USING BEHAVIOURAL ACTIVATION AS A PSYCHOLOGICAL INTERVENTION TO TREAT AND PREVENT DEPRESSION. Professor David Ekers PhD, MSc ENB 650, RMN

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1 USING BEHAVIOURAL ACTIVATION AS A PSYCHOLOGICAL INTERVENTION TO TREAT AND PREVENT DEPRESSION Professor David Ekers PhD, MSc ENB 650, RMN

2 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

3 The problem

4 Depression 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

5 Taken from UK Psychiatric Morbidity Survey 2016

6 UK Psychiatric morbidity survey 2016 (conducted in 2014) 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

8 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

9 DEPRESSION AND LONG TERM HEALTH PROBLEMS

10 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 , DOI: /S (12) ) 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.)

11 Naylor et al 2012 Kings Fund

12 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

13 The intervention Behavioural Activation

14 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

17 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

18 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

19 A reminder of Behavioural principles reinforcement

20 Behavioural principles within BA Positive Reinforcement- behaviour by positive state as followed Negative Reinforcement- behaviour as followed by omission of unpleasant feeling

21 Reinforcement Presented Omitted Positive Negative Positive Reinforcement Punishment Frustrative non reward Negative Reinforcement

23 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

24 Behavioural activation (Ekers et al 2011)

25 Behavioural activation (BA) Such as a physical health problem, retirement, bereavement etc.

26 Behavioural activation (BA) Life event leads to fewer behaviours that provide value and meaning in life

27 Behavioural activation (BA) which leads the person to feel low

28 Behavioural activation (BA) Attempts to cope may include avoidance behaviours, which can maintain the problem

29 Behavioural activation (BA) Avoidance behaviours are negatively reinforced Reduction in positive reinforcement

30 George Life event Became ill with diabetes and heart problems Secondary problems, friends stopping coming round 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 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

31 George Life event Became ill with diabetes and heart problems Secondary problems, friends stopping coming round 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 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

32 Life event Became ill with diabetes and heart problems Secondary problems, friends stopping coming round 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 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 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. 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

33 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

34 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

35 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

36 R2D2 s guide to treating depression

37 Goals relevant to a person s particular areas of value

38 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?

39 The evidence so far- Does this stuff work

40 Systematic review and Meta-analysis of behavioural treatment for depression Psychological Medicine 2008; 38(5):

41 Findings in 2008 BA vs. Control/Usual Care 12 studies (459 participants) Effect size 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 (p=0.03) BA vs. CT/CBT Twelve studies (476 patients) No difference effect size at post treatment and follow up (SMD % 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)

43 When you take out the dodgy ones

45 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

46 First step test the feasibility of non specialists doing BA

47 BDI-II Results at follow up (3 months post randomisation n=47) Figure 3: BA vs TAU BA Usual Care 0 Baseline FU

48 Economic Analysis Ekers D, Godfrey C, Gilbody S, Parrott S, Richards D, Hammond D and Hayes A. (In Press BJ Psych)

49 Effect Difference Cost more/less effective 2,000 Cost more/more effective 1,500 1, ,000-1,500 Cost less/less effective - 2,000 Cost Difference Cost less/more effective

50 The SCIENTIFIC project-warning for next research slides

51 Open access- The Lancet July 2016

52 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?

53 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

54 Non-inferiority margin Treatment A Gold Standard 5 0 Time 1 Time 2

55 Non-inferiority margin Treatment A Gold Standard 5 0 Time 1 Time 2

56 Non-inferiority margin Treatment A Gold Standard Treatment B Experimental 5 0 Time 1 Time 2

57 Non-inferiority margin Treatment A Gold Standard Treatment B Experimental 5 0 Time 1 Time 2

58 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.

59 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

60 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

61 What we found

62 CBT BA Adjusted A-B difference* P-value N Mean (SD) N Mean (SD) Mean (95% CI) Baseline (4.8) (4.8) - - Intention to treat 12-months (7.5) (7.0) 0.1 (-1.3 to 1.5) 0.89 Per protocol 12-months (7.3) (6.5) 0.0 (-1.5 to 1.6) 0.99 *Adjusted for baseline PHQ9, and stratification variables (i.e., symptom severity (PHQ < 19, PHQ 19), site (Devon, Durham, Leeds), antidepressant use (currently taking antidepressant medication, not currently taking anti-depression medication)

63 Non inferiority margin Non-Inferiority at primary endpoint CBT-BA Study between group ID difference (95% CI) 12 mo ITT 0.10 (-1.50, 1.30) 12 mo PP 0.00 (-1.60, 1.60) favours CBT favours BA

64 SCID Caseness Across Trial (repeated measures logistic regression model) Intention to Treat 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 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

65 Secondary Outcomes What about anxiety (GAD-7) CBT BA Adjusted difference* P-value N Mean (SD) N Mean (SD) Mean (95% CI) Baseline (5.1) (5.1) - - Intention to treat 12-months (6.0) (5.9) 0.1 (1.3 to -1.0) 0.82 Per protocol 12-months (5.8) (5.5) 0.01 (-1.3 to 1.2) 0.95 *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)

66 ECONOMICS

67 4% 500 Cost Effectiveness Plane Cost More/Less Effective Cost More/More Effective Difference in cost 6% Difference in QALY % Cost Less/Less Effective 20k/QALY threshold line % confidence ellipse 66% Cost Less/More Effective

68 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.

69 Using BA with older adults

71 The CASPER trial (does it meet SCIENTIFIC standards) Collaborative Care for Screen Positive Elders

72 CASPER Care for Screen Positive Elders

73 CASPER Care for Screen Positive Elders

74 CASPER Care for Screen Positive Elders

75 Collaborative care Primary care physician Case manager Older adult Mental health specialist Non-specialist Liaises with other health professionals Symptom monitoring Brief psychological treatment Over the phone Medication management

76 Collaborative care Primary care physician Case manager Older adult Mental health specialist Non-specialist Liaises with other health professionals Symptom monitoring Brief psychological treatment Over the phone Medication management

77 Functional equivalence Life events as we get older } Physical health conditions These Bereavement Retirement Change / loss of roles life events may make it difficult or impossible to reinstate previous behaviours 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?

78 Who took part? 705 participants Over 65s mean age 77 (range 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

79 Characteristics at baseline (N= 705) Characteristic Collaborative care (n = 344) Age in years M = 77.1 (sd = 7.1) Treatment as usual (N = 361) 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)

80 Physical health problems in CASPER 60% 50% 48% 40% 38% 30% 30% 25% 21% 22% 20% 17% 10% 6% 8% 9% 11% 14% 12% 0%

81 Primary outcome

82 PHQ9 scores at 4 and 12 months Collaborative Care Usual Care Randomisation 4 Months 12 Months

83 Does collaborative care prevent the onset of depression?

84 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)

85 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)

86 Did collaborative care prevent case level depression? Prevention of Case-level depression at 12 months OR = 1.98 (1.21 to 3.25)

87 What about secondary outcomes? SF12 GAD7 PHQ15

88 GAD7 anxiety symptoms 10 9 Collaborative Care Usual Care Baseline 4 Months 12 Months

89 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

90 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.

91 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

92 Acknowledgements thanks for listening Too many to mention Team-CASPER/COBRA and beyond study participants More info 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.

Behavioural Activation for Depression. The story so far and the rise of COBRA. David Ekers PhD, MSc, ENB 650 (CBT), RMN

Behavioural Activation for Depression. The story so far and the rise of COBRA David Ekers PhD, MSc, ENB 650 (CBT), RMN What is Behavioural Activation Views depression as based in interaction with environment-loss