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Both Positive Mental Health and Psychopathology Should Be Monitored in Psychotherapy Confirmation For The Dual-Factor Model in Acceptance and Commitment Therapy.
Both Positive Mental Health and Psychopathology Should Be Monitored in Psychotherapy Confirmation For The Dual-Factor Model in Acceptance and Commitment Therapy.
PII: S0005-7967(17)30018-9
DOI: 10.1016/j.brat.2017.01.008
Reference: BRT 3085
Please cite this article as: Trompetter, H.R., Lamers, S.M.A., Westerhof, G.J., Fledderus, M., Bohlmeijer,
E.T., Both positive mental health and psychopathology should be monitored in psychotherapy:
Confirmation for the dual-factor model in acceptance and commitment therapy, Behaviour Research and
Therapy (2017), doi: 10.1016/j.brat.2017.01.008.
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Trompetter, H. R.1, Lamers, S. M. A.1, Westerhof, G. J.1, Fledderus, M.2, & Bohlmeijer, E.
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T.1
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1
Centre for Ehealth and Wellbeing Research, University of Twente, the Netherlands
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2
Tactus Addiction care, the Netherlands
Corresponding author:
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University of Twente,
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7500 AE Enschede
Netherlands
h.r.trompetter@utwente.nl
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Abstract
The dual-factor model of mental health suggests that enhancing positive mental health and
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health of Acceptance and Commitment Therapy (ACT). It draws on RCT data (n=250) of a
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self-help ACT. Patients depression/anxiety symptoms and positive mental health were
completed at baseline, at post-intervention after nine weeks, and at follow-up after five
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months. Percentage of unique variance of depression/anxiety symptoms explained by positive
mental health (and vice versa), and the degree of classificatory agreement between
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improvements in positive mental health and depression/anxiety, were examined using
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regression analysis and Reliable Change Index (RCI). Positive mental health, i.e. baseline and
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change, explained 15% and 12% of the variance in follow-up depression and anxiety
symptoms, beyond the 7% and 9% that was explained by baseline levels of depression and
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anxiety. Depression and anxiety symptoms, i.e., baseline and change, explained 10% and 9%
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of the variance in follow-up positive mental health, on top of the 35% that was explained by
baseline levels of positive mental health. Cross-classification of the Reliable Changes showed
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that 64% of the participants that improved during the ACT-intervention, improved on either
depression symptoms or positive mental health, and 72% of the participants improved on
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either anxiety symptoms or positive mental health. The findings support the dual-factor model
psychopathology and positive mental health in mental health care and therapy evaluations.
Keywords: dual-factor model, positive mental health, depression, anxiety, Acceptance and
In addition to the absence of disease and illness, positive mental health has been increasingly
recognized as a key element of population health and well-being (Keyes, 2005; World Health
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Organization, 2004, 2005). To be categorized as exhibiting excellent positive mental health,
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or flourishing, an individual should not experience psychopathology, and additionally exhibit
high levels of emotional well-being as well as high levels of psychological and social, societal
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functioning. The need to improve positive aspects of mental health, such as positive emotions,
self-acceptance, purpose in life, positive social relations and social integration (Keyes, 2002),
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has recently appeared on policy agendas throughout the world (Barry, 2009). In mental health
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care, this emerging focus on positive mental health is reflected by the increased development
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well-being, such as Well-being Therapy (Fava & Ruini, 2003), Positive Clinical Psychology
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(Wood & Tarrier, 2010), and Positive Psychotherapy (Seligman, Rashid, & Parks, 2006).
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(e.g., Gloaguen, Cottraux, Cucherat, & Blackburn, 1998; Hofmann & Smits, 2008; Westen &
Morrison, 2001). Whenever these traditional psychotherapies do aim to improve general well-
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being outcomes, such as quality of life or functioning (e.g. Hofmann et al., 2014), this focus is
still not in alignment with positive mental health defined as excellent, optimal emotional,
psychological and social functioning and thriving. Furthermore, whenever present, the aim to
gains in well-being.
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The dual-factor model of mental health suggests that enhancing positive mental health
wide range of studies have shown that positive mental health and psychopathology are not
simply opposite poles, but form two negatively related dimensions of mental health
(Greenspoon & Saklofske, 2001; Keyes et al., 2008; Lamers, Westerhof, Bohlmeijer, Ten
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Klooster, & Keyes, 2011; Lyons, Huebner, Hills, & Shinkareva, 2012; Westerhof & Keyes,
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2010). However to date, it is unknown whether this dual-factor model of mental health can be
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factor model might be of significance, because it could be that a therapy that is effective in
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psychopathology and vice versa. This lack of research underlines the need to evaluate the
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effectiveness of the dual-factor model on both dimensions of mental health and the
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interrelatedness between the two mental health dimensions. The dual-factor model of positive
mental health and psychopathology as two related yet distinct dimensions evokes some
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interesting questions in psychotherapy. For example, are the people who benefit in terms of
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positive mental health the same people who benefit in terms of psychopathology? Does
psychotherapy have independent effects on both outcomes? And do all people who increase in
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positive mental health during the psychotherapeutic intervention also decrease in their level of
psychopathology and vice versa? The answers to these questions are highly relevant in the
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light of the recent developments in health services which aim for a mentally healthy
such as positive psychological interventions (Bolier et al., 2013; Lyubomirsky, King, &
Diener, 2005), existential therapies (Vos, Craig, & Cooper, 2015), and CBT (Spek et al.,
date, no research has investigated the relationship between the effects on both mental health
dimensions.
In order to address this lack in the scientific literature, the present study aimed to
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investigate the relationship between the effectiveness on positive mental health and on
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depression and anxiety symptoms as indicators of psychopathology of a self-help therapy. In
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Lamers, & Fledderus, 2015; Fledderus, Bohlmeijer, Pieterse, & Schreurs, 2012; Hayes,
Luoma, Bond, Masuda, & Lillis, 2006). Face-to-face and self-help ACT can significantly
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improve outcomes including acceptance skills, depressive and anxiety symptoms in a large
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and heterogeneous range of somatic and psychiatric disorders (A-Tjak et al., 2015; Cavanagh,
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Strauss, Forder, & Jones, 2014). Critics do pose, however, that more studies of high
methodological quality are necessary to supplement the present evidence base for ACT,
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particularly for diagnoses where present quantity of evidence is modest (st, 2014; Powers,
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Zum Vrde Sive Vrding, & Emmelkamp, 2009). More so than for its effectiveness, we
included ACT in this study as ACT is explicitly aligned with many elements of both mental
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health dimensions. ACT focuses on reducing unhelpful experiences, cognitions and behaviors
vulnerability for psychopathology (Biglan, Hayes, & Pistorello, 2008). Experiential avoidance
acceptance, present-moment awareness) that will help individuals to undertake actions in line
with intrinsically motivating values. This focus directly creates a context for living a
meaningful and fulfilling life (Bohlmeijer et al., 2015; Ciarrochi & Kashdan, 2013). These
considerations are in line with the significant effects of the ACT intervention in this study in
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increasing positive mental health and decreasing depression and anxiety symptoms, making it
a good case study to investigate the relationship between the two mental health dimensions
(Bohlmeijer et al., 2015; Fledderus et al., 2012; Fledderus, Bohlmeijer, Smit, & Westerhof,
2010).
Since positive mental health and psychopathology are distinct yet moderately related
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dimensions of mental health, we hypothesized that baseline levels of positive mental health
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and changes in positive mental health during the intervention could moderately predict the
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addition, at baseline levels of depression and anxiety symptoms and changes in depression
and anxiety symptoms could moderately predict the effectiveness of the intervention on
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positive mental health at follow-up. Moreover, we hypothesized that some people would
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improve on both positive mental health and depression/anxiety symptoms during the ACT-
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between the latent constructs and changes in positive mental health and psychopathology
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during the intervention (r = -.40 to -.50). Based on this hypothesis and the subsequent
expected shared variance between measures of positive mental health and depression/anxiety
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symptoms, we exploratory hypothesize that the majority of participants will improve on either
positive mental health or depression/anxiety symptoms but not the other. The latter result
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would not be possible from a traditional model that views positive mental health and
psychopathology as mere opposites. Under this traditional model, the majority of participants
can be expected to improve on both positive mental health and psychopathology (given
symptoms, but not the other, would comply with the dual-factor model of mental health.
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Method
The present study draws on data from the Randomized Controlled Trial (RCT) by Fledderus
et al. (2012). The study was approved by an independent medical ethics committee
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(METIGG; no. 9212) and recorded in the Dutch primary trial register for clinical trials
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(NTR1985). For an extensive description of the RCTs design and procedure, please refer to
Fledderus et al. (2012). In the RCT, participants were included if they were 18 years or older
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and had mild to moderate depression symptoms (>10 and <39) as determined by the Center of
Epidemiological Studies Depression Scale (CES-D; Radloff, 1977) and/or anxiety symptoms
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(<3 and <15) as determined the Hospital Anxiety and Depression Scale Anxiety subscale
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(HADS-A; Zigmond & Snaith, 1983). Exclusion criteria were severe depressive
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symptomatology and/or anxiety (more than one standard deviation above the population mean
within the last three months, and/or a high suicide risk as measured by the Web Screening
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Questionnaire (Donker, van Straten, Marks, & Cuijpers, 2009). After signing informed
consent forms, a total of 376 participants were randomly assigned to the Acceptance and
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Commitment Therapy (ACT; N = 250) and waiting list (N = 126) condition. In the present
study, only data from the participants in the ACT condition were used. The 9-week ACT
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intervention consisted of a self-help book on ACT (Bohlmeijer & Hulsbergen, 2008) and
weekly e-mail support. Participants were on average 42.5 years old (SD = 11.00). The
majority was female (n = 174; 69.6%), married (n = 107; 42.8%), and higher educated (n =
213; 85.2%).
Measures
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Measures were completed at baseline (T0, before the intervention), at post-intervention (T1,
nine weeks after baseline), and at follow-up (T2, five months after baseline). In the present
study, three measures were used. The CES-D (Radloff, 1977) and HADS-A (Zigmond &
Snaith, 1983) were used as measures of psychopathology. The CES-D was used to measure
depression symptoms. A higher total score (0 to 60) indicates more depression symptoms. A
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cut-off score of 16 can be used to classify people at risk for depressive disorder. The CES-D
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has been well-validated in Dutch samples (Bouma, Ranchor, Sanderman, & Sonderen, 1995).
The HADS-A was used to measure anxiety symptoms. A higher total score (0-14) indicates
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more anxiety symptoms. A cut-off score of 8 or higher can be used to classify people at risk
for anxiety disorder. The HADS-A has been well validated in Dutch samples (Spinhoven et
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al., 1997). The 14-item Mental Health Continuum-Short Form (MHC-SF) was used to
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measure positive mental health based on its three items on emotional well-being, five items on
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social well-being, and six items on psychological well-being. In this study, the total score for
the MHC was used. A higher mean total score (1 to 6) indicates a better positive mental health
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(Lamers et al., 2011). The MHC can be used to categorize people into either flourishing,
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languishing, or moderately mentally healthy. A flourisher exhibits high levels on at least one
out of three items of emotions well-being as well as high levels on at least six of eleven items
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he/she exhibits low levels on at least one item of emotional well-being as well as low levels
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Individuals who are neither languishing nor flourishing are termed moderately mentally
healthy. The MHC-SF has shown good psychometric properties in the Dutch population
Statistical analyses
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The relationship between positive mental health and depression symptoms in the intervention
analysis. We first computed the correlation of change in positive mental health from baseline
to follow-up with change in depression and anxiety symptoms from baseline to follow-up. In
the first regression analysis, the level of depression symptoms at follow-up (T2) was predicted
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by positive mental health. Firstly, the baseline level of depression symptoms was added to
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control for the auto-regression in depression symptoms between baseline and follow-up. In
the second step, baseline positive mental health (T0) and change in positive mental health
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during the intervention (T1 T0) were added to the analysis. We repeated this analysis with
anxiety symptoms. Similarly, in the first step of the next regression analysis, we controlled for
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the baseline levels of positive mental health (T0), and, in the second step, we added the
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baseline level of depression symptoms (T0) and change in depression symptoms (T1 T0) as
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predictors of positive mental health at follow-up (T2). Again, we repeated this analysis for
anxiety symptoms.
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In the last analysis, Reliable Change Indices (RCI) were computed to examine whether
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the change of depression symptoms and positive mental health in the participants were more
than could be expected from any measurement error (Jacobson & Truax, 1991). The RCI for
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positive mental health was calculated using the baseline (T0) standard deviation (SD = 0.79)
in the present study and mean test-retest reliability (r = .68) on the MHC-SF in the general
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population ( Lamers et al., 2011). The RCI was 1.23, so changes greater than 1.23 on the
MHC-SF were regarded as reliable (p < .05). The RCI for depression symptoms was 12.41
(SD = 6.60; test-retest reliability CES-D = .54) (Fledderus et al., 2012). The RCI for anxiety
was 2.37 (SD=2.58; test-retest reliability HADS-A=.89 (Spinhoven et al., 1997)). A cross-
classification of reliable change (RC) in depression symptoms and positive mental health was
made in the participants that improved during the ACT-intervention to investigate the
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percentage of participants who showed either a RC in both of the outcomes as well as the
percentage of participants who showed an improvement in one outcome but not in the other.
The latter would not be possible in the traditional model of mental health and, therefore,
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Results
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The change in positive mental health had a moderate relation to both the change in depression
symptoms (r=-.51; p<.001) and anxiety symptoms (r=-.36; p<.001). First, the effects of
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baseline positive mental health (T0) and change in positive mental health during the
intervention (T1-T0) on depression symptoms at follow-up (T2) were examined (see Table 1).
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Both a higher baseline level of positive mental health ( = -.32) and an increase in positive
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mental health during the intervention ( = -.38) were significantly related to less depression
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symptoms at follow-up, controlled for baseline levels of depression ( = .20). Positive mental
health, i.e. baseline and change, explained 15% of the variance in follow-up depression
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Second, the effect of depression on follow-up positive mental health was investigated.
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In addition to baseline positive mental health (T0), both the level of depression symptoms at
baseline (T0) and change in depression symptoms during the intervention (T1-T0) were added
as predictors of follow-up positive mental health (T2). Table 2 shows the results. A lower
baseline level of depression symptoms ( = -.22) and a decrease in depression during the
intervention ( = -.38) were significantly related to a higher positive mental health at follow-
up. Baseline levels of positive mental health explained 35% of the variance in follow-up
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positive mental health, indicated by the auto-regression coefficient of .60. On top of this,
depression, i.e. baseline and change, explained 10% of the variance in follow-up positive
mental health.
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Our last aim was to evaluate the cross-classification of Reliable Change in
depression/anxiety symptoms and positive mental health from baseline (T0) to follow-up
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(T2). Table 3 shows the results. Overall, 43.6% of participants improved on positive mental
health and/or depression symptoms from baseline to follow-up, and 69.6% improved on
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positive mental health and/or anxiety symptoms from baseline to follow-up. This indicated
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that for these participants, respectively, the change on positive mental health and depression
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or anxiety symptoms was more than could be expected on the basis of measurement error. Of
the participants that improved on positive mental health and/or depression symptoms, 35.9%
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improved on both positive mental health and depression symptoms and 64.1% improved on
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either one of the outcomes but not the other. Of the participants that improved on positive
mental health and/or anxiety symptoms, 27.6% improved on both positive mental health and
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anxiety symptoms and 72.4% improved on either one of the outcomes but not the other. This
means that two-thirds to three-quarters of participants that improved during the ACT-
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anxiety symptoms, which is in line with our hypothesis based on the dual-factor model of
mental health. *1
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As the Reliable Change Index can be a stringent criterion for change, we also analyzed cross-classifications of
change using absolute cut-offs for clinically meaningful change available for MHC (shift from either
languishing/moderate to flourishing ), CES-D (shift from CES-D 16 to < 16) and HADS-A (shift from
HADS-A > 8 to 8). The percentage of participants with clinically meaningful improvement was almost
identical to reported outcomes using RCI (67% of participants that showed improvement, improved on either
CES-D or MHC, while 75% improved on either HADS-A or MHC).
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Discussion
The dual-factor model of mental health states that positive mental health and psychopathology
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should be considered as two related yet distinct dimensions of mental health. In line with this
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model, mental health is best defined as a complete state of both the presence of positive
mental health and absence of psychopathology ( Keyes, 2005a). Although the dual-factor
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model has been well-established in cross-sectional studies (e.g., Westerhof & Keyes, 2010),
this is the first study to our knowledge that has investigated the applicability of the dual-factor
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model of mental health in an intervention study based on an effective psychotherapeutic
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intervention, namely, ACT (Fledderus et al., 2012).
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Our findings confirmed the dual-factor model and our hypotheses based on this model.
Baseline levels of positive mental health and changes in positive mental health during the
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anxiety symptoms at follow-up, and baseline levels of depression and anxiety symptoms and
changes in depression and anxiety symptoms moderately predicted the effectiveness of the
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intervention on positive mental health at follow-up. These findings indicate that there is a
moderate correlation between both effects, and that the effectiveness of the ACT intervention
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on depression and anxiety symptoms is related to the effectiveness on positive mental health.
Moreover, the effects on positive mental health do not fully explain the effects on depression
symptoms, and vice versa. The cross-classification of participants that showed a clinical
relevant change in positive mental health and depression symptoms confirms these results. Of
the people that improved during the ACT-intervention on one of the outcomes, two-thirds to
psychopathology. This is in line with our hypothesis based on the dual-factor model, and
would not have been possible from a traditional model, which defines positive mental health
unidimensional model of mental health had fitted the data better, the percentage would
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certainly not be the majority of participants, based on the assumption that expected
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intercorrelations between the latent constructs of positive mental health and psychopathology
and their operationalisations would be r = .75 or, expectedly, even higher. Hence, our findings
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comply better with a dual-factor model than a unidimensional model of mental health. As the
Reliable Change Index can be considered a stringent criterion for clinically meaningful
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change (Eisen, Ranganathan, Seal, & Spiro III, 2007), we performed additional analyses using
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absolute cut-offs for clinically meaningful change available for all three measures. The fact
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that the percentage of people shifting from either non-flourishing to flourishing, and/or from
at risk for depressive or anxiety disorder to not-at-risk for depressive or anxiety disorder, is
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highly identical to outcomes using the reliable change criterion replicates and strengthens our
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findings.
confirmation of the dual-factor model shows that an intervention that is effective in alleviating
psychopathology is not necessarily effective in enhancing positive mental health, and vice
should be measured. Moreover, an average effectiveness does not automatically mean that the
therapy is effective for all participants. While the therapy is on average effective (Fledderus et
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al., 2012), the intervention for a substantial group of participants is only effective on one
dimension, and, consequently, these participants do not reach complete mental health (Keyes,
2005a).
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awareness, recognizing and undertaking valued activities), this finding may be even more
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profound in psychotherapies that primarily aim at improving one of the mental health
dimensions instead of both, such as CBT. The group of people who gain from the therapy in
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terms of positive mental health or psychopathology deserve considerable attention in mental
health care, as the risk of relapse may be higher in this group. For example, several studies
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have shown that low well-being is a risk factor for developing psychopathology (Keyes, 2010;
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Lamers, Westerhof, Glas, & Bohlmeijer, 2015; Wood & Joseph, 2010) and positive aspects
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such as positive emotions can reduce recurrent relapses in depression (Santos et al., 2013).
For people experiencing low well-being after therapy, positive interventions such as Well-
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being Therapy (Fava & Ruini, 2003) can be offered and integrated into clinical practice
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(Duckworth, Steen, & Seligman, 2005; Rashid, 2009; Wood & Tarrier, 2010). Therapies
focusing on well-being may also be more appealing and less stigmatizing, which is a vital
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concern as the patients resistance towards therapy is related to their non-adherence (Zickgraf
et al., 2015). ACT in itself might be offered to individuals who have been resistant to
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treatment using more traditional psychotherapies (Clarke, Kingston, James, Bolderston, &
Remington, 2014; Gloster et al., 2015), or who did not increase in positive mental health in
previous treatment. Future research is necessary to gain insight into this group of people who
do not fully benefit on both mental health dimensions from intervention. This might be done,
for example, by applying a N-of-1 design that enables researchers to intensively follow the
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processes of change of single individuals during interventions (Forman et al., 2012; Villatte et
al., 2016).
Some limitations of this study need to be considered. In the trial we reported upon,
individuals with severe depression or anxiety symptoms were excluded from participation.
Our findings are therefore only generalizable to mild to moderately depressed and anxious
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individuals. It might be that the relationship between psychopathology and positive mental
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health is different for populations experience more severe symptoms, or other forms, of
psychopathology and/or studies with different samples will results in differential intervention
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effects. For example, we examined the effects of the same self-help ACT intervention in a
sample of chronic pain patients experiencing high interference of pain complaints with daily
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living. This resulted in significant improvement in depressive symptoms, but not positive
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mental health (Trompetter, Bohlmeijer, Veehof, & Schreurs, 2015). Furthermore, given the
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self-help nature of the treatment, it is very possible that the results regarding positive mental
health are very different than would be the case in a set of individuals who are, possibly, less
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motivated or less confident in their ability to manage their treatment through self-help means.
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Lastly, ACT aims to both enhance positive mental health and alleviate vulnerabilities related
to psychopathological symptoms. More research on the dual-factor model and the interplay
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interventions that aim to primarily improve just one of the two mental health dimensions.
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In conclusion, our findings confirm that mental health is best defined as a complete
state of both the presence of positive mental health and absence of psychopathology.
Although a moderate correlation between the effects on positive mental health and
psychopathology exists, interventions that are effective in enhancing positive mental health
are not necessarily effective in alleviating psychopathology, and vice versa. Our findings
Acknowledgements
The study was funded by the Netherlands Foundation for Mental Health (Fonds Psychische
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Gezondheid).
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Table 1.
The Effects of Baseline and Change in Positive Mental Health on Follow-up Depression/Anxiety Symptoms, Beyond the Effects of
Baseline Depression/Anxiety Symptoms (N=250)
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T2 Depression symptoms T2 Anxiety symptoms
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Step 1 Step 2 Adjusted R R Step 1 Step 2 Adjusted R R
Beta Beta Beta Beta
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Step 1
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Step 2
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T0 Depression/anxiety symptoms .20*** .25***
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T0 Positive Mental Health -.32*** -.27***
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T0-T1 Positive Mental Health -.38*** .22 .15 -.37*** .21 .12
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Note: T0 = baseline, T0-T1 = change during ACT-intervention, T2 = follow-up; * p < .05, ** p < .01, ***
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Table 2.
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Step 1 Step 2 Adjusted R R
Beta Beta
Independent variable: Depression
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Step 1
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T0 Positive Mental Health .60*** . .35
Step 2
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T0 Positive Mental Health .52***
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T0 Depression symptoms -.22***
Step 1 .
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Step 2
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Note: T0 = baseline, T0-T1 = change during ACT-intervention, T2 = follow-up; * p < .05, ** p < .01, ***
p < .001
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Table 3a.
Cross-Classification of participants showing Reliable Change in Psychological Symptoms and/or Positive Mental Health from
Baseline to Follow-up
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Reliable change in
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Participants Psychological Positive Mental Psychological
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Mental Health
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Positive Mental Health (MHC) x n n (%) n (%) n (%)
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..Depression Symptoms (CES-D) 109 48 (44.0) 22 (20.1) 39 (35.9)
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..Anxiety Symptoms (HADS-A) 174 113 (64.9) 13 (7.5) 48 (27.6)
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Note. RC = Reliable Change.
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Highlights
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positive mental health, and not on both.
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Both psychopathology and positive mental health need to systematically evaluated in
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An average effectiveness of a therapy does not automatically mean that the therapy is
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