Discussion
guilt, psychological inflexibility, anxiety, reductions in stress, grief,, reductions in stress and, dementia, depressive, depressed, depressive symptoms, gradual loss of selfhood in
SECONDARY, RECRUITMENT
As a small-scale pilot RCT, the present study was not adequately powered, but found
promising results. Compared to the control group provided with psychoeducation materials
only, the ACT group supplemented with psychoeducation materials showed a significantly
larger reduction in grief from pretest to posttest, with a medium effect size. Such
statistically significant reductions in grief in the ACT group compared to the control group
are due to the ACT group’s statistically significant reduction in grief at posttest compared
to the pretest (Studies found grief in family caregivers was greatest when their relatives had moderate to
severe stages of dementia, and that their grief can increase over time due to gradual
deterioration of dementia and gradual loss of selfhood in PLWD (In addition, grief was measured using the MM-CGI-BF, which was specifically developed to
assess grief in caregivers of PLWD and showed good reliability and validity (In summary, findings of grief in the present study can be explained by the participants’
characteristics (i.e. high levels of grief in both groups as caregivers of relatives of
people with moderate to severe stages of dementia), the intervention component (i.e. ACT
addressing grief vs. psychoeducation not particularly addressing grief), and the use of a
reliable valid grief measure specifically developed for caregivers of PLWD (the MM-CGI-BF).
According to recent systematic reviews regarding ACT for family caregivers of people with
chronic conditions (The present study found small effects of ACT in anxiety at posttest, grief at 1-month F/U,
psychological QoL at posttest, psychological flexibility at 1-month F/U, and engagement in
meaningful activities at posttest and 1-month F/U compared to the control group, but
statistically significant differences between groups were not found in these outcomes,
possibly due to the small sample size for group comparisons. These findings are supported to
some extent by findings of previous full-scale RCTs in Spain, which found medium effects of
eight weekly individual in-person ACT sessions on decreasing anxiety and increasing
participation in leisure activities at posttest compared to control groups provided with a
2-hour psychoeducation session on dementia (In particular, there was no statistically significant between-group difference in
depressive symptoms at posttest and 1-month F/U compared to the pretest. These results could
be because the present small-scale RCT was not powered enough to show between-group
differences, and the study involved family caregivers who had at least mild symptoms of
psychological distress (i.e. at least mild depressive symptoms, anxiety, or stress) rather
than focusing on depressed caregivers. When participants with at least mild depressive
symptoms were included for the additional secondary analyses only (For the within-group comparisons across time, the ACT group showed statistically
significant reductions in stress, grief, guilt, and psychological inflexibility and
improvements in QoL and self-compassion, which are supported to some extent by previous ACT
studies for caregivers of PLWD (The control group provided with psychoeducation materials showed statistically significant
reductions in stress and guilt and improvements in self-compassion at posttest and 1-month
F/U compared to pretest, which indicates benefits from the evidence-based psychoeducation
materials (Several limitations should be considered when interpreting the findings of the present
study. Because it was a small-scale pilot RCT, its findings should be confirmed by a future
full-scale RCT with adequate power to detect the efficacy of ACT. The present study involved
a convenience sampling method, and all participants were female. About 67% of primary family
caregivers of PLWD in the USA are female (Although the present study did not screen caregivers who were experiencing high levels of
grief, the participants’ pretest scores in grief were quite high, reflecting the high
prevalence of experiencing grief while caring for PLWD (This pilot study was the first RCT that investigated ACT for family caregivers of PLWD in
the USA and that involved videoconferencing ACT for these caregivers in the world.
Forty-three potential participants contacted the research team with interest in the study
participation over the 7-month recruitment period. This number is promising considering that
our research team did not have the access to the population through clinics, and recruitment
relied on sharing our study invitation letter in the community by e-mail only. All
participants in the ACT group completed all eight ACT sessions, and only one person in the
control group dropped from the study after the group assignment. Although this was a small
scale study that was not adequately powered, findings were promising, including a
significantly larger reduction in grief at posttest in the ACT group with a medium effect
size, compared to the control group. Future full-scale RCTs are needed to assess the
efficacy of ACT for family caregivers of PLWD.