Behavioral Activation for Depression: From its Roots to Real-World Application

Transcription

1 Behavioral Activation for Depression: From its Roots to Real-World Application Cynthia L. Ramirez, Ph.D. W. Edward Craighead, Ph.D. Anahi Collado, Ph.D. CAMP Emory University

2 Financial Disclosures Dr. Craighead receives support from the NIH for his research, and he receives book royalties from John Wiley & Sons. He is an officer of Hugarheill ehf, an Icelandic company dedicated to prevention of depression. He is on the National Advisory Board of the George West Foundation for Mental Health. His work is supported in part by NIMH, Mary and John Brock Foundation, and Fuqua Family Foundations.

3 Learning Objectives for Today s Workshop Review depression definition, incidence and prevalence rates, gender differences, and common treatments Learn the history of Behavioral Activation Understand empirical support for Behavioral Activation Promote understanding of the basic principles underlying BA Learn how to use BA session by session Learn about BA adaptations for use across a wide range of populations and settings Be able to spot and address treatment barriers

4 Significant weight gain/loss or change in appetite Insomnia or hypersomnia Plus at least 3 of: Psychomotor agitation or retardation Fatigue or loss of energy Dysphoria AND OR Anhedonia Plus at least 4 of: Feelings of worthlessness or excessive or inappropriate guilt Decreased concentration or indecisiveness Recurrent thoughts of death or suicidal ideation, plan, or attempt Symptoms present most of the day, nearly every day for 2 weeks Significant distress or decrease in functioning Diagnosis of MDD

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6 Percent Clinically Depressed Total Male Female Age Hankin et al., 1998

7 Scope of Major Depression-U.S. Lifetime risk: 1 in 5-6 (17.5%) 65-70% with MDD have first episode during Youth 73% that have teen episode have recurrence by age 27 (Rohde et al., 2014) Past year risk: (20 million people) Approx. 40% received treatment Kessler et al., JAMA 2005; 62:593. Marcus et al., Arch Gen Psychiatry, 2010; 67:1265.

8 Costs: Scope of Major Depression-U.S. Productivity losses: $83 billion Suicide: 34,000 per year, at least 75% in MDE Family Dysfunction: Divorce/ Abuse/ Child-rearing Substance Abuse: Odds Ratio = 7.2 vs non-mdd Tobacco use significantly increased Medical use - 4X Poor academic performance Lower income Marcus et al., Arch Gen Psychiatry, 2010; 67:1265.

9 Psychotherapy First-Line Treatments for MDD Cognitive-Behavior Therapy Interpersonal Psychotherapy Behavioral Marital Therapy Behavioral Activation Medication Selective Serotonin Reuptake Inhibitor (SSRI) Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline Serotonin Norepinephrine Reuptake Inhibitor (SNRI) Desvenlafaxine, Duloxetine, Venlafaxine Bupropion, LI, Mirtazapine, Vortioxetine, APA Practice Guideline for Treatment of Patients with Major Depressive Disorder, 2 nd ed., Am J Psychiatry 2000 Apr;157(4 Suppl):1-45.

10 Influences Learning Theory Cognitive Psychology 1. Modeling 2. Problem-solving 3. Language control of behavior (SIT) 4. Self-control Therapies Behavior Therapy Cognitive/Behavior Therapy Cognitive Therapy Cognitive Therapy

11 Individual variables Causes Environmental variables Current Depression Environmental variables Biological Genetic, neurochemical, neuroendocrine, immunology, neural connectivity Behavioral Activity, avoidance Cognitive Distortions,Attention, schemas Emotional Reactivity, regulation Biological Behavioral Cognitive Emotional

12 Rise and Fall of Early Behavioral Interventions According to early theorists such as Ferster and Lewinsohn, depression develops/maintains in response to unsupportive environments with limited access to rewarding (pleasant) events: Reinforcement for healthy behavior is delayed and uncertain Punishment for healthy behavior is immediate and certain Reinforcement for depressed behavior is immediate and certain Lewinsohn & colleagues (1972) based treatment on increasing reinforcing (pleasant) events Purely behavioral approaches did not endure and over time, cognitive interventions were integrated As Lewinsohn and colleagues work developed, BA incorporated more and more cognitive techniques

13 Jacobson et al., 1996 Component analysis of cognitive behavioral therapy (CBT) for depression Conditions (with 152 randomly assigned depressed outpatients) 1. Behavioral Component (BC) 2. Behavioral Component plus modification of dysfunctional automatic thoughts (BC+AT) 3. Entire CBT package No difference in recovery rates across conditions BC = 62%; BC+AT = 65%; CBT = 71% Behavioral components alone may be as efficacious to treat depression Follow up studies indicated additional support vs. cognitive therapy and extended to medication, with some evidence suggesting strongest results for most impaired patients

14 What is Behavioral Activation Jacobson (and Colleagues): BA Following from 1996 study, behavioral component developed into full 20-session behavioral activation (BA) protocol (Martell & Addis, 2001) From this work, BA can be loosely defined as a set of strategies that engender positive behaviors that include: monitoring of daily activities assessment of pleasure and mastery that is achieved by engaging in a variety of activities assignment of increasingly difficult tasks to engender sense of pleasure or mastery discussion of specific problems and the prescription of relevant BA techniques BA also places emphasis on in-session efforts to target/disrupt avoidance, and strategies more indirectly related to BA including periodic distraction from problems/unpleasant events, mindfulness training, skills training, cognitive rehearsal of scheduled activities, and self-reinforcement.

15 BA Basic Principles Structured and brief psychotherapy Depression = decreased ability to experience environmental reward as a result of avoidance Understanding contingent relationships (if-then) is critical BA focuses on increasing activation Increases pleasurable experiences, mastery, productivity Reduces escape, avoidance, rumination Focuses on proximal rather than distal factors Strongly idiographic Therapist provides assistance in selecting activation tasks, setting realistic goals, problem-solving, and maintaining motivation BA is theory vs. protocol driven

16 BA Assumptions Change behavior and surroundings to improve thoughts, feelings, and overall quality of life Focus on behavior change does not mean thoughts and feelings are ignored: Negative thoughts/feelings will improve with positive behavior change and resulting positive outcomes Depression remits and resiliency develops when doing valued activities that bring pleasure and accomplishment

17 Simplified BA Conceptual Model Vicious cycle of depression Positive cycle of activity Feel low Feel better I will do X when I feel better I don t feel like it Stop doing things Behavioural Activation Do more I m going to do it anyway

18 Behavioral Activation Meta-Analyses Cuijpers, P., van Straten, A., & Warmerdam, L. (2007). Behavioral activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27, Ekers, D., Richards, D., & Gilbody, S. (2008). A meta-analysis of randomized trials of behavioural treatment of depression. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences. 38, Mazzucchelli, T., Kane, R., & Rees, C. (2009). Behavioral activation treatments for depression in adults: A meta-analysis and review. Clinical Psychology: Science and Practice. 16, Sturmey, P. (2009). Behavioral activation is an evidence-based treatment for depression. Behavior Modification, 33,

19 Cumulative Number of Behavioral Activation Relevant Publications

20 BA in Action

21 Adult BA Protocol Phase I: Orientation Phase II: Development of Treatment Goals Phase III: Individualizing Targets for Activation Phase IV: Application of Activation Strategies Phase V: Review of Treatment Gains ** Approximately 24 sessions over 16 weeks

22 Phase I: Orientation Discuss the BA model of depression and primary treatment strategies Highlight how the model fits with the client s experiences Respond to questions/concerns about model: buy in in critical! Provide information about treatment structure Between-session practice Collaborative approach to therapy Structure of session: agenda, homework review, & take-home message Define role of client and therapist

23 Phase II: Development of Treatment Goals Identify basic escape/avoidance patterns Replace avoidance with active coping responses Changing basic routines to decrease withdrawal Addressing short and long-term goals Short-term goals: increase engagement in mastery and pleasant activities regardless of how the client feels before or during the behavior Long-term goals: Goals that take longer to accomplish and that lead to significant changes in client s life situation (e.g., getting a job, going back to school, etc.)

24 Phase III: Individualizing Targets for Activation Activation strategies that work for one person may not work for another. Functional analysis What is maintaining the depression? Antecedents and consequences of behaviors Negative and positive reinforcement of avoidance behaviors What behaviors are amenable to change? What are the obstacles of engaging in change?

25 Activity Monitoring Detailed and ongoing; between sessions Record both activity and mood rating for each hour of client s waking day using a weekly Activity Record (or variation) Therapist must review records in detail: case conceptualization and reinforcement What would the client be doing if not depressed? Is there variety in activities? Are there deficits in coping skills? How do behaviors affect mood?

26 Phase IV: Application of Activation Strategies Activity Scheduling and Self-monitoring Assign activity and strategy for implementing activity at the end of each session Develop regular routines for things like sleeping, eating, working, and social contact Pay attention to contingency management (e.g., public commitment, arbitrary reinforcers, aversive contingency) Therapist must provide feedback and reinforcement Trouble-shoot what got in the way if client did not complete homework

27 Phase IV: Application of Activation Strategies Graded Task Assignment Break down behavior into specific, achievable units Grade behaviors (stepwise) from simple to complex Avoidance Modification Begin with collaboration and validation Teach basic problem-solving methods: ACTION vs. TRAP ACTION: Assess, Choose, Try, Integrate, Observe the results, Never give up TRAP: Trigger, Response, Avoidance Pattern

28 Phase IV: Application of Activation Strategies Engagement Strategies Decrease the behavior of rumination Focus on the consequences of rumination (both positive and negative) Help client practice attention to experience (i.e., mindfulness)

29 Phase V: Review of Treatment Gains Relapse prevention: review and consolidate gains Anticipate stressors and generate plans to cope with these situations Develop a self-help plan Review basic methods/strategies used in therapy

30 Modifying BA for Adolescents Developmentally appropriate handouts for adolescents and their parents At least 3 parent/teen joint sessions for the purposes of psycho-education, discussion of progress, goal setting, and relapse prevention Modifications to the phases of treatment

31 Modified Adolescent Protocol Phase I: Orientations and Commitment Phase II: Getting Active Phase III: Problem Solving Phase IV: Setting Goals and Sub-goals Phase V: Practice, Practice, Practice! Phase VI: Relapse Prevention and Termination

32 Additional Developmental Considerations Consider changes in adolescent schedules (i.e., school week vs. weekend; school year vs. summer vacation) Need to incorporate parents in activity scheduling for both assistance and permission Parents should give feedback when reviewing progress (mid-way and at end of treatment) and during relapse prevention

33 BA Cultural Adaptations

34 Similar or greater MDD rates relative to non-latino, White individuals Underserved population The Case of U.S. Latinos Reports suggest high levels of stigma Attitudes towards antidepressant medication have been negative Antidepressants argued to go against poner de su parte (putting effort into one s recovery, doing one s part) Positive attitudes towards psychosocial treatment Depression attribution to environmental influences

35 The Case of U.S. Latinos BA may be useful because it: Attributes depression to the environment/context Allows individuals to perceive control over their environment Is highly consistent with poner de su parte Is about making life changes as opposed to addressing illness Is brief/parsimonious Allows detachment from possible cultural stereotypes

36 Treatment Resistance and Other Clinical Challenges

37 Treatment Rationale Important toward developing therapeutic alliance Understanding and integrating this model into one s lifestyle is perceived as critical toward facilitating positive treatment outcome. Significant responsibility on therapist to ensure rationale is presented comprehensively and in appropriate language to facilitate understanding. If following discussion of treatment rationale there is minimal patient satisfaction, disagreement, or even resistance, BA may not be the most optimal intervention. BUT focus of BA may be different than what a patient expects in therapy. Maybe not resistance, but rather surprise or confusion. Working with patient to understand differences can have positive results once the patient understands BA as it differs from their expectations.

38 Non-Adherence I Missed sessions Homework adherence issues Difficult to understand behavior patterns without completed behavior monitoring forms Consequently, session can drift from BA Keep the focus by completing forms in session Activity adherence issues Problem solve difficulty Consider making activities easier, more manageable steps Activity might not be as enjoyable or important as originally assumed Skill deficiencies?

39 Non-Adherence II: Difficulty Focusing on BA in Session Client is off topic, doing a lot of venting or longwinded storytelling making it difficult to stay focused on BA Venting is behavior. Is it important? Does it enhance or deteriorate mood? (i.e., is it a depressed or healthy behavior?) Look for where it might be occurring outside of session (could be an interpersonal style that puts others off as well.) Red flag that client needs a stronger social support system Compartmentalize venting to a specific time period at the end of session (IF it is helpful, as noted above). Set agenda at beginning of each session and stick to it.

40 Acknowledgements These research projects were supported by the Mary and John Brock Foundation and the Fuqua Family Foundations.

41 Collaborators CAMP Michael Treadway Sean Carey Kate Phillips Lara Alexander Margaret Martinez Allison McDonald Lorie Ritschel