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USING BEHAVIOURAL ACTIVATION
AS A PSYCHOLOGICAL
INTERVENTION TO TREAT AND
PREVENT DEPRESSION
Professor David Ekers
PhD, MSc ENB 650, RMN
Aims for the session
The problem-Why are we interested in BA-what may it offer that is different to other psychotherapies
The intervention-Outline Behavioural Activation (BA) for
Depression and how it works (could GPs use it?)
The evidence so far-Does BA work for adults and older
adults
Where next-New research-what is the direction of travel
The problem
Mental health disorders are very common in the community:
One in six people (17%) have a common mental health disorder (1 in 5 in female, 1 in 8 in male) (Psychiatric Morbidity Survey 2016)
Most common is mixed anxiety and depression.
The disorders are even more common in primary care settings:
Prevalence among general practice patients 20.7% versus14.8% in the community (New Zealand Magpie Study, 2006)
Depression/anxiety generate more than half of total disability attributed to mental disorder (Andrews & Hamilton 2000)
Depression leads to high use of GP services (50% more than equivalent non depressed) high economic burden (2nd only to heart disease by 2020), exceed resources for treatment
Depression
Taken from UK Psychiatric Morbidity Survey 2016
Rates for women gradually increasing, for men relatively
stable
Most sufferers do not consult their GP
Rates of diagnosis and treatment are relatively low
Intervention rates are improving
1in 4 in 2007 (24.4%)
1in 3 in 2014 (37.3%)
Largely driven by use of psychotropic medication
UK Psychiatric morbidity survey 2016 (conducted in 2014)
Challenge of effective treatment of depression
Generally people like to have an option of a talking treatment
GPs are often the only provider of care with medication as only easy
access intervention
Access to talking treatments is limited even in the better provisioned area,
this remains the case (Inverse Care Law)
In UK, most depression remains managed in GP practice even where an
IAPT service is in place
Often missed when dealing with CHP
DEPRESSION AND LONG
TERM HEALTH PROBLEMS
Coexistence of depression is associated with poorer outcomes, increased mortality, and unscheduled care, with significant cost implications:
Depression increases the cost of care for patients with LTCs by at least 45% (£3910 to £5670 a year, Naylor 2012, Kings Fund)
Increasing number of people with LTCs have multiple conditions
The number with ≥3 is expected to increase from 1.9 million in 2008 to 2.9 million in 2018)
≥3 LTCs is associated with greatest reductions in quality of life; of a mental health problem contributes to greater declines in quality of life than the addition of a physical health problem (Barrnett et al The Lancet 2012
380, 37-43. DOI: 10.1016/S0140-6736(12)60240-2)
Sub threshold depression is highly prevalent and a major risk factor for progression to major depression. It has comparable rates of associated excess mortality (Cuijpers P, de Graaf R, van Dorsselaer S. Minor depression: risk profiles, functional disability, health care use and risk of developing major depression. Journal of Affective Disorders. 2004;79(1–3):71-9.)
Naylor et al 2012 Kings Fund
Implications
Health outcomes are worse- if you have depression there is a strong likelihood it is harder to manage your other health problems
This is as true for mild symptoms (low mood-sub-threshold depression)
Low mood is a risk factor for depression
Self management and quality of life are worse in people with these symptoms and health problems
Treatment costs rise considerably
The intervention
Behavioural Activation
A contextual rationale for depression
and low mood
List 5 activities that you do that are important to you in your daily life
What would it be like if these activities were stopped tomorrow
If during the time that you used to do them you sat and thought about not doing them
What is Behavioural BA for depression?
In BA we develop an understanding of how life events change our connection with our environment and how this may result in the development of low mood
We then determine how patterns of behaviour/coping that are deployed maintain or exacerbate low mood into depression
From this understanding we develop a treatment plan to modify behaviour patterns to provide access to more positive reinforcement from our environment
The resultant increased activation results in reduction of depression symptoms
Background to BA
Skinner 1950’s introduces the operant conditioning. Observes depression associated with a break from established sources of positive reinforcement from environment
Ferster 1973-When stable sources of positive reinforcement lost-depression occurs-activity scheduling treatments introduced
Showed promise in early randomised controlled trials
Until the cognitive model took over in 1980s
External to the person
Views depression as an understandable response in the context of client’s lives.
Looks at depression as a consequence of person-environment interactions
As such this relationship ‘person-environment’ is focus of the treatment
A reminder of Behavioural principles
reinforcement
Behavioural principles within BA
Positive Reinforcement- behaviour as followed by positive state
Negative Reinforcement- behaviour as followed by omission of unpleasant feeling
Reinforcement
Presented Omitted
Positive
Negative
Positive Reinforcement Frustrative non reward
Punishment Negative Reinforcement
BA Key Principles
Relies on sound therapeutic alliance and collaborative relationship
‘Outside-In’ rather than ‘Inside-Out’ approach
We don’t tell people to wait for some internal state to change before
they can begin to change.
Change the outside and the inside will change
Rather than ‘waiting to feel better to do it’ – ‘do it to feel better’
Behavioural activation (Ekers et al
2011)
Behavioural activation (BA)
Such as a physical health problem,
retirement, bereavement etc.
Behavioural activation (BA)
Life event leads to fewer behaviours that provide value and meaning in life
Behavioural activation (BA)
…which leads the person to feel low
Behavioural activation (BA)
Attempts to cope may include avoidance
behaviours, which can maintain the problem
Reduction in positive
reinforcement
Avoidance behaviours are
negatively reinforced
Behavioural activation (BA)
Life event
Became ill with diabetes and heart problems
Secondary problems, friends stopping coming round
Isolation from valued activities: This led to not being able to do as much at the allotment and not going to football.
George also had to reduce alcohol so didn't see friends as much
Feeling Bad: Gradually George felt his confidence drop and he felt tired all the time. Some of this was illness
and some low mood. He had no motivation to do any more than
watch TV
Coping by avoidance: When friends called George didn’t feel up to going out
so would make excuses. He stopped going to allotment even for short periods
and hardly ever saw his friends
George
Life event
Became ill with diabetes and heart problems
Secondary problems, friends stopping coming round
Isolation from valued activities: This led to not being able to do as much at the allotment and not going to football.
George also had to reduce alcohol so didn't see friends as much
Feeling Bad: Gradually George felt his confidence drop and he felt tired all the time. Some of this was illness
and some low mood. He had no motivation to do any more than
watch TV
Coping by avoidance: When friends called George didn’t feel up to going out
so would make excuses. He stopped going to allotment even for short periods
and hardly ever saw his friends
George
Life event
Became ill with diabetes and heart problems
Secondary problems, friends stopping coming round
Isolation from valued activities: This led to not being able to do as much at the allotment and not going to football.
George also had to reduce alcohol so didn't see friends as much
Feeling Bad: Gradually George felt his confidence drop and he felt tired all the time. Some of this was illness
and some low mood. He had no motivation to do any more than
watch TV
Coping by avoidance: When friends called George didn’t feel up to going out
so would make excuses. He stopped going to allotment even for short periods
and hardly ever saw his friends
Behavioural activation worked here to stop the cycle going round and round and worsening. Through step by step activity George gradually started to be more active towards his goals and broke the cycle.
Exercise
Think of a person you know
How does the cycle relate to them
What might be the life events
What might be the reduced positive reinforcement
What might be the target then of BA for the person
Three core components that underpin
BA
Self-monitoring Used to reinforce rationale and build a shared understanding of the persons
problems, the patterns of mood and the types of activity that are of value
Functional analysis Used to help break down situations to identify the triggers (Antecedents) ,
responses (Behaviour), what happens after (Consequence). Used to problem
solve blocks to:
Activity Scheduling Used to plan schedules, help person gradually begin to work from ‘outside in’ in
a value direction so environment provides positive reinforcement
Guided Activity
Select activities that can be readily incorporated into daily/weekly routine
Select activities at which the client is likely to succeed Remember the goal of BA is to place the patient back in contact with a wide and diverse range of stable positive reinforcement
Therefore guided activity must be directed by valued goals for that individual
R2D2’s guide to treating depression
Goals relevant to a person’s particular areas of value
Exercise
Back to last case what might be early activity
schedules
Prob similar to some advice you give, stucture seems
important, could GPs do this?
The evidence so far-
Does this stuff work
Systematic review and Meta-analysis
of behavioural treatment for
depression
Psychological Medicine 2008; 38(5): 611-
623.
Findings in 2008
BA vs. Control/Usual Care
12 studies (459 participants)
Effect size -0.70 in favour of BA (large) (95% CI −0.39 to −1, p=0.001), recovery rate favours BA OR= 4.18 CI 1.14 to 15.28 (p=0.03)
BA vs. CT/CBT
Twelve studies (476 patients)
No difference effect size at post treatment and follow up (SMD 0.08 95% CI −0.14 to 0.30, SMD of 0.25, 95% CI −0.21 to 0.70, p=0.28) or recovery rate (OR 0.92, 95% CI 0.59 to1.44, p=0.72)
When you take out the dodgy ones
Evidence gaps
All studies used highly qualifies therapists
Small studies of questionable quality
NICE (2009) made a clear research recommendation “to establish whether behavioural activation is an effective alternative to CBT” using a study “large enough to determine the presence or absence of clinically important effects using a non-inferiority design”
First step test the feasibility of non
specialists doing BA
Figure 3: BA vs TAU
0
5
10
15
20
25
30
35
40
Baseline FU
BD
I-II BA
Usual Care
Results at follow up (3 months post
randomisation n=47)
Economic Analysis
Ekers D, Godfrey C, Gilbody S, Parrott S,
Richards D, Hammond D and Hayes A. (In
Press BJ Psych)
-£2,000
-£1,500
-£1,000
-£500
£0
£500
£1,000
£1,500
£2,000
-0.15 -0.10 -0.05 0.00 0.05 0.10 0.15
Cost Difference
Eff
ec
t D
iffe
ren
ce
Cost more/less effective
Cost less/less effective Cost less/more effective
Cost more/more effective
The SCIENTIFIC project-warning for
next research slides
Open access- The Lancet July 2016
COBRA is a two-arm Phase III, non-inferiority randomised controlled trial of
a psychological intervention: Behavioural Activation (BA) N=440.
The COBRA programme of research seeks to answer two interlinked
questions:
What is the clinical effectiveness of BA compared to CBT for depressed adults in
terms of depression treatment response measured by the PHQ9 at six, 12 and
18 months?
What is the cost-effectiveness of BA compared to CBT at 18 months?
COBRA Hypotheses
BA is non-inferior (1.92 PHQ9 points) to CBT (gold
standard) for depressed adults in terms of depression
treatment response at twelve and 18 months
BA is more cost-effective than CBT at 18 months
Non-inferiority margin
0
5
10
15
20
25
Time 1 Time 2
Treatment AGold Standard
Non-inferiority margin
0
5
10
15
20
25
Time 1 Time 2
Treatment AGold Standard
Non-inferiority margin
0
5
10
15
20
25
Time 1 Time 2
Treatment AGold Standard
Treatment BExperimental
Non-inferiority margin
0
5
10
15
20
25
Time 1 Time 2
Treatment AGold Standard
Treatment BExperimental
Who took part
Inclusion: People aged 18 and older with DSM Major Depressive Disorder assessed by
standard clinical interview (Structured Clinical Interview for Depression –SCID).
Exclusion: People who are alcohol or drug dependent, acutely suicidal or cognitively
impaired, have a bipolar disorder or psychosis/psychotic symptoms, ascertained by
baseline research interviews. We also exclude people currently in receipt of
psychological therapy.
What we did
BA and CBT are both active psychological treatments which have previously demonstrated positive effects for people with depression
In both arms of the study, participants received a maximum of 20 face to face one-hour duration sessions over 16 weeks with the option of four additional booster sessions.
BA: delivered by band 5 qualified Psychological Wellbeing Practitioners
CBT: delivered by band 7 qualified CBT therapists
Both groups of therapists received five days of protocol specific training and weekly supervision from a relevant expert
Quality and fidelity assessed through independently rated audio-tapes and session records
What we looked at
Primary outcome measure: self reported depression severity as
measured by the PHQ-9.
Secondary outcome measures: DSM depression status,
depression free days; Health Related Quality of Life (SF-36),
GAD-7; SCID anxiety status.
Economic analysis at 18 months
What we found
*Adjusted for baseline PHQ9, and stratification variables (i.e., symptom severity (PHQ <
19, PHQ ≥ 19), site (Devon, Durham, Leeds), antidepressant use (currently taking anti-
depressant medication, not currently taking anti-depression medication)
CBT BA Adjusted A-B
difference*
P-value
N Mean (SD) N Mean (SD) Mean (95% CI)
Baseline 219 17.4 (4.8) 221 17.7 (4.8) - -
Intention to treat
12-months 189 8.4 (7.5) 175 8.4 (7.0) 0.1 (-1.3 to 1.5) 0.89
Per protocol
12-months 151 7.9 (7.3) 135 7.8 (6.5) 0.0 (-1.5 to 1.6) 0.99
Non-Inferiority at primary endpoint
12 mo ITT
12 mo PP
ID
Study
0.10 (-1.50, 1.30)
0.00 (-1.60, 1.60)
difference (95% CI)
between group
CBT-BA
0.10 (-1.50, 1.30)
0.00 (-1.60, 1.60)
difference (95% CI)
between group
CBT-BA
favours CBT favours BA 0-1.9 0 2 4
Non
infe
rio
rity
ma
rgin
SCID Caseness Across Trial (repeated measures logistic regression model)
Treatment Baseline 6 months 12 months 18 months
CBT
n/N (%)
219/219
(100%)
49/171
(29%)
37/163
(23%)
34/162
(21%)
BA
n/N (%)
221/221
(100%)
51/167
(31%)
31/154
(20%)
35/156
(22%)
P-value for between groups comparison: P=0.73
Intention to Treat
Per protocol Treatment Baseline 6 months 12 months 18 months
CBT
n/N (%)
158/158
(100%)
37/140
(26%)
30/141
(21%)
25/137
(18%)
BA
n/N (%)
147/147
(100%)
42/138
(30%)
24/128
(18%)
25/125
(20%)
P-value for between groups comparison: P=0.80
Secondary Outcomes – What about anxiety
(GAD-7)
*Adjusted for baseline GAD, and stratification variables (i.e., symptom severity (PHQ < 19, PHQ ≥
19), site (Devon, Durham, Leeds), antidepressant use (currently taking anti-depressant medication,
not currently taking anti-depression medication)
CBT BA Adjusted difference* P-value
N Mean (SD) N Mean (SD) Mean (95% CI)
Baseline 219 12.6 (5.1) 221 12.7 (5.1) - -
Intention to treat
12-months 176 6.3 (6.0) 161 6.4 (5.9) 0.1 (1.3 to -1.0) 0.82
Per protocol
12-months 146 6.0 (5.8) 129 5.9 (5.5) 0.01 (-1.3 to 1.2) 0.95
ECONOMICS
6% 4%
66% 24% -£1000
-£
500
£0
£500
Difference in cost
-.1 -.05 0 .05 .1 .15
Difference in QALY
£20k/QALY threshold line 95% confidence ellipse
Cost More/Less Effective Cost More/More Effective
Cost Less/More Effective Cost Less/Less Effective
Cost Effectiveness Plane
Clinical Implications
BA delivered by less experienced mental health workers leads to
identical clinical outcomes for patients with depression, but at a
financial saving to clinical providers of 21% compared with
the costs of providing CBT.
This is particularly relevant to the dissemination of effective
psychological interventions for depression globally,
particularly in low and medium income countries.
Using BA with older adults
The CASPER trial (does it meet
SCIENTIFIC standards)
Collaborative
Care for
Screen
Positive
Elders
CASPER
Care for
Screen
Positive
Elders
CASPER
Care for
Screen
Positive
Elders
CASPER
Care for
Screen
Positive
Elders
Collaborative care
Older adult
Case manager
Mental health
specialist
Primary care
physician
Non-specialist
Liaises with other health professionals
Symptom monitoring
Brief psychological treatment
Over the phone
Medication management
Collaborative care
Older adult
Case manager
Mental health
specialist
Primary care
physician
Non-specialist
Liaises with other health professionals
Symptom monitoring
Brief psychological treatment
Over the phone
Medication management
Functional equivalence
Functional equivalence
Behaviours may look very different but serve the same function
What function did the previous behaviour serve?
Are there different behaviours that may serve the same function?
} These life events may make it
difficult or impossible to
reinstate previous behaviours
Life events as we get older
Physical health conditions
Bereavement
Retirement
Change / loss of roles
Who took part?
705 participants
Over 65s – mean age 77 (range 65 – 99 yrs)
Whooley +ve with DSM-IV Subthreshold depression
Very few exclusions Recently bereaved
Alcohol dependence
Terminal illness
Cognitive impairment (ascertained by the GP)
Comorbidity OK – 80% or more had 2+ LTCs
Characteristics at baseline (N= 705)
Characteristic Collaborative care
(n = 344)
Treatment as usual
(N = 361)
Age in years M = 77.1
(sd = 7.1)
M = 77.5
(sd = 7.2)
% female
54% 62%
Ethnicity (% White: British)
99% 99%
Antidepressant use
10% 14%
Depression severity (PHQ-9) M = 7.8
(sd = 4.7)
M = 7.8
(sd = 4.6)
Physical health problems in CASPER
6%
8%
48%
25%
9%
17%
21%
11%
14%
30%
12%
38%
22%
0%
10%
20%
30%
40%
50%
60%
Primary outcome
PHQ9 scores at 4 and 12 months
0
1
2
3
4
5
6
7
8
9
10
11
12
PH
Q-9
Sco
re (
Hig
her
Sco
re =
Gre
ate
r D
epr
ess
ion)
Randomisation 4 Months 12 Months
Collaborative Care
Usual Care
Does collaborative care prevent the
onset of depression?
Did collaborative care prevent case
level depression?
Odds of case level
depression were halved
at 12 months
OR = 1.98 (1.21 to 3.25)
Did collaborative care prevent case
level depression?
Odds of case level
depression were halved
at 12 months
OR = 1.98 (1.21 to 3.25)
Did collaborative care prevent case
level depression?
Prevention of Case-level
depression at 12 months
OR = 1.98 (1.21 to 3.25)
SF12
GAD7
PHQ15
What about secondary outcomes?
GAD7 – anxiety symptoms
0
1
2
3
4
5
6
7
8
9
10
GA
D-7
An
xie
ty
(Hig
he
r S
core
= W
ors
e A
nxi
ety
)
Baseline 4 Months 12 Months
Collaborative Care
Usual Care
Summary of findings
Effect size on primary outcome: 0.3
Prevented the onset of case-level depression
Cost-effective
Positive across a range of outcomes
Including physical functioning
Largest UK trial of collaborative care to date
Largest ever trial of collaborative care for
subthreshold depression
In Summary
Depression places a great challenge on health care
which will increase in coming years
This is especially noted in older adults who are
under represented in clinical services
BA appears to be a simple and practical
psychological approach that works
It can be delivered by people with limited training
Further research is needed to explore use in people
with mental physical multimorbidity.
New Research
Multi morbidity in older adults is key challenge
Functional outcomes in this group, psychological and physical
Community Pharmacy Mood Intervention Study (CHEMIST)
CI Professor David Ekers
Multi Morbidity in Older Adults (MODS). NIHR Programme grant for Applied Research. 6 Year from Oct 18
CI- Professor David Ekers, Joint CI Professor Simon Gilbody
Too many to mention
Team-CASPER/COBRA and beyond
study participants
More info
Twitter @DavidEkers
Acknowledgements
thanks for listening
Disclaimer
These project was funded by the NIHR Health Technology Assessment programme .
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.
