in addition to symptom severity among depressed samples”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    It is less clear how ACT compares to CBT due to the number of trials and small sample sizes, but results suggest it is likely at least equally effective for depression, with questions at follow-up.

    “It is less clear how ACT compares to CBT due to the number of trials and tendency for small sample sizes in existing studies, but results suggest it is likely at least equally effective for depression, with some questions raised regarding which treatment may be more effective at follow up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In one trial, CBT performed better for those with moderate pretreatment anxiety sensitivity, and ACT performed better for those with comorbid disorders.

    “Moderation effects for that same trial were also found in that CBT performed better for those with moderate levels of pretreatment anxiety sensitivity, and ACT performed better for those with comorbid disorders.25”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] Wolitzky-Taylor, 2012, Moderators and non-specific predictors of treatment outcome for anxiety disorders: a comparison of cognitive behavioral therapy to acceptance and commitment therapy, J Consult Clin Psychol source

  • May combine two claims.

    Interpretationcitation

    ACT can be delivered online with an impact on depression similar to face-to-face delivery.

    “these results at least suggest that ACT can be delivered in an online format with similar impact on depression.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    ACT's evidence base for depressive and anxiety disorders continues to grow, indicating that it is a promising treatment approach warranting dissemination and further study.

    “Overall, ACT's evidence base for depressive and anxiety disorders continues to grow, indicating this unique, modern CBT is a promising treatment approach warranting dissemination and further study.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: ACT is a unified treatment protocol.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    One-day workshops, self-help books, and websites are especially promising formats for expanding service reach in cost-effective ways.

    “These include formats that are especially promising for increasing the reach of services in cost effective formats such as one-day workshops, self-help books, and websites.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    A large body of research indicates that ACT is effective for depression and potentially as effective as traditional CBT.

    “However, there is also a large amount of research indicating ACT is effective for depression, and potentially as effective as traditional CBT.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Depression was one of the first clinical problems evaluated with ACT and has been one of the most studied, with 17 RCTs published over three decades.

    “Depression was one of the first clinical problems evaluated with ACT 62 and one of the most studied problems since, with 17 RCTs published over the past three decades.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [62] Dabbaghi, 2016, Effectiveness of group training of acceptance and commitment therapy on depression symptoms in soldiers, EBNESINA

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a study of test anxiety, 16 students assigned to CT or AABT showed that AABT did markedly better on exams and CT did worse.

    “In the second study, 16 students were assigned to CT or AABT for test anxiety.61 There were surprising results in that those in the AABT condition did markedly better on exams and those in the CT condition did worse.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [61] Zettle, 1987, Component and process analysis of cognitive therapy, Psychol Rep source

  • May combine two claims.

    Premisecitation

    In an open trial, AABT for GAD with 16 adults produced large effect sizes at post and follow-up, with 75% responders at post and 50% at follow-up.

    “In their first work, Roemer and Orsillo 26 tested AABT in an open trial with 16 adults diagnosed with GAD.Results were promising with large effect sizes at post and follow-up with 75% responders at post and 50% at follow-up.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Roemer, 2007, An open trial of an acceptance-based behavior therapy for generalized anxiety disorder, Behav Ther source
45 of 45

  • The paper relies on this without support.

    Psychological inflexibility is a core concern in mixed anxiety disorders.

    “ACT has always been a unified treatment protocol for issues where psychological inflexibility is a core concern.”

  • The paper relies on this without support.

    Most primary outcome measures used in ACT treatment outcome work mix changes to internal events and overt actions.

    “However, most primary outcome measures used in treatment outcome work have a mix of changes to internal events and overt actions.”

  • The paper relies on this without support.

    The six processes of change in ACT all work together.

    “Psychological flexibility is made up of six processes of change that all work together.”

  • The paper relies on this without support.

    ACT is a unified treatment protocol.

    “As ACT is a unified treatment protocol and there is a growing number of trials testing ACT across anxiety and depression issues.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Process-based cognitive-behavioral therapy (PB-CBT) has proved efficacious for alleviating anxiety and depression levels among both the general and chronic pain population, with very good acceptability.

    “So far, PB-CBT proved to be efficacious for alleviating anxiety and depression levels among both the general and chronic pain population, with very good acceptability [38,39,40].”

    From A Single-Session Process-Based Cognitive-Behavioral Intervention Combined with Multimodal Rehabilitation Treatment for Chronic Pain Associated with Emotional Disorders (2024) · cites this paper as [38]

    The Abstract (page unavailable) reports that ACT, a modern form of CBT, appears effective for anxiety and depression relative to waitlist or treatment as usual. The Conclusions (page unavailable) place ACT among process-based CBT approaches but describe it as promising, not definitively proven. The paper does not establish the claimed efficacy in a chronic-pain population or report very good acceptability. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Mediation analyses report increasing psychological flexibility as a mediator or process variable of ACT treatment effects, such as increases in quality of life and decreases in symptoms.

    “Corresponding to the underlying theory, mediation analyses report increasing psychological flexibility as a mediator or process variable of ACT treatment effects, such as increases in quality of life and decreases in symptoms (20–22).”

    From Increasing psychological flexibility is associated with positive therapy outcomes following a transdiagnostic ACT treatment (2024) · cites this paper as [22]

    The Depression RCT Processes of Change section (page unavailable) reports formal analyses finding that increased psychological flexibility mediated ACT’s effect on depression. The Quality of Life section (page unavailable) reports improvements in quality of life, but does not say that psychological flexibility mediated those improvements. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • In agreement with the current findings, the literature revealed promising outcomes about the use of group ACT to manage mood disorders regardless of age, gender, ethnicity, and type of disease.

    “In agreementwithourfindings, theliterature revealed promising outcomes about the use of group ACT to manage mood disorders, regardless of age, gender, ethnicity, and type of disease (40, 41).”

    From The Effect of Group Acceptance and Commitment Therapy on the Management of Asthma: A Randomized Clinical Trial (2022) · cites this paper as [40]

    The depression RCT table (Additional information; page not provided) reports improved depression outcomes with group ACT in Dutch adults and Australian adolescent females. The Depression RCT Sample Types section also describes promising results across several depressive populations, but those findings are not all from group ACT studies. The copy does not establish that group ACT works regardless of age, gender, ethnicity, or type of disease. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • ACT-based interventions are effective across a broad range of health and psychological problems.

    “ACT-based interventions have been proven effective with regard to abroad range of health and psychological problems (Kishita et al . 2017; Twohig and Levin 2017; Brown et al . 2016; Lee and Song 2018; Hayes et al . 2006; Bai et al . 2020).”

    From Effectiveness of a training programme based on acceptance and commitment therapy aimed at older adults – no moderating role of cognitive functioning (2021) · cites this paper as Twohig and Levin 2017

    The review reports evidence that ACT is effective for anxiety and depression, including depression in people with comorbid health or psychological conditions (Depression RCT Sample Types; Several RCTs have been conducted comparing ACT to various control conditions; pages unavailable). It does not establish effectiveness across a broad range of health problems themselves, and its conclusion describes ACT as promising for those complex populations rather than proven effective across them. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • ACT appears to be more effective than waitlist and treatment as usual with effects relatively equivalent to CBT.

    “-A review of thirty-six RCTs of anxiety and depression treatments: ACT appears to be more effective than waitlist and treatment as usual with effects relatively equivalent to CBT (Twohig & Levin, 2017).”

    From Prolonged grief disorder treatment: An approach to COVID-19 grief (2023) · cites this paper as Twohig & Levin, 2017

    The section on RCT comparisons (page unavailable) reports that ACT generally outperformed waitlists and treatment as usual for depression, while most post-treatment comparisons with CT/CBT found equivalent outcomes; follow-up results were mixed. The anxiety-disorder RCT table also reports waitlist and CBT comparisons. The retrieved passages do not establish the citing sentence’s specific count of thirty-six RCTs. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • The same trial has two sample sizes

    Minor

    The anxiety and depression tables describe the Forman et al. (2007) ACT comparison with different sample sizes: 101 and 132 participants.

  • A CBT comparison is cited as a waitlist trial

    Minor

    The social anxiety summary places reference 44 among waitlist comparisons, but reference 44 describes a trial comparing CBT with ACT.

2 of 2

Cites

Flagged first, then by citations

8 of the 101 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. Baghooli, 2014, Effectiveness of acceptance and commitment therapy in reduction of severity symptoms of patients with obsessive–compulsive disorder, Adv Environ Biol, 8, 2519
  2. Vakili, 2014, The comparison of acceptance and commitment therapy with selective serotonin reuptake inhibitors in the treatment of obsessive-compulsive disorder, Zahedan Journal of Research in Medical Sciences, 16, 10

Cited by

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Related

Authors
Twohig, M. P., & Levin, M. E.
Affiliations
Utah State University (US)
Corresponding author
Twohig, Michael P.
ORCID
Venue
Psychiatric Clinics of North America
Publisher
Elsevier BV
Published
2017-12
Volume
40
Issue
4
Pages
751-770
ISSN
0193-953X (ISSN-L)
DOI
10.1016/j.psc.2017.08.009
OpenAlex
W2725508837
Cited by
268
References
101
Citations by year
2026: 28 · 2025: 33 · 2024: 37 · 2023: 33 · 2022: 42 · 2021: 39 · 2020: 27 · 2019: 20 · 2018: 8 · 2017: 1
FWCI
2.34
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Psychiatric Clinics of North America (publishedVersion)
  • PubMed (publishedVersion)
  • Digital Commons - USU (Utah State University) (submittedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
acceptance and commitment therapy, anxiety disorders, depression, psychological flexibility, cognitive behavioral therapy, change processes, treatment efficacy, psychopathology models
MeSH terms
Anxiety Disorders, Depressive Disorder, Humans, Acceptance and Commitment Therapy

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-09-30.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-30.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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