College students are markedly at risk for depression. In a recent survey of over 50,000 students in the United States, 22 % reported a lifetime diagnosis of depression (American College Health Association, 2019). Additionally, research suggests that students have higher depression than the general population (Beiter et al., 2015), and about a quarter of students meet criteria for suicide risk (ACHA, 2019). Traditional mental health interventions for students (i.e., in-person counseling) struggle to keep up with the demand for services on college campuses. A recent study indicated an average of one counselor position per 1064 students, a discrepancy that often forces providers to place students on a waitlist or limit the number of therapy sessions they can receive (Association for University and College Counseling Center Directors, 2019).
To promote student wellbeing in an efficient manner, self-guided interventions for depression can be used, such as cognitive behavioral therapies (CBTs), which is a group of well-established treatments for depression that can be delivered in online formats (Karyotaki et al., 2021). However, a persistent issue in online CBTs is a high rate of dropout, with up to 74 % of users not fully completing treatment (Karyotaki et al., 2015; Richards and Richardson, 2012). An understudied approach to promoting engagement with online CBTs is allowing clients to choose the specific intervention they use.
Within the broader family of CBTs are in fact multiple evidence-based approaches to choose from. Traditional CBT (tCBT) emphasizes cognitive restructuring along with behavioral activation techniques. Another popular approach is acceptance and commitment therapy (ACT), which focuses on mindfulness and acceptance practices in addition to behavioral activation. ACT and tCBT approach the treatment of depression in distinct ways (A-Tjak et al., 2021). tCBT focuses on identifying and restructuring thoughts that contribute to cycles of depressed feelings and associated behaviors such as social withdrawal. Conversely, treatment using ACT brings awareness to the role of entanglement with depressive thoughts and feelings while teaching skills to engage in meaningful activities while still experiencing them. While both self-help ACT (Sierra et al., 2018) and tCBT (Webb et al., 2017) have shown effectiveness in treating depression, there is a lack of research comparing these approaches for college students specifically or examining the effects of allowing clients to choose between these two distinct approaches for their treatment. Prior research comparing ACT and tCBT suggest these approaches have equivalent positive effects on depression (Twohig and Levin, 2017), raising the key question of whether it's more important for clients to select a modality they personally prefer and are likely to commit to.
In a meta-analysis of 53 in-person therapy trials, clients receiving their choice of therapy had both lower rates of treatment dropout and better overall outcomes (Swift et al., 2018). In a recent study testing a tCBT intervention compared to yoga and stress education for generalized anxiety, clients were asked about their treatment preference prior to randomization but did not actually get to select their intervention. The effect of treatment preference differed by modality, with participants who did not receive their preference showing better outcomes if they were randomized to CBT, and participants who both preferred and received yoga more likely to dropout of treatment (Szuhany et al., 2022). Overall, there is a lack of research in which a choice of intervention is explicitly offered and compared to a randomized condition, and self-help treatments are especially understudied in regards to client choice effects.
The issue of client choice is also a practical one related to how self-help treatments are disseminated on college campuses. Universities may debate which programs are most worthwhile to give their students, or whether the more important factor is to offer a variety of choices. Allowing clients a choice of treatment is a common clinical perspective, but one rarely tested empirically. Clarifying the role of this overlooked component of self-help implementation (i.e., whether to assign a specific resource or give a choice between resources), such as whether it may increase adherence and outcomes, would help in delivering the most effective care to college students and other populations with a high need for support but limited resources.
The present study tested the feasibility, acceptability, and efficacy of ACT and tCBT self-help books for depression, accessed through the university's online library, in a randomized trial with college students. Specifically, we examined the role of client choice on treatment adherence and clinical outcomes by including an experimental condition in which participants were allowed to choose their treatment, relative to conditions where either ACT or tCBT was randomly assigned. We predicted that students who had a choice of intervention would show greater adherence than those who were randomized, as well as greater satisfaction with their book. Based on prior research comparing ACT and tCBT for depression (Twohig and Levin, 2017), we predicted that we would not observe significant differences on clinical outcomes based on the intervention itself (ACT or tCBT), but rather depression (primary outcome) and anxiety symptoms (secondary outcome) would improve over time in both conditions. We predicted, however, that having a choice of book would lead to greater improvements in depression and anxiety for both interventions compared to randomized students.
