Acceptance and commitment therapy for enhancing mental health in military personnel: A comprehensive review and meta-analysis

Table 1 Information about the literature that met the inclusion criteria

Included literature	Country/region	Research design	Sample size (example, experimental group/control group)	Age (years, experimental group/control group)	Intervene object	Research content	Experimental group intervention	Control group Intervention measure	Main evaluation index	Main intervention effect
Reyes et al[24]	United States	Quasi-experiment	23	31.22 ± 5.53	College veteran	PTSD	The smart phone ACT intervention (listen to the assigned audio at least once a day, watch the assigned video once a week (for 4 weeks) and write about the viewing experience) was assessed at baseline, weekend 2, and weekend 4		PCL-5; AAQ-II; MAAS; CD-RISC	Resilience, mindfulness, mental activity and symptoms of traumatic stress disorder were all improved
Kelly et al[31]	United States	RCT	21/19	54.9 ± 10.7/56.8 ± 13.3	Veteran	PTSD	Twelve weekly 50min individual counseling ACT sessions, each with a specific topic, were assessed at baseline, at the end of treatment (12 weeks), and at 3 months	PCT therapy (person-centered therapy) for 50 minutes 12 times a week	MAAS; AAQ-II; PCL-5; CSQ-8; VLQ; SAS-SR; MOS-SSS; Q-LES-Q-SF	Improving the quality of social relations and participation in social activities can effectively improve the symptoms of traumatic stress disorder
Ramirez et al[28]	United States	Quasi-experiment	311	37.6 ± 8.06	Active serviceman	PTSD	Act-led outpatient treatment program for trauma: 6 weeks, 12 hours of group therapy per week, 2 individual sessions of 60 to 90 minutes		PCL-5; AAQ-II; VLQ; PHQ-9; GAD; ISI; CFQ; BASIS-24	Improved mental activity, cognitive dissociation degree, traumatic stress disorder symptoms were effectively improved, but did not improve sleep
Reyes et al[32]	United States	Quasi-experiment	23	31.22 ± 5.53	College veteran	PTSD	The smartphone ACT intervention was assessed over a 4-week period (including audio-guided mindfulness meditation and video lessons based on ACT principles, listening to the assigned audio at least once a day, watching the assigned video once a week and writing about the viewing experience) at baseline, weekend 2, and weekend 4		CD-RISC; PCL-5; AAQ-II; MASS; RRS; ISS	Improve mindfulness, improve traumatic stress disorder, reduce experiential avoidance, and reduce rumination
Gobin et al[34]	United States	RCT	54/50	Male: 34.7 ± 8.9; Female: 33.8 ± 7.3	Veteran	PTSD (emphasis on the difference between male and female effects)	Conduct 12 one-hour individual sessions using the ACT manual developed by a professional therapist	PCT Therapy (Human-Centered Therapy)	BSI-18; SF-12; PCL-M	There was a significant advantage in the treatment effect of ACT in women, but no difference in the treatment effect in men
Meyer et al[35]	United States	Quasi-experiment	43	45.26 ± 8.6	Veteran	PTSD, alcohol use disorder	Once a week for a total of 12 ACT individual outpatient treatments		PCL-5; AAQ-II; AUDIT; DAST;PHQ-9; QOL-BREF	Improved traumatic stress disorder, reduced depressive symptoms and suicidal ideation, and reduced alcohol dependence; Quality of life improved
Jacobs et al[36]	United States	Quasi-experiment	12	68 ± 6.59	Senior veterans over 60 years old	PTSD	12 ACT courses		GDS-15; GAD-7; AAQ-II	Anxiety and psychoactivity were improved, and depressive symptoms were significantly improved
Lang et al[37]	United States	RCT	80/80	65 ± 81.83/63 ± 78.8	Veteran	PTSD/anxiety/depression	Structured treatment according to the ACT manual, 11-hour treatment per week for a total of 12 times, at baseline, in the middle of treatment, after treatment, 3 months, 6 months, and 9 months	A total of 12 PCT treatments were performed once a week for 1 hour	PCL-MBSI-18; AUDIT; SDS; ISIAAQ-II; CSQ-8; PHQ-9; QOL-BREF	There was no difference between mental activity and anxiety and depression. There was a statistically significant difference in insomnia improvement in the ACT group
Kelly et al[38]	United States	Quasi-experiment	19	56 ± 7	Veteran	PTSD combined with tobacco addiction	ACT treatment for post-traumatic stress disorder combined with tobacco addiction (ACT-PT), 9 times a week for 50 minutes each time, the fifth time to encourage smoking cessation, plus 8 weeks of nicotine patch therapy, measured at baseline, end of treatment, 1 month, and 3 months		PCL-5; FTND; Number of cigarettes smoked; QSU; CSQ-8	The symptoms of traumatic stress disorder were improved, the impulse to smoke was reduced, and the amount of smoking was significantly reduced
Dindo et al[39]	United States	RCT	27/12	37.7 ± 6.3/34.7 ± 5.8	Veteran	Chronic pain	Each of the 1-day workshops included 4-hour ACT intervention, 2-hour behavior change training, and follow-up after 3 months	Routine psychiatric care	PCL-C; AAQ-II; BPI; DASS-21	Improvement: anxiety depression, mental activity; Pain improvement was less than in the control group
Herbert et al[40]	United States	Quasi-experiment	126	51.88 ± 13.14	Veteran	Chronic pain	Face-to-face or video teleconferencing, 60 minutes ACT therapy per session 8 times per week		PCL-C; BPI; CPAQ; PASS-20 PHQ-9	The improvement of pain and depression with PTSD was better, and the improvement of pain without PTSD was not significant
Udell et al[41]	United States	Quasi-experiment	242/310	No statistical difference	Seaman	Pain	An improved pain treatment program based on ACT conceptual skills, 3 times per week for 1.5 hours per session, 6 sessions for 2 weeks. And receive standard care	Standard treatment services (physical, psychological, medical)	AAQ-II; PRS; GAD-7	Effective pain relief; The psychoactive effect of anxiety and depression is small
Huddleston et al[42]	United States	Mixed study	25		Veteran	Depression and anxiety combined with migraine	A five-day, 5-hour workshop that included ACT and migraine education was followed for 3 months		AAQ-II; HRSA; IDAS; CPAQ	Effectively improve migraine, anxiety depression, mental activity
Dindo et al[43]	United States	RCT	40/35	62.2 ± 10.1/63.0 ± 10.7	Veteran	Pain associated with anxiety and depression after orthopedic surgery	ACT (5-hour workshop led by 2 psychologists, issue of ACT manual) + usual treatment, 3 months follow-up	Routine treatment: analgesia, education before and after operation	Stop pain time; Duration of opiate withdrawal; CPAQ; CPVI	The duration of pain cessation and opioid use decreased, and pain acceptance increased
Herbert et al[44]	United States	RCT	64/65		Veteran	Chronic pain (difference between remote and face-to-face intervention)	Telemedicine: 8-week ACT Manual Chronic Pain Intervention with 3-month and 6-month follow-up	Face to face ACT	BPI; PASS-20; CPAQ; PHQ-9; PSQI	Both groups had good effects on pain and anxiety. There was no significant effect on improving sleep
Cosio[29]	United States	Quasi-experiment	50/46	No statistical difference	Veteran	Chronic pain	Twelve one-hour sessions using the ACT manual over a 10-week period	Cognitive Behavioral therapy is administered once or twice a week for 12 sessions	BPI; CPCI; BSI-18	There was no significant difference in pain improvement between the two groups
Cosio and Schafer[45]	United States	Quasi-experiment	50	29-79	Veteran	Chronic pain	Twelve pain summation management sessions with ACT manual therapy, each one hour, for 10 weeks		BPI; CPCI; BSI-18	Effective pain relief
Grau et al[46]	United States	Quasi-experiment	831	Mean age 49.1	Veteran	Depression	And received at least two ACT-D (Acceptance and Commitment Therapy for Depression) treatments		AAQ-II; PHQ-9	Depression improved, and depression with PTSD was less effective
Barnes et al[30]	United States	RCT	35/35	The median was 42/49	Veteran	Suicide prevention	ACT (3 to 6 independent treatments) + conventional treatment,1 month, 3 months follow-up	Conventional treatment: Psychotropic drug therapy and individual and group psychotherapy; And all mental health services available after discharge	CSSRS; CSQ-8; AAQ-II	Suicide intention decreased and intervention acceptance was good
Kumpula et al[48]	United States	Quasi-experiment	665/844/271	51.8/51.9/55.7	Veteran	Suicide prevention	After 12 courses of ACT-D, BDI-II evaluation was performed before, during and at the end of treatment	Cognitive behavioral therap; Interpersonal Therapy	BDI-II	ACT was less effective at reducing suicidal intentions than the other two treatments
Walser(et al[49]	United States	Quasi-experiment	981	50.5	Veteran	Suicide prevention	At least 10 sessions of ACT-D therapy for 6 months with weekly 90 minutes phone consultations		BDI-II; AAQ-II; FFMQ	Suicidal intention decreased, mindfulness increased
Karlin et al[50]	United States	Quasi-experiment	731	51 ± 12.4	Veteran	Depression	ACT-D: Part I a 3-day workshop personal experience; The second part was a weekly telephone consultation for 6 months		BDI-II WHOQOL-BREF	Depression and quality of life were significantly improved in the older group (> 65) and the younger group
Afari et al[51]	United States	RCT	45/43	56 ± 10.3/58.1 ± 9.5	Male veteran	Lose weight	Four weekly 2-hour session ACT intervention sessions measuring baseline, 3-month, 6-month data	Behavioral weight loss intervention	Weight; BES; AAQ-W	The two interventions had the same effect on weight loss, and the effect of ACT on overeating control was weaker than behavioral weight loss
Heffner et al[52]	United States	RCT	25/24	47.9 ± 13.3/54.8 ± 16.1	Veteran	Give up smoking	Web-based ACT program: Vet Flexiquit, a 6-session online course and a 6-week SMS program	Smoke-free Veterans Program: Smoke free VET	Smoking quantity; FTND	There was no difference between the two groups, and combined treatment was recommended
Dindo et al[53]	United States	Mixed study	31		Rural veteran	Restoration of social function	A 1-day (5-hour) community ACT group workshop +5 thematic qualitative interviews were assessed 1 month and 3 months later		PCL-5; AAQ-II; OQ-45; M2C-Q	Pain, post-traumatic stress disorder symptoms, social inclusion, and psychoactivity were improved
Harvey et al[21]	New Zeeland	Quasi-experiment	69/31		Active serviceman	Alcohol use disorder	A 1-week ACT short course, intervention day 1, assessment 1 month later	Non-intervention population included in the study	AUDIT; BPAQ; PSS-10; GAD-7	Emotional management, aggression, alcohol consumption, anxiety, stress, etc., were effectively improved

PCL-5: Post-traumatic Stress Disorder Checklist for DSM-5; PCL-C: Post-traumatic Stress Disorder Checklist – Civilian Version; PCL-M: Military version of post-traumatic Stress Disorder Checklist; PTSD: Post-traumatic stress disorder; RCTs: Randomized controlled trials; AAQ-II: Admission Action Questionnaire-II; AAQ-W: Weight Related Acceptance and Behavior Questionnaire; CFQ: Cognitive Integration Questionnaire; MAAS: The Mindful Attention Awareness Scale; CD-RISC: Connor-Davidson Resilience scale; RRS: Ruminative Response Scale; FFMQ: Five Factor Mindfulness Scale; PHQ-9: Patient Health Questionnaire 9; GDS-15: Geriatric Depression Assessment Scale; SDS: Self-rating Depression Scale; BDI-II: Baker Depression Scale; HRSA: Hamilton Depression Scale; GAD-7: Generalized self-rating Anxiety Scale; DASS-21: Depression-anxiety-stress Scale; IDAS: Depression and Anxiety Symptom Scale; BASIS-24: Behavior and Symptom Recognition Scale; BSI-18: Brief symptom inventory-18; CSSRS: Columbia Suicide Severity Rating Scale; ISI: Insomnia Severity Index Scale; PSQI: Pittsburgh Sleep Quality Index; CPAQ: Simple Chronic Pain Response Questionnaire; PASS-20: 20-item Pain and Anxiety Symptom Scale; PRS: Pain Resilience Scale; BPI: Concise Pain Assessment Scale; CPAQ-8: Simple Chronic Pain Response Questionnaire; CPVI: Chronic Pain Values Survey; CPCI: Chronic Pain Coping Scale; CSQ-8: Client Satisfaction Questionnaire-8; ISS: Intervention Satisfaction Scale; VLQ: Personal Value Scale of Daily Life; SAS-SR: Social Self-Assessment Scale; MOS-SSS: Social Support Scale; Q-LES-Q-SF: Brief Happiness and Quality of Life Satisfaction Questionnaire; SF-12: 12-Item Short Form Health Survey; WHOQOL-BREF: Quality of Life Assessment Brief Form; QSU: Smoking Addiction Questionnaire; FTND: Nicotine dependence Test; AUDIT: Alcohol Consumption Disorders Screening Scale; DAST: 20 Drug Abuse Screening Test; BES: Binge Eating Scale; BPAQ: Buss-Perry Aggression Questionnaire; PSS-10: Stress Perception Scale; M2C-Q: Reintegration Questionnaire; OQ-45: Psychological Counseling Effects Questionnaire-45.

Table 2 Sensitivity analysis

Deleted document	Pooled effect size of remaining literature (Pooled MD)	95%CI for the remaining literature
Kelly et al[31]	-5.0595	-6.7125 to -3.4065
Ramirez et al[28]	-4.1187	-5.3140 to -2.9234
Meyer et al[35]	-5.1322	-6.7874 to -3.4769
Dindo et al[39]	-5.1192	-7.0131 to -3.2253
Udell et al[41]	-5.5820	-7.0866 to -4.0773
Huddleston et al[42]	-4.9395	-6.2009 to -3.1573
Barnes et al[30]	-4.6791	-6.2009 to -3.1573
Dindo et al[53]	-5.1108	-6.7211 to -3.5005