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Behavioural Activation for Depression Flashcards

1
Q

BEHAVIORAL ACTIVATION IN DEPRESSION

A
  • Behavioral activation (BA) is based on the behavioral model of psychopathology
  • Original model for behavioral therapy for depression developed from 1960 by Lewinsohn and Ferster
  • Principles of behavioral activation also part of cognitive (behavioral) therapy as developed by Beck
  • Renewed attention for BA after Jacobson’s famous component analysis
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2
Q

INTEGRATIVE MODEL (LEWINSOHN, 1985)

A

………..

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3
Q

FERSTER (1974)

A

“I think the conceptual formulation as well as the treatment of depression really depend upon focusing on the behaviors the patient is not engaged in … the most obvious aspect of depression is a marked reduction in the frequency of certain kinds of behavior and an increase in the frequency of others, usually avoidance and escape”

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4
Q

BEHAVIORAL ACTIVATION IN COGNITIVE THERAPY

A
  • Behavioral activation is an important part of cognitive therapy
  • Often the start of therapy
  • Especially indispensable for major depression
  • Structuring, planning and evaluating (mood, pleasure, satisfaction) of activities
  • Behavioral experiments
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5
Q

COMPONENT ANALYSIS JACOBSON (1996)

(Jacobson, N.S., et al., A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 1996. 64(2): p. 295-304.)

A
  • Which components of CT are most effective?
  • Three components: behavioral activation (BA), editing automatic thoughts (AT), editing schemas or core beliefs (CB)
  • RCT with three conditions: BA; BA+AT; BA+AT+CB (complete CT)
  • All three conditions are equally effective
  • can BA also be used as a stand-alone intervention?
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6
Q

FOLLOW-UP RESEARCH DIMIDJIAN (2006)

(Dimidjian, S., et al., 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, 2006. 74(4): p. 658-70. )

(Dobson, K.S., et al., Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of Consulting and Clinical Psychology, 2008. 76(3): p. 468-77.)

A
  • RCT with three conditions: BA, CT and antidepressants (ADM)
  • All three interventions equally effective
  • But: in moderate to severe depression, BA and ADM are equally effective, and slightly more effective than CT
  • Long term: BA and CT more effective in preventing relapse than ADM
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7
Q

BA BY MENTAL HEALTH NURSES (2011) Ekers, D. et al., Behavioural activation delivered by the non-specialist: phase II randomised controlled trial. The British Journal of Psychiatry, 2011. 198: p. 66-72

A
  • RCT with two conditions: BA provided by mental health nurses in primary care and usual care by the general practitioner
  • Behavioral activation is more effective than usual care
  • First proof that BA can also be performed by non-specialists
  • Major implications for the possibilities for implementation: is BA an easy to execute, relatively inexpensive intervention for depression?
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8
Q

BEHAVIORAL ACTIVATION VS. COGNITIVE

(THERAPY Richards DA, Ekers D, et al. (2016) Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. Lancet. Aug 27;388(10047):871-80.)

A
  • RCT (2016) with two conditions: BA provided by ‘junior mental health workers’ versus cognitive behavioral therapy provided by ‘psychological therapists’
  • In total 440 (!) depressed patients from the UK
  • Behavioral activation is just as effective as cognitive behavioral therapy
  • Behavioral activation is a simpler, cheaper psychological treatment than CBT, but the effect is apparently the same.
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9
Q

BEHAVIORAL ACTIVATION IN OLDER ADULTS

(Gilbody S et al (2017) Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression: The CASPER Randomized Clinical Trial. JAMA. Feb 21;317(7):728-737.)

A
  • RCT (2017) with two conditions: BA (as part of collaborative care) versus ‘usual care’ provided by general practitioner
  • In total 705 (!) older adults (65+) with depressive complaints from the UK
  • Behavioral activation more effective than usual care
  • So this vulnerable group of ‘older adults’ can also benefit from behavioral activation
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10
Q

META-ANALYSES OF BEHAVIORAL ACTIVATION

(Cuijpers, P., A. van Straten, and L. Warmerdam, Behavioral activation treatments of depression: a meta-analysis. Clin Psychol Rev, 2007. 27(3): p. 318-26.)

(Ekers, D., D. Richards, and S. Gilbody, A meta-analysis of randomized trials of behavioural treatment of depression. Psychol Med, 2008. 38(5): p. 611-23. Mazzucchelli, )

(T., R. Kane, and C. Rees, Behavioral activation treatments for adults: a meta-analysis and review. Clinical Psychology: Science and Practice, 2009. 16: p. 383-411.)

A

SUMMARY

  • Behavioral activation has a long history of origin
  • Behavioral activation is a proven effective intervention, even as a standalone approach
  • Behavioral activation appears to be very effective, particularly in the case of major depression
  • Non-specialists also seem to be able to apply behavioral activation effectively
  • Behavioral activation works for depressed adults and older adults
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11
Q

KEY ELEMENTS BEHAVIORAL ACTIVATION

A
  • Behavioral case conceptualization
  • Functional analysis: what sustains the depression?
  • Monitoring, planning and structuring activities
  • Attention to avoidance patterns
  • Attention to the regulation of healthy habits
  • Behavioral strategies to combat rumination
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12
Q

COURSE OF THERAPY IN BA

A
  • Treatment orientation
      • Rationale, functional analysis, and treatment goals
      • Role and cooperation between therapist and patient
  • Development treatment goals
  • Repeated application of activation and engagement strategies
  • ‘Trouble shooting’
  • Evaluation and consolidation of treatment results and progress
  • Behavioral strategies to combat rumination
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13
Q

STRUCTURE OF EACH SESSION

A
  • “How are you?”
  • Bridge to previous session (own notes of patient)
  • Determine the agenda
  • Look at homework and assignments
  • Discuss agenda items
  • New homework and assignments
  • Summary and feedback, by patient and therapist
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14
Q

TEN CORE PRINCIPES OF BA

A
  1. By changing what you do, you change your mood
    * outside-in: perform behavior first, then evaluate mood
  2. Life changes can lead to depression, and short-term strategies can cause people to get stuck in depression
  • Avoidance leads to short-term relief
  • TRAP: trigger, response, avoidance pattern
  • TRAC: trigger, response, alternative coping
  1. Possible ‘antidepressants’ (anti-depressive behavior) can be deduced from what precedes and what follows through important behavioral patterns (functional analysis)
  2. Structure and plan activity according to plan, not according to mood
    * Determine importance of goals in therapy
  3. Change is easier if you start small
    * All or nothing versus small steps
  4. Look for behavior that is ‘natural’ (of itself) and not artificially rewarding
  5. As a therapist act as a coach
  6. As a therapist, adopt problem-solving attitude and acknowledge that all outcomes are helpful
    * If it doesn’t work, what else can we come up with?
  7. Don’t just talk, act!
    * Discuss planned homework
  8. ‘Troubleshoot’ possible obstacles to activation
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15
Q

Ten core principles (first five)

A
  1. By changing what you do, you change your mood
    * outside-in: perform behavior first, then evaluate mood
  2. Life changes can lead to depression, and short-term strategies can cause people to get stuck in depression
  • Avoidance leads to short-term relief
  • TRAP: trigger, response, avoidance pattern
  • TRAC: trigger, response, alternative coping
  1. Possible ‘antidepressants’ (anti-depressive behavior) can be deduced from what precedes and what follows through important behavioral patterns (functional analysis)
  2. Structure and plan activity according to plan, not according to mood
    * Determine importance of goals in therapy
  3. Change is easier if you start small
    * All or nothing versus small steps
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16
Q

Ten core principles of BA (6-10)

A
  1. Look for behavior that is ‘natural’ (of itself) and not artificially rewarding
  2. As a therapist act as a coach
  3. As a therapist, adopt problem-solving attitude and acknowledge that all outcomes are helpful
    * If it doesn’t work, what else can we come up with?
  4. Don’t just talk, act!
    * Discuss planned homework
  5. ‘Troubleshoot’ possible obstacles to activation
17
Q

RATIONALE FOR BA AS AN INTERVENTION

A
  • Explain how the (social) environment, mood and activity interact with each other
    • Use behavioral activation model for this
  • Explain how a vicious cycle can arise between a depressed mood, avoidance, and withdrawal and a deteriorated depressed mood
  • Name activation as a means to break this vicious cycle
  • Explain the ‘Outside-in’ principle: act according to a predetermined goal or plan and not how you feel at that moment
  • Explain that it will take effort to change
18
Q

BEHAVIORAL CASE CONCEPTUALISATION

A
19
Q

BEHAVIORAL CASE CONCEPTUALISATION II

A
  • What are the most important problems?
  • Identify life events or other circumstances that led to the current problems
    • In present and past
  • Identify the depressive symptoms but also other complaints
  • Identify coping behavior, and determine to what extent this has become problematic and should therefore be part of the treatment
  • “depressive” behavior sustains the symptoms
  • Consider in advance what behavior can break the vicious cyle and work as “antidepressants”
  • List “enjoyable activities”
20
Q

SET GOALS

A
  • Important step during functional analysis !!!
    • Base for all further interventions
  • From a behavioral perspective: patients change their behavior to come into contact with ‘positive reinforcers’ in their environment
  • Other goals: breaking through avoidance patterns, breaking routine behaviors and establishing healthy behaviors; changing environmental factors
  • Distinction between short and long term goals
  • Make goals and required behavioral changes specific, focused, and testable
21
Q

BEHAVIOR ANALYSIS (A-B-C-SCHEME)

A
22
Q

UNDERSTANDING CONSEQUENCES

A
  • Negative reinforcement: behavior is reinforced because something disappears from the “environment”
    • Watching television negatively reinforced by numbing negative emotions
  • Positive reinforcement: behavior is reinforced because something is added to the “environment”
    • Waking up on time positively reinforced by a loving comment from partner
  • Punishment: behavior is unlearned because an aversive consequence is added to the “environment”
    • Asking for help is punished by a critical, judgmental reaction from the other
23
Q

REGISTRATION OF ACTIVITIES

A

Rate your mood (M), pleasure (P) satisfaction (S)

24
Q

GENERAL APPROACH BEHAVIORAL ACTIVATION

A
  • Determine basic level of activities
  • Make a connection between activity and depressed mood
  • Make a connection between activity and other emotions
  • Plan concrete activities; step-by-step and in small units
  • Monitor progress and achievement of the set goals
25
Q

BA IS ALSO ROUTINE REGULATION

A
  • Basic conditions for a healthy life
  • Rest, cleanliness and regularity
  • State the need for a fixed structure for (adequate) sleep, (healthy) eating, working, going to school
  • Begin structuring activities with these type of basic behavioral changes
  • Monitor progress and achievement of the set goals
26
Q

STRATEGIES FOR BEHAVIORAL ACTIVATION

A
  • Make plan as concrete as possible (what, when, where, with who?)
  • Use ‘public commitment’ with commitment social environment
  • Celebrate every minimal progress like a cheerleader (!)
  • Make sure that plans are gradual, step-by-step, and feasible
  • Choose plans with high success rate
  • Return to rationale of functional analysis if you get stuck
  • Be consistent, persistent and solution-oriented
  • Even if plans are not implemented, it provides valuable information
27
Q

STRATEGIES AGAINST RUMINATION

A
  • Rumination: repetitive and passive thinking about negative emotions, with a focus on the symptoms (“I feel so bad”) and worrying about the meaning of the complaints (“will I ever be okay?”)
  • Cognitive therapy attempts to change the content of those thoughts
  • In behavioral activation rumination is strictly seen as avoidant behavior, and is therefore addressed behaviorally
  • Problem solving as a strategy against rumination
  • Shifting attention to experience (mindfulness) as a strategy
28
Q

PROBLEM SOLVING

A
  • Problem solving as a specific strategy within BA to tackle avoidance and flight behavior
    1. What is the problem?
    2. What do you want to change/achieve (goals)?
    3. What are possible solutions (brainstorming)?
    4. Which solution do you choose (implementation)?
    5. How does the solution work out (evaluation)?
  • Problem-solving therapy as a stand-alone intervention
29
Q

RELAPSE PREVENTION

A
  • Generalization of learned behavior to a different context
  • Systematically implemented behavioral activation is essentially relapse prevention
  • have patients take notes from the first session onwards
  • Coaching role of therapist (“learn to become your own therapist”)
  • Make a relapse prevention plan towards the end of therapy (workbook)
  • Use booster sessions to evaluate and adjust elements of a relapse prevention plan
30
Q

COGNITIVE MODEL (BECK, 1979)

A
31
Q

EXAMPLE RATIONALE for BA AS AN INTERVENTION

A

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