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Design and Participants: This parallel, multicenter, two-arm trial (2019-2022, in 16 UK MND care centers and clinics) evaluated the effectiveness of ACT plus usual care (ACT+UC), vs UC alone, for improving quality of life in people with MND. Eligible adults had a diagnosis of definite or laboratory-supported probable, clinically probable, or possible familial or sporadic amyotrophic lateral sclerosis, progressive muscular atrophy, or primary lateral sclerosis, which met the World Federation of Neurology’s El Escorial diagnostic criteria. Participants were assigned (1:1) to receive up to eight sessions of ACT (adapted for MND) plus UC or UC by a web-based system, stratified by site. Participants were followed up at 6 months and 9 months post-randomization. Seventy-one patients in the intervention arm and 68 people in UC completed the study. In the treatment arm, 70% (n=68) of participants completed all eight sessions. The analysis was done with modified intention to treat. Outcome assessors and trial statisticians were masked to allocation. The primary outcome was quality of life using the McGill Quality-of-Life Questionnaire-Revised (MQOL-R) at 6 months post-randomization. Analyses (intention to treat) included multilevel mixed-effects modeling.
Results: Participants (n=97 ACT+UC, n=94 UC) were aged mean 63 years (SD=11); 42% female; and 0% Black, 0% mixed/multiple ethnicities, 3% Asian, and 97% White. Eighty-one percent had primary outcome data. After controlling for baseline scores, age, sex, and therapist clustering, ACT+UC was superior to UC at 6 months and 9 months, with an adjusted mean difference on the MQOL-R of 0.66 (95% CI=0.22-1.1) at 6 months (d=0.46 [95% CI=0.16-0.77]) and 0.76 (95% CI=0.30-1.2) at 9 months (d=0.53 [95% CI=0.21-0.85]).
Commentary: Psychiatric comorbidities are linked to higher care utilization and worsened clinical outcomes for patients with serious illness. Thus, integrating mental health and palliative care services could improve patients’ quality of life.3 Evidence supports the effectiveness of ACT in treating psychiatric disorders while also helping alleviate psychological symptoms in individuals with advanced cancer.4 The current study found moderate, yet clinically meaningful, benefits to ACT for patients with MND. Perhaps most interestingly are indications that ACT might stabilize quality of life rather than ameliorate it in MND; may prevent patients from reaching clinical depression if there was none previously; and could have a delayed positive effect via psychological flexibility for patients with MND.
Bottom Line: Core ACT skills such as psychological flexibility5,6 have a moderate impact on quality-of-life measures in MND and are suggestive of a protective effect on mental well-being.
Reviewer: Jack Kimball, PA-C, Duke University Health System, Durham, NC
References:
1. McCracken LM, Yu L, Vowles KE. New generation psychological treatments in chronic pain. BMJ. 2022;376:e057212.
2. Rose M, Graham CD, O’Connell N, et al. A randomized controlled trial of acceptance and commitment therapy for improving quality of life in people with muscle diseases. Psychol Med. 2023;53:3511-3524.
3. Sadowska K, Fong T, Horning DR, et al. Psychiatric comorbidities and outcomes in palliative and end-of-life care: a systematic review. J Pain Symptom Manage. 2023;66(1):e129-e151. doi:10.1016/j.jpainsymman.2023.03.007.
4. Gibson Watt T, Gillanders D, Spiller JA, Finucane AM. Acceptance and commitment therapy (ACT) for people with advanced progressive illness, their caregivers and staff involved in their care: a scoping review. Palliat Med. 2023;37(8):1100-1128. doi:10.1177/02692163231183101.
5. Harris R. The Happiness Trap: How to Stop Struggling and Start Living. Robinson Publishing; 2008.
6. Hayes SC. A Liberated Mind: How to Pivot Toward What Matters. Avery; 2019.
Source: Gould RL, McDermott CJ, Thompson BJ, et al. Acceptance and commitment therapy plus usual care for improving quality of life in people with motor neuron disease (COMMEND): a multicentre, parallel, randomised controlled trial in the UK. Lancet. 2024;403(10442):2381-2394. doi:10.1016/S0140-6736(24)00533-6.
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