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Using Behavioural Activation in Later Life

and its Effects on Mental Health

Research Team: Assoc. Prof. Christina Bryant, Dr Lydia Brown , Dr Meg Polacsek, Dr Frances Batchelor, Ms Hannah Capon, Assoc. Prof. Briony Dow

Overview

• Depression in late life

• Behavioural activation

– Link between mood and activities

– Implementation

• The Pleasant Activities for Wellbeing study

(PAW)

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Horackova et al.

Europ. J. Psychiat.

2019

N =28,796

Mean age

74

Depression in Residential Aged Care Facilities (RACFs)

• Over 50% of Australian RACF residents experience clinical levels of depression1

• Depression reduces quality of life

• Depression is associated with serious health consequences such as increased risk of suicide; all cause mortality; hospitalisations2

• Depression is undertreated in RACFs1 and tailored treatments are needed3

1.. AIHW. (2013); 2. Simning, A., & Simons, K. V. (2017). ; 3. Joo, J. H., Hwang, S., Abu, H., & Gallo, J. J. (2016)

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Treatments for Depression

• Medication

– Can be effective - but side effects

• Cognitive-behaviour therapy (CBT)

– Needs to be delivered by trained professionals

– Works best with high level of cognitive ability on part of client

• What might be an alternative?

Behavioural Activation (BA)

1. A treatment for depression that aims to lift mood by helping people to do more activities

2. Different from some treatments that focus more on talking or changing the way we think

3. We all need activities that are

1. ENJOYABLE and some that

2. GIVE A SENSE OF ACHIEVEMENT

4. And this is even more important for treating or preventing depression

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Compare…

a day spent… with…

or

The Cycle of Depression

SAD MOOD

LOW ENERGY

AVOID PLEASANT

AND MEANINGFUL ACTIVITIES

SOCIAL ISOLATION

4. Ekers et. al., (2014)

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The Cycle out of Depression

HAPPIER MOOD***

MORE ENERGY

SCHEDULE PLEASANT

AND MEANINFUL ACTIVITIES

SOCIAL CONNECTION

SCHEDULE

PLEASANT

AND

MEANINGFUL

ACTIVITIES

4. Ekers et. al., (2014)

Behavioural Activation (BA)

• Scheduled engagement in pleasant and meaningful activities

• Problem-solving to overcome withdrawal from activities

• Tailored to suit individual needs and interests

• And it works…

4. Ekers et. al., (2014); 5. Dimidjian et al., 2006; 6. Mazzucchelli, Kane& Rees, 2006; 7. Richards et. Al., 2016

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BA: A Powerful Antidepressant

• As good as CBT in reducing depressive symptoms8, 9.

• Meta-analysis of 26 randomized trials has found that BA is more effective than antidepressants at reducing symptoms of depression4

• Effective among those with some degree of cognitive impairment4

8. Jacobson et. Al., 2000; 9. Dimidjian et. Al., 2006b; 4. Ekers et. al., (2014);

Over to you…

Think of six activities that could lift your

mood…

And three that would not lift your spirits

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How behaviour and mood work

together (1)

EVENT/TRIGGER

Learn that

granddaughter’s visit

has been cancelled

Learn that

granddaughter’s visit

has been cancelled

BEHAVIOURStay in room and avoid

talking to people

Take a short walk in the

gardens

MOOD

CONSEQUENCE

How behaviour and mood work

together (1)

EVENT/TRIGGER

Learn that

granddaughter’s visit

has been cancelled

Learn that

granddaughter’s visit

has been cancelled

BEHAVIOURStay in room and avoid

talking to people

Take a short walk in the

gardens

MOOD

CONSEQUENCEMore depressed Less depressed

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The link between behaviour and

moodPositive mood

• Get up out of bed

• Get showered

• Get dressed

• Tell yourself you can do it

• Call a friend

• Water the garden

• Make a nice cup of coffee

and enjoy it

Negative mood

• Stay in bed

• Don’t have a shower

• Stay in pyjamas

• Think about paying a bill

• Go back to bed

• Miss out on meals

Volunteer-Led BA

• Staff in RACFs are often too busy to provide extra time or therapy to residents

• BA can be successfully implemented by paraprofessionals such as volunteers4, 7

• May benefit both the depressed resident and the volunteer

• Volunteer-led program is cost effective, using existing volunteer resources - including their enthusiasm - more effectively with a tailored evidence-based approach

4. Ekers et. al., (2014); 7. Richards et. Al., (2016)

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Traditional volunteering

engages the resident

while the volunteer is

present.

BA creates the

foundations for longer

lasting change.

BA helps the resident

plan for a pleasant and

meaningful week ahead,

so the benefits ‘spill over’

long after the volunteer

has left

Over to you again…

Using the handout please think about some

activity goals for yourself

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ACTIVITY SCHEDULE

More than just the blues

(PAW)

Pleasant Activities for Wellbeing

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What we wanted to do

1. To investigate the feasibility and acceptability of an eight-week, volunteer-led behavioural activation program

2. Find out whether it would improve the well-being of residents in residential aged care ?

Volunteer training

• Two half-day training workshops covering:– What is depression?

• The link between activities and depression

– What is behavioural activation?

• What is it?

• How does it work?

• How can we use it with aged care residents?

– Planning activities with residents

– Skills practice, demonstrations, role plays, homework

– Ideas for each week of the study

– Safety, what to do if concerned about a resident

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Design and measures

• Pre-post intervention study

• Measures of feasibility

Mobility

De Morton Mobility Index

(DEMMI)

Recruitment

• Volunteers:

• NARI’s volunteer database

• Current Benetas volunteers

• Aged care residents:

• Identified through discussion with staff

• If interested and eligible, approached by researcher for consent and screening

• Paired with a volunteer and met for 2x30 minutes each week

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General Session Structure* *flexible

Session Component Description

1. Review Homework Review resident’s activity schedule from the previous week. Discuss any

problems or issues that arose while using the activity schedule.

2. Help resident to notice links

between their behaviour and their

mood

Using the activity schedule, volunteers inquired about any links that the

resident noticed between their activities and mood.

3. Introduce and explore weekly

theme

Volunteers were provided with resources for six domains of pleasant

activities: Physical activity, relaxation, creativity, kindness, relationships

and savouring. From week three to eight, volunteers were invited to

introduce one of these themes to the resident, and explore a suitable

activity relating to the theme that could be scheduled for the week ahead.

4. Activity scheduling for the week

ahead

From week two onward, volunteers worked with the resident to plan

pleasant activities for the week ahead using an activity scheduling sheet.

Results: Participants

• 12 volunteers

• 18 residents

• Two Benetas sites

• Mean age: 84.6 for residents; 63.8 for volunteers

• Most were female

• Broad ethnic diversity

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Results: Depression

Results: Anxiety

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Results: Well-being

Resident comments

I'm consciously thinking about what

I'm doing and why. I'm making sure

that I do things. It’s good. (R002)

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• Volunteers

• Enjoyed program

• Indication of improvement in wellbeing

• Felt that the program gave additional focus and structure to what they are already doing

• But also emphasised how important the relationship with the resident was

• Staff

• Relief at additional support

Qualitative Results: Volunteers and staff

Volunteer comments

I would normally just go in

and talk, whereas this way,

you've got an agenda, what

you're going to try and do

with the time. (VO15)

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Implications

• An 8-week volunteer-led BA intervention was feasible and acceptable to depressed RACF residents

• Potential to be a relatively low cost, sustainable intervention that does not make heavy demands on staff time

• Mutual benefits to depressed RACF residents and volunteers

• Randomised Controlled Trial is warranted to expand on our promising early results

Workshop 19th Sept 2019

Aims:

• Disseminate outcomes of pilot project

• Discuss how the intervention could be improved and/or extended

• Gauge interest in a larger study

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Preliminary outcomes

Some suggested improvements:

• Improve matching – explicit criteria

• Additional training – booster session

• Involve residents as volunteers

• Involve students as volunteers

Suggestions for expansion

• PAW for family carers

• PAW at transition into aged care

Lots of interest in a larger study

Acknowledgements

• Volunteers

• Life style coordinators

• Residents

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References1. AIHW. (2013). Depression in Residential Aged Care 2008–2012. Canberra: AIHW.2. Simning, A., & Simons, K. V. (2017). Treatment of depression in nursing home residents without significant cognitive impairment: a

systematic review. International psychogeriatrics, 29(2), pp. 209-2263. Joo, J. H., Hwang, S., Abu, H., & Gallo, J. J. (2016). An Innovative Model of Depression Care Delivery: Peer Mentors in Collaboration with a

Mental Health Professional to Relieve Depression in Older Adults. The American Journal of Geriatric Psychiatry, 24(5), pp. 407-416. doi:https://doi.org/10.1016/j.jagp.2016.02.002 Retrieved from http://www.sciencedirect.com/science/article/pii/S106474811600155X

4. Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D., & Gilbody, S. (2014). Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis. PLoS ONE, 9(6), p e100100.

5. Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., . . . Gollan, J. K. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658.

6. Mazzucchelli, T. G., Kane, R. T., & Rees, C. S. (2010). Behavioral activation interventions for well-being: A meta-analysis. The Journal of Positive Psychology, 5(2), 105-121.

7. Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., . . . Kuyken, W. (2016). Cost and Outcome of BehaviouralActivation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. The Lancet, 388(10047), pp. 871-880.

8. Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., . . . Prince, S. E. (2000). A component analysis of cognitive–behavioral treatment for depression.

9. Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., . . . Gollan, J. K. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658.

10. Australian Bureau of Statistics. (2015). Causes of death. (No. 3303.0). Retrieved from http://www.abs.gov.au11. Murphy, B. J., Bugeja, L. C., Pilgrim, J. L., & Ibrahim, J. E. (2018). Suicide among nursing home residents in Australia: A national

population‐based retrospective analysis of medico‐legal death investigation information. International Journal of Geriatric Psychiatry, 33(5), 786-796. doi:10.1002/gps.4862

12. Pearce, J., Cherrie, M., Shortt, N., Deary, I., & Ward Thompson, C. (2018). Life course of place: A longitudinal study of mental health and place. Transactions of the Institute of British Geographers, 43(4), 555-572. doi:10.1111/tran.12246

13. Stargatt, J., Bhar, S. S., Davison, T. E., Pachana, N. A., Mitchell, L., Koder, D., . . . Helmes, E. (2017). The availability of psychological services for aged care residents in Australia: a survey of facility staff. Australian Psychologist, 52(6), 406-413.

14. Franck, L., Molyneux, N., & Parkinson, L. (2016). Systematic review of interventions addressing social isolation and depression in aged care clients. Quality of Life Research, 25(6), 1395-1407.

Feasibility OutcomesRecruitment Given that recruitment of older adults for psychology interventions is known to be slow and challenging (Moody

et al., 2008), we expected that just 50% of residents who were approached would be interested in participating in

the study. We deemed that approaching 40 prospective age-care residents, and recruiting approximately 20

residents (three to four residents per month) over a six-month recruitment period (July 2018 – Jaunary 2019)

would be evidence of feasible recruitment.

Acceptability On completion of the study, participants were asked to indicate their satisfaction with the intervention on visual

analogue scale from 1 (least satisfied) to 10 (most satisfied). Qualitative feedback from participants was also

collected at the conclusion of the final session.

Attrition An intervention completion rate of ≥ 85% has been deemed acceptable in previous studies of older adults with

physical conditions (Blandy, Beevers, Fitzmaurice, & Morris, 2015). Therefore, a feasible attrition rate was

determined to be 15% or less.

Safety Behavioural activation is a low-risk intervention, with no known risks. However, any adverse psychological and/or

physiological symptoms were recorded at each session. Volunteers were instructed to notify the research

coordinator immediately following any adverse events.

Data

collection

The research questionnaire was kept very brief, to minimize participant burden. We expected that data collection

would not be problematic, and that we would have minimal (<5%) missing data.

Fidelity The extent to which the volunteer facilitated activity scheduling with their assigned resident was taken as a

measure of treatment fidelity. Activity scheduling was measured via volunteer submission of activity scheduling

sheets and/or submission of notes outlining activity plans for the week ahead.