An internet-delivered acceptance and commitment therapy program for anxious affect, depression, and wellbeing: A randomized, parallel, two-group, waitlist-controlled trial in a Middle Eastern sample of college students

The study addresses the need for accessible, evidence-based interventions for anxiety and depression among college students, particularly in Middle Eastern settings where stigma and limited resources hinder help-seeking. The research question asks whether a brief, self-directed, internet-delivered ACT program is feasible to implement and efficacious in reducing anxiety and depression and improving wellbeing among Arab college students in the Middle East. The authors hypothesized successful enrollment (feasibility), greater reductions in generalized and social anxiety, depression, and symptom-related disability, and improvements in wellbeing for the intervention versus waitlist group. They further anticipated reductions in experiential avoidance and increases in valued action as secondary mechanisms of change.

The paper reviews evidence that college students experience high prevalence of anxiety and depression with adverse academic impacts. Barriers to care include counselor shortages, long waitlists, financial constraints, and stigma, especially in Middle Eastern contexts. Internet-delivered interventions, including CBT and acceptance/mindfulness-based approaches, have demonstrated effectiveness for anxiety and depression in general and college populations. Meta-analyses suggest internet-delivered therapies with support can be comparable to face-to-face treatment while requiring less therapist time. Acceptance and commitment therapy (ACT) has shown efficacy across diverse groups, including university students, and internet-delivered programs based on ACT and mindfulness have yielded reductions in distress and improvements in wellbeing. The literature highlights the need to evaluate culturally acceptable, scalable, self-directed programs for Middle Eastern college students.

Design: Two-group, parallel, randomized, waitlist-controlled trial conducted at two university campuses (United Arab Emirates and Sultanate of Oman), both high-income Middle Eastern countries. Participants: College students (≥18 years) enrolled at the institutions; elevated anxiety or depression was not required. Recruitment: Random selection of 15 undergraduate and postgraduate classes across faculties. A researcher visited classes during Spring 2022/2023 (data collection 03/20/2023–06/28/2023). Students scanned a QR code linking to the baseline survey and provided informed consent. Sampling frame ≈560; exclusions: under 18 (n=2), consent not provided (n=429), resulting in n=129 enrolled. Ethics: Written informed consent obtained; approved by the Social Sciences Research Ethics Committee, United Arab Emirates University (ERSC_2022_1866); conducted per Declaration of Helsinki. Randomization and masking: Participants informed they would receive the program immediately or after 4 weeks. Random allocation (1:1) via minimization controlling for demographics to intervention (n=64) or waitlist (n=65), executed by the PI. Intervention group received Module 1 within 7 days of baseline; control group received an email indicating delayed access. After post-intervention assessment (week 5), control participants received full program access; no follow-up assessments were conducted. Intervention: Self-directed, four-module ACT-based program delivered via the university online platform. Weekly access to narrated PowerPoint slides with text, images, and experiential activities; one module per week for 4 weeks; post-assessment in week 5. Designed by Masters-level clinical psychology trainees under supervision of a senior clinical psychologist (ZV). Outcomes and instruments: Assessed at baseline and post-intervention. - Generalized Anxiety Disorder-7 (GAD-7); α=.78. - Social Interaction Anxiety Scale (SIAS); α=.90. - Depression (DASS-21 depression subscale); α=.83. - Wellbeing (Short Warwick-Edinburgh Mental Well-Being Scale, SWEMWBS); α=.75. - Symptom-related disability (Sheehan Disability Scale, SDS); α=.80. - Experiential avoidance/psychological inflexibility (AAQ-II); α=.89. - Valued Living (Valued Living Questionnaire, VLQ); α=.92. Sample characteristics: n=129; UAE n=82 (63.6%), Oman n=47 (36.4%); female n=90 (69.8%); age 18–27 (M=20.69, SD=1.53). Baseline group comparability: No significant baseline differences across primary outcomes (all p>.05). Power and statistical analysis: A priori power analysis (G*Power): for f=.4, α=.05, required n=84 for power=.95. Missing data: Mean replacement for baseline item-level missingness; multiple imputation for missing post-intervention data of untraceable participants (n=12; attrition 9.3%); intention-to-treat used (n=129). Analysis: Descriptive statistics computed; ANCOVA comparing post-intervention means between groups with baseline scores as covariates for each outcome; significance p<.05; effect size partial eta squared (ηp²): small .01, medium .06, large .14. Participant flow: Intervention n=64; waitlist n=65; post-intervention assessments completed n=117; intention-to-treat analysis n=129.

- Feasibility: Approx. 23% of the sampling frame enrolled; 9.3% attrition at post-intervention; attrition not related to group, demographics, or baseline outcomes. - No baseline differences between groups across outcomes (all p>.05). - Generalized anxiety (GAD-7): Intervention post mean 6.45 (SD=3.90) vs control 9.14 (SD=4.15); ANCOVA F(1,126)=23.95, p<.001, ηp²=.16 (large). Within-group reduction in intervention: t(63)=5.51, p<.001. - Social anxiety (SIAS): Intervention post mean 28.03 (SD=15.07) vs control 34.69 (SD=12.06); ANCOVA F(1,126)=6.681, p=.011, ηp²=.05 (small-to-moderate). Within-group change in intervention not significant; control group increased significantly over time (t(63)=-1.91, p<.05). - Depression (DASS-21 depression subscale): Intervention post mean 11.59 (SD=8.24) vs control 13.63 (SD=8.01); ANCOVA not significant (reported F(1,126)=20.543, p>.05, ηp²=.006). - Wellbeing (SWEMWBS): Intervention post mean 24.03 (SD=4.45) vs control 22.06 (SD=4.37); ANCOVA F(1,126)=16.81, p<.001, ηp²=.12 (moderate); within-group improvement in intervention: t(63)=-4.58, p<.001. - Disability (SDS): Intervention post mean 10.75 (SD=8.27) vs control 10.68 (SD=6.92); ANCOVA F(1,126)=.434, p>.05, ηp²=.003 (ns). - Experiential avoidance (AAQ-II): Intervention post mean 19.72 (SD=9.38) vs control 23.18 (SD=8.21); ANCOVA F(1,126)=5.138, p=.025, ηp²=.039 (small). Change in AAQ associated with change in generalized anxiety (r=.20, p<.05). - Valued living (VLQ): Intervention post mean 62.31 (SD=24.17) vs control 58.01 (SD=20.43); ANCOVA F(1,126)=2.052, p>.05, ηp²=.016 (ns). Change in VLQ inversely associated with depression (r=-.17, p<.05) and positively with wellbeing (r=.18, p<.05).

The study demonstrates that a brief, self-directed, internet-delivered ACT program is feasible and effective for reducing generalized and social anxiety and improving wellbeing among Middle Eastern college students, addressing barriers such as stigma and limited access to face-to-face services. While depressive symptoms and disability did not show significant between-group differences over the 4-week period, trends toward improved valued living and reductions in experiential avoidance suggest potential mechanisms aligned with ACT, with experiential avoidance changes modestly associated with anxiety reductions. The lack of significant change in valued living may reflect insufficient time for values clarification to translate into behavior change, highlighting the need for longer follow-ups. The results extend the cross-cultural relevance of internet-delivered ACT and mindfulness-based interventions and support their scalability given minimal clinician input and brief module design. Future work should assess durability of effects via follow-up, examine booster sessions, and compare to active controls (e.g., CBT components) to isolate specific efficacy. Enhanced measurement of engagement, adherence, and completion, and cultural acceptability markers are needed to interpret implementation success and inform optimization.

A brief, online, self-directed ACT program was feasible and efficacious for alleviating anxiety and enhancing wellbeing among Arab college students in the Middle East. This first trial in the region provides preliminary support for internet-delivered ACT in this population. Future research should include longer follow-up, detailed engagement/adherence metrics, active control comparators, potential booster sessions, and assessment of cultural appropriateness to refine and validate the intervention.

- No follow-up assessments; durability of effects unknown. - Engagement/adherence/completion not objectively measured, limiting interpretation of dose received. - Short intervention and assessment window (4 weeks) may be insufficient for changes in depression, disability, and valued living. - Use of a waitlist (non-active) control may inflate treatment effects compared to trials with active comparators. - Reliance on self-report measures; absence of structured diagnostic interviews may introduce recall and social desirability bias. - No multiplicity adjustment for multiple secondary analyses; exploratory findings should be interpreted cautiously. - Missing post-intervention data addressed via multiple imputation; although standard, imputation assumptions may affect estimates. - Cultural acceptability not directly measured; generalizability across Middle Eastern subpopulations requires further study.