Acceptance and commitment therapy as a web-based intervention for depressive symptoms: Randomised controlled trial
Open accessAbstract
Background: Depression is a highly prevalent disorder, causing a large burden of disease and substantial economic costs. Web-based self-help interventions seem promising in promoting mental health. Aims: To compare the efficacy of a guided web-based intervention based on acceptance and commitment therapy (ACT) with an active control (expressive writing) and a waiting-list control condition (Netherlands Trial Register NTR1296). Method: Adults with depressive symptoms from the general population were randomised to ACT (n= 82), expressive writing (n= 67) or waiting-list control (n= 87). The main outcome was reduction in depressive symptoms assessed with the Center for Epidemiological Studies – Depression scale. Results: Significant reductions in depressive symptoms were found following the ACT intervention, compared with the control group (Cohen's d= 0.56) and the expressive writing intervention (d= 0.36). The effects were sustained at 6-month and 12-month follow-up. Conclusions: Acceptance and commitment therapy as a web-based public mental health intervention for adults with depressive symptoms can be effective and applicable.
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Assuming an 18% attrition rate, the current sample size allows detection of small to moderate effect sizes (d = 0.365) with 80% power at the planned follow-up assessment.
“Assuming an attrition rate of 18% as in previous trials evaluating the long-term effectiveness of ACT [45, 80], the current sample-size allows us to detect small to moderate effect sizes (i.e., d = 0.365) with a power of 80% at the planned follow-up assessment [81].”
From Effectiveness of a guided ACT-based self-help resilience training for depressive symptoms during pregnancy: Study protocol of a randomized controlled trial embedded in a prospective cohort. (2020) · cites this paper as [80]
The Results (page unavailable) report 13% attrition in the ACT group at the 12-month follow-up, not 18%. This source is cited for the assumed attrition rate; the sentence cites a different source for the sample-size and power calculation. (LLM, conf=0.85)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredOnline ACT interventions and ACT self-help books have been shown to improve psychological flexibility in other populations.
“online ACT interventions or ACT self-help books could be used in suspected patients of COVID-19, which were proven to improve psychological flexibility in other populations (Pots et al., 2016; Wersebe et al., 2018).”
From Is psychological flexibility a mediator between perceived stress and general anxiety or depression among suspected patients of the 2019 coronavirus disease (COVID-19)? (2021) · cites this paper as Pots et al., 2016
The Outcomes section reports significantly greater improvement across measured outcomes, including psychological flexibility, for the web-based ACT group than for the waiting-list and expressive-writing groups. The Acceptance and commitment therapy section also reports earlier evidence for a guided ACT self-help intervention, but this paper does not show that ACT self-help books improve psychological flexibility. Page numbers are unavailable in our copy. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe online module "Living to the Full" was proven effective in reducing psychological distress in adults.
“the online module “Living to the Full” [28], which was proven to be effective in reducing psychological distress in adults [29, 30].”
From Cost-effectiveness and cost-utility of an Acceptance and Commitment Therapy intervention vs. a Cognitive Behavioral Therapy intervention for older adults with anxiety symptoms: A randomized controlled trial (2022) · cites this paper as [30]
The Acceptance and commitment therapy section identifies the web intervention as based on ‘Living to the Full,’ and the Discussion reports significant post-treatment reductions in depressive and anxiety symptoms. The trial enrolled adults with depressive symptoms; it did not establish effectiveness for psychological distress generally across adults. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThe results on depression, anxiety, and stress are largely inconsistent with recent research among non-clinical samples, which reported the efficacy of ACT self-help interventions in significantly improving depression, anxiety and stress in distressed participants compared to wait-list.
“These results are largely inconsistent with recent research among non-clinical samples, which reported the efficacy of ACT self-help interventions in significantly improving depression, anxiety and stress in distressed participants compared to wait-list (Jeffcoat & Hayes, 2012; Pots et al., 2016).”
From A randomised controlled trial of brief web-based acceptance and commitment Therapy on the general mental health, depression, anxiety and stress of college Students (2022) · cites this paper as Pots et al., 2016
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredThe effect sizes at post-treatment were small to moderate and ranged from 0.35 to 0.56.
“The effect sizes at post-treatment were small to moderate and ranged from 0.35 to 0.56.”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [11]
Table 3 (Study implications) shows post-treatment effect sizes of 0.35–0.56 for ACT compared with expressive writing or the waiting-list control, consistent with the paper’s small-to-moderate classification. The unqualified range does not cover all post-treatment comparisons: expressive writing versus the waiting-list control has effect sizes as low as 0.06. (LLM, conf=0.84)
Experimental — accuracy not yet measured
As reported in Pots et al., the web-based ACT intervention was superior to both the active control condition (EW) and the WLC on all outcome measures (depressive symptoms, anxiety and positive mental health) and process variables (psychological flexibility and mindfulness, except for the mindfulness facets observing and acting with awareness).
“Overall, the results showed that on the short term the web-based ACT intervention was significantly more effective to both control conditions”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [11]
The Outcomes section reports that ACT produced significantly greater short-term improvement than both controls on most measures. The claim misses one exception: compared with expressive writing (EW), the mindfulness facet describing was also not significantly improved (P = 0.12), alongside observing and acting with awareness. (LLM, conf=0.91)
Experimental — accuracy not yet measuredAt follow-up there were no significant differences between the web-based ACT intervention and the web-based EW intervention or the WLC.
“However, at follow-up there were no significant differences between the web-based ACT intervention and the web-based EW intervention or the WLC.”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [11]
The Discussion says ACT and expressive writing had similar effects on depressive symptoms and secondary measures at 6- and 12-month follow-up. The Study implications section also reports no significant difference between either intervention and the waiting-list control in the proportion achieving clinically significant change at six months. But the unqualified claim overlooks significant follow-up findings: ACT improved more from baseline than the waiting-list group on most outcomes, and a greater proportion achieved clinically significant change than in the expressive-writing group. (LLM, conf=0.89)
Experimental — accuracy not yet measuredACT-based interventions have been explored in a self-directed format in various contexts, demonstrating potential acceptance across therapeutic formats.
“ACT-based interventions have been explored in a self-directed format in various contexts, demonstrating its potential acceptance across therapeutic formats [41].”
From Acceptance and commitment therapy adapted for women with infertility: a pilot study of the Infertility ACTion program. (2024) · cites this paper as [41]
The Aims and Acceptance and commitment therapy sections (pages not supplied) describe a guided web-based ACT intervention based on a self-help programme, and note that the programme has also been used as a group course and as self-help with email support. The Adherence section reports high completion and says this may indicate feasibility for its participants. The paper does not establish acceptance across therapeutic formats or various contexts; its own trial concerned guided web-based ACT for depressive symptoms. (LLM, conf=0.83)
Experimental — accuracy not yet measuredEquality of therapy hours between conditions was good in the 3 studies that had an active treatment control.
“The equality of therapy hours between conditions was good in the 3 studies that had an active treatment control [44,53,55].”
From Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review. (2019) · cites this paper as [53]
The Active control condition section says expressive writing was adapted to a format equivalent to ACT, with nine online sessions; the Counselling section says both groups were instructed to complete one session per week. These passages support similar treatment schedules in this study, but they do not compare therapy hours between conditions. (LLM, conf=0.82)
Experimental — accuracy not yet measuredJust over half of the studies (60%, 12/20) randomly assigned participants to treatment conditions, with 6 of these also randomly assigning therapists.
“Just over half of the studies (60%, 12/20) randomly assigned participants to treatment conditions, with 6 of these also randomly assigning therapists [38,39,44,53-55].”
From Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review. (2019) · cites this paper as [53]
The Method section (page unavailable) confirms that participants in this study were randomly assigned to treatment conditions, so the paper supports its inclusion as an example of a randomized study. The Counselling section (page unavailable) describes counsellors working in both intervention conditions but does not report random assignment of counsellors. This individual trial also cannot establish the citing document’s totals of 12 of 20 studies or six studies randomizing therapists. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe highest quality RCT evidence in this review revealed that iACT was just as efficacious as expressive writing.
“Furthermore, the highest quality RCT evidence in this review revealed that iACT was just as efficacious as iCBT [44], and expressive writing [53,55].”
From Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review. (2019) · cites this paper as [53]
The Discussion reports similar effects for web-based ACT and expressive writing at 6 and 12 months. But ACT was significantly more effective in the short term, so the unqualified claim that they were just as efficacious overstates the finding. (LLM, conf=0.90)
Experimental — accuracy not yet measuredThe effectiveness of the web-based intervention Living to the Full, both with and without support from a counselor, in reducing depression and associated anxiety in adults has been established in randomized controlled trials.
“The effectiveness of this web-based intervention (both with and without support from a counselor) in reducing depression and associated anxiety in adults has been established in RCTs [21, 40, 41, 61].”
From An Internet-based Acceptance and Commitment Therapy intervention for older adults with anxiety complaints: study protocol for a cluster randomized controlled trial. (2018) · cites this paper as [41]
The Abstract and Outcomes sections report an RCT in which the web-based intervention reduced depressive symptoms and improved anxiety symptoms in adults. The Counselling section says participants received personal feedback from a counsellor before proceeding to the next session. This paper therefore supports the counsellor-supported result, but not effectiveness without counsellor support. (LLM, conf=0.88)
Experimental — accuracy not yet measuredOf the 10 included studies, 4 (40%) were judged low risk of bias, 1 (10%) high risk, and 5 (50%) unclear risk.
“Of the 10 studies included, 4 (40%) were judged to be of low risk of bias [29,46,49,52], one (10%) of high risk [36], and an unclear risk of bias was assigned to 5 (50%) [45,47,48,50,51] of the included studies.”
From Effectiveness of Web-Delivered Acceptance and Commitment Therapy in Relation to Mental Health and Well-Being: A Systematic Review and Meta-Analysis. (2016) · cites this paper as [52]
The Method section identifies this paper as a randomised controlled trial, so it supports the citation’s identification of a study. Neither the Method nor the Strengths and limitations section reports a risk-of-bias judgment for this trial or the stated counts across ten studies; those judgments belong to the citing document. (LLM, conf=0.78)
Experimental — accuracy not yet measuredThe web-based ACT module Living to the Full was proven effective in reducing distress and depression in earlier studies.
“This module (an adaptation of the similarly titled self-help book [43,44]) was proven effective in reducing distress and depression in earlier studies [45,46].”
From Blended Acceptance and Commitment Therapy Versus Face-to-face Cognitive Behavioral Therapy for Older Adults With Anxiety Symptoms in Primary Care: Pragmatic Single-blind Cluster Randomized Trial. (2021) · cites this paper as [46]
The Abstract and Discussion report that the web-based ACT intervention reduced depressive symptoms, and the Discussion also reports reduced anxiety. The Assessment section does not identify a general distress measure, so this paper does not establish the claimed reduction in distress as such. (LLM, conf=0.83)
Experimental — accuracy not yet measuredThe findings corroborate post-treatment outcomes of recent studies among non-clinical populations, which showed the efficacy of ACT self-help interventions in increasing general mental health compared to a wait-list condition.
“The findings corroborate post-treatment outcomes of recent studies among non-clinical populations, which showed the efficacy of ACT selfhelp interventions in increasing general mental health compared to a wait-list condition (Jeffcoat & Hayes, 2012; Levin et al., 2014; Pots et al., 2016).”
From A randomised controlled trial of brief web-based acceptance and commitment Therapy on the general mental health, depression, anxiety and stress of college Students (2022) · cites this paper as Pots et al., 2016
Since the publication of the two meta-analyses (data up to November 2013), a number of RCTs investigating the effectiveness of online MBIs have appeared in the scientific literature.
“Since the publication of these two meta-analyses, both of which included data collected up until November 2013, a number of RCTs investigating the effectiveness of online MBIs have appeared in the scientific literature (e.g. Dowd et al., 2015; Pots et al., 2016; Trompetter et al., 2014; Zernicke et al., 2014).”
From Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials (2016) · cites this paper as Pots et al., 2016
Multiple trials have shown that effects of online MBIs are maintained up to one year after baseline.
“This is considered important, because multiple trials have shown that effects of online MBIs are maintained up to one year after baseline (e.g. Hesser et al., 2012; Pots et al., 2016).”
From Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials (2016) · cites this paper as Pots et al., 2016
There is growing evidence for the efficacy of web-based ACT interventions.
“In addition, there is growing evidence for the efficacy of web-based ACT interventions [6–11].”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [11]
Non-study treatment was checked and revealed no difference between the conditions.
“Also, as there was no restricted access to care for the WLC, non-study treatment was checked but revealed no difference between the conditions.”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [11]
The effects of the web-based ACT intervention were maintained at 6- and 12-month follow up.
“The effects of the web-based ACT intervention were maintained at 6- and 12-month follow up.”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [11]
The web-based EW condition showed significant improvement compared with the WLC from baseline to follow-up (T0 to T2) for psychological flexibility and some facets of mindfulness, and no significant improvement on other outcome measures.
“Additionally, the web-based EW condition showed significant improvement compared with the WLC from baseline to follow-up (T0 to T2) for psychological flexibility and some facets of mindfulness, and no significant improvement on other outcome measures.”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [11]
In the previously reported results from the RCT, the web-based ACT intervention had similar effects on depressive symptoms and secondary measures after 6 and 12 months compared to the EW intervention.
“In the previously reported results from the RCT [11], we found that the web-based ACT intervention had similar effects on depressive symptoms and secondary measures after 6 and 12 months compared to the EW intervention.”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [11]
Internet interventions based on ACT have been shown to be effective for adults with depressive and anxiety symptoms.
“Internet interventions based on ACT have also been shown to be effective for adults with depressive and anxiety symptoms [40, 41].”
Pots et al. reported an effect size of 0.41 for web-based ACT with e-mail support compared to an active control group using expressive writing.
“Furthermore, Pots et al. reported an effect size of 0.41 for web-based ACT (with e-mail support) compared to an active control group (expressive writing) [41].”
Five interventions were primarily designed to manage and reduce depression and depressive symptoms.
“Five interventions were primarily designed to manage and reduce depression and depressive symptoms [36,45,46,51,52]”
From Effectiveness of Web-Delivered Acceptance and Commitment Therapy in Relation to Mental Health and Well-Being: A Systematic Review and Meta-Analysis. (2016) · cites this paper as [52]
Email reminders were included in 4 RCTs.
“Email reminders were included in 4 RCTs [46-48,52]”
From Effectiveness of Web-Delivered Acceptance and Commitment Therapy in Relation to Mental Health and Well-Being: A Systematic Review and Meta-Analysis. (2016) · cites this paper as [52]
Four interventions specified that they included stakeholders in the design and development process to address adherence, or specifically employed persuasive design features to encourage adherence and engagement.
“Four interventions [47,48,50,52] specified that they included stakeholders in the design and development process to address adherence, or specifically employed persuasive design features in a bid to encourage adherence and engagement.”
From Effectiveness of Web-Delivered Acceptance and Commitment Therapy in Relation to Mental Health and Well-Being: A Systematic Review and Meta-Analysis. (2016) · cites this paper as [52]
In instances where more than one comparator group data was available, the review compared against the active treatment.
“In the instance where more than one comparator group data was available [29,50,52] we compared against the active treatment.”
From Effectiveness of Web-Delivered Acceptance and Commitment Therapy in Relation to Mental Health and Well-Being: A Systematic Review and Meta-Analysis. (2016) · cites this paper as [52]
18 studies directly targeted people with depressive symptoms.
“Moreover, 18 studies directly targeted people with depressive symptoms [14,21,23-25,27,30-40].”
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“of COVID-19, which were proven to improve psychological flexibility in other populations (Pots et al., 2016; Wersebe et al., 2018).”
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“[11], analyses using repeated measures ANOVA showed that the web-based ACT intervention was superior to both the active control condition (EW intervention) and the WLC, on all outcome measures (depressive symptoms, anxiety and positive mental health) and process variables (psychological flexibility and mindfulness, ex…”
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“This module (an adaptation of the similarly titled self-help book [43,44]) was proven effective in reducing distress and depression in earlier studies [45,46].”
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“In line with research by Walser et al. (2015), acceptance and commitment therapy can reduce depression and suicidal ideas, while, in research by Pots et al. (2016), acceptance and commitment therapy can reduce symptoms of depression, although with a different method based on telehealth.”
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A guide to what works for depression: An evidence-based review
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Feasibility of a brief, remote self-compassion intervention for employed mothers
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- Authors
- Pots, W. T. M., Fledderus, M., Meulenbeek, P. A. M., ten Klooster, P. M., Schreurs, K. M. G., & Bohlmeijer, E. T.
- Affiliations
- University of Twente (NL)
- Corresponding author
- Pots, Wendy T. M.
- Venue
- British Journal of Psychiatry
- Publisher
- Royal College of Psychiatrists
- Published
- 2016-01
- Volume
- 208
- Issue
- 1
- Pages
- 69-77
- ISSN
- 0007-1250 (ISSN-L)
- 1472-1465
- OpenAlex
- W1098503608
- Semantic Scholar
- 761f5201f9ec716d4efcbfbcc93d35c2ceb8b2b7
- Cited by
- 133
- References
- 55
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 14 · 2023: 11 · 2022: 22 · 2021: 18 · 2020: 12 · 2019: 11 · 2018: 12 · 2017: 15 · 2016: 6 · 2015: 5
- FWCI
- 20.62
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The British Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- University of Twente Research Information (publishedVersion, other-oa)
- University of Twente Research Information (submittedVersion, other-oa)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- acceptance and commitment therapy, online intervention, depressive symptoms, depression, self-help, expressive writing, public mental health, treatment efficacy, sustained effects
- MeSH terms
- Adult, Aged, Counseling, Depression, Female, Humans, Male, Middle Aged, Netherlands, Patient Compliance, Psychiatric Status Rating Scales, Logistic Models, Treatment Outcome, Internet, Young Adult, Acceptance and Commitment Therapy
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