Internet-delivered guided self-help acceptance and commitment therapy for family carers of people with dementia (iACT4CARERS): a feasibility study

Adapting a Dutch Web-Based Intervention to Support Family Caregivers of People With Dementia in the UK Context: Accelerated Experience-Based Co-Design

BACKGROUND

Around 700,000 family caregivers provide unpaid care for 900,000 people living with dementia in the United Kingdom. Few family caregivers receive support for their own psychological needs and funding for community respite services has declined. These trends are seen across Europe as demographic and budgetary pressures have intensified due to public spending cuts arising from the 2008 financial crisis and the COVID-19 pandemic. The World Health Organization has prioritized the need to expand the provision of support for caregivers and families of people with dementia by 2025. Web-based interventions have the potential for development as they require modest investment and can be accessed by family caregivers at home. Further cost benefits can be realized by adapting existing interventions with demonstrated effectiveness for new contexts. This paper reports initial findings from the CareCoach study, which is adapting Partner in Balance (PiB), a web-based coaching intervention developed in the Netherlands, for family caregivers in the United Kingdom.

OBJECTIVE

This study aims to work with unpaid family caregivers and staff in adapting the Dutch web-based support tool PiB to improve its acceptability and usability for use in the United Kingdom.

METHODS

Accelerated Experience-Based Co-Design (AEBCD) was used with caregivers, staff, and core stakeholders. Interviews, workshops, and stakeholder consultations were conducted. Data were analyzed iteratively. Recommendations for the redesign of PiB for use across the United Kingdom were adjudicated by the study Adaptation Working Party.

RESULTS

Sixteen caregivers and 17 staff took part in interviews. Thirteen caregivers and 17 staff took part in workshops. Most (n=26) participants were White, female, and retired. All except 4 caregivers (2 male and 2 female) found the PiB's offer of web-based self-help learning acceptable. Caregivers identified complexity and lack of inclusivity in some wording and video resources as problematic. The staff took a stronger perspective on the lack of inclusivity in PiB video resources. Staff and caregivers coproduced new inclusive wording and recommended creating new videos to adapt PiB for the UK context.

CONCLUSIONS

AEBCD methods facilitated the engagement of caregivers and staff and advanced the adaptation of the PiB complex intervention. An important addition to the AEBCD method in this process was the work of an Adaptation Working Party, which adjudicated and agreed to new wording where this could not be established in consultation with caregivers and staff.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN12540555; https://doi.org/10.1186/ISRCTN12540555.

Engaging care partners of persons living with dementia in acceptance and commitment therapy (ACT) programs: a scoping review

OBJECTIVES

Acceptance and commitment therapy (ACT) is a relatively new type of psychotherapy effective for treating depression and anxiety amongst family care partners of persons living with dementia [PLWD]. However, care partner engagement in mental health services is low and specific guidelines for designing ACT programs for care partners of PLWD do not exist. The purpose of this scoping review was to examine patterns in care partner engagement in ACT programs to identify program factors potentially influencing engagement.

METHODS

A comprehensive scoping review according to Arksey and O'Malley's framework was followed. Databases and grey literature were searched for primary studies of ACT programs with care partners of PLWD. Data were charted and synthesized.

RESULTS

Ten studies met inclusion criteria and were analyzed. Amongst these, engagement was highest in three ACT programs that were delivered individually, remotely and were therapist-led or supported. Conversely, engagement was the lowest in two ACT programs that were self-directed, web-based and had minimal or no care partner-therapist interaction. Program factors perceived as influencing engagement included tailoring and personalization, mode of delivery and format, therapeutic support and connectedness, program duration and pace.

CONCLUSION

Findings from this review suggest that care partners engagement may be promoted by designing ACT programs that focus on the therapeutic client-therapist relationship, are delivered remotely and individually. Future research should focus on evaluation of best implementation practices for engagement and effectiveness.

A Web-Based Intervention Based on Acceptance and Commitment Therapy for Family Caregivers of People With Dementia: Mixed Methods Feasibility Study

BACKGROUND

Acceptance and commitment therapy (ACT), as an empirically based third-wave cognitive behavioral therapy, has shown promise in enhancing well-being and functioning across diverse populations. However, in the context of caregiving, the effect size of available ACT interventions remains at best moderate, sometimes accompanied by high dropout rates, highlighting the need for more effective and feasible intervention designs.

OBJECTIVE

The objective of our study was to evaluate the feasibility and acceptability of a fully online ACT program designed for family caregivers of people with dementia. This study aimed to boost psychological flexibility and support caregivers, enabling them to realize and prioritize their own life values alongside their caregiving responsibilities.

METHODS

A mixed methods feasibility study using an uncontrolled pretest-posttest design was conducted. This intervention included a 9-week web-based self-help program based on ACT incorporating collaborative goal setting and weekly web-based motivational coaching for family caregivers of people with dementia. This study involved 30 informal caregivers recruited through memory clinics and social media platforms in the Netherlands and received approval from the Medical Ethics Committee of the Maastricht University Medical Center+ (NL77389.068.21/metc21-029).

RESULTS

A total of 24 caregivers completed the postintervention assessment, indicating a high adherence rate (24/29, 83%). Caregivers reported positive feedback regarding collaborative goal setting, but some found challenges in implementing new skills due to their own habitual responses or the unpredictable context of dementia caregiving. Personalizing the intervention based on individual value preferences was highlighted as beneficial.

CONCLUSIONS

Compared to other web-based self-help ACT interventions for family caregivers, this intervention showed a high adherence and sufficient level of feasibility, which underscores the use of personalization in delivering web-based interventions. Moreover, the potential of this ACT-based intervention for family caregivers of people with dementia was demonstrated, suggesting that further research and a larger-scale controlled trial are warranted to validate its effectiveness.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2022-070499.

Network Analysis of Comorbid Depressive and Anxious Symptoms in Family Caregivers of People with Dementia

OBJECTIVES

The aim of this study is an in-depth approach to depressive-anxious comorbidity in caregivers according to stress reactivity to disruptive behaviors using network analysis.

METHODS

The sample was composed of 317 primary family caregivers recruited through Day Care Centers and Neurology Services. The sample was split into low and high stress reactivity groups, based on their reports of reaction to disruptive behaviors. Depressive and anxious symptoms, daily hours dedicated to caregiving, time of caring, frequency of disruptive behaviors, co-residence, and kinship were also cross-sectionally measured.

RESULTS

The sample had a mean age of 62.38 years (SD = 12.97) and 68.5% were women. Regarding the network analysis, while the low reactivity group presents a sparse network, with no connection between anxious and depressive symptoms, the high reactivity group shows a high connection of intra and intercategory symptoms, with apathy, sadness, feeling depressed, and tension being the bridge symptoms between disorders.

CONCLUSIONS

Caregivers' stress reaction to disruptive behaviors might be a key factor for understanding comorbidity between depressive and anxious symptoms.

CLINICAL IMPLICATIONS

Tension, apathy, sadness, and feeling depressed should be clinical targets in the interventions, as they act as bridge symptoms between anxious and depressive symptomatology.

The use of Acceptance and Commitment Therapy (ACT) in informal caregivers of people with dementia and other long-term or chronic conditions: A systematic review and conceptual integration

Informal caregivers are the primary source of support for adults with chronic conditions and disabilities. Empirical research highlights chronic stress and other risks of adverse outcomes of caregiving. Acceptance and Commitment Therapy (ACT) is an emerging evidenced-based practice that shows promise in improving an array of outcomes, theoretically by increasing psychological flexibility as the primary process of change. Research has begun to evaluate ACT among informal caregivers of adult populations, and a systematic review is now needed to summarise this evidence base. Electronic searches from five databases, including PubMed, PsycInfo, Embase, CINAHL, and Cochrane Library, yielded an initial 7896 hits, which after screening for inclusion criteria, resulted in 21 clinical trials. Studies were coded to synthesise the feasibility, effectiveness, and quality of evidence. Findings show that ACT was reported to be largely feasible and acceptable. However, the efficacy of ACT was mixed, with a more consistent pattern for informal caregivers of people with dementia. Several methodological quality issues limited the findings. However, theoretical synthesis and preliminary evidence support the promising effect of ACT in subgroups of informal caregivers. Research on the process of change, as well as larger-scale, methodologically rigorous trials, are needed to consolidate these findings.

Does Avoiding Distressing Thoughts and Feelings Influence the Relationship between Carer Subjective Burden and Anxiety Symptoms in Family Carers of People with Dementia?

Anxiety remains understudied in family carers of people with dementia. Understanding factors that moderate the relationship between stressors and anxiety symptoms in this population is critical to inform interventions. This study examined whether generic experiential avoidance (AAQ-II) and experiential avoidance specific to caregiving-related thoughts and feelings (EACQ) moderate the relationship between subjective burden (ZBI-12) and anxiety symptoms (GAD-7) in carers of people with dementia. The first model (R2 = .66, ∆R2 = .03) exploring the moderating effect of AAQ-II demonstrated a significant interaction term between AAQ-II and subjective burden. The second model (R2 = .53, ∆R2 = .03), exploring the moderating effect of EACQ, demonstrated a significant interaction term between EACQ and subjective burden. These results provide evidence that carers with higher levels of experiential avoidance may be particularly prone to the negative effect of subjective burden on anxiety symptoms. Clinical implications for assessment of experiential avoidance and its treatment in carers of people with dementia are discussed.

Adaptation of ACTivate Your Wellbeing, a Digital Health and Well-being Program for Young Persons: Co-design Approach

BACKGROUND

ACTivate your wellbeing is a digital health and well-being program designed to support and encourage positive lifestyle behavior change. The website includes 5 lifestyle behavior change modules and a 12-week well-being intervention based on acceptance and commitment therapy. It was timely to adapt the resource for a new audience in the wake of the COVID-19 pandemic. Young persons' mental health needs have increased substantially, and lifestyle behaviors play a critical role in both mental and physical health statuses.

OBJECTIVE

This study aimed to adapt an existing health and well-being website for use by young persons aged 16 to 24 years.

METHODS

A 3-staged participatory, co-design approach was adopted. The participants reviewed the existing program and provided feedback (stage 1) before cocreating new content (stage 2). Finally, the updated program underwent formative evaluation (stage 3). Two groups were created: one had access for 3 weeks and the other could self-select their study duration. The options were 3 weeks, 60 days, or 90 days. Outcome measures were the Warwick and Edinburgh Mental Well-being Scale, 4-item Patient Health Questionnaire, and Acceptance and Action Questionnaire version 2.

RESULTS

Stage 1 identified that the website was appealing to the new audience (19/24, 79%), and the 3 web-based focus group discussions explored data from the written review in more depth to identify and clarify the main areas for update and adaptation. Overall, 3 themes were developed, and the data informed the creation of 6 tasks for use in 5 web-based co-design workshops. Stage 2 led to the cocreation of 36 outputs, including a new name, new content, scenarios, images, and a new user dashboard, which included streaks and an updated color scheme. After the website update program was completed, 40 participants registered to use the website for formative evaluation (stage 3). Data analysis revealed differences in engagement, completion, and mean well-being after intervention between the 2 groups. The completion rate was 68% in the 3-week duration group, and well-being scores improved after intervention.

CONCLUSIONS

Young persons engaged actively with the participatory design process. The participants discussed the updates they desired during the web-based discussions, which worked well via Zoom (Zoom Video Communications Inc) when small groups were used. The participants easily cocreated new content during the web-based co-design workshops. The web-based format enabled a range of participants to take part, share their ideas, search for images, and design digital content creatively together. The Zoom software enabled screen sharing and collaborative whiteboard use, which helped the cocreation process. The formative evaluation suggested that younger users who engage more with the website for a shorter duration may benefit more.

The feasibility and preliminary effects of a pilot randomized controlled trial: Videoconferencing acceptance and commitment therapy in distressed family caregivers of people with dementia

This pilot randomized controlled trial (RCT) examined preliminary effects of an 8-week videoconferencing acceptance and commitment therapy (ACT) program supplemented with psychoeducation materials on distressed family caregivers of persons living with dementia (PLWD) compared to the control group provided with psychoeducation materials only. Nineteen family caregivers of PLWD in the USA were randomly assigned to the ACT group or the control group. Data was collected at pretest, posttest, and 1-month follow-up (F/U). Compared to the control group, the ACT group showed a significantly larger reduction in grief at posttest, with a medium effect size. Small effects of ACT were found in anxiety, psychological quality of life, and engagement in meaningful activities at posttest and grief, engagement in meaningful activities, and psychological flexibility at F/U compared to the control group. These promising findings warrant a full-scale RCT with adequate power to measure the efficacy of videoconferencing ACT for caregivers of PLWD.

Cross-cultural analysis of the role of ambivalent feelings for understanding caregivers' depressive symptoms

OBJECTIVES

Behavioral and psychological symptoms of dementia (BPSD) are considered to cause ambivalent feelings in caregivers that may contribute to understanding their depressive symptoms. Transnational research is needed in order to increase our knowledge about the cross-cultural equivalence of theoretical models to understand caregivers' mental health. The aim of this study was to cross-culturally analyze the association between BPSD, ambivalent feelings and depressive symptoms in two samples of family caregivers of people with dementia from Spain and the UK.

METHODS

Participants in this study were 432 caregivers who completed measures of BPSD, ambivalent feelings and depressive symptoms. The association between the assessed variables was tested through path-analysis, with differences between countries tested through multigroup analysis.

RESULTS

The results suggest that the influence of BPSD on caregivers' depressive symptoms is indirect, through ambivalent feelings. The observed associations were equivalent between countries and explained a significant percentage of the variance of depressive symptoms.

CONCLUSION

The findings of this study provide, for the first time, evidence of equivalent cross-cultural paths analyzing the role of ambivalent feelings for understanding caregivers' depressive symptoms. The practical implications of these results are discussed.

Therapists’ perceptions and acceptability of providing internet-delivered guided self-help acceptance and commitment therapy (ACT) for family carers of people with dementia (iACT4CARERS): a qualitative study

This study aimed to explore therapists’ perceptions and acceptability of providing internet-delivered, therapist-guided, self-help acceptance and commitment therapy (ACT) for family carers of people with dementia (iACT4CARERS). To achieve this, a qualitative approach with semi-structured interviews was employed with eight novice therapists recruited from primary and secondary care services taking part in a feasibility study of iACT4CARERS. The interviews were audio-recorded, transcribed, and analysed using thematic analysis. Four over-arching themes were identified: (1) positive attitudes towards the intervention, (2) therapists’ workload, (3) therapists’ confidence to perform their role, and (4) connecting with family carers in a virtual context. Theme 1 included seeing their involvement as an opportunity for personal growth and perceiving benefits to the family carers, which contributed to greater acceptability. Theme 2 reflected that while workload and the user-friendliness of the online platform were highly acceptable among the therapists, there were also time-consuming cases that increased therapists’ burden. Theme 3 revealed that practical resources provided during the training, continued supervision, and opportunities to learn from other therapists, increased therapist confidence and facilitated greater acceptability. Finally, Theme 4 highlighted that improving the connection between therapists and carers was critical in a virtual context and strategies to improve the therapist–carer relationship were recommended. The implementation of iACT4CARERS was largely acceptable for the therapists involved in the trial. Ways to strengthen the therapeutic relationship in the virtual context and practical strategies to deal with common problems may enhance therapist experience and delivery in a full-scale effectiveness trial.

Key learning aims

(1)