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Manage Your Mood: Behavioural Activation for Depression

Manage Your Mood: Behavioural Activation for Depression. David Veale. Learning objectives. Describe NICE guidelines depression Understand theory and principles of Behavioural Activation (BA) Describe and use functional analysis. Screening for depression. “During the past month….

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Manage Your Mood: Behavioural Activation for Depression

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  1. Manage Your Mood: Behavioural Activation for Depression David Veale

  2. Learning objectives • Describe NICE guidelines depression • Understand theory and principles of Behavioural Activation (BA) • Describe and use functional analysis

  3. Screening for depression “During the past month…. • Have you often had low energy? • Have you often felt down? • Have you often had little interest or pleasure in doing things? • Have you often felt hopeless?” • If yes, to any question, ask...

  4. Screening for depression • Have you had difficulty concentrating? • Have you lost weight or had a poor appetite? • Have you been waking early? • Have you felt slowed up? • Have you tended to feel worse in the mornings? • Yes to 3 or more, Dx depression 85% sensitivity & 90% specificity – can be atypical increased sleep and comfort or binge eating

  5. Diagnosis depression • Adolescent – more behavioural symptoms and irritability • Elderly – more somatic symptoms • Cultural – somatic symptoms may predominate • Always exclude alcohol & substance abuse

  6. Screening questionnaires PHQ - 9 for depression (> 10) GAD - 7 for anxiety ( >10)

  7. Themes in depression • Loss • Inter-personal conflict • Change of role in life • Deficits in life • Failure to achieve an ideal and highly self-critical

  8. Suicide • Always ask about suicidal ideation • Do you sometimes feel as if you’d like to end it all? • Tell me about those feelings… • How long have you had these feelings? Do you have a specific plan for your method? • Have you told anyone? • What’s stopped you so far? • Have you left you affairs in order? • Have you prepared a note?

  9. Suicide Risk factors: • Significant depression or delusions; alcohol or substance abuse; • Hopelessness and sense that family would be better off ; • an organized plan or easily available method • absence of protective factors (religion, loved ones) • regret at survival from a recent attempt • attempt to avoid discovery from recent attempt

  10. Who is responsible for care? What do they do? Acute Wards Risk to Life Medication,ECT nursing care CMHT, OPD, crisis team, Day Hospital Treatment resistance frequent recurrences Medication, complex Psychological i.v’s PCMHW, GP, Counsellor, social worker, psychologist Moderate or Severe Depression Medication,Brief psych. interventions, support groups GP, Practice nurse, Practice counsellor Mild Depression Active Review: Self Help, Computerised CBT, Exercise Recognition Why do they do it?

  11. Consider 2 young unmarried female patients; both aged 18; both with a Ham-D score of 24 Patient 1: is a lone mother Parents divorced Mother was depressed Sexual abuse since age 11 Left home age 14 Casual sex since Depressed for 2 years Recently worse since child taken into care

  12. Consider 2 young unmarried female patients; both aged 18; both with a Ham-D score of 24 Patient 1: is a lone mother Parents divorced Mother was depressed Sexual abuse since age 11 Left home age 14 Casual sex since Depressed for 2 years Recently worse since child taken into care Patient 2: university student Supportive parents No FH of depression Many friends Affair with boyfriend last 2 years He recently left with another girl Depressed for 2 weeks since he left

  13. Mild depression Guided self-help[A] Physical exercise [B] Problem solving [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort (with reservations)[B] AD’s not recommended for initial Rx of mild depression [C]

  14. When “watchful wait” ? • Less than 2 weeks • Symptoms mild and intermittent • Good social support • No family history of depression • No past history of depression

  15. Mild depression Guided self-help[A] Physical exercise [B] Problem solving or counselling [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort (with reservations)[B] AD’s not recommended for initial Rx of mild depression [C]

  16. Guided self-help based on CBT – David Burns- Feeling Good http://www.feelinggood.com/

  17. Overcoming depression Chris Williams Guided self help CBT Published in UK Also CD ROM http://http://www.fiveareas.com/

  18. Guided self-help using BA • Sleep management • Eating healthily • Problem Solving • Exercise • Alcohol, substances • St John’s Wort • Medication

  19. “Guided” self-help • Usually done with “low intensity” therapist (with support over telephone) • Books on prescription scheme • If use, read book yourself and refer to it in f/u consultations • Agree with patient chapters to read and homework to do before next session • Ask to see homework at next consultation

  20. Mild depression Guided self-help[A] Computerised CBT [B] Physical exercise [B] Problem solving or counselling [B] “watchful waiting” [GPP] St. John’s Wort (with reservations)[B] AD’s not recommended for initial Rx of mild depression [C]

  21. Computerised CBT NICE Technology appraisal, 2002 • Calipso (Leeds) CD • COPE (ST Solution) CD • Beating the Blues (Ultrasys) • Restoring the Balance (Mental Health Foundation) • Mood Gym on Web FREE http://moodgym.anu.edu.au/

  22. Mild depression Guided self-help[A] Physical exercise [B] Problem solving or counselling [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort (with reservations)[B] AD’s not recommended for initial Rx of mild depression [C]

  23. Physical exercise • Dose 45-60 minutes, 3 times a week for 12 weeks but not related to aerobic fitness • Adherence – just telling your depressed patient to exercise not effective • RCT are different (selection bias, enthusiastic trainer, often group) • Choice of exercise may relate to one’s personality?

  24. Mild depression Guided self-help[A] Physical exercise [B] Problem solving or counselling [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort (with reservations)[B] AD’s not recommended for initial Rx of mild depression [C]

  25. St John’s Wort • Hypericum perforatum • 300-600mg recommended daily dose • Bought over the counter • Improvement should occur within 3-5 weeks • Continue for at least 6 months • BUT Induces CYP450 (warfarin, coumadin, theophylline, digoxin, contraceptive pill) • St John’s Wort Helpline 01803 528 668

  26. Mild depression Guided self-help[A] Physical exercise [B] Problem solving or counselling [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort(with reservations)[B] AD’s not recommended for initial Rx of mild depression [C]

  27. Severity of depression and placebo response in adults Per cent response Baseline HAM-D Angst (1993)

  28. Meta-analysis of 4 anti-depressants Kirsch (2008) included studies FDA including never published Fluoxetine, venlafaxine, nefazodone, paroxetine Only severe depression (>28) met clinical significance criteria above placebo response Culture from neurotransmitters to context

  29. Drug treatments in PCFirst line treatment SSRI’s are 1st line AD’s [A] Continue treatment for 6/12 [A] Fluoxetine cheap, fewest discontinuation symptoms of SSRIs but interact [C] Avoid venlafaxine as 1st line Rx [B] Avoid paroxetine as 1st line Rx [B]

  30. Counselling • For mild to moderate depression, recent onset (not chronic depression) • Insufficient evidence for benefit at f-u at 6 months • 6-8 sessions over 10 weeks • Counselling is a generic term and covers many different types from “support”, psychodynamic to problem solving

  31. Psychological treatments for moderate depression Problem solving or counselling [B] If psychological treatment preferred, CBT or IPT [A]

  32. Increasing Access to Psychological Therapies (IAPT) • Waiting lists for psychological therapies excessively long • DoH plan to train and employ about 1000 therapists per annum (60% CBT / 40% low intensity) £171m over 3 years • Pilot sites Doncaster/ Newham • Depression & anxiety disorders • Primary & secondary care - supervision from centre • Partly funded by reduction in incapacity benefit and unemployment?

  33. Behavioural Activation • Core competency in both CBT and low intensity therapists in new centres • Skills probably more easily transferable than CBT • Increasing evidence base • Therapists not enthusiastic as it lacks complexity!

  34. Learning Theory Ferster (1973) Depression characterized by 1) low rate of positive reinforced behaviour (eye contact, verbal behaviour, eating and in pleasant or satisfying activities) 2) high rate of escape and avoidance of aversive stimuli (thoughts, images, feelings or external situations) by complaining, help-seeking, suicidal behaviours, social withdrawal reinforced

  35. Evolution of BA Lewinsohnet al (1974, 1976) • increase the frequency of both pleasant activities and positive interactions with their social environment • to decrease intensity and frequency of unpleasant events and improve social skills in obtaining reinforcement RCTs showed benefit but emergence of Cognitive therapy 1980s.

  36. Cognitive Therapy A.T. Beck – CBT for depression uses Activity Scheduling in early stage. Aim of Activity Scheduling to target passivity but also elicit and change thoughts.

  37. Meta-analyses(Cuijpers, 2006; Ekers, 2007) 17 studies, n >1000 No difference in efficacy between behaviour therapy (activity scheduling) and cognitive behaviour therapy for depression in adults.

  38. Dismantling study CBT BT v CT v CBT (Jacobson, Martell, 1996) n=150 depression outpatients BT – Activity Scheduling CT – Negative Thought records CBT – Combined standard treatment Equally effective after treatment (50% recovered) and 2 year fu.

  39. “BA II not simply about increasing positive activity – but trying to discover through functional analysis what is maintaining a person’s depression and teaching client’s about the functional aspects of their behaviour “ Learn underlying principles – not session by session instructions.

  40. Behavioural Activation IIDimidjian, et al, Journal of Consulting and Clinical Psychology (2006) 241 out patients Major Depressive episode in USA HDRS> 14, BDI > 20, age 18-60, 2/3 female, 33% duration >12m, 28% comorbid

  41. Behavioural ActivationDimidjian, et al, Journal of Consulting and Clinical Psychology (2006) RCT of BA (n=43) v CBT (n =45) v paroxetine (n=100) v placebo (n=53) (compared at 8 weeks) BA v CBT v paroxetine (at 16 weeks) BA or CBT had maximum 24 sessions Paroxetine/placebo had maximum 8 sessions up to 50mg, mean 35mg Higher drop out rate in paroxetine

  42. Behavioural Activation BA = CBT = paroxetine = placebo for mild depression at 8 weeks BA = paroxetine > CBT for severe depression at 16 weeks Predictors of poor outcome any treatment - chronicity, unemployment, poor social support

  43. Continuation phase & Cost effectiveness N= 106 responders Paroxetine randomly reassigned continue paroxetine or placebo CBT = BA = paroxetine at 12/ 24 months Discontinue paroxetine higher risk relapse at 12/24 months At 6 months, paroxetine more expensive

  44. Behavioural Activation • Engage patient and good relationship • Functional analysis & Formulation • Gradually structure day, timetable activities and act according to a plan rather than how they feel (e.g. when I am motivated) • Non engagement in ruminations • No search for internal causes or focus on content • Review homework and agree agenda one or two items and negotiate new homework • Therapist is empathic coach

  45. Functional Analysis ABC Model page 64 A - Activating event/ context which is aversive B - Behaviour (what a person does) which is reinforced C - Consequences - Immediate reduction in aversive stimuli or an increase in desired stimuli which reinforces behaviour - Unintended (long-term) undesired

  46. What do depressed people avoid and escape ? • withdrawn • not answer telephone • conflict • inactive • challenging tasks • self-care/ grooming • untidy What are the consequences?

  47. Inter-personal behaviours in depression • Head down, poor eye contact • Complaining, moaning • Verbalizing self-criticism • Verbalizing self-pitying • Body language What are the consequences on others?

  48. Excessive behaviours that might function as avoidance • TV • Playing on internet • Gambling • Comfort-eating; • Excessive exercise; • Alcohol and other substances • Sex • Excessive tidying and ordering What are the unintended consequences ?

  49. What might one avoid thinking about in depression? Avoid thinking about problems in relationships, family issues, try not to figure things out Avoid thinking future, making decisions, taking opportunities, not serious about work/education or what to do in life

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