Behavioral activation in acute inpatient psychiatry: a multiple baseline evaluation

Behavioral activation for depression in groups embedded in psychosomatic rehabilitation inpatient treatment: a quasi-randomized controlled study

Background

Behavioral activation (BA) and cognitive-behavioral therapy (CBT) have shown to be efficacious treatment methods for depression. Previous studies focused mostly on the outpatient treatment either in group or individual setting. The present study aimed at comparing the efficacy of group treatment BA vs. CBT, when embedded in inpatient psychosomatic rehabilitation treatment.

Methods

375 inpatients were randomly assigned to either BA (N = 174) or CBT (N = 201). We used established scales for depression such as the Beck Depression Inventory II (BDI-II, self-rating), the Quick Inventory of Depressive Symptomatology (QIDS; expert rating) and the Behavioral Activation for Depression Scale (BADS) to assess changes over the course of the treatment and at follow-up (4 to 6 months). In addition, we measured disability-related functioning with the Mini-ICF-APP, a rating scale built in reference to the International Classification of Functioning, Disability and Health (ICF). Multilevel models with repeated measures were conducted to examine the differences between groups in relation to change over time with patients' random effects.

Results

Both group formats showed substantial reduction in depressive symptoms at the end of treatment (d= 0.83 BA vs. d= 1.08 CBT; BDI-II) and at follow-up after 4 to 6 months (d = 0.97 BA vs. d = 1.33 CBT, BDI-II; and d = 1.17 BA vs. d = 1.09 CBT, QIDS). There were no significant differences between treatment approaches. At least 50% symptom reduction was achieved by 53.7% and 54.2% in BA vs. CBT respectively. Reported activation levels increased from pre- to posttreatment (d = 0.76 BA vs. d = 0.70CBT), while showing loss of increment between the end of the treatment until follow up in both formats (d = 0.28 BA vs. d = 0.29 CBT).

Discussion

Both modalities led to significant improvement of symptomatology and functioning at the end of the treatment and at follow-up, thus for the first time demonstrating the practicability of BA in rehabilitation clinics. Considering its lower requirements regarding cognitive abilities and its easier implementation, BA proved to be a good alternative to other psychotherapeutic treatments.

Functioning of the EROS-R Scale in a Clinical Sample of Psychiatric Patients: New Psychometric Evidence from the Classical Test Theory and the Item Response Theory

Reliable and valid assessment instruments that can be applied briefly and easily in clinical and outpatient settings that provide information about the sources of reinforcement that the patient finds in his life are especially relevant in therapy. The study aimed to evaluate the psychometric properties of the Environmental Reward Observation Scale (EROS-R) in a sample of psychiatric patients. A sample of 228 psychiatric patients of both sexes (56.1% men and 43.9% women) aged between 18 and 70 years was selected. Along with the EROS-R, other instruments were administered to assess depression and anxiety. The results show that the scale fits a unidimensional model, presenting adequate fit indices (RMSEA = 0.077 (IC 90% 0.055−0.100); SRMR = 0.048; CFI = 0.98; TLI = 0.98). It was also shown that the degree of reward provided by the environment (EROS-R) correlates negatively with the level of depression (ρ = −0.54; p < 0.01) and anxiety (ρ = −0.34; p < 0.01). From the IRT perspective, all the items present adequate discrimination indices, where item 4 is the most precise indicator to measure the degree of environmental reward. All this leads us to conclude that the EROS-R is an instrument with robust psychometric guarantees from TCT and IRT’s perspectives, making it suitable for use in clinical contexts.

Exploring how to improve access to psychological therapies on acute mental health wards from the perspectives of patients, families and mental health staff: qualitative study

BACKGROUND

Psychological therapy is core component of mental healthcare. However, many people with severe mental illnesses do not receive therapy, particularly in acute mental health settings.

AIMS

This study identifies barriers to delivering and accessing psychological therapies in acute mental health settings, and is the first to recommend how services can increase access from the perspectives of different stakeholders (staff, patients and carers).

METHOD

Sixty participants with experiences of acute mental health wards (26 staff, 22 patients and 12 carers) were interviewed about barriers to accessing therapy in in-patient settings and how therapies should be delivered to maximise access.

RESULTS

Four themes were identified: (a) 'Models of care', including the function of in-patient wards, beliefs about the causes of mental health problems and the importance of strong leadership to support psychosocial interventions; (b) 'Integrated care', including the importance of psychologists being ward-based, as well as having strong links with community teams; (c) 'Acute levels of distress', including factors that aggravate or ameliorate the impact of this on engagement in therapy; and (d) 'Enhancing staff capability and motivation', which is influenced by contextual issues.

CONCLUSIONS

It is possible to improve access to therapy through strong leadership (that is supportive of talking treatments), flexible delivery of therapy (that considers short admissions) and a whole-systems approach that promotes ward staff understanding of the psychosocial causes of mental illness and staff well-being. It is essential to ensure continuity between in-patient and community therapy services, and for wards to have physical space to carry out therapy.

Staff experiences related to implementation of a recovery-oriented nursing programme in psychiatric inpatient care

Nursing in psychiatric inpatient care is peripheral to a dominating biomedical model of care. Efforts are being made to implement nursing models based on core values and theories for nursing, such as recovery-oriented practices. The aim of the study was to explore experiences of a recovery-oriented nursing programme (Steps Towards Recovery, STR) among nursing staff in psychiatric inpatient care and their ratings of stress (Maslach Burnout Inventory scores), quality of care (Quality of Psychiatric Care - Inpatient staff scores) and satisfaction with nursing care (Satisfaction with Nursing Care and Work scale scores), before and after the implementation-and compare with ratings from reference wards. A quasi-experimental and prospective, pretest-post-test design was used. Specific questions about the nursing programme were answered by staff at the intervention wards. Staff reported predominantly positive experiences of the nursing programme. At follow-up, higher ratings were reported in two dimensions of quality of care in the STR group, and lower ratings in one dimension of stress were evident in the reference group. No differences in ratings between the STR and reference wards were found. Staff members' positive experiences of STR and higher ratings regarding participation and secure environment after implementation suggest that STR is a well-accepted and promising nursing programme. It is important to implement and evaluate recovery-oriented interventions in psychiatric inpatient care, where a focus on symptom relief still prevails. The results indicate that there is potential for further exploration of STR in this context.

Effectiveness of a web-based behavioural activation intervention for individuals with depression based on the Health Action Process Approach: protocol for a randomised controlled trial with a 6-month follow-up

INTRODUCTION

Behavioural activation is a highly effective treatment for depression. However, there is considerable heterogeneity of interventions grouped under the term 'behavioural activation'. A main reason for the heterogeneity is the lack of a unified theory in the intervention development: few of the established intervention manuals give a theoretical rationale for their intervention techniques. For the first time, this study will examine the effectiveness of a theory-based behavioural activation intervention (InterAKTIV) based on the Health Action Process Approach. The intervention is implemented online to ensure broad dissemination and standardisation.

METHODS AND ANALYSIS

In a two-arm randomised controlled trial, the effectiveness of a guided web-based behavioural activation intervention for people with depression will be evaluated. Participants are recruited via the print and online media of a large German healthcare insurance company. Individuals (age 18-65), who meet criteria for major depressive episode in a clinical interview and no exclusion criteria are eligible for inclusion. A target sample of 128 participants is randomly allocated to either the intervention group (immediate access to InterAKTIV) or treatment as usual (access after follow-up assessment). The primary outcome of depressive symptom severity (Quick Inventory of Depressive Symptomatology Clinician Rating) and secondary outcomes, including behavioural activation, physical activity and motivational and volitional outcomes are assessed at baseline, post treatment and 6-month follow-up. Data will be analysed on an intention-to-treat basis with additional per-protocol analyses.

ETHICS AND DISSEMINATION

This trial is approved by the ethics committee of the Albert-Ludwigs-University of Freiburg (no.: 20-1045). All participants are required to submit their informed consent online before study inclusion. The results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

This trial was registered in the German Clinical Trials Register (DRKS): DRKS00024349 (date of registration: 29 January 2021).

How Does Behavioural Activation Work? A Systematic Review of the Evidence on Potential Mediators

INTRODUCTION

Behavioural activation is an effective treatment for depression, but little is known about its working mechanisms. Theoretically, its effect is thought to rely on an interplay between activation and environmental reward.

OBJECTIVE

The present systematic review examines the mediators of behavioural activation for depression.

METHODS

A systematic literature search without time restrictions in Medline, EMBASE, PsycINFO, The Cochrane Library, and CINAHL resulted in 14 relevant controlled and uncontrolled prospective treatment studies that also performed formal mediation analyses to investigate their working mechanisms. After categorising the mediators investigated, we systematically compared the studies' methodological quality and performed a narrative synthesis of the findings.

RESULTS

Most studies focused on activation or environmental reward, with 21 different mediators being investigated using questionnaires that focused on psychological processes or beliefs. The evidence for both activation and environmental reward as mediators was weak.

CONCLUSIONS

Non-significant results, poor methodological quality of some of the studies, and differences in questionnaires employed precluded any firm conclusions as to the significance of any of the mediators. Future research should exploit knowledge from fundamental research, such as reward motivation from neurobiology. Furthermore, the use of experience sampling methods and idiographic analyses in bigger samples is recommended to investigate potential causal pathways in individual patients.

Explaining the efficacy of an internet-based behavioral activation intervention for major depression: A mechanistic study of a randomized-controlled trial

Background

Behavioral activation is an effective treatment for depression that is theorized to facilitate structured increases in enjoyable activities that increase opportunities for contact with positive reinforcement; to date, however, only few mechanistic studies focused on a standalone intervention.

Method

Interventions using internet-based behavioral activation or psychoeducation were compared based on data from a randomized-controlled trial of 313 patients with major depressive disorder. Activation level and depression were measured fortnightly (baseline, Weeks 2, 4, 6, 8, 10), using the Patient Health Questionnaire-9 and the Behavioral Activation for Depression Scale-Short Form, respectively. Analysis was performed to determine if a change in activation level mediated treatment efficacy.

Results

Latent growth modeling showed that internet-based behavioral activation treatment significantly reduced depressive symptoms from baseline to the end of treatment (standardized coefficient = −.13, p = .017) by increasing the rate of growth in the activation level (mediated effect estimate = −.17, 95% CI [−.27, −.07]. Results from mixed effects and simplex models showed that it took 4 weeks before mediation occurred (i.e., a significant change in activation that led to a reduction in depressive symptoms).

Conclusion

Activation level likely mediated the therapeutic effect of behavioral activation on depression in our intervention. This finding may be of significant value to clinicians and depressed individuals who should anticipate a 4-week window before seeing a prominent change in activation level and a 6-week window before depressive symptomatology reduces. Future research must consolidate our findings on how behavioral activation works and when mediation occurs.

Psychometric evaluation of the Behavioral Activation for Depression Scale-Short Form in Alzheimer's caregivers

The present study evaluated the psychometric properties of scores from the Behavioral Activation for Depression Scale Short Form (BADS-SF) in a sample of older age, spousal, Alzheimer's caregivers participating in an evaluation of Behavioral Activation (BA) therapy compared to an Information Support (IS) group. At baseline assessment, caregivers (N = 170) completed the BADS-SF, which is comprised of two subscales (Activation and Avoidance) that can be summed to produce a total score. Confirmatory factor analysis was used to evaluate structural validity. A two-factor solution fit the data adequately; however, the first item on the scale did not load onto either factor. Internal consistency reliability for the total and subscales scores was poor as measured by Cronbach's alpha. Construct validity was evidenced by significant expected relationships with depression. Pre- to post-intervention scores did not evidence sensitivity to change. These findings provide some support but raise important concerns about the validity and reliability of BADS-SF scores in a population of older adult caregivers.

A systematic review of the implementation of psychological therapies in acute mental health inpatient settings

OBJECTIVES

Research has demonstrated that psychological therapies are not routinely delivered in acute mental health inpatient settings despite being recommended by the National Institute for Health and Care Excellence (NICE) guidelines. This study aimed to identify the barriers and facilitators to implementing psychological therapies in acute mental health inpatient settings.

METHODS

A systematic review and narrative synthesis was undertaken. Primary studies were included if they examined the implementation of a NICE recommended psychological therapy in acute psychiatric inpatient settings and were of any study design. Four databases were searched for eligible studies (MEDLINE, CINAHL Plus, PsycINFO and Embase) and Google Scholar.

RESULTS

A total of 16 studies (a mixture of both qualitative and quantitative methodologies) were included in the review, and the majority evaluated the implementation of Cognitive Behaviour Therapy. Overall, the literature was deemed to be of poor to moderate quality. The main barriers to the implementation of psychological therapy were the busy nature of the ward, multi-disciplinary professionals not being suitability trained and the acute nature of service users mental health difficulties. Facilitators to implementation included the adaptation of interventions to be specifically delivered in the acute inpatient setting, training of multi-disciplinary professionals, leadership support with the delivery of psychological therapies and prioritising the therapeutic relationship.

CONCLUSIONS

There is a requirement for senior management to prioritise the implementation of psychological therapies and update clinical guidelines to describe modifications necessary to implement psychological therapies in acute inpatient settings. Future research should improve their methodological quality and continue to develop the evidence base of brief psychological therapies in acute inpatient settings.

Behavioral Activation as a Mechanism of Change in Residential Treatment for Mood Problems: A Growth Curve Model Analysis

Research on the efficacy, effectiveness, and dissemination potential of behavioral activation (BA)-focused interventions for depression and comorbid disorders has expanded rapidly. However, research that examines how BA interventions work has seen less growth. A primary purported mechanism of BA is activation, which reflects a person's meaningful (re)engagement in life. BA theory posits that depression will decrease as activation increases, and that changes in the mechanism variable will lead to changes in outcome. The current study aims to investigate activation as a potential mechanism of change in the context of a BA-focused residential treatment intervention for mood problems using repeated measures of self-reported activation and depression from a large comorbid sample (N = 578). Growth curve modeling was used to examine between-person differences in within-person change over time. Findings suggest that self-reported activation increases and depression decreases over time. Moreover, results show both linear and quadratic growth and that the rate of change in activation predicts the rate of change of depression. BA-focused residential treatment may facilitate activation, which exerts an effect on depression among residents with diagnostically complex presentations.

Time-intensive behavioural activation for depression: A multiple baseline study

BACKGROUND AND OBJECTIVES

Depression is the second leading cause of disability, worldwide, and increasing access to its effective/preferred treatment requires more attention. Behavioural activation and time-intensive treatment delivery both show promise in this regard, yet research into their combination is limited. This study aimed to investigate the feasibility, effectiveness, and acceptability of time-intensive behavioural activation (BA) for depression METHODS: Eight adults with major depressive disorder were recruited from three outpatient IAPT services in London. The study employed a single case experimental design with multiple baselines. All participants completed time-intensive BA, consisting of up to seven twice weekly sessions with daily prompting in-between and three optional booster sessions. Idiographic, standardised and process measures of depression symptomatology were collected.

RESULTS

Treatment recruitment and retention indicated that the intervention was feasible. Visual and statistical analyses showed that relative to baseline, 6 out of 8 participants made significant improvements in all idiographic symptoms of depression following the intervention. According to standardised measures of depression, four out of eight participants were considered treatment responders. Five participants completed follow-up measures and the majority of progress was maintained after the withdrawal of the intervention. The intervention was also considered highly acceptable by participants and therapists.

LIMITATIONS

Conclusions cannot be drawn about the generalizability or the long-term durability of the findings CONCLUSIONS: Overall this study provides new, but tentative evidence highlighting the potential of time-intensive BA as a feasible, effective and acceptable treatment for some adult outpatients with depression. The findings now warrant further, more rigorous evaluation of the treatment.

Activation therapy for the treatment of inpatients with depression - protocol for a randomised control trial compared to treatment as usual

BACKGROUND

Inpatients with depression have a poor long term outcome with high rates of suicide, high levels of morbidity and frequent re-admission. Current treatment often relies on pharmacological intervention and focuses on observation to maintain safety. There is significant neurocognitive deficit which is linked to poor functional outcomes. As a consequence, there is a need for novel psychotherapeutic interventions that seek to address these concerns.

METHODS

We combined cognitive activation and behavioural activation to create activation therapy (AT) for the treatment of inpatient depression and conducted a small open label study which demonstrated acceptability and feasibility. We propose a randomised controlled trial which will compare treatment as usual (TAU) with TAU plus activation therapy for adult inpatients with a major depressive episode. The behavioural activation component involves therapist guided re-engagement with previously or potentially rewarding activities. The cognitive activation aspect utilises computer based exercises which have been shown to improve cognitive function.

DISCUSSION

The proposed randomised controlled trial will examine whether or not the addition of this therapy to TAU will result in a reduced re-hospitalisation rate at 12 weeks post discharge. Subjective change in activation and objectively measured change in activity levels will be rated, and the extent of change to neurocognition will be assessed.

TRIAL REGISTRATION

Unique trial number: U1111-1190-9517. Australian New Zealand Clinical Trials Registry (ANZCTR) number: ACTRN12617000024347p .

Nursing staff-led behavioural group intervention in psychiatric in-patient care: Patient and staff experiences

A promising intervention in mental health in-patient care is behavioural activation (BA). Interventions based on BA can be used by mental health nurses and other staff members. The aim of this study was to evaluate patients' and staff members' experiences of a nursing staff-led behavioural group intervention in mental health in-patient care. The intervention was implemented at three adult acute general mental health in-patient wards in a public hospital setting in Sweden. A self-administrated questionnaire, completed by 84 patients and 34 nurses and nurse assistants, was administered, and nonparametric data analysed using descriptive statistics. Our findings revealed that both patients and nursing staff ranked nursing care and care environment as important aspects in the recovery process. Patients and staff members reported overall positive experiences of the group sessions. Patients with higher frequencies of attendance and patients satisfied with overall care had a more positive attitude towards the intervention. A more positive experience of being a group leader was reported by staff members who had been leading groups more than ten times. The most common impeding factor during implementation, reported by staff members, was a negative attitude to change. Conducive factors were having support from a psychologist and the perception that patients were showing interest. These positive experiences reported by patients and nursing staff, combined with previous research in this field, are taking us one step further in evaluating group sessions based on BA as a meaningful nursing intervention in mental health in-patient care.

The Checklist of Unit Behaviours (CUB): Validation within a Canadian outpatient day hospital programme

WHAT IS KNOWN ON THE SUBJECT?: The psychometrics of the CUB measure have been tested within an inpatient psychiatric setting. Results show that the CUB has two factors that reflect patients' approach and avoidance of dimensions of the treatment milieu, and that an increase of approach and decrease of avoidance are correlated with discharge. No empirical research has examined the validity of the CUB in a day hospital programme. WHAT THIS ARTICLE ADDS TO EXISTING KNOWLEDGE?: This study was the first to address the validity of this questionnaire within a psychiatric day hospital setting. This now allows other mental health service providers to use this questionnaire following administration of patient engagement interventions (such as behavioural activation), which are routinely used within this type of a setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our results can enable healthcare providers to employ an effective and psychometrically validated tool in a day hospital setting to measure treatment outcomes and provide reflections of patients' approach behaviours and avoidance behaviours.

ABSTRACT

Introduction We evaluated the Checklist of Unit Behaviours (CUBs) questionnaire in a novel mental health setting: a day hospital within a large acute care general hospital. No empirical evidence exists, as of yet, to look at the validity of this measure in this type of a treatment setting. The CUB measures two factors, avoidance or approach, of the patients' engagement with the treatment milieu within the previous 24 hr. Aim A confirmatory factor analysis (CFA) was conducted to validate the CUB's original two factor structure in an outpatient day programme. Methods Psychiatric outpatients (n = 163) completed the CUB daily while participating in a day hospital programme in Toronto, Canada. Results A CFA was used to confirm the CUB factors but resulted in a poor fitting model for our sample, χ² (103) = 278.59, p < .001, CFI = 0.80, RMSEA = 0.10, SRMR = 0.10. Questions 5, 8 and 10 had higher loadings on a third factor revealed through exploratory factor analysis. We believe this factor, "Group Engagement," reflects the construct of group-related issues. Discussion The CUB was a practical and useful tool in our psychiatric day hospital setting at a large acute care general hospital. Implications for practice Our analysis identified group engagement, a critical variable in day programmes, as patients have autonomy regarding staying or leaving the programme.

Exploring the relationship between activities and emotional experience using a diary in a mental health inpatient setting

Mental health inpatient milieus have repeatedly been found to be associated with passivity, social disengagement, and low levels of interaction with staff. However, little is known about patients' experiences related to different ward activities. In the present study, we aimed to study the reports of activities and associated experiences of patients admitted to acute psychiatric inpatient wards. Disengaged, inactive, and solitary activities were hypothesized to be associated with less reward and more distress than their counterparts. We also aimed to investigate if such activities predicted distress, and if they were associated with clinical severity. Participants (n = 102) recorded their activities along with concurrent ratings of reward and distress in a structured 1-day diary, and nurses provided clinical severity ratings. On average, 3.74 of the 11 hours assessed (34%) were spent doing nothing, only 0.88 hours (8%) were spent with staff, and most of the time was spent in solitude. Doing nothing, being alone, and passivity were associated with the greatest levels of distress and lowest levels of reward, whereas informal socializing demonstrated the opposite pattern. Distress was not predicted by activity or reward when adjusting for baseline distress. Clinical severity was not associated with the amount of time spent alone or the experience of reward during activity. In conclusion, the risk for passivity and social disengagement during admission prevails. This activity pattern could have detrimental emotional consequences and warrants action, but more studies are needed to determine if activity actually precedes emotional experience.

Pilot Study of an Exercise Intervention for Depressive Symptoms and Associated Cognitive-Behavioral Factors in Young Adults With Major Depression

This study assesses the feasibility of integrating motivational interviewing (MI) with an exercise intervention. It also explores patterns of depressive symptom changes (cognitive, affective, and somatic subscales) and their relationship to cognitive, behavioral, and immunological factors (interleukin 6, IL-6, a marker for inflammation) across the exercise intervention. Twelve young adults (20.8 ± 1.7 years) meeting DSM-IV criteria for major depressive disorder received a brief MI intervention followed by a 12-week exercise intervention. Assessments were conducted preintervention, postintervention, throughout the intervention, and at follow-up. Preliminary results show differential effects of exercise, with the largest standardized mean improvements for the affective subscale (-1.71), followed by cognitive (-1.56) and somatic (-1.39) subscales. A significant relationship was observed between increased behavioral activation and lower levels of IL-6. Despite study limitations, the magnitude of changes suggests that natural remission of depressive symptoms is an unlikely explanation for the findings. A randomized controlled trial has commenced to evaluate effectiveness of the intervention.