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Group acceptance and commitment therapy

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 Cognitive Behaviour Therapy

ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: http://www.tandfonline.com/loi/sbeh20

Group acceptance and commitment therapy (ACT)

for bipolar disorder and co-existing anxiety – an
open pilot study

Sara Pankowski, Mats Adler, Gerhard Andersson, Nils Lindefors & Cecilia
Svanborg

To cite this article: Sara Pankowski, Mats Adler, Gerhard Andersson, Nils Lindefors & Cecilia
Svanborg (2017) Group acceptance and commitment therapy (ACT) for bipolar disorder and
co-existing anxiety – an open pilot study, Cognitive Behaviour Therapy, 46:2, 114-128, DOI:
10.1080/16506073.2016.1231218

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Cognitive Behaviour Therapy, 2017
VOL. 46, NO. 2, 114–128
http://dx.doi.org/10.1080/16506073.2016.1231218

Group acceptance and commitment therapy (ACT) for bipolar

disorder and co-existing anxiety – an open pilot study
Sara Pankowskia  , Mats Adlera  , Gerhard Anderssona,b  , Nils Lindeforsa  and
Cecilia Svanborga 
a
Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; bDepartment of Behavioural
Sciences and Learning, Linköping University, Linköping, Sweden

ABSTRACT ARTICLE HISTORY

Previous studies have supported acceptance and commitment Received 7 January 2016
therapy (ACT) for reducing impairment related to various chronic Accepted 29 August 2016
conditions. ACT may possibly be beneficial for bipolar disorder (BD) KEYWORDS
with co-existing anxiety, which is associated with a poorer treatment Acceptance and
outcome. Efforts are needed to identify suitable psychological commitment therapy;
interventions for BD and co-existing anxiety. In this open clinical bipolar disorder; anxiety;
trial, we included 26 patients with BD type 1 or 2 at an outpatient quality of life
psychiatric unit specializing in affective disorders. The intervention
consisted of a 12-session manualized group treatment that included
psychoeducation, mindfulness, engaging in values-based behaviour,
cognitive defusion, acceptance and relapse prevention modules.
Participants completed four self-report questionnaires covering
anxiety symptoms (Beck Anxiety Inventory - BAI), depressive
symptoms (Beck Depression Inventory - BDI-II), quality of life (Quality
of Life Inventory - QOLI) and psychological flexibility (Acceptance and
Action Questionnaire - AAQ-2) before, during and after the treatment.
At post-treatment, the participants reported significant improvements
in all outcome measures, with large effects (Cohen’s d between 0.73
and 1.98). The mean reduction in anxiety symptoms was 45%. At post-
treatment, 96% of the patients were classified as responders on at
least one of the outcome measures. A limitation is that the trial is
uncontrolled. The results suggest that ACT has the potential to be an
effective treatment for BD patients with co-existing anxiety. Further
randomized studies are warranted.

Introduction
Acceptance and commitment therapy (ACT; Hayes, Wilson, Gifford, Follette, & Strosahl,
1996) is a form of cognitive behaviour therapy (CBT) based on the theoretical model that
human suffering mainly springs from a poor understanding of long-term values and avoid-
ance of aversive internal experiences, either by directly attempting to avoid or by trying
to gain control over difficult thoughts, emotions or sensations. By fostering acceptance-,
mindfulness- and values-guided behaviour processes (Hayes, Luoma, Bond, Masuda, &

CONTACT  Sara Pankowski  sara.pankowski@ki.se

Affective Disorder Unit, M57, Psychiatry Southwest, Karolinska university hospital, Huddinge, 141 86 Stockholm, Sweden
© 2016 Swedish Association for Behaviour Therapy
 Cognitive Behaviour Therapy   115

Lillis, 2006), the general aim of ACT is to increase psychological flexibility towards these
aversive internal experiences, instead of avoiding them. Psychological flexibility reflects the
ability to notice and accept aversive thoughts, emotions and physical sensations without
acting on them, and in their presence engage in behaviour in accordance with personal
values and long-term goals (Forman et al., 2012; Hayes et al., 1996).
The ACT approach has been successfully used in the management of chronic health
conditions, e.g. pain (Thorsell et al., 2011; Turk, Wilson, & Cahana, 2011) and tinnitus
(Zetterqvist Westin et al., 2011), helping patients with chronic symptoms to form more
realistic expectations regarding future symptom relief (Gregg, Callaghan, Hayes, & Glenn-
Lawson, 2007; Levin, Hildebrandt, Lillis, & Hayes, 2012; McCracken, Vowles, & Eccleston,
2005). Current research has shown that ACT interventions are able to improve disability-
related functioning of patients with chronic conditions (Johnston, Foster, Shennan, Starkey,
& Johnson, 2010). ACT could possibly be an efficacious and feasible treatment for mental
health difficulties as well. It may have some potential advantages and be a highly viable
alternative to traditional CBT (Arch et al., 2012). Still, evidence is currently insufficient
(A-Tjak et al., 2015; Hacker, Stone, & MacBeth, 2016; Öst, 2014).
With this in mind, the ACT approach has the potential to be suitable for psychiatric
conditions that are chronic. One of the most serious psychiatric conditions is Bipolar disorder
(BD), characterized by recurrent episodes of depression, mania and mixed affective states,
generally with serious consequences for the patient’s daily life, career and interpersonal
relationships (Michalak, Yatham, Kolesar, & Lam, 2006). In between episodes, patients can
experience long periods of affective stability. However, patients with BD type I or II seem
to be symptomatic about 50% of their lives, predominately with cognitive deficits (Bourne
et al., 2013), depressive symptoms and associated functional impairment (Judd et al., 2003).
Another common residual symptom in BD is co-existing anxiety (Otto et al., 2006), which
often occurs in an unspecified form. An “anxious distress specifier” was introduced in
the Diagnostic and Statistical Manual of Mental Disorders, (5th ed.; DSM-5; American
Psychiatric Association [APA], 2013) in order to identify patients with BD and co-existing
anxiety symptoms that are additional to the BD criteria (American Psychiatric Association
[APA], 2013). Lifetime comorbidity with anxiety is estimated to be between 24% (Henry
et al., 2003) and 74.9% (Merikangas et al., 2007), and is associated with a higher risk of
relapse and suicide (Rucci et al., 2002) as well as illness severity (Lee & Dunner, 2008).
Incomplete remission from anxiety symptoms can lower the quality of life and the level of
functioning (Kauer-Sant’Anna, Kapczinski, & Vieta, 2009).
The primary treatment for BD is mood-stabilizing medication; psychological treatment
is given as a supplement. The most common psychotherapy is CBT, which focuses on
preventing relapse and shortening the duration of affective episodes (Miklowitz, 2008;
Szentagotai & David, 2010). Still, this treatment tends to have a poor outcome for patients
who have gone through many affective episodes, have cognitive impairment (Scott et al.,
2006) or any kind of co-existing anxiety (Kauer-Sant’Anna et al., 2009).
Consequently there is an increasing interest in innovating and improving CBT for
BD. It has been suggested that in order to achieve a positive impact on the general long-
term management of BD, it is important to consider the co-existing anxiety (Stratford,
Cooper, Di Simplicio, Blackwell, & Holmes, 2015), since this is highly common, destabilizes
mood (Holmes et al., 2011) and has a negative effect on treatment response (Feske et al.,
2000). Recent studies have focused on evaluating new CBT-approaches for BD, such as
116    S. Pankowski et al.

Mindfulness-based Cognitive Therapy for residual symptoms (Deckersbach et al., 2012)

and Dialectical Behaviour Therapy for depressive symptoms and emotional dysregulation
(Van Dijk, Jeffrey, & Katz, 2013). Still, no study has to our knowledge focused on ACT and
co-existing anxiety in BD.
For patients with BD, attempts to avoid thoughts, feelings and other internal experiences
might lessen the capacity to detect early signs of relapse. Thus, ACT’s focus on replacing
experiential avoidance with presence and openness towards one’s internal experiences,
disorders and symptoms could possibly help patients with BD to reduce the risk of relapse
into new episodes and to achieve a better quality of life. There are several interventions in
ACT that could play a role in reducing experiential avoidance and functional impairment of
this population: acceptance and mindfulness to develop awareness of one’s thoughts, feelings
and sensations, cognitive defusion to cut off rumination, and defining values to enhance
goal-focused behaviours. Put together, these interventions could promote a greater flexi-
bility towards aversive stimuli. None of these interventions has previously been addressed
in a study on patients with BD.

The present study

In the present study, we evaluated an ACT protocol designed to decrease experiential avoid-
ance associated with co-existing anxiety in BD. The aim was to test the protocol on patients
with BD and co-existing anxiety. The goals were: (a) to evaluate treatment effects on anxiety-
and depressive symptoms, quality of life and psychological flexibility, and (b) to examine
the feasibility of ACT in this patient group by assessing adherence to the treatment.
We hypothesized that engaging in an ACT-protocol group treatment would decrease anx-
iety- and depressive symptoms, improve quality of life and increase psychological flexibility.

Method
Participants
Patients were recruited from a specialist mental health service for affective disorders at
Psychiatry Southwest, Karolinska University Hospital, in Stockholm, Sweden. Between years
2010 and 2014, clinicians were aware that patients with BD and significant anxiety could
be recruited to ACT-protocol group treatment. A total of 26 adult patients with BD with
a mean age of 44 years (range 24–65 years) received the ACT-protocol group treatment.
Table 1 contains the participants’ other characteristics.
No diagnoses were assessed while the study was being conducted. When recruited, the
patients had already been diagnosed with BD by a psychiatrist at the specialized mental
health service for affective disorders. The dates of the diagnostic assessments ranged from 1
month to 13 years before the study. The structure of the diagnostic assessment of BD differed
between the participants, due to changes over time in the practiced diagnostic procedure.
Patients with comorbid diagnoses (autism and cognitive decline) had been diagnosed by
psychiatrists in a previous diagnostic procedure, so these comorbidities were not assessed
in connection with the study.
Inclusion criteria were BD and anxiety symptoms according to clinical evaluation by a
psychiatrist at the mental health service for affective disorders. All participants reported
 Cognitive Behaviour Therapy   117

Table 1. Participants’ demographic and clinical characteristics (N = 26).

n %
Female 18 (69)
Employment status
 Employed or student 16 (61)
 Retired 3 (12)
  Sick leave 7 (27)
Married 9 (35)
Education, university college 12 (46)
Previous psychological treatment 16 (62)
Current use of psychiatric medication
  Current mood-stabilizers 20 (77)
  Current neuroleptics 13 (50)
  Current antidepressants 7 (27)
  Current benzodiazepines 11 (42)
Bipolar Disorder
 Type 1 14 (54)
 Type 2 12 (46)
Comorbid autistic spectrum disorder 2 (8)
Diagnosed with cognitive decline 3 (12)
Previous alcohol abuse 8 (31)
Previous suicide attempts 6 (23)
Note: n = number of participants, % = percentage of participants, BD=Bipolar disorder..

anxiety symptoms on the Beck Anxiety Inventory (BAI; Beck, Brown, & Steer, 1988). The
level of anxiety varied from mild to severe and included worry, rumination, panic attacks,
somatic symptoms and avoidance behaviour. None of the participants was diagnosed with
an anxiety disorder, since at the time of the study this category of diagnoses was not part
of the assessment at the mental health service for affective disorders.
Patients were excluded if they had been diagnosed with schizoaffective syndrome or
had ongoing manic or psychotic symptoms according to clinical evaluation. They were also
excluded if they had an alcohol or drug abuse during the past 3 months.

Procedure
The standard routine for enroling psychotherapy at the mental health service for affective
disorders at Psychiatry Southwest, Karolinska University Hospital in Stockholm, Sweden, is
that the psychiatrist sends a request to the psychologist when a patient diagnosed with BD
needs to complete medication with psychotherapy. For this study, psychiatrists at the clinic
were made aware of the ACT treatment’s criteria for participant selection and, based on
meeting criteria, they suggested patients diagnosed with BD. A psychological interview with
the suggested patients was undertaken 3–4 weeks before the start of the ACT treatment. In
the interview, the psychologist followed a given structure, including a conceptualization of
the anxiety symptoms. The inclusion and exclusion criteria for the study were determined for
each patient. Accepted participants completed baseline self-report questionnaires. Figure 1
presents a flow chart describing participant attrition.
New treatment groups started once or twice a year. The participants were enroled in a
treatment group that started 3–4 weeks after the psychological interview. A psychologist
trained in the method of ACT delivered the interventions in all treatment groups.
In 2013, the clinical evaluation of the ACT protocol was transformed into a scientific pilot
study approved by the regional ethical review board in Stockholm (ID: 2013/983-31/1). For
118    S. Pankowski et al.

Enrolment psychological
Excluded
interview
Schizoaffective syndrome (n = 1)
(n = 35)

Included
(n = 34)

Started the treatment Drop-outs

(n = 34) Session 1: hospitalized (n = 2)
declined to continue (n = 1)
Session 2: declined to continue (n= 1)
Session 3: hospitalized (n= 1)
declined to continue (n= 2)
Completed the treatment relapse alcohol abuse (n= 1)
(n = 26)

Figure 1. Participant flow through the study.

patients who completed the ACT treatment in 2010–2012, informed consent was obtained
post-treatment, whereas patients undergoing the ACT treatment in 2013–2014 gave their
informed consent pre-treatment, during the psychological interview.
At the start of the treatment, all participants were encouraged to contact the clinic if their
affective status changed. The majority of the participants were already in regular contact
with their psychiatrist or psychiatric nurse at the clinic, and continued to be so during
the group treatment. The affective status of each participant was monitored by self-rating
scales assessed before, during and after the treatment. If a significant worsening of affective
symptoms was noticed, an appointment with one of the clinic’s psychiatrists was arranged
on the same or the following day.

Treatment
The treatment protocol was developed at the clinic in 2010 based on existing ACT manuals
for anxiety (Eifert & Forsyth, 2005; Forsyth & Eifert,2008; Hayes & Smith,2005; Twohig
& Hayes,2008), adapted to meet the needs of patients with BD. There was a total of six
treatment groups with 3–7 patients in each. The same psychologist (SP) delivered the inter-
ventions in all treatment groups. The treatment consisted of 12 weekly 3-h group sessions
spread over 6 main themes, with 2 sessions for each theme. Each session started with a
mindfulness exercise. Homework, consisting of reading and in vivo exercises, was always
given between sessions. Session content is presented in Table 2.

Assessments
Patients were assessed, using self-report questionnaires, on five occasions: 3–4 weeks before
treatment (baseline), at treatment start (pre), at the beginning of sessions 4 and 8, and
immediately after treatment (post). Self-reports were missing for one patient at session
 Cognitive Behaviour Therapy   119

Figure 2. Course of change (mean scores with error bars) in anxiety- and depressive symptoms from
baseline to post-treatment of Acceptance and Commitment group therapy. Abbreviations: BAI, Beck
Anxiety Inventory; BDI-II, Beck Depression Inventory-II.

4 and for another patient at session 8. For the repeated analysis of variance, the missing
values were replaced by the mean of nearby points for the measures of these individuals.
Symptoms of anxiety and depression. The Beck Anxiety Inventory (BAI; Beck et al., 1988)
is a validated self-rating scale of the severity of clinical anxiety symptoms. Patients rate
how bothered they have been by 21 somatic symptoms such as “Heart pounding/racing”
in the past week on a 4-point scale from Not at all to Severely. Items are summed to obtain
a total score ranging from 0 to 63. A higher score is indicative of more severe anxiety. A
score under eight is indicative of a minimal level of anxiety. BAI has shown high test–retest
reliability (r = 0.75) and internal consistency (α = 0.92).
The Beck Depression Inventory (BDI-II) is a 21-item self-rating scale of depression (Beck
& Brown, 1996). Items are summed to obtain a total score ranging from 0 to 63. A score
under 14 is indicative of a minimal level of depression. The BDI-II is recognized for having
high internal consistency, retest reliability and validity (Dozois, Covin, & Brinker, 2003).
Quality of life. The Quality of Life Inventory (QOLI; Frisch, 1994) is a self-rating scale
that assesses domain-based life satisfaction. Patients rate 16 areas of life (e.g. health, money)
in terms of importance (from 0 Not important to 2 Extremely important) and current sat-
isfaction (from -3 Dissatisfied to 3 Satisfied). Areas of importance rated above 0 points are
counted in terms of satisfaction. Internal consistency coefficients have ranged from .77 to .89
across 3 clinical and 3 non-clinical samples (Lindner, Andersson, Öst, & Carlbring, 2013).
Psychological flexibility. The Acceptance and Action Questionnaire (AAQ-2; Bond
et al., 2011) is a 10-item self-rating scale of psychological flexibility. Items are rated on a sev-
en-point scale ranging from Never true to Always true with higher scores indicating greater
psychological flexibility. There is no established cut-off for the AAQ-2 10-item scale and
psychometric studies are mainly performed on the 7-item version, resulting in an alpha coef-
ficient of about .84. However, the 10-item and 7-item versions correlate strongly (r = .96).

Follow-up
Between 1.5 and 42 months (median = 2.5 months, M = 11 months) after post-treatment,
patients were asked to report whether they had had any new affective (depressive and manic)
120    S. Pankowski et al.

episodes after the ACT treatment. Patients’ reports of presence and absence of affective
episodes were checked against information in their case reports. There was a discrepancy
for one patient and the information in the case record was deemed reliable. For the other
patients the information was congruent.

Analysis
All statistical analyses were performed using the SPSS 23. In order to assess changes over
time from baseline to post-treatment and for comparison of subgroups, repeated measures
analysis of variance was performed with the outcome measures (BAI, BDI-II, QOLI, AAQ-2)
as within repeated factors and with sex and type of BD as between factors. Assumptions of
the ANOVA were met by means of normal distribution of the outcome measures, homo-
geneity of variance and multi-sample sphericity. Paired samples t-tests were performed to
assess changes from baseline to pre-treatment. The threshold for statistical significance
was set at the standard 5%. Sizes of within-group effects were calculated by dividing the
difference between pre-treatment and post-treatment scores by the within-group SD, cor-
rected for correlation between the means (d = mean1- mean2/SD (mean diff)/ √2 × (1 – r)).
Reliable change was calculated for each patient on outcome measures, using the Reliable
Change Index (RCI = (xpost – xpre))/√2SE2) based on Cronbach’s alpha from previous studies.

Results
Treatment compliance and feasibility
Of the 34 patients included, 8 (24%) dropped out from treatment at an early stage. For three
of these patients, this was due to relapse in severe affective episode, of which one mania
and two depression. Other reasons were alcohol abuse (n = 1), practical obstacles such as
time management or geographical distance (n = 3), or that participants found the treatment
too demanding and not suitable for their problems (n = 1). Of the participants completing
treatment, patients attended on average 7.8 of the 12 group sessions; 22 of the 26 patients
attended 8 or more sessions and 2 patients attended 5 or fewer sessions.

Continuous outcomes
All 26 patients completed the assessments at baseline, pre- and post-treatment. Results of
all self-report assessments are summarized in Table 3. No significant differences were found
between baseline and pre-treatment for BAI, QOLI and AAQ-2. For BDI-II, the pre-treat-
ment mean score was significantly lower, t(25) = 5.21, p < .001, than the score at baseline.
Patients showed significant improvement in all outcome measures during the course
of treatment. No significant differences in improvement were found between women and
men, or between patients with BD types 1 and 2. The mean reduction in anxiety was 45%.
The analysis showed a significant decrease in anxiety symptoms on BAI (F(4,22) = 40.6;
p < .001), and a decrease in depressive symptoms on BDI-II (F(4,22) = 17.8; p < .001).
Quality of life on QOLI increased significantly, from −0.72 (SD = 2.56) at pre-treatment to
1.04 (SD = 2.10) at post-treatment (M = 1.77; 95% CI: 2.36, 1.17). The analysis of variance
showed significant increases on QOLI (F(4,22) = 21.3; p < .001) and of psychological flex-
ibility on AAQ-2 (F(4,22) = 47.2; p < .001).
 Cognitive Behaviour Therapy   121

Table 2. Session content.

Session Theme Main intervention
1–2 Emotional avoidance and its Psychoeducation about BD and anxiety
consequences Education about a psychological model of BD symptoms and anxiety,
where negative effects of behaviours that serve to control or avoid
symptoms or negative affect related to symptoms are analyzed. The
patients’ own experiences of the apparent failure of symptom control
strategies and the detrimental effects of avoidance behaviours on quali-
ty of life are discussed from this perspective.
3–4 Being present and aware Mindfulness skills
Education and exercises with main focus on awareness and presence
during daily activities.
5–6 Identifying your valued path Values-guided exposure
Patient’s values in major life areas are identified and followed by exposure
to engaging in values-guided behaviour in situations where anxiety or
affective symptoms are unwanted. The patients are also instructed on
how to use mindfulness during exposure.
7–8 My thoughts, feelings and I Self as context and cognitive defusion
Focus on thoughts, feelings and self-esteem, with education and exercises
of decentering and self-observation.
9–10 Developing acceptance Acceptance skills
Acceptance of aversive symptoms, thoughts and feelings through willful
engagement in exposure exercises.
11–12 My acceptance- and action plan Committed action and relapse prevention
for the future The patient gets to develop an individual acceptance- and action plan
consisting of alternative strategies to symptom control and avoidance.

The treatment effects (Cohen’s d) were overall large at post-treatment, with the largest
effects on AAQ-2 (d = 1.98; 95% CI: 1.21, 2.55) and the smallest effects on BDI-II (d = 0.73;
95% CI: 0.31, 1.15). As a comparison, effect sizes were almost zero and non-significant
between baseline and pre-treatment, except for depressive symptoms. There were early
improvements in psychological flexibility and anxiety symptoms, with medium high effect
sizes between pre-treatment and session 4. Changes over the course of treatment concerning
all outcome measures are illustrated in Figures 2 and 3.

Categorical outcomes
Pre-post RCI was calculated for each patient on BAI, BDI-II and QOLI. An RCI greater
than 1.96 or −1.96 was considered indicative of reliable change (Jacobson & Truax, 1991).
Patients experiencing reliable improvement were referred to as responders and those of them
who also experienced non-significant levels of anxiety and depression at post-treatment
were considered to be in remission, defined as <8 points on BAI and <14 points on BDI-II.
On BAI, 21 of 26 patients (81%) experienced pre-post reliable improvement, of whom
12 (46%) were in remission. Of the five patients who did not improve, two had a non-sig-
nificant level of somatic anxiety to begin with. On BDI-II, 17 of 26 patients (65%) experi-
enced pre-post reliable improvement, of whom 10 (38%) were in remission. Three patients
(11%) experienced reliable deterioration concerning depressive symptoms. On QOLI, 14
of 26 patients (54%) experienced pre-post reliable improvement. RCI was not calculated
on AAQ-2, but no patients had a negative change compared to baseline on this measure.
In total, 8 patients were classified as responders on all 3 measures (BAI, BDI and QOLI),
while 14 patients experienced reliable improvement on BAI and BDI-II. Six patients did
not have reliable improvement on two of three outcome measures. One patient (4%) did
122    S. Pankowski et al.

Figure 3. Course of change (mean scores with error bars) in psychological flexibility and quality of life
from baseline to post-treatment of Acceptance and Commitment group therapy. Abbreviations: AAQ-2,
Acceptance and Action Questionnaire-2; QOLI, Quality of Life Inventory.

not have a reliable change in any of the outcome measures, though there was a late positive
change on AAQ-2.

Follow-up
A follow-up assessment could be performed with 16 of 26 participants. Ten patients did
not answer their phone, did not want to participate or were no longer patients at the clinic.
Five of 16 (31%) reported they had been depressed 1–2 times after the ACT treatment. Of
them, two already had an ongoing depression when the ACT treatment started. Three of 16
patients (19%) reported 1–2 hypomanic episodes after the ACT treatment. Patients’ reports
whether or not they had had any affective episodes after termination of group treatment
were validated in all but one case in the chart information from the clinic.

Discussion
The aim of this open study was to evaluate an ACT protocol with respect to feasibility and
outcome on a group of patients with BD and co-existing anxiety. The treatment included
mindfulness-, decentralization- and acceptance-techniques and exposure to engaging in
values-guided behaviour in situations where anxiety was unwanted. The ACT protocol was
deemed feasible, as about 75% of the participants completed treatment, even though many
had severe affective and cognitive symptoms. The rate of completers was extremely high
compared to the mean percentage of psychiatric patients completing ACT treatment in Ost’s
meta-analysis, where the rate was 47.6% (SD = 36.1) (Öst, 2014). Future studies will have
to explore whether this can be explained by ACT being an especially suitable method for
patients with BD and co-existing anxiety. In order to further explain completer rates, it is
important to collect comprehensive information about patients with BD before a psycholog-
ical treatment. A recent study using a cluster analysis of 135 symptomatic individuals with
BD found that illness onset, number of previous episodes, and illness duration significantly
influenced response to psychotherapy (Deckersbach et al., 2016). Moreover, it is essential to
 Cognitive Behaviour Therapy   123

Table 3. Means (M) and effect sizes of outcome measures from baseline to post-treatment (N = 26).
Baseline – Pre –
Measure Baseline Pre Session 4 Session 8 Post Pre Session 4 Pre – Post
M (SD) M (SD) M (SD) M (SD) M (SD) d d d
BAI 19.77 20.77 16.88 12.96 9.42 –0.15 0.49 1.53
(6.31) (7.00) (8.29) (8.18) (7.83)
BDI-II 24.54 21.15 19.84 15.35 13.92 0.33 0.13 0.73
(10.53) (10.08) (10.54) (10.37) (9.74)
QOLI −0.64 −0.72 −0.04 0.51 1.04 −0.03 0.26 0.76
(2.34) (2.56) (2.09) (2.02) (2.10)
AAQ-2 28.42 27.62 34.12 40.88 46.19 0.11 0.79 1.98
(7.19) (7.14) (8.59) (10.98) (11.20)
Note: SD denotes standard deviation; BAI, Beck Anxiety Inventory; BDI-II, Beck Depression Inventory-II; QOLI, Quality of Life
Inventory; AAQ-2, Acceptance and Action Questionnaire-2. d denotes within group effect sizes (Cohen’s d).

collect information about patients during treatment since affective symptoms can change
suddenly and need to be handled immediately. Therefore, we chose to collect data at different
time points of the ACT treatment. We also collected reasons for drop-out from treatment.
Participants experienced significant improvements in all outcome measures. The with-
in-group effect sizes for improvements ranged from .73 to 1.98. Using the formula for RCI
(the degree of change that occurred beyond the fluctuations of an imprecise measuring
instrument), 96% of the patients were classified as responders on at least one of the three
evaluated outcome measures. The most promising results were observed for anxiety, with a
mean reduction of 45%, even though ACT does not primarily focus on eliminating symp-
toms. One way of interpreting these results is that ACT targets a broad range of outcomes,
both functional and experiential, by developing psychological flexibility towards experiences
associated with aversive feelings and thoughts. Although symptom reduction is not the
explicit focus of the intervention, the reduced engagement in control- and avoidance behav-
iour may affect the experience of anxiety. High and early treatment effects in the present
study on AAQ-2, measuring psychological flexibility, support this hypothesis. Furthermore,
if ACT is indeed a treatment that can lower anxiety in patients with BD, it can possibly have
benefits for other treatment outcomes as well, since anxiety in BD is predictive of poorer
treatment outcomes (Coryell et al., 2009).
Patients decreased their depressive symptoms already between baseline and pre-treat-
ment. One way of interpreting these results is that, as a consequence of being aware that
ACT treatment would start in a couple of weeks, patients’ hope for change increased.
Compared with the Swedish norms for QOLI for generalized anxiety disorder (0.49;
SD = 1.80), mixed anxiety and depression (0.41; SD = 1.69) and depression (−0.21; SD = 1.77)
(Lindner et al., 2013), our sample had a low quality of life at pre-treatment (M = −0.73) and
a high quality of life post-treatment (M = 1.04). Still, perceived quality of life varied a lot
between individuals post-treatment. One explanation for this variation could be that some
patients still had ongoing depression or other comorbidities and that some items in QOLI
have poor correlation to responses to given treatment, for example satisfaction with one’s
home and neighbourhood. Furthermore, patients described that formulating values and
goals had been revealing, but that it takes time to repair broken relations and reach goals.
Not all participants experienced post-treatment improvements on all assessments. Three
of the participants became more depressed during treatment. One patient had no change
in symptoms or perceived quality of life, but a slight increase in psychological flexibility.
124    S. Pankowski et al.

It is possible that these patients would have benefited from additional or other interven-
tions. Further, individual aspects and feedback concerning feasibility are examined in the
qualitative evaluation of the ACT treatment that has been conducted and will be presented
in the near future.
The sample was heterogeneous, which could be considered both a limitation and a
strength. It consisted of newly diagnosed patients as well as patients who had been in
treatment for a long time and patients with varying duration of illness. There was autism,
past alcohol abuse and cognitive impairment, but also former uninvestigated comorbidity.
The degree of diagnostic examination varies in a naturalistic clinical setting. The co-existing
anxiety took many forms and ranged widely, from mild to severe at pre-treatment. Patients
were opportunistically recruited from a public health setting. Opportunistic sampling
cannot control for possible time- or group effects. The observed differences between
participants raise the question whether the given group therapy was suitable for each one
of them? On the other hand, the variety of the sample increases ecological validity, since
this resembles a typical clinical setting of BD. It also enables a qualitative evaluation of
the benefits and limitations both of the treatment and of the face-to-face group setting
for different patients. This open pilot study shows promising results for ACT as a possible
psychological treatment for BD and co-existing anxiety. It may also target a more general
deficit in BD, emotional regulation, by improving the ability to notice and accept aversive
states and to make conscious choices how to act.

Limitations
We have chosen Öst’s recommendations for ACT studies (Öst, 2014) to identify the limi-
tations that need to be considered when interpreting the results of this trial and to further
improve studies in this area.
First of all, this is an uncontrolled trial. In a future study, it is important to conduct an
RCT to compare the ACT treatment with both waitlist and traditional CBT for BD. It is
also important to use an unobjectionable randomization procedure, and conceal the type
of treatment from persons involved in the evaluation of the study.
Secondly, the diagnostic assessment of our study was not satisfying. We used a represent-
ative sample of patients, but they were not assessed in connection with study enrolment.
Clinicians had already established the BD diagnoses, as well as anxiety symptoms, when
participants entered the study. This set-up made it impossible to explore the effect of the
ACT group treatment on different types of anxiety in BD (specific syndromes vs. co-existing
anxiety symptoms). In a future study, the patients should be diagnosed in direct connection
with study enrolment, with suitable instruments in the hands of trained interviewers, and
the diagnostic reliability should be tested.
Thirdly, Öst recommends the use of reliable and valid outcome measures; both general
and specific to the disorder. In our study, no monitoring of manic symptoms was included
since no validated Swedish versions of manic self-rating scales were available when the study
started. This must be considered a limitation, although most patients did not experience an
increase in manic symptoms and no further relapses were reported immediately after the
group treatment. Another limitation is that only self-assessments were used. All patients
were considered to have anxiety at the pre-treatment clinical interview, but not all of them
scored high on BAI. This could simply depend on the lack of a formal assessment of anxiety.
 Cognitive Behaviour Therapy   125

Still, it raises the question about the properties of co-existing anxiety in BD. Perhaps BAI,
which focuses on somatic symptoms, does not cover the full range of anxiety symptoms
in BD? What if co-existing unspecific anxiety in BD manifests primarily as rumination
and cognitive difficulties? This is important to consider when designing future studies in
the field. Other outcome measures targeting expert-rated level of functioning could add
important information on possible treatment effects.
Fourthly, Öst recommends a one-year follow-up. Instead of a follow-up of continuous
outcomes used pre- and post-treatment, participants in our study were asked to report if
they had had any new affective episodes after the treatment. The broad time span for this
report and the lack of a formalized method for collecting signs of relapse over time can be
considered a limitation. However, information in case records confirmed patients’ reports.
It is important that various aspects of long-term effects of the ACT treatment are evaluated,
especially since the post-treatment results imply a promising trend.
Fifthly, we did not use blind assessors or audiotape any therapy sessions. The same psy-
chologist (SP) assessed and treated all patients. Öst recommends the use of at least three
properly trained therapists and the randomization of patients to therapist to enable an
analysis of possible therapist effect on the outcome.
Sixthly, there was no established procedure to control for treatments that patients
obtained concurrently with the ACT treatment. Data on parallel medication were collected
after the treatment through case files. In a future RCT, the attrition should be described and
a drop-out analysis as well as an intent-to-treat analysis should be made.
Considering these limitations, it is not possible to draw causal inferences from the
observed changes. Instead, this trial should be considered as an exploration of the feasibil-
ity of ACT for patients with BD and co-existing anxiety in a clinical setting.

Implications and future directions

Despite several limitations, the results suggest that ACT has the potential to reduce
symptoms and increase quality of life and psychological flexibility for patients with BD
and co-existing anxiety. Controlled trials are needed to further validate ACT for BD and co-
existing anxiety.

Acknowledgements
The authors wish to thank all staff at the Affective Disorders Unit for generous support and the
participants for taking part in the study.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
The research was supported by grants from Stockholm County Council (PPG project) and the
Söderströmska-Königska Foundation to Cecilia Svanborg.
126    S. Pankowski et al.

ORCiD
Sara Pankowski   http://orcid.org/0000-0002-4368-1964
Mats Adler   http://orcid.org/0000-0002-5905-0171
Gerhard Andersson   http://orcid.org/0000-0003-4753-6745
Nils Lindefors   http://orcid.org/0000-0002-7369-4969
Cecilia Svanborg   http://orcid.org/0000-0002-5681-9416

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
ed.). Washington, DC: Author.
Arch, J. J., Eifert, G. H., Davies, C., Vilardaga, J. C., Rose, R. D., & Craske, M. G. (2012). Randomized
clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy
(ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80, 750–765.
http://dx.doi.org/10.1037/a0028310
A-Tjak, J. G., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A., & Emmelkamp, P. M. (2015).
A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant
mental and physical health problems. Psychotherapy and Psychosomatics, 84, 30–36. http://dx.doi.
org/10.1159/000365764
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety:
Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897.
Beck, A. T., Steer, R. A., & Brown, G. (1996). Manual for the beck depression inventory-II (BDI-II).
San Antonio, TX: Psychological Corporation.
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., … Zettle, R. D.
(2011). Preliminary psychometric properties of the acceptance and action questionnaire-II: A
revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42,
676–688. http://dx.doi.org/10.1016/j.beth.2011.03.007
Bourne, C., Aydemir, O., Balanza-Martinez, V., Bora, E., Brissos, S., Cavanagh, J. T., … Goodwin,
G. M. (2013). Neuropsychological testing of cognitive impairment in euthymic bipolar disorder:
An individual patient data meta-analysis. Acta Psychiatrica Scandinavica, 128, 149–162. http://
dx.doi.org/10.1111/acps.12133
Coryell, W., Solomon, D. A., Fiedorowicz, J. G., Endicott, J., Schettler, P. J., & Judd, L. L. (2009).
Anxiety and outcome in bipolar disorder. American Journal of Psychiatry, 166, 1238–1243. http://
dx.doi.org/10.1176/appi.ajp.2009.09020218
Deckersbach, T., Hölzel, B. K., Eisner, L. R., Stange, J. P., Peckham, A. D., Dougherty, D. D., …
Nierenberg, A. A. (2012). Mindfulness-based cognitive therapy for nonremitted patients with
bipolar disorder. CNS Neuroscience & Therapeutics, 18, 133–141. http://dx.doi.org/10.1111/j.1755-
5949.2011.00236.x
Deckersbach, T., Nierenberg, A. A., McInnis, M. G., Salcedo, S., Bernstein, E. E., Kemp, D. E., …
Kamali, M. (2016). Baseline disability and poor functioning in bipolar disorder predict worse
outcomes. The Journal of Clinical Psychiatry, 77, 100–108. http://dx.doi.org/10.4088/JCP.14m09210
Dozois, D. J., Covin, R., & Brinker, J. K. (2003). Normative data on cognitive measures of depression.
Journal of Consulting and Clinical Psychology, 71, 71–80.
Eifert, G. H., & Forsyth, J. P. (2005). Acceptance & commitment therapy for anxiety disorders: A
practitioner's treatment guide to using mindfulness, acceptance, and values-based behavior change
strategies. Oakland, CA: New Harbinger Publications.
Feske, U., Frank, E., Mallinger, A. G., Houck, P. R., Fagiolini, A., Shear, M. K., … Kupfer, D. J. (2000).
Anxiety as a correlate of response to the acute treatment of bipolar I disorder. American Journal
of Psychiatry, 157, 956–962. http://dx.doi.org/10.1176/appi.ajp.157.6.956
Forman, E. M., Shaw, J. A., Goetter, E. M., Herbert, J. D., Park, J. A., & Yuen, E. K. (2012). Long-term
follow-up of a randomized controlled trial comparing acceptance and commitment therapy and
standard cognitive behavior therapy for anxiety and depression. Behavior Therapy, 43, 801–811.
http://dx.doi.org/10.1016/j.beth.2012.04.004
 Cognitive Behaviour Therapy   127

Forsyth, J. P., & Eifert, G. H. (2008). The mindfulness & acceptance workbook for anxiety: A guide to
breaking free from anxiety, phobias, and worry using Acceptance and Commitment Therapy. Oakland,
CA: New Harbinger Publications.
Frisch, M. B. (1994). Quality of life inventory manual and treatment guide. Minneapolis, MN: NCS
Pearson & Pearson Assessments.
Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving diabetes self-
management through acceptance, mindfulness, and values: A randomized controlled trial. Journal
of Consulting and Clinical Psychology, 75, 336–343. http://dx.doi.org/10.1037/0022-006X.75.2.336
Hacker, T., Stone, P., & MacBeth, A. (2016). Acceptance and commitment therapy – Do we know
enough? Cumulative and sequential meta-analyses of randomized controlled trials. Journal of
Affective Disorders, 190, 551–565. http://dx.doi.org/10.1016/j.jad.2015.10.053
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment
therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25. http://
dx.doi.org/10.1016/j.brat.2005.06.006
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance
and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal
of Consulting and Clinical Psychology, 64, 1152–1168.
Hayes, S. C., & Smith, S. (2005). Get out of your mind and into your life: The new Acceptance and
Commitment Therapy. Oakland, CA: New Harbinger Publications.
Henry, C., Van Den Bulke, D., Bellivier, F., Etain, B., Rouillon, F., & Leboyer, M. (2003). Anxiety
disorders in 318 bipolar patients: prevalence and impact on illness severity and response to mood
stabilizer. Journal of Clinical Psychiatry, 64, 331–335.
Holmes, E. A., Deeprose, C., Fairburn, C. G., Wallace-Hadrill, S. M., Bonsall, M. B., Geddes, J. R.,
& Goodwin, G. M. (2011). Mood stability versus mood instability in bipolar disorder: a possible
role for emotional mental imagery. Behaviour Research and Therapy, 49, 707–713. http://dx.doi.
org/10.1016/j.brat.2011.06.008
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful
change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19.
Johnston, M., Foster, M., Shennan, J., Starkey, N. J., & Johnson, A. (2010). The effectiveness of an
acceptance and commitment therapy self-help intervention for chronic pain. The Clinical Journal
of Pain, 26, 393–402. http://dx.doi.org/10.1097/AJP.0b013e3181cf59ce
Judd, L. L., Schettler, P. J., Akiskal, H. S., Maser, J., Coryell, W., Solomon, D., … Keller, M. (2003).
Long-term symptomatic status of bipolar I vs. bipolar II disorders. The International Journal of
Neuropsychopharmacology, 6, 127–137. http://dx.doi.org/10.1017/S1461145703003341
Kauer-Sant’Anna, M., Kapczinski, F., & Vieta, E. (2009). Epidemiology and management of anxiety
in patients with bipolar disorder. CNS Drugs, 23, 953–964. http://dx.doi.org/10.2165/11310850-
000000000-00000
Lee, J. H., & Dunner, D. L. (2008). The effect of anxiety disorder comorbidity on treatment resistant
bipolar disorders. Depression and Anxiety, 25, 91–97. http://dx.doi.org/10.1002/da.20279
Levin, M. E., Hildebrandt, M. J., Lillis, J., & Hayes, S. C. (2012). The impact of treatment components
suggested by the psychological flexibility model: A meta-analysis of laboratory-based component
studies. Behavior Therapy, 43, 741–756. http://dx.doi.org/10.1016/j.beth.2012.05.003
Lindner, P., Andersson, G., Öst, L. G., & Carlbring, P. (2013). Validation of the internet-administered
quality of life inventory (QOLI) in different psychiatric conditions. Cognitive Behaviour Therapy,
42, 315–327. http://dx.doi.org/10.1080/16506073.2013.806584
McCracken, L. M., Vowles, K. E., & Eccleston, C. (2005). Acceptance-based treatment for persons with
complex, long standing chronic pain: A preliminary analysis of treatment outcome in comparison
to a waiting phase. Behaviour Research and Therapy, 43, 1335–1346. http://dx.doi.org/10.1016/j.
brat.2004.10.003
Merikangas, K. R., Akiskal, H. S., Angst, J., Greenberg, P. E., Hirschfeld, R. M., Petukhova, M., &
Kessler, R. C. (2007). Lifetime and 12-month prevalence of bipolar spectrum disorder in the
national comorbidity survey replication. Archives of General Psychiatry, 64, 543–552. http://dx.doi.
org/10.1001/archpsyc.64.5.543
 128    S. Pankowski et al.

Michalak, E. E., Yatham, L. N., Kolesar, S., & Lam, R. W. (2006). Bipolar disorder and quality of life:
A patient-centered perspective. Quality of Life Research, 15, 25–37. http://dx.doi.org/10.1007/
s11136-005-0376-7
Miklowitz, D. J. (2008). Adjunctive psychotherapy for bipolar disorder: State of the evidence. American
Journal of Psychiatry, 165, 1408–1419. http://dx.doi.org/10.1176/appi.ajp.2008.08040488
Öst, L. G. (2014). The efficacy of acceptance and commitment therapy: An updated systematic review
and meta-analysis. Behaviour Research and Therapy, 61, 105–121. http://dx.doi.org/10.1016/j.
brat.2014.07.018
Otto, M. W., Simon, N. M., Wisniewski, S. R., Miklowitz, D. J., Kogan, J. N., Reilly-Harrington, N.
A., … Investigators, S.-B. (2006). Prospective 12-month course of bipolar disorder in out-patients
with and without comorbid anxiety disorders. The British Journal of Psychiatry, 189, 20–25. http://
dx.doi.org/10.1192/bjp.bp.104.007773
Rucci, P., Frank, E., Kostelnik, B., Fagiolini, A., Mallinger, A. G., Swartz, H. A., … Kupfer, D. J.
(2002). Suicide attempts in patients with bipolar i disorder during acute and maintenance phases
of intensive treatment with pharmacotherapy and adjunctive psychotherapy. American Journal of
Psychiatry, 159, 1160–1164.
Scott, J., Paykel, E., Morriss, R., Bentall, R., Kinderman, P., Johnson, T., … Hayhurst, H. (2006).
Cognitive-behavioural therapy for severe and recurrent bipolar disorders: Randomised controlled
trial. The British Journal of Psychiatry, 188, 313–320. http://dx.doi.org/10.1192/bjp.188.4.313
Stratford, H. J., Cooper, M. J., Di Simplicio, M., Blackwell, S. E., & Holmes, E. A. (2015). Psychological
therapy for anxiety in bipolar spectrum disorders: A systematic review. Clinical Psychology Review,
35, 19–34. http://dx.doi.org/10.1016/j.cpr.2014.11.002
Szentagotai, A., & David, D. (2010). The efficacy of cognitive-behavioral therapy in bipolar disorder.
The Journal of Clinical Psychiatry, 71, 66–72. http://dx.doi.org/10.4088/JCP.08r04559yel
Thorsell, J., Finnes, A., Dahl, J., Lundgren, T., Gybrant, M., Gordh, T., & Buhrman, M. (2011). A
comparative study of 2 manual-based self-help interventions, acceptance and commitment therapy
and applied relaxation, for persons with chronic pain. The Clinical Journal of Pain, 27, 716–723.
http://dx.doi.org/10.1097/AJP.0b013e318219a933
Turk, D. C., Wilson, H. D., & Cahana, A. (2011). Treatment of chronic non-cancer pain. The Lancet,
377, 2226–2235. http://dx.doi.org/10.1016/S0140-6736(11)60402-9
Twohig, M., & Hayes, S. C. (2008). ACT verbatim for depression and anxiety: Annotated transcripts
for learning Acceptance and Commitment Therapy. Oakland, CA: New Harbinger Publications.
Van Dijk, S., Jeffrey, J., & Katz, M. R. (2013). A randomized, controlled, pilot study of dialectical
behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. Journal
of Affective Disorders, 145, 386–393. http://dx.doi.org/10.1016/j.jad.2012.05.054
Zetterqvist Westin, V., Schulin, M., Hesser, H., Karlsson, M., Noe, R., Olofsson, U., … Andersson, G.
(2011). Acceptance and commitment therapy versus tinnitus retraining therapy in the treatment
of tinnitus: A randomised controlled trial. Behaviour Research and Therapy, 49, 737–747.

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