Lecture 11 - Behavioural Activation for Depression

Question 1

What are behavioural models of depression? What did Ferster and Lewinsohn say were the causes of depression?

Answer 1

➢Depression associated with a particular behaviour-environment relationship that evolves over time
➢Focused on “if-then” contingencies –what are the consequences of the behaviourfor the person?

➢Ferster: Decreased rates of response-contingent reinforcement lead to:
1) “turning inward”;
2) “doing nothing”;
3) escape and avoidance

➢Lewinsohn: Social avoidance core to depression

Question 2

How does the behavioural activation model work?

Answer 2

➢Behavioural responses reduce ability to experience positive reward from environment
➢Treatment focuses on activation and processes that inhibit activation, such as escape and avoidance behaviours and ruminative thinking

CBT was originally developed for depression
Behavioural activation = Variation often incorporated but also treatment on its own (without cognitive component)
Lack of reward

Feeling depressed leads to feeling inside, withdrawing from friends, stopping activities, etc. which then feed into the depression. Vicious cycle

Question 3

What is the Behavioural Activation treatment?

Answer 3

➢Review activity monitoring form to look for contingencies maintaining behaviour
▫Positive reinforcement from friends/family…The positive reinforcement from friends and family isn’t necessarily positive! It’s reinforcing the depressive symptoms
▫Negative reinforcement through escape/avoidance of painful feelings

➢Use activity monitoring to design intervention
▫What would client be doing if (s)he were not depressed?
▫What is relationship between specific activities and ratings of mastery and pleasure?
In the daily monitoring form, record all activities (even if regular) and rate mastery and pleasure
▫What is the relationship between specific life contexts/problems and ratings of mastery and pleasure?
▫How are avoidance and withdrawal contributing to depression?

➢Activity scheduling
▫Use monitoring forms to schedule activities for the week
▫Help client maximize success!
Public commitment… having other people to hold you accountable
Structure environment… ex: trying to workout, put workout clothes beside the door to remind you. Preparing to be able to carry out the thing
Arbitrary reinforcers… rewarding yourself by doing something that you like. Ex: went to the gym and now I get to buy a treat. Natural reinforcers better but still
Aversive contingencies… punishment if you don’t do the thing. Not ideal but a possibility
▫Record context and consequences of activation= ratings of mastery and pleasure
▫Gather information about incomplete homework to understand barriers and avoidance patterns

➢ACTION!
▫Targeting avoidance of tasks, emotions, interpersonal conflicts, etc.
Assess whether the behaviour is approach or avoidance
Choose to continue the behaviour, even if it is making you feel worse, or to try a new behaviour
Try the behaviour chosen
Integrate a new behaviour into your routine –give it a fair chance
Observe the results –monitor the effects of the new behaviour
Never give up! Change requires repeated efforts and attempt

Question 4

Engagement strategies

Answer 4

➢Engagement Strategies
▫Rumination prevents people from engaging with their activities and environments
▫Unlike cognitive therapy, don’t care about content of rumination
▫If client does not experience pleasure in an activity (s)he normally would, explore level of engagement
▫Rumination can be negatively reinforced!▫Attention to experience

Question 5

What is the evidence? Describe the Dimidjian article.

Answer 5

➢Dimidjian et al. (2017)

Not an efficacy trial, but effectiveness

▫Pragmatic effectiveness randomized controlled trial conducted at four sites across USA
▫163 pregnant women randomized to behavioural activation (BA) or treatment as usual (TAU)
▫BA: 10 sessions provided in clinic, by phone, or in women’s homes by health care professionals naïve to BA

▫Primary outcomes: change in symptoms and remission rates based on Patient Health Questionnaire (PHQ-9)

▫Secondary outcomes: anxiety, stress, treatment satisfaction

▫Changes in activation and environmental reward early in treatment would mediate association between treatment condition and improvement in depression symptom

▫Depression symptoms were lower in the BA vs. the TAU condition at all follow-up time points; d= 0.34
▫56.3% remission in BA vs. 30.3% remission in TAU
▫Anxiety: d= 0.41; Stress: d= 0.33
▫Change in engagement and environmental reward early in treatment mediated effect of treatment condition on follow-up improvement in depression symptoms
▫BA is a scalable behavioural intervention that can help improve depression during pregnancy, consistent with women’s preferences for psychological vs. pharmacological interventions

Summary:
What were the characteristics of the sample?
-Pregnant women receiving treatment at one of 3 health clinics
Who delivered the BA treatment?
-Nurses, nurse practitioners, people with a master’s degree in behavioural health, occupational therapist
What were the two potential mediators studied?
-extent of activation and experience of environmental reward
What are the implications of the study?
-brief psychosocial treatment for depression, can be delivered in-clinic to pregnant women to help prevent consequences of prenatal depression

▫Dimidjianet al. (2006): Journal of Consulting and Clinical Psychology
Among moderate-to-severely depressed patients, BA was superior to cognitive therapy and equivalent to or superior than antidepressant medicatiion

Question 6

Other evidence?

Answer 6

▫Ekerset al., (2014): PLOS ONE
Meta-analysis of 26 RCTs; BA superior to control conditions and to antidepressant medication
▫Richards et al. (2016); The Lancet
BA delivered by junior mental health workers was not inferior to CBT delivered by psychological therapists