Is a Brief Behavioral Activation Intervention Effective in Reducing Depressive

Symptoms?.Jennifer Funderburk, Ph.D.1,2,3

Collaborative Family Healthcare AssociationOctober 5th, 2012 Austin, Texas

1 Clinical Research Psychologist, Center for Integrated Healthcare, Syracuse VAMC

2 Department of Psychiatry, University of Rochester3 Department of Psychology, Syracuse University

Jennifer Funderburk does not have any relevant financial relationships during the past 12 months.

The views expressed in this article are those of the authors and do not reflect the official policy of the Veterans’

Affairs’ departmentor other departments of the U.S. government.

Thanks to Robyn Fielder, M.S. & Spiro Tzeztsis, M.D. who are instrumental in helping to obtain the data presented in

this presentation as an example. Thanks to Dev Crasta for helping me to

organize the information.

Understand the fundamental components of a clinical case study/series research design

Describe our application of the design to the implementation of a brief behavioral activation intervention for depressive symptoms

Discuss how this approach can provide preliminary data on interventions providers are using regularly within primary care

Detailed report of the initial presentation, treatment, and follow-up of an individual patient.

Presentation

Detailed Description

Signs & SymptomsMD Impressions

Presentation

Detailed Description

Signs & SymptomsMD Impressions

Treatment

Thorough & Full Explanation of

Tx Process

Treatment

Thorough & Full Explanation of

Tx Process

Follow-Up

Symptom CourseTx ResponseFollow-ups

Follow-Up

Symptom CourseTx ResponseFollow-ups

Case Report

Case Report

Case Report

Case Report Case Report

Case Report

A study describing the outcomes of multiple patients who were given a similar treatment.

Patients

DemographicsSelect Diagnoses

Patients

DemographicsSelect Diagnoses

Common Treatment

Shared Features&

Individualized Adaptations

Common Treatment

Shared Features&

Individualized Adaptations

Outcomes

% Positive Change

# Adverse Events

Follow-ups

Outcomes

% Positive Change

# Adverse Events

Follow-ups

Decide on clear criteria ◦Examples: Treatment used Condition shows up in chart Symptoms above a certain threshold Demographic Characteristic (e.g.,

Gender; Age)

Decide on a clear definitions of outcomes.◦Examples: Patient drops below a certain symptom

threshold Symptoms drop a measurable amount Patient experiences ANY symptom reduction ABSENCE of negative outcomes or

complications Measurable restoration of patient functioning

Best Practice: Do this prospectively so you can make sure you collect all the data you would like to have

Consider talking to your IRB if you plan on sharing this information through publication in the future

However, you may already have the data already

ELECTRONIC MEDICAL RECORD/CHART REVIEW

Quick and Simple Systematic Method for Evaluating Clinical

Experience Provides a Way to Evaluate Things as a

Clinician Without Funding Provides a Way to Evaluate Things

Diffucult to Evaluate Other Ways

Selection criteria and outcome definitions must be used consistently.

Keep track of relevant treatment differences for each patient.

Remember, the results suggest implications but are not conclusive. This is not a way to determine cause and effect and a limitation is that the findings may not generalize.

CONSIDER MULTIPLE ASSESSMENTS PRIOR TO INTERVENTION AND AT FOLLOW-UP

Depressive symptoms especially common in college students◦High Risk for Suicide

Evidence mixed for antidepressants in:◦Sub-threshold depressive symptoms◦Suicide management

Brief Behavioral Activation (BA)◦Effective in a wide range of populations◦Easily implemented in Primary Care

Syracuse University Health Clinic◦Serves Syracuse University (total

enrollment approx. 20,000)◦ E9,464 patients per semester, E146

patients per day◦2 physicians, 7 nurse practitioners, 4 per

diem practitioners Integrated Behavioral Healthcare (IBHC)

◦Regular screening◦Behavioral Health Providers

BHPs encouraged to use BA with patients reporting depression because:◦ Research demonstrating its effectiveness in reducing

depressive symptoms (Cuijpers, van Straten & Warmerdam, 2007; Mazzucchelli, Kane & Rees, 2009)

All BHPs received additional training and supervision by the first author ◦ Lejuez et al. (2011) manual as a guide

Modifications needed to adjust to brief sessions was necessary◦ Education about depression and the link between

thoughts, behaviors, and mood◦ The importance of increasing pleasurable activities

All charts reviewed for patients in:◦Aug. 2009 –May 2010◦Aug. 2010– Dec. 2010

Charts selected if:◦Presented with depressive

symptoms(n=102)◦Behavioral Activation discussed in 1st

Session (n=42)◦Came back for a second session (n=14)

and a second PHQ-9 score was recorded 11 charts met criteria

Patient Characteristics◦8 Female◦8 White◦Age 19-27 (M= 20.9)◦3 Upperclass; 2 Graduate

Presentation◦Reason for Referral to BHP: Depression/Positive PHQ-9 screen (8) Depression and Sleep (2) Depression and Anxiety (1)

◦Diagnosis on Encounter: Major Depressive Disorder: unspecified (1),

mild (2), moderate (1) Depressive Disorder N.O.S. (2) Adjustment Reaction (2) No Diagnosis (3)

◦PHQ-9: Mean=12.82; SD= 3.55◦5 marked suicidal screening item on

PHQ-9 as greater than 0 3 indicated experiencing thoughts of

death/hurting oneself several days 2 indicated experiencing thoughts of

death/hurting oneself more than ½ the days in the past 2 weeks

At All Sessions◦ BA was used◦ BHP provided educational info about

depression◦ Additional educational materials were provided

Avg. 13 days (SD=6.99) --session 1 & 2 Extra Components

◦ 3 Referred for extra treatment (long-term psychotherapy, medication management)

◦ 2 were seen for a 3rd session, no PHQ-9 data though

◦ Other interventions were also given depending on problem complexity (e.g., stimulus control for sleep problems)

Intake◦ 5 marked suicidal screening item on PHQ-9 as

greater than 0 3 indicated experiencing thoughts of death/hurting

oneself several days 2 indicated experiencing thoughts of death/hurting

oneself more than ½ the days in the past 2 weeks 2nd Session

◦ Only one individual continued to report suicidal ideation and it was maintained at the level of experiencing thoughts several days across the past 2 weeks

Disadvantages◦No way to determine cause/effect

relationships◦Hard to generalize◦Possible biases in data collection and

interpretation Advantages

◦Makes some studies possible◦Easier to implement◦Rich data◦Good way to examine innovative ideas

Lejuez, C., Hopko, D.R., Acierno, R., Daughters, S., and Sherry, L. (2011). Revised Treatment Manual Ten Year Revision of the Brief Behavioral Activation Treatment for Depression. Behavioral Modification, 35, 111-161. DOI: 10.1177/0145445510390929