Accepted Manuscript

Both positive mental health and psychopathology should be monitored in

psychotherapy: Confirmation for the dual-factor model in acceptance and commitment
therapy

H.R. Trompetter, S.M.A. Lamers, G.J. Westerhof, M. Fledderus, E.T. Bohlmeijer

PII: S0005-7967(17)30018-9
DOI: 10.1016/j.brat.2017.01.008
Reference: BRT 3085

To appear in: Behaviour Research and Therapy

Received Date: 20 October 2015

Revised Date: 9 January 2017
Accepted Date: 17 January 2017

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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ACCEPTED MANUSCRIPT

Both positive mental health and psychopathology should be monitored in psychotherapy:

Confirmation for the dual-factor model in Acceptance and Commitment Therapy

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

Running head: Dual-factor model ACT

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For submission in: Behaviour Research and Therapy

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Corresponding author:
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Dr. Hester Trompetter

Centre for eHealth and Wellbeing Research,

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Department of Psychology, Health and Technology,

University of Twente,
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P.O. Box 217

7500 AE Enschede

Netherlands

P: +31 53 489 3985

h.r.trompetter@utwente.nl
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Abstract

The dual-factor model of mental health suggests that enhancing positive mental health and

alleviating psychopathology do not automatically go hand-in-hand. This study investigates the

relationship between the effectiveness on depression/anxiety symptoms and positive mental

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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

and suggest that it is important to systematically implement measures of both

psychopathology and positive mental health in mental health care and therapy evaluations.

Keywords: dual-factor model, positive mental health, depression, anxiety, Acceptance and

Commitment Therapy, psychotherapy, monitoring

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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

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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and availability of psychotherapeutic interventions that explicitly aim to increase participants

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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These interventions complement the more traditional problem-oriented psychotherapies, such

as Cognitive Behavioural Therapy (CBT), that mainly aim at alleviating psychopathology

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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

enhance general well-being is often secondary to a focus on reducing psychopathology, or it

might be implicitly assumed that a reduction in psychopathology will automatically lead to

gains in well-being.
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The dual-factor model of mental health suggests that enhancing positive mental health

and alleviating psychopathology do not automatically go hand-in-hand (Keyes, 2005a). A

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

confirmed in studies on psychotherapeutic interventions. Especially in treatment, the dual-

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factor model might be of significance, because it could be that a therapy that is effective in

enhancing positive mental health may not necessarily be effective in alleviating

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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

population with both improved well-being and psychopathology (Slade, 2010).

Several meta-analyses have shown that a broad range of psychological interventions

such as positive psychological interventions (Bolier et al., 2013; Lyubomirsky, King, &

Diener, 2005), existential therapies (Vos, Craig, & Cooper, 2015), and CBT (Spek et al.,

2007) are effective in increasing positive mental as well as in alleviating psychopathological

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symptoms. However to our knowledge, studies on the effectiveness of psychotherapy have

only investigated effects on psychopathology and positive mental health independently. To

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

particular, we selected to use Acceptance and Commitment Therapy (ACT; Bohlmeijer,

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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

that create a context for experiential avoidance of these experiences, an important

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vulnerability for psychopathology (Biglan, Hayes, & Pistorello, 2008). Experiential avoidance

is reduced in ACT to enable reinforcement of several psychological resources (e.g.

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

effectiveness of the intervention on depression and anxiety symptoms at follow-up. In

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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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intervention, while others would improve on either positive mental health or

psychopathology. More specifically, we expected to find a moderate interrelationship

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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

expected intercorrelations between latent constructs and measures .75). Consequently, a

majority of people improving on either positive mental health or depression/anxiety

symptoms, but not the other, would comply with the dual-factor model of mental health.
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Method

Participants and procedure

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

on the CES-D and HADS-A), receiving psychological or psychopharmacological treatment

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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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of positive psychological and social functioning. An individual is considered languishing if

he/she exhibits low levels on at least one item of emotional well-being as well as low levels
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on at least six of eleven measures of positive psychological and social functioning.

Individuals who are neither languishing nor flourishing are termed moderately mentally

healthy. The MHC-SF has shown good psychometric properties in the Dutch population

(Lamers, Glas, Westerhof, & Bohlmeijer, 2012; Lamers et al., 2011).

Statistical analyses
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The relationship between positive mental health and depression symptoms in the intervention

was analysed by correlation coefficients, regression analyses and a cross-classification

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,

would indicate the presence of a dual-factor model.

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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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symptoms, on top of the 7% that was explained by baseline levels of depression.

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*** Insert Table 1***

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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.

*** Insert Table 2***

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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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intervention, only showed improvement on either positive mental health or depressive or

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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*** Insert Table 3***

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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intervention moderately predicted the effectiveness of the intervention on depression and

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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

three-quarters improved on either positive mental health or depressive/anxiety symptoms

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while only a quarter to one-third of people improved on both positive mental health and

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

and psychopathology as mere opposites of the same continuum. If such a traditional,

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.

Consequently, these findings have important implications regarding the effectiveness

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of psychotherapeutic interventions, which are often evaluated by investigating only

psychopathology instead of both psychopathology and positive mental health. The

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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

versa. For two-third to three-quarters of the participants improvements do not go hand-in-

hand. To fully evaluate the effectiveness of a psychotherapeutic intervention, both dimensions

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).

Considering that ACT aims to improve vulnerabilities for psychopathology

(experiential avoidance) as well as resources for flourishing (acceptance, present-moment-

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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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between the effectiveness on positive mental health and psychopathology is needed in

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

suggest that it is important to systematically implement measurements of both

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psychopathology and positive mental health in order to take better informed decisions about

the continuation and focus of patients in mental health treatment.

Acknowledgements

The study was funded by the Netherlands Foundation for Mental Health (Fonds Psychische

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Gezondheid).

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Barry, M. M. (2009). Addressing the Determinants of Positive Mental Health: Concepts ,
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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

T0 Depression/anxiety symptoms .28*** .07 .30*** .09

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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.

The Effects of Baseline and Change in Depression/Anxiety Symptoms on Follow-up Positive

Mental Health, Beyond the Effects of Baseline Positive Mental Health (N=250)
T2 Positive Mental Health

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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***

T0-T1 Depression symptoms -.38*** .45 .10

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Independent variable: Anxiety

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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 .55***

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T0 Anxiety symptoms -.20***

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T0-T1 Anxiety symptoms -.32*** .44 .09

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

showing RC Symptoms only Health only Symptoms and Positive

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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

The effectiveness of ACT on depression and anxiety symptoms is moderately related to

the effectiveness on positive mental health, and vice versa.

A large majority of participants improved on either depression/anxiety symptoms or

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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

clinical research and interventions.

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An average effectiveness of a therapy does not automatically mean that the therapy is

effective for all patients and on all outcomes.

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