Using Behavioural Activation as a psychological intervention to treat and prevent Depression in the third age Professor David Ekers PhD MSc ENB 650 RMN The talk What is BAhow does it work ID: 1043776
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1. It aint what you do it’s the way that you do it. Using Behavioural Activation as a psychological intervention to treat and prevent Depression (in the third age)Professor David EkersPhD, MSc ENB 650, RMN
2. The talkWhat is BA/how does it workThe evidence for BA to treat depression-a pragmatic choiceCan it prevent depression (the CASPER study)Current ongoing studies
3. The interventionBehavioural Activation
4. Background to BASkinner 1950’s introduces the operant conditioning. Observes depression associated with a break from established sources of positive reinforcement from environmentFerster 1973-When stable sources of positive reinforcement lost-depression occurs-activity scheduling treatments introducedShowed promise in early randomised controlled trialsUntil the cognitive model took over in 1980sExternal to the personViews depression as an understandable response in the context of client’s lives.Looks at depression as a consequence of person-environment interactionsAs such this relationship ‘person-environment’ is focus of the treatment
5. But may be somewhat older!
6. Robert Burton 1626‘I write of melancholy by being busy to avoid melancholy’Connection between the mind and the bodyEmphasised the ‘creative blessings’ which come with melancholyProposed activity, creativity and interaction with the natural world as a treatment
7. A reminder of Behavioural principles ofreinforcement
8. Reinforcement Presented OmittedPositiveNegativePositive ReinforcementFrustrative non rewardPunishmentNegative Reinforcement
9. Practical daily use of negative reinforcement
10. Behavioural activation cycle rationale (developed for our 2011 study
11. Behavioural activation (BA)Such as a physical health problem, retirement, bereavement etc.
12. Behavioural activation (BA)Life event leads to fewer behaviours that provide value and meaning in life
13. Behavioural activation (BA)…which leads the person to feel low
14. Behavioural activation (BA)Attempts to cope may include avoidance behaviours, which can maintain the problem
15. Reduction in positive reinforcementAvoidance behaviours are negatively reinforcedBehavioural activation (BA)
16. 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.
17. BA Key PrinciplesRelies on sound therapeutic alliance and collaborative relationshipFocus on meaningful connection with the world‘Outside-In’ rather than ‘Inside-Out’ approachWe 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 changeRather than ‘waiting to feel better to do it’ – ‘do it to feel better’
18. R2D2’s BA guide to treating depressionTwo Rs:Re-instate previous behavioursReplace old behaviours with newTwo Ds: Disrupt unhelpful patterns of behaviourDecrease avoidance behaviours
19. Valued goals/not just any activity-need good targeting- Case examples scheduling for emotional goals
20. BA and depression
21. A long-long time agoPsychological Medicine 2008; 38(5): 611-623.
22. Findings in 2008BA 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/CBTTwelve 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)
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24. When you take out the dodgy ones
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26. Evidence gap in 2008/9 All studies used highly qualified therapistsSmall studies of questionable qualityNICE (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”
27. First step- test the feasibility of the idea of non specialist delivery
28. Results at follow up (3 months post randomisation n=47)
29. Economic AnalysisEkers D, Godfrey C, Gilbody S, Parrott S, Richards D, Hammond D and Hayes A. (In Press BJ Psych)
30. Cost more/less effectiveCost less/less effectiveCost less/more effectiveCost more/more effective
31. Beware
32. Small Study - Big LimitationsSmall sample2 therapistsNo follow upStrong signs of proof of principle and used as basis for COBRA and CASPER study applications
33. Open access- The Lancet July 2016
34. 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 sought to answer two interlinked questions:What is the clinical effectiveness of BA (non specialist) 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?
35. COBRA HypothesesBA is non-inferior (1.92 PHQ9 points) to CBT (gold standard) for depressed adults in terms of depression treatment response at twelve and 18 monthsBA is more cost-effective than CBT at 18 months
36. What we found
37. *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)CBTBA Adjusted A-B difference*P-valueNMean (SD)NMean (SD)Mean (95% CI)Baseline21917.4 (4.8)22117.7 (4.8)--Intention to treat12-months1898.4 (7.5)1758.4 (7.0)0.1 (-1.3 to 1.5)0.89Per protocol12-months1517.9 (7.3)1357.8 (6.5)0.0 (-1.5 to 1.6)0.99
38. Non-Inferiority at primary endpointNon inferiority margin
39. 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)CBTBAAdjusted difference*P-valueNMean (SD)NMean (SD)Mean (95% CI)Baseline21912.6 (5.1)22112.7 (5.1)--Intention to treat12-months1766.3 (6.0)1616.4 (5.9)0.1 (1.3 to -1.0)0.82Per protocol12-months1466.0 (5.8)1295.9 (5.5)0.01 (-1.3 to 1.2)0.95
40. Economics
41. 6%4%66%24%-£1000-£500£0£500Difference in cost-.1-.050.05.1.15Difference in QALY£20k/QALY threshold line95% confidence ellipseCost More/Less EffectiveCost More/More EffectiveCost Less/More EffectiveCost Less/Less EffectiveCost Effectiveness Plane
42. Clinical ImplicationsBA 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.
43. Using BA to prevent depression
44. Rationale-BA to Prevent Depression in over 65sCan be delivered by non specialistsPossibly a good public health messageMakes sense to people
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46. The CASPER trialCollaborativeCare forScreenPositive Elders
47. CASPERCare forScreenPositive Elders
48. CASPERCare forScreenPositive Elders
49. CASPERCare forScreenPositive Elders
50. Who took part?705 participantsOver 65s – mean age 77 (range 65 – 99 yrs) Whooley +ve with DSM-IV Subthreshold depressionVery few exclusionsRecently bereavedAlcohol dependenceTerminal illnessCognitive impairment (ascertained by the GP)Comorbidity OK – 80% or more had 2+ LTCs
51. Collaborative careNon-specialistLiaises with other health professionalsSymptom monitoringBrief psychological treatmentOver the phoneMedication management
52. Functional equivalenceFunctional equivalenceBehaviours may look very different but serve the same functionWhat 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 behavioursLife events as we get olderPhysical health conditionsBereavementRetirementChange / loss of roles
53. DesignRecruitment from primary careOlder adults with sub-threshold depression(N = 705)Collaborative care (with BA)(n = 344)Treatment as usual(N = 361)PHQ-9, GAD-7, PHQ-15, EQ-5D, SF-12(4 and 12 months)PHQ-9, GAD-7, PHQ-15, EQ-5D, SF-12(4 and 12 months months)
54. Physical health problems in CASPER
55. PHQ9 – continuous measure and ‘caseness’ for depressive disorderSF12GAD7PHQ15RISC2Outcomes @ 4 and 12 months
56. CASPER trial recruitment
57. Primary outcome
58. PHQ9 scores at 4 and 12 months
59. Does collaborative care prevent the onset of depression?
60. 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)
61. 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)
62. Is there a preventative element to CC?Odds of case level depression were halved at 12 months OR = 1.98 (1.21 to 3.25)
63. SF12GAD7PHQ15What about secondary outcomes?
64. SF12 physical component score
65. SF12 mental component score
66. GAD7
67. PHQ15 – somatoform complaintsSymptoms for which the greatest improvements were observed were: Pain in arms, legs or joints; Dizziness; Shortness of breath; Constipation, loose bowels or diarrhoea; and Trouble sleeping.
68. What about antidepressants?
69. Some qualitative findings
70. BA and collaborative careCos I suppose that the ideas are very kind of common sense but perhaps it’s this going through a more kind of formal process of like analysing what you do, how you feel, how they relate to each other and then sort of writing things down, I guess people say that that’s helpful to …reflect and then think about what they might like to change…..little things.
71. Functional equivalenceBut I think it was very good later on in the thing [booklet] where it said, ‘What could you do to replace, erm, you know, various activities if you had to stop doing them’. And I think that was good, to help you think round things
72. Using the phoneBecause I don’t like talking on the telephone all that much because of sort of interviews where you try and sort something out like your telephone or your inter, internet or something, and people talk too fast and too quickly and you feel terribly slow, but she wasn’t like that at all. She was very clear and patient … and it was fine, and relaxed and yeah. I thought it would be odd talking over a telephone about yourself, but it was alright.
73. Phone vs face to faceInt: So would you have preferred having it face to face, all the sessions face to face? Q11347F: Well I think, yes I mean one would say that, but it wouldn’t matter. It’s, erm, ….it’s slightly self-indulgent having face to face [interactions] I think
74. And the cash!
75. Was it cost effective?Direct costs of collaborative care = £494Some evidence of cost offset - £55 Worst case cost/QALY £9,633CC as delivered cost/QALY £3328
76. Was it cost effective?
77. Summary of findingsGood engagement; liked the BA focus of the intervention and telephone managementModerate effect size 0.3Positive across a range of outcomes (signs in Physical and psychological functioning) Prevented the onset of case level depression (based on PHQ scores)Cost effectiveLargest UK trial of collaborative care to dateLargest ever trial of CC for subthreshold depression
78. Our Current studies/collaborations Community Pharmacy Mood Intervention Study CHEMIST- Feasibility and Pilot study- Intervention adaption and Pilot RCT-results due early 2020.Good engagement and signs can deliver in innovative new settings- ave age 65 Multi-Morbidity in Older Adults (MODS)- 6 year program grant for applied research-adaption of BA to target functioning in over 65s with 2 or more LTC inc depression. 3 or more LTC in people over 65 with sub threshold up to major depression-flexible BA design to target functioning
79. BA collaborationsImpact BEACON study- Adaption of BA in South Asia settings with co morbid non Communicable disease.Insika Yomama- BA delivered by community workers in South Africa in perinatal depression with HIV+ status. BaNDep-BA for depression in Elderly care homes in Melbourne and Perth Depression prevention in older adults in Brazil using BA focused targeted health promotion audio messages.Audio whats app!-Sao Paulo-BA advice and case stories via audio message-story arc over 4 themes and upp to 48 1 minute messages.
80. SummaryBA is a practical treatment aiming to re engage people with positive reinforcement from their environment.Evidence in adults-older adults suggest it works wellEvidence in younger people is limited and probably requires a large scale RCTCurrent research is testing BA in a range of new settings
81. Too many to mentionTeam-CASPER/COBRA and beyondstudy participantsMore info david.ekers@nhs.netTwitter @DavidEkersAcknowledgementsthanks for listeningDisclaimer for COBRA and CASPER studiesThese 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.