TYPE Mini Review

PUBLISHED 14 October 2022

DOI 10.3389/fpsyt.2022.976363

Is acceptance and commitment

OPEN ACCESS therapy helpful in reducing
anxiety symptomatology in
EDITED BY
Gianfranco Spalletta,
Santa Lucia Foundation (IRCCS), Italy

REVIEWED BY
Vendela Westin Zetterqvist,
people aged 65 or over? A
Uppsala University, Sweden
Federica Piras,
Santa Lucia Foundation (IRCCS), Italy
systematic review
*CORRESPONDENCE
Laura Lacomba-Trejo Iraida Delhom1 , Joaquín Mateu-Mollá1 and
[email protected]

SPECIALTY SECTION
Laura Lacomba-Trejo2*
This article was submitted to 1
Faculty of Health Sciences, Valencian International University, Valencia, Spain, 2 Departament of
Aging Psychiatry, Personality, Assessment and Psychological Treatment, Faculty of Psychology and Speech Therapy,
a section of the journal Universitat de València, Valencia, Spain
Frontiers in Psychiatry

RECEIVED 23 June 2022

ACCEPTED 23 September 2022 Anxiety-related mental health problems constitute a health challenge,
PUBLISHED 14 October 2022
especially in the elderly population. At present, there are few psychological
CITATION
Delhom I, Mateu-Mollá J and treatments to reduce anxiety adapted to this group. The aim of this study was
Lacomba-Trejo L (2022) Is acceptance to conduct a systematic review of the literature to determine the therapeutic
and commitment therapy helpful in
effects of Acceptance and Commitment Therapy (ACT) on anxiety in older
reducing anxiety symptomatology in
people aged 65 or over? A systematic adults, using the Preferred Reporting Items for Systematic Reviews and
review. Front. Psychiatry 13:976363. Meta-Analyses (PRISMA) protocol. Two blinded reviewers participated in the
doi: 10.3389/fpsyt.2022.976363
search, selection and methodological quality assessment processes; reaching
COPYRIGHT
satisfactory levels of agreement between reviewers (κ > 0.70). The search
© 2022 Delhom, Mateu-Mollá and
Lacomba-Trejo. This is an open-access was performed in PubMed, Proquest Central, Scopus and Web of Science;
article distributed under the terms of making use of standardized terms for the construction of the algorithm. In
the Creative Commons Attribution
License (CC BY). The use, distribution the general search 348 studies were found. After applying the eligibility criteria
or reproduction in other forums is and excluding duplicates, seven articles were extracted for qualitative analysis.
permitted, provided the original
The total number of subjects was 633, with an average age of 68.89 years
author(s) and the copyright owner(s)
are credited and that the original (68.94% women). The analysis of methodological rigor showed moderate
publication in this journal is cited, in indices on average. The publications focused primarily on samples with a
accordance with accepted academic
practice. No use, distribution or
diagnosis of generalized anxiety disorder, proposing a variety of assessment
reproduction is permitted which does tests for related dependent variables, especially depressive symptoms and
not comply with these terms. psychological flexibility. Critical analysis of the findings provides evidence for
the efficacy of ACT in reducing anxious and depressive symptoms in older
adults. This study proposes the use of this procedure as a non-pharmacological
alternative for a group usually underrepresented in the scientific literature on
this topic.

KEYWORDS

anxiety, acceptance and commitment therapy, systematic review, older adult, aging

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Delhom et al. 10.3389/fpsyt.2022.976363

Introduction unwanted thoughts has been associated with a less subjective

meaning of one’s life in older adults (14). Petkus & Wetherell,
Anxiety-related mental health problems in older adults are et al. (12) confirmed how thought suppression was associated
among the most persistent, prevalent and impactful (1–3). with more somatic, depressive and anxiety symptoms after
However, even today, their prevalence is not yet established. physical, functional and cognitive disease control in a sample
Values for anxiety-related mental health problems range from of older adults with functional disability and chronic illness
1.20 to 15%, while rates of clinically significant anxiety (12). In the same line, more recent research exploring ACT in
symptoms vary from 15 to 52% (4). It has been found that older adults suggests that ACT contributes more significantly
anxiety disorders tend to be persistent in older adults, with an to alleviating anxious symptoms than traditional cognitive-
average duration of 20 years or more (5). Furthermore, there behavioral techniques (2, 15, 16).
appears to be a bidirectional association between anxiety and Numerous reasons support the appropriateness of ACT in
disability (2, 6): anxiety increases disability and worsens both older adults (9, 10, 17). On the one hand, anxiety disorders
quality of life and life satisfaction (4) and is associated with an often present a chronic condition resulting in their onset prior
increased risk of mortality in older adults, both from suicide and to old age and their persistence over time (5). In addition,
physical illness (7). Besides, anxiety is considered a risk factor for anxiety disorders often show greater resistance to treatment in
cognitive impairment in cognitively normal older adults (8). In older adults (9). On the other hand, comorbidity of anxiety
fact, there is evidence that suggests that anxiety in older adults and depression are common in older adults, making them more
may lead to mild cognitive amnestic impairment (8). Despite difficult to differentiate (18). The transdiagnostic nature of ACT
the above, few studies have focused on developing psychological makes assessment and intervention for anxiety and depression
treatments adapted to older people (9). more efficient, as it is not necessary to distinguish between
The tendency toward fear and avoidance of internal both pathologies, as it focuses exclusively on determining
experiences is a relevant feature of people with anxiety how core processes of psychological inflexibility contribute to
(10). Experiential avoidance is defined by Acceptance and psychopathology in order to intervene on them, regardless of
Commitment Therapy (ACT) as one of the psychological the current mental health problem (12). In addition, ACT can
inflexibility processes associated with psychopathology (11). be beneficial in cases where psychological distress is associated
According to Hayes, et al. (11), the six processes associated with with loss-related factors that are unavoidable and immutable.
psychological inflexibility and consequently psychopathology In this way, the acceptance approach and refocusing behaviors
are experiential avoidance, cognitive defusion, dominance on attainable goals aligned with one’s values can be particularly
of the conceptualized past or future, disengagement from beneficial (17).
personal values, impulsivity, and persistent avoidance. Research In summary, the particularities and challenges presented
suggests that these core psychopathology processes persist into by anxiety in older adults require special attention to address
adulthood, with a significant association between experiential this issue in an idiosyncratic manner. ACT has shown to be
avoidance of distressing internal experiences and increased potentially successful in this regard; however, more evidence is
anxiety in later life (12). People who display psychological needed to support these findings so far, especially in older adults.
inflexibility are considered to exert energy and resources toward Therefore, this study aimed to conduct a systematic review in
experiential avoidance, as well as neglecting and disengaging order to compile the available evidence on the efficacy of ACT in
from core values in their lives (12). Kashdan, et al. (13) older adults with anxiety problems.
used a 21-day experience sampling methodology to examine
the relationships between experiential avoidance, suppressing
emotions, and cognitive reappraisal with daily reports of Methods
social anxiety. Including cognitive reappraisal allowed the
comparison of a core process of traditional cognitive-behavioral This systematic review was developed according to the
therapies with the core process of acceptance and attention- Preferred Reporting Items for Systematic Reviews and Meta-
based therapies, experiential avoidance or acceptance. The Analyses (PRISMA) (19).
results showed that people who worked with ACT intervention
techniques reported a significant reduction in anxiety levels.
ACT-based treatment aims to focus attention on feeling better Bibliographic search
and living better. These authors consider ACT-based exercises
to be more effective than cognitive behavioral therapy as The Proquest, Pubmed, Web of Science and Scopus
they are not portrayed as a way to reduce anxiety, but as a databases were consulted by two authors (LL-T and JM-M),
strategy to develop a willingness to deal with anxiety while exploring articles published before 29th May 2022. Using the
progressing toward a set of desired goals (13). Similar studies PICO approach (20), the following research question was posed:
have shown how thought suppression as a mechanism to combat do older people who undergo ACT improve their anxiety levels?.

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Delhom et al. 10.3389/fpsyt.2022.976363

The searching protocol was applied to all the selected Headings—MeSH (English) and from Descriptores en Ciencias
databases and was constructed as follows: “acceptance and de la Salud—DeCS (Spanish).
commitment therapy” AND (anxiety OR “anxiety disorders”) All selected articles were managed through the Covidence
AND (aged OR aging). In order to optimize the process, software. First, duplicate articles were eliminated, after which
standardized terms were retrieved from the Medical Subject the two authors (LL-T and JM-M) reviewed the manuscripts

FIGURE 1
Flowchart of selection process.

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Delhom et al. 10.3389/fpsyt.2022.976363

with emphasis on the title and abstract, determining compliance collection methods, (g) data analysis, and (h) reporting. Studies
with the eligibility criteria separately. In this process, articles can have between 4 and 8 component ratings based on these
were screened independently and in a blind manner with criteria (41). The average quality score was 1.84, with quality
regard to the other author’s decision. If there were conflicts, a scores ranging from 1 to 3, with 1 being the highest score (least
second in-depth reading was performed individually. Finally, likely to be biased and highest quality) and 3 being the weakest
disagreements were resolved through active discussion. A third score (most likely to be biased or lowest quality). A study with 6
reviewer (IDL) provided arbitration in cases where consensus ratings could be rated as “strong” if there are no weak ratings and
could not be reached. at least 3 strong ratings, “moderate” if there is one rating and <3
The Cohen’s Kappa index (κ) (21) was used to evaluate strong ratings, or “weak” if there are two or more weak ratings.
the agreement between judges; values between−1 and.40 are
considered unsatisfactory, those between 0.41 and 0.75 are
considered acceptable, and those that score 0.76 or higher are Results
considered satisfactory (22). Figure 1 displays the flowchart that
depicts the selection process. Study selection and screening

The study selection process is shown in Figure 1. The

Inclusion and exclusion criteria literature screening resulted in a total of 348 records. After
removing duplicates, the total number of records was 77. The
The inclusion criteria were: (a) the study assessed the initial selection excluded 189 studies based on title and abstract,
benefits attributable ACT on the anxious symptomatology, (b) and the full content of the remaining 42 papers was read as part
the age of the sample was 65 years or older, (c) the manuscript of a second selection process. The reliability of prior agreement
underwent a peer review process, (d) the article was published between the two independent reviewers (LL-T and JM-M) in
in a journal with significant impact factor, (e) the study was the full-text selection was excellent (κ = 0.84). In the second
published in English or Spanish, and (f) the paper was published screening, 30 papers were excluded resulting in 7 dependent
within the last 10 years. studies being eligible for inclusion. The degree of agreement
The following exclusion criteria were agreed upon: (a) between the reviewers was also excellent (κ = 0.82).
samples of patients diagnosed with schizophrenia and bipolar
disorder, (b) samples of patients diagnosed with severe medical
conditions, (c) publications derived from conferences, (d) Characteristics of the study
studies based on a narrative review, and (e) studies that did not
explore anxiety using a scientifically validated questionnaire. The characteristics of the studies are summarized in Table 1.
The seven studies investigated included a total of 633 older
adults. The samples ranged from 15 participants to 134,
Data collection with an average sample size of 90.43. Of the participants,
68.94% were female. The age of participants ranged from
One of the authors (LLT) developed an ad hoc table to 57.14 to 94.22 years, with an average of 68.89 years. All
synthesize all relevant information from the selected articles. studies were longitudinal. However, only two of them included
This information included: (a) first author, (b) year of a control group; one had the same control group as the
publication, (c) source country, (d) objectives, (e) sample, (f) experimental group (waiting list), and in the other, the control
variables and instruments, (g) design, (h) intervention, (i) group received CBT. Three of the studies had at least one
results, (j) main conclusions, (k) methodological rigor indices, follow-up. The mean assessment time in these studies was
and (l) dropouts (Table 1). 6.86 weeks for the first measurement, ranging from 6 to 24
months between assessments. The mean number of weeks at
follow-up was 24.60.
Quality assessment Regarding the sample’s representativeness for treatment
dropout, all but one study reported this information. This
Two authors (LL-T and JM-M) assessed the methodological percentage ranged from 6.25 to 39.17. The mean dropout
rigor of the selected studies in an independent and blinded rate from the studies was estimated at 24.66%. Futhermore,
manner using an adapted version of the Quality Assessment although most papers do not mention the reason, they are
Tool for Quantitative Studies developed by the Effective Public generally high. In those that do mention the reason for
Health Practice Project (40). This tool consists of 19 items that dropout, it is said to be due to difficulties in following
assess 8 criteria: (a) study design, (b) blinding, (c) selection treatment or death. There was considerable heterogeneity in
bias, (d) withdrawals and dropouts, (e) confounders, (f) data the independent and dependent variables assessed (χ ² = 8.55,

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Delhom et al.
TABLE 1 Characteristics of studies included in the systematic review (N = 7) and article quality assessment.

First Year Country Objectives Sample Variables and instruments Design Intervention Results Conclusions Dropouts
author

Davison 2016 Australia - Assess the efficacy 41 older adults - Sociodemographic (sex, gender, Descriptive - 12 individual - After the - ACT appears to be 50 %
of ACT to 63–97 years time of residence). non-experimental, sessions of 60 min intervention, helpful for older
improve anxiety (85.33 ± 9.20) - Clinical (medical files baseline longitudinal (two per week). depression was people in
and depression. (85.24% and medication). - Implemented by reduced, but not reducing depression.
women) - Psychological: depression PhD students with anxiety. - It has not been
(Geriatric Depression Scale training in - These improvements proven to be
(GDS-15) (23), and The Cornell psychotherapy and were maintained successful in
Scale for Depression in older people. after 3 months. reducing anxiety.
Dementia (24), anxiety (Geriatric - It was observed that - It appears to be a
Anxiety Inventory (GAI) (25). both participants well-received
- Treatment satisfaction in and healthcare staff treatment by
participants (Client Satisfaction found the treatment participants and
Questionnaire; CSQ-8) (26) and useful and expressed health workers.
05

staff (ad hoc). satisfaction.

Fowler 2021 United States - To assess the 15 participants - Sociodemographic: age, sex, Descriptive - 6 Telephone-based - After the - ACT seems useful 6.25 %
feasibility, aged >21 ethnicity, education, income, non-experimental, sessions of 60 min intervention anxiety for older people in
acceptability, and (68.85 ± 11,70) place of recruitment, relationship longitudinal (one per week) was reduced, but not reducing anxiety.
preliminary (80.00 women) of the caregiver and the patient - Implemented by a depression - ACT could improve
effects of an ACT with ADRD, severity of ADRD. bachelor’s-level - The improvements caregiver
intervention on - Psychological: Anxiety interventionist with were maintained at 6 psychological
ADRD caregiver (Generalized Anxiety Disorder a 4-year degree in months. suffering and
anxiety, Scale; GAD-7) (27), Depression Psychology but not a - At 6 months, caregiver burden.
depressive (Patient Health Questionnaire-9; licensed therapist or statistically - Benefits can be
symptoms, PHQ-9) (28), Caregiver burden psychologist that significant decreases maintained
burden, suffering, (Zarit Burden Interview; ZBI) received supervision in caregiver over time.
and psychological (29), Cognitive Flexibility throughout the study psychological

10.3389/fpsyt.2022.976363
flexibility. (Acceptance and Action from a Master’s level suffering and
Questionnaire-II; AAQ-II) (30) clinician with caregiver burden
Coping (Brief COPE) (31). ACT training were observed
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Delhom et al.
TABLE 1 (Continued)

First Year Country Objectives Sample Variables and instruments Design Intervention Results Conclusions Dropouts
author

Gould 2021 United Kingdom - To examine the 37 older adults - Sociodemographic: age, sex, Descriptive - 16 individual 60-min - Improvements in - There was excellent 24.32 %
acceptability, aged >65 (74.80 ethnicity, marital status, mean non-experimental, ACT sessions. The anxiety, depression evidence of
feasibility, and ± 6,30) (81.00% years of education, highest longitudinal first 14 sessions were and the acceptance feasibility and good
preliminary women) educational qualification, weekly, while the and action evidence of
estimates of the employment status. following sessions questionnaire. acceptability of ACT
effectiveness of - Psychological: Anxiety (Geriatric were fortnightly to - The improvements for older people with
ACT for older Anxiety Inventory (GAI) (25) facilitate the were maintained at generalized anxiety
people with and Penn State Worry completion of 20 weeks. disorder. However,
generalized Questionnaire (PSWQ) (31), the intervention. - Adequate satisfaction with
anxiety disorder Depression (Geriatric - Therapists were satisfaction with therapy scores
Depression Scale (GDS-15) (23), qualified clinical therapy. suggested that
Cognitive Flexibility (Acceptance psychologists, further refinement of
and Action Questionnaire-II cognitive-behavioral the intervention may
(AAQ-II) (30), therapists or be necessary.
06

- Cognitive: Standardized counseling

Mini-Mental State Examination psychologists, with a
(SMMSE) (51). minimum of 1 year
- Satisfaction: Satisfaction with of experience in
Therapy and Therapist conducting
Scale-Revised (48). psychotherapy
interventions.
Jacobs 2018 United States - To develop, 17 older adults - Sociodemographic: sex, race, Descriptive - 12-session ACT of - After the - Results provide 23.52 %
implement, and aged 55–84 ethnicity, marital status. non-experimental, 60 min, that included intervention, support for the use
evaluate a (68.00 ± 6.59) - Clinical: diagnosis of longitudinal brief homework depression was of ACT in the
12-session ACT (100% men) anxiety disorder. assignments (one reduced, but not treatment of
for older veterans - Psychological: Anxiety per week) anxiety depressive

10.3389/fpsyt.2022.976363
group protocol. (Generalized Anxiety Disorder - Therapist were symptomatology
Scale; GAD-7) (27), Cognitive working in an among older adults
Flexibility (Acceptance and outpatient - Results failed to
Action Questionnaire-II geropsychology show significant
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(Continued)
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Delhom et al.
TABLE 1 (Continued)

First Year Country Objectives Sample Variables and instruments Design Intervention Results Conclusions Dropouts
author

(AAQ-II) (30), Depression clinic at a rural changes in anxiety.

(Geriatric Depression Scale Veterans Affairs
(GDS-15) (23). Medical Center
Lappalainen 2021 Finland - To develop and 149 older adults - Sociodemographic: sex, marital Descriptive - 12 web-based ACT - Web-based ACT - Online Care ACT 28.86 %
investigate aged >60 status, education, caregiver non-experimental, sessions of 90 min, sessions were better intervention
whether a novel (72.90 ± 6, 10) diagnosis, care recipient, age of longitudinal one per week, than standardized produced significant
ACT-based (80.50% the care recipient, number of divided into six institutional effects on depressive
online women) years providing care, receiving of progressive rehabilitation for symptoms over the
intervention care allowance. intervention reducing depressive duration of the
effectively - Psychological: Depression (Beck modules on ACT symptoms and intervention (12
enhances the Depression Inventory—II; processes enhanced enhancing the weeks), and the
07

psychological BDI-II) (32), Anxiety with a compassion psychological quality CareACT

well-being of (Generalized Anxiety Disorder module (group 1) of life. intervention was
family caregivers Scale; GAD-7) (27), Quality of - Standardized - No statistical superior to the
aged 60 and over. Life (WHOQOL-BREF Quality institutional differences were comparison
of Life Survey) (33), sense of rehabilitation found between interventions.
coherence (SOC) (34), provided by groups for anxiety, - Treatment effects
Psychological Flexibility rehabilitation physical quality of were not fully
(Acceptance and Action centers during 10 life, social quality of maintained at
Questionnaire-II (AAQ-II) (30), months (group 2). life, environmental 10 months.
Experiential Avoidance in quality of life, and
Caregiving Questionnaire sense of coherence.
(EACQ) (52), White Bear
Suppression Inventory

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(WBSI) (50).

(Continued)
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Delhom et al.
TABLE 1 (Continued)

First Year Country Objectives Sample Variables and instruments Design Intervention Results Conclusions Dropouts
author

Chojak 2021 Poland - To assess the 60 older adults - Sociodemographic: age, sex, Descriptive - 12 ACT sessions of - After the training, - The results of 0%
effectiveness of aged 60–91 education level. non-experimental, 60 min (three-four the level of anxiety statistical analyses
psychological (73.48 ± 8.87) - Psychological: Depression, longitudinal per week) symptoms in the confirmed the
skills training (80.00% Anxiety and Stress Scale (intervention group; experimental group hypothesis about the
based on ACT in women) (DASS-21) (35), WHO Quality N = 30). was significantly effectiveness of ACT
lowering the of Life—AGE Scale - Passive (Control reduced. based training of
psychopathological (WHO-QOL-AGE) (36). Group; N = 30). - Simple effect analysis psychological
symptoms and - Cognitive: Mini Mental State for the measurement competencies in
increasing the Examination (MMSE) (37). showed no lowering the
quality of life in significant difference symptoms of
older adults over in the level of psychopathology
60 years of age. depressive and improving the
symptoms in the quality of life.
08

control group, while - ACT-based

in the experimental programes can be
group, the difference implemented for
was significant. older adults at risk of
- Simple effects social exclusion or
analysis for the suffering from
measurement higher levels of
showed no psychopathological
significant difference symptoms.
for the control
group, while there
was a significant

10.3389/fpsyt.2022.976363
difference between
measurements in the
experimental group.
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Delhom et al.
TABLE 1 (Continued)

First Year Country Objectives Sample Variables and instruments Design Intervention Results Conclusions Dropouts
author

Wiltox 2021 Netherland - To examine the 314 older adults - Sociodemographic: age, sex, Randomized - Living to the Fullest - Regardless of the - No differences 39.17 %
effectiveness of a aged 55–75 nationality, education, relational Controlled Trial Programme (ACT condition, GAD-7 between blended
combined brief (62.75 ± 5.69 in status, work status, group): 9 lessons scores decreased ACT and
ACT intervention ACT group and living situation, (15–30 min) to be significantly from T0 face-to-face CBT in
for older adults 63.33 ± 5.71 in - Clinical: somatic comorbidity, completed in 9–12 to T1, increased their effects on
with anxiety CBT group) use of psychomedication and weeks. The significantly between anxiety
symptoms (66.70% women anxiety disorder. web-based module T1 and T2, and did symptom severity.
compared to a in ACT group - Psychological: Anxiety can be accessed via not change - In both groups,
face-to-face CBT and 56.10% (Generalized Anxiety Disorder computers and significantly from T1 anxiety symptoms
intervention. women in CBT Scale; GAD-7) (27), Depression mobile devices. to T3. improved
Group) (Patient Health Questionnaire-9; - Standard treatment: - MHC-SF scores significantly from
PHQ-) (28), Mental Health Face-to-face CBT decreased in the baseline
Continuum Short Form (CBT group): 4 CBT group, whereas to posttreatment.
(MHC-SF) (38), Disability face-to-face sessions they increased in the - Blended ACT is a
09

(Sheehan Disability Scale; SDS) over a period of 9–12 ACT group. valuable treatment
(39), Personality weeks. Participants - Regardless of the alternative to CBT
(MINI-Plus) (49). received homework condition, for anxiety in
- Satisfaction: Client Satisfaction exercises requiring depression severity later life.
Questionnaire (26) 15–30 min per day (a decreased over time.
similar time - Functional
investment to the impairment in work,
ACT intervention). social life and family
life decreased
significantly from
baseline to
post-treatment in all
groups. These

10.3389/fpsyt.2022.976363
improvements were
maintained at the
one-month
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follow-up.

(Continued)
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Delhom et al.
TABLE 1 (Continued)

First Year Country Objectives Sample Variables and instruments Design Intervention Results Conclusions Dropouts
author

- Treatment
satisfaction was
significantly higher
in the ACT group
than in the CBT
group, and the effect
size of the difference
was large.

Article quality assessment

First author Study Blinding Representativeness Representativeness Confounders Data Data Reporting Total Overall quality
design selection bias withdrawals and collection analysis assessment
dropouts methods
10

Davison 2 3 3 2 1 1 1 1 1.38 Weak

Fowler 2 3 3 1 1 1 2 2 1.88 Weak
Gould 2 3 3 2 1 1 1 2 1.88 Weak
Jacobs 2 3 3 2 1 1 1 1 1.88 Weak
Lappalainen 2 3 3 2 1 1 2 2 2.00 Weak
Chojak 2 3 3 1 1 1 2 2 1.88 Weak
Wiltox 1 1 1 2 1 1 2 2 1.38 Strong

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Delhom et al. 10.3389/fpsyt.2022.976363

p = 0.010, V = 0.45) as well as in the number of participants rehabilitation centers, finding that the online modality of
(χ ² = 10.00, p = 0.007, V = 0.60). However, the study ACT was more effective in reducing depressive symptoms
designs were acceptably heterogeneous (χ ² = 0,09, p = ,520, and strengthening the psychological components of quality
V = 0,01). Most studies assessed anxiety, depression, stress of life.
or burden, and ACT elements such as cognitive flexibility. The findings of the reviewed studies have some limitations.
Other variables of interest were personality, psychopathology, Some of the studies have been conducted with very small
life satisfaction, cognitive impairment and quality of life. samples (42, 45). Furthermore, there is a lack of control
Four studies report that the therapy was conducted by and experimental groups (15, 42, 43, 45, 46), and only one
qualified psychologists, while the rest do not provide any randomized controlled trial was found (47). On the other hand,
information. Most interventions lasted for about 12 weeks, the available studies assess anxiety in various ways, in many cases
but in one case (42), treatment lasted for 6 sessions, and alongside other emotional problems. In 25% of the studies, the
in another (15), it lasted for 16 sessions. There was also GAI was used (25), 50% used the GAD-7 (34), 12.50% used
heterogeneity in the presentation of the therapies. Overall, the DASS-21 (35) and the remaining 12.50% used ad hoc semi-
4 studies were individual and face-to-face, while one study structured interviews. In addition to the above, most of the
(42) was conducted over the telephone and two studies studies included have high drop-out rates of over 20%. Not all
were conducted over online modules. In this regard, the studies provide reasons for the dropouts. Finally, despite having
two reviewers (LL-T and JM-M) assessed the presence or performed a heterogeneity analysis, results should be considered
absence of a control group and the presentation format, cautiously. This type of analysis should be conducted in more
with inter-rater reliability reaching an almost perfect level endline studies.
of agreement (κ = 90). Every study controlled at least one However, preliminary results indicate that ACT can be
confounding variable (medication intake, type of medication, beneficial for treating anxiety problems in older adults,
caregiver relationship, gender, background, session attendance, particularly suitable for this population’s characteristics (2, 15,
waiting time between treatment and assessment, marital status, 17). Therefore, these tools should be studied in greater depth to
education, employment status, mental health status, and socio- maximize their benefits. In this regard, further research of higher
demographic and clinical variables), and they all mention quality is required, including additional randomized controlled
inclusion and exclusion criteria. In general, weak statistical tests trials specifically targeting older people.
were used. However, two studies (15, 43) did use ANCOVA to The results of this research may be affected by some biases,
evaluate the programmes. including the following: biases in the sample size, as well
as in the research design (non-randomization of participants,
general lack of control and experimental group, no double-
Discussion blind allocation between control and experimental group; use
of weak statistics and general lack of follow-up), assessment
This study aimed to conduct a systematic review to compile biases (selection of non-specific assessment instruments for
the available evidence on the efficacy of ACT in older adults with older adults), and sampling biases.
anxiety problems. A total of 7 papers were included. Overall, On the other hand, the limited selection of articles
57.14% of the studies focused on the population with generalized directly related to the systematicity of the review requires
anxiety disorder, 28.57% on caregivers of dependent persons and further research. In addition to the above, most articles
14.29% on anxious and depressive symptoms associated with address the benefits of ACT in older people with a
long-term institutionalization. diagnosis of generalized anxiety disorder, but other clinical
These studies showed how ACT was effective in reducing conditions of the same psychopathological category are
depressive (15, 43–47), and anxiety symptoms (15, 42, 44, 47). underrepresented. Furthermore, there has been a significant
Regarding anxiety, the results are less consistent, with heterogeneity of assessment methods and therapeutic
studies concluding that ACT could reduce anxiety symptoms procedures. Although the number of sessions tends to
(15, 42, 44, 47) and other studies finding that it does not be similar among the studies; their contents, timing and
(43, 45, 46). One of the studies (47) compared the benefits administration methods are highly variable, making it
of ACT with those of traditional CBT, concluding that both impossible to carry out a meta-analysis at the present time.
procedures effectively reduce symptoms of anxiety and Similarly, the quality of the studies analyzed has been found to
depression. However, ACT showed a superior therapeutic be moderate or weak.
impact on mental health and treatment satisfaction. To the best of our knowledge, this is the first systematic
For both ACT and CBT, the effects were maintained at review conducted on the possible benefits of ACT on anxiety in
follow-up. Another paper (46) compared ACT treatment older adults. Based on the results obtained, it can be concluded
conducted online with the traditional approach provided by that there is a need for further higher-quality research focused on

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Delhom et al. 10.3389/fpsyt.2022.976363

this area that would allow to truly evaluate the benefits of ACT Acknowledgments
in older adults.
We thank the Valencian International University and the
Universitat de València for the funding received.
Author contributions
ID: project management, literature search, writing the
original manuscript, and revising the manuscript. JM-M: review
Conflict of interest
proposal, conducting the search process, methodology, review
The authors declare that the research was conducted in the
and synthesis of the review articles, and writing the original
absence of any commercial or financial relationships that could
manuscript and revision. LL-T: review proposal, conducting the
be construed as a potential conflict of interest.
search process, review and synthesis of the review articles, and
statistical analysis and revision of the manuscript.

Publisher’s note
Funding
All claims expressed in this article are solely those of the
Research Project Emotional intelligence as a resource for authors and do not necessarily represent those of their affiliated
successful adaptation in everyday life (PII2021_06), funded by organizations, or those of the publisher, the editors and the
Valencian International University. LL-T is a beneficiary of reviewers. Any product that may be evaluated in this article, or
the Ayuda de Atracció a Talent de la Universitat de València claim that may be made by its manufacturer, is not guaranteed
(0113/2018). or endorsed by the publisher.

References
1. Andreas S, Schulz H, Volkert J, Dehoust M, Sehner S, Suling A, et al. Prevalence 11. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and
of mental disorders in elderly people: the European MentDis_ICF65+ study. Br J commitment therapy: model, processes and outcomes. Behav Res Ther. (2006)
Psychiatry. (2017) 125:125–31. doi: 10.1192/bjp.bp.115.180463 44:1–25. doi: 10.1016/j.brat.2005.06.006
2. Lenze E, Wetherell JL. A lifespan view of anxiety disorders. Dial Clin Neurosci. 12. Petkus AJ, Wetherell JL. Acceptance and commitment therapy with
(2022) 13:381–99. doi: 10.31887/DCNS.2011.13.4/elenze older adults: rationale and considerations. Cogn Behav Pract. (2013) 20:47–
3. Zilber N, Lerner Y, Eidelman R, Kertes J. Depression and anxiety 56. doi: 10.1016/j.cbpra.2011.07.004
disorders among Jews from the former Soviet Union five years after 13. Kashdan TB, Barrios V, Forsyth JP, Steger MF. Experiential
their immigration to Israel. Int J Geriatr Psychiatry. (2001) 16:993–9. avoidance as a generalized psychological vulnerability: comparisons
doi.org/10.1002/gps.456 doi: 10.1002/gps.456 with coping and emotion regulation strategies. Behav Res Ther. (2006)
4. Bryant C, Jackson H, Ames D. The prevalence of anxiety in older adults: 44:1301–20. doi: 10.1016/j.brat.2005.10.003
methodological issues and a review of the literature. J Affect Disord. (2008) 14. Krause N. Thought suppression and meaning in life: a
109:233–50. doi: 10.1016/j.jad.2007.11.008 longitudinal investigation. Int J Aging Hum Dev. (2007) 64:67–
5. Le Roux H, Gatz M, Wetherell JL. Age at onset of generalized 82. doi: 10.2190/2044-390U-7106-5610
anxiety disorder in older adults. Am J Geriatr Psychiatry. (2005) 13:23–
15. Gould RL, Wetherell JL, Kimona K, Serfaty MA, Jones R, Graham
30. doi: 10.1097/00019442-200501000-00005
CD, et al. Acceptance and commitment therapy for late-life treatment-resistant
6. Brenes GA, Kritchevsky SB, Mehta KM, Yaffe K, Simonsick EM, generalised anxiety disorder: a feasibility study. Age Ageing. (2021) 50:1751–
Ayonayon HN, et al. Scared to death: results from the health, aging, 61. doi: 10.1093/ageing/afab059
and body composition study. Am J Geriatr Psychiatry. (2007) 15:262–
5. doi: 10.1097/JGP.0b013e31802e21f0 16. Wetherell JL, Liu L, Patterson TL, Afari N, Ayers CR, Thorp
SR, et al. Acceptance and commitment therapy for generalized anxiety
7. Allagulander C, Lavori PW. Causes of death among 936 elderly patients disorder in older adults: a preliminary report. Behav Ther. (2011)
with “pure” anxiety neurosis in Stockholm County, Sweden, and patients 42:127–34. doi: 10.1016/j.beth.2010.07.002
with depressive neurosis or both diagnoses. Compr Psychiatry. (1993) 34:299– 17. Roberts SL, Sedley B. Acceptance and commitment therapy with older adults:
302. doi: 10.1016/0010-440X(93)90014-U rationale and case study of an 89-year-old with depression and generalized anxiety
8. Hanseeuw BJ, Jonas V, Jackson J, Betensky RA, Rentz DM, Johnson KA, et al. disorder. Clin Case Stud. (2016) 15:53–67. doi: 10.1177/1534650115589754
Association of anxiety with subcortical amyloidosis in cognitively normal older 18. Gum AM, Cheavens JS. Psychiatric comorbidity and depression in older
adults. Mol Psychiatry. (2020) 25:2599–607. doi: 10.1038/s41380-018-0214-2 adults. Curr Psychiatry Rep. (2008) 10:23–9. doi: 10.1007/s11920-008-0006-5
9. Lawrence V, Kimona K, Howard RJ, Serfaty MA, Wetherell JL, Livingston G, 19. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew
et al. Optimising the acceptability and feasibility of acceptance and commitment M, et al. Preferred reporting items for systematic review and meta-analysis
therapy for treatment-resistant generalised anxiety disorder in older adults. Age protocols (prisma-p) 2015: elaboration and explanation. BMJ. (2015) 349:1–
Ageing. (2019) 48:741–50. doi: 10.1093/ageing/afz082 25. doi: 10.1136/bmj.g7647
10. Roemer L, Salters K, Raffa SD, Orsillo SM. Fear and avoidance of internal 20. Santos CMC, Pimenta CAM, Nobre MRC. The PICO strategy for the research
experiences in GAD: preliminary tests of a conceptual model. Cognit Ther Res. question construction and evidence search. Rev Lat Am Enfermagem. (2007)
(2005) 29:71–88. doi: 10.1007/s10608-005-1650-2 15:508–11. doi: 10.1590/S0104-11692007000300023

Frontiers in Psychiatry 12 frontiersin.org

Delhom et al. 10.3389/fpsyt.2022.976363

21. Orwin RG. Evaluating coding decisions. In: Cooper H, Hedges LV, editors. 38. Lamers SMA, Westerhof GJ, Bohlmeijer ET. ten Klooster PM, Keyes CLM.
The Handbook of Research Synthesis. New York, NY: Russell Sage Foundation Evaluating the psychometric properties of the mental health continuum-short
(1994). p. 139–62. form (MHC-SF). J Clin Psychol. (2011) 67:99–110. doi: 10.1002/jclp.
20741
22. Hernández Nieto R. Contribuciones al analisis estadistico: sensibilidad
estabilidad y consistencia de varios coeficientes de variabilidad relativa y el 39. Leon AC, Olfson M, Portera L, Farber L, Sheehan DV. Assessing psychiatric
coeficiente de variacion proporcional cvp el coeficiente: CreateSpace Independent impairment in primary care with the sheehan disability scale. Int J Psychiatry Med.
Publishing Platform; (2002). (1997) 27:93–105. doi: 10.2190/T8EM-C8YH-373N-1UWD
23. Sheikh JI, Yesavage JA. Geriatric depression scale (GDS): recent 40. Wermelinger Ávila MP, Lucchetti ALG. Association between depression and
evidence and development of a shorter version. Clin Gerontol. (1986) 5:165– resilience in older adults: a systematic review and meta-analysis. Int J Geriatr
73. doi: 10.1300/J018v05n01_09 Psychiatry. (2017) 32:237–46. doi: 10.1002/gps.4619
24. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. 41. McMullan RD, Berle D, Arnáez S, Starcevic V. The relationships
Cornell scale for depression in dementia. Biol Psychiatry. (1988) between health anxiety, online health information seeking and cyberchondria:
23:271–84. doi: 10.1016/0006-3223(88)90038-8 a systematic review and meta-analysis. J Affect Disord. (2019) 15:270–
25. Pachana NA, Byrne GJ, Siddle H, Koloski N, Harley E, Arnold E. 8. doi: 10.1016/j.jad.2018.11.037
Development and validation of the geriatric anxiety inventory. Int Psychogeriatr. 42. Fowler NR, Judge KS, Lucas K, Gowan T, Stutz P, Shan M, et al. Feasibility and
(2007) 19:103–14. doi: 10.1017/S1041610206003504 acceptability of an acceptance and commitment therapy intervention for caregivers
26. Attkisson CC, Greenfield TK. The UCSF Client Satisfaction Scales: I. of adults with Alzheimer’s disease and related dementias. BMC Geriatr. (2021)
The Client Satisfaction Questionnaire-8. In: Maruish ME, editor. The use 1:127. doi: 10.1186/s12877-021-02078-0
of psychological testing for treatment planning and outcomes assessment: 43. Davison TE, Eppingstall B, Runci S, O’Connor DW. A pilot trial of
Instruments for adults. Lawrence Erlbaum Associates Publishers (2004). acceptance and commitment therapy for symptoms of depression and anxiety
p. 799–811. in older adults residing in long-term care facilities. Aging Ment Health. (2017)
27. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing 21:766–73. doi: 10.1080/13607863.2016.1156051
generalized anxiety disorder: the GAD-7. Arch Intern Med. (2006) 166:1092– 44. Chojak A. Effectiveness of a training programme based on acceptance and
7. doi: 10.1001/archinte.166.10.1092 commitment therapy aimed at older adults – no moderating role of cognitive
28. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity functioning. Neuropsychiatria i Neuropsychol/Neuropsychiatry Neuropsychol.
of a brief depression severity measure. J Gen Intern Med. (2001) (2021) 16:138–46. doi: 10.5114/nan.2021.113314
16:606–13. doi: 10.1046/j.1525-1497.2001.016009606.x 45. Jacobs ML, Luci K, Hagemann L. Group-based acceptance and commitment
29. Zarit SH, Reever KE, Bach Peterson J. Relatives of the impaired therapy (ACT) for older veterans: findings from a quality improvement project.
elderly. Correlates of feelings of burden. Gerontologist. (1980) Clin Gerontol. (2018) 41:458–67. doi: 10.1080/07317115.2017.1391917
20:649–54. doi: 10.1093/geront/20.6.649 46. Lappalainen P, Pakkala I, Lappalainen R, Nikander R. Supported
30. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, et al. web-based acceptance and commitment therapy for older family
Preliminary psychometric properties of the acceptance and action questionnaire-II: caregivers (CareACT) compared to usual care. Clin Gerontol. (2021)
a revised measure of psychological inflexibility and experiential avoidance. Behav 45:939–55. doi: 10.1080/07317115.2021.1912239
Ther. (2011) 42:676–88. doi: 10.1016/j.beth.2011.03.007 47. Wiltox M, Garnefski N, Kraaij V, De Waal MWM, Smit F, Bohlmeijer E,
31. Meyer TJ, Miller ML, Metzger RL, Borkovec TD. Development and et al. Blended acceptance and commitment therapy versus face-to-face cognitive
validation of the penn state worry questionnaire. Behav Res Ther. (1990) 28:487– behavioral therapy for older adults with anxiety symptoms in primary care:
95. doi: 10.1016/0005-7967(90)90135-6 pragmatic single-blind cluster randomized trial. J Med Internet Res. (2021)
23:e24366. doi: 10.2196/24366
32. Beck AT, Steer RA, Ball R, Ranieri W. Comparison of beck depression
inventories – IA and II in psychiatric outpatients. J Pers Assess. (1996) 67:588– 48. Oei TP, Green AL. The satisfaction with therapy and therapist
97. doi: 10.1207/s15327752jpa6703_13 scale-revised (STTS-R) for group psychotherapy: psychometric
properties and confirmatory factor analysis. Prof Psychol Res Pr. (2008)
33. Skevington SM, Lotfy M, O’Connell KA. The world health organization’s
WHOQOL-BREF quality of life assessment: psychometric properties and results 39:435–42. doi: 10.1037/0735-7028.39.4.435
of the international field trial. A report from the WHOQOL group. Qual Life Res. 49. Lecrubier Y, Sheehan D, Weiller E, Amorim P, Bonora I, Sheehan K. The mini
(2004) 13:299–31. doi: 10.1023/B:QURE.0000018486.91360.00 international neuropsychiatric interview (MINI). A short diagnostic structured
34. Antonovsky A. Unraveling the Mystery of Health. How People Manage Stress interview: reliability and validity according to the CIDI. Eur J Psychiatry. (1997)
and Stay Well. San Francisco, CA: Jossey-Bass (1987). 12:224–31. doi: 10.1016/S0924-9338(97)83296-8

35. Lovibond PF, Lovibond SH. The structure of negative emotional 50. Wegner DM, Zanakos S. Chronic thought suppression. J Pers. (1994) 62:615–
states: comparison of the depression anxiety stress scales (DASS) with the 40. doi: 10.1111/j.1467-6494.1994.tb00311.x
beck depression and anxiety inventories. Behav Res Ther. (1995) 33:335– 51. Molloy DW, Alemayehu E, Roberts R. Reliability of a standardized
43. doi: 10.1016/0005-7967(94)00075-U mini-mental state examination compared with the traditional mini-mental
36. Zawisza K, Gałaś S, Adamczyk BT. Validation of the Polish version of the state examination. Am J Psychiatry. (1991) 148:102–5. doi: 10.1176/ajp.14
WHOQOL-AGE scale in older population. Gerontologia Polska. (2016) 24:7–16. 8.1.102

37. Pangman V, Sloan J, Guse L. An examination of psychometric properties 52. Losada A, Márquez González M, Romero Moreno R, López J. Development
of the mini-mental state examination and the standardized mini-mental state and validation of the experiential avoidance in caregiving questionnaire
examination: implications for clinical practice. Appl Nurs Res. (2000) 13:209– (EACQ). Aging Ment Health. (2014) 18:897–904. doi: 10.1080/13607863.2014.
13. doi: 10.1053/apnr.2000.9231 896868

Frontiers in Psychiatry 13 frontiersin.org