Feasibility study of a new behavioural activation programme for young people with depressed mood

Is behavioural activation an effective treatment for depression in children and adolescents? An updated systematic review and meta-analysis

Behavioural Activation (BA)-a brief therapy based on the scheduling of enjoyable, purposeful and rewarding activities-is an effective and cost-effective treatment for depression in adults that shows promise for children and adolescents. We provide an update on a previous systematic review of evidence on BA-delivered in-person, telephone, or online-for depression and comorbid anxiety in children and adolescents. We conducted systematic literature searches in 6 databases up to February 2024. We included all study designs evaluating BA with participants up to 18 years old with diagnosable depression, as established by a validated screening tool or diagnostic manual. We used the Moncrieff Scale and the Cochrane Risk of Bias tool to assess study quality. We summarised the findings of all study types with a narrative synthesis and of randomised controlled trials (RCTs) with a meta-analysis. Overall, 24 studies (6 RCTs, 18 pre-post evaluations, n = 2,758) met our inclusion criteria. A meta-analysis of 4 RCTs (n = 156) showed that BA has a small effect of 0.24 (Hedge's adjusted g) in reducing depression symptoms compared to a waiting-list control, usual care and other therapies. Online and telephone-facilitated BA was shown to be feasible in 3 studies and effective in 1. Outcomes on comorbid anxiety were mixed. No economic evaluations met our inclusion criteria. BA shows sufficient promise as an intervention for reducing depression symptoms in children and adolescents to justify the need for further RCTs, providing that five conditions are met: studies are powered to detect a minimal clinically important difference; BA materials are fit-for-purpose to produce clinically meaningful change; follow-ups are longer than 6 months; primary outcomes are child-reported; and intervention costs, resource use and adverse events are reported.

Validation of a Behavioral Activation Model Including Self-Compassion: A Longitudinal Study at Three Time Points

INTRODUCTION

Depression is highly prevalent among university students. While behavioral activation has been shown to be an effective psychotherapy for depression, there is a lack of research regarding the behavioral activation mechanism. Furthermore, although self-compassion seems to be a factor in promoting behavioral activation, no studies have attempted to validate a behavioral activation model that includes positive self-compassion. In addition, mechanistic studies have lacked consideration in longitudinal studies of behavioral activation. Thus, in this longitudinal study, we constructed and validated an exploratory model of behavioral activation.

METHODS

A total of 300 undergraduate students completed online surveys in 2019, 2020, and 2021. We examined the longitudinal effects of five factors (value-based behavior, goal-oriented and scheduled activities, positive reinforcement, self-compassion, and depressive symptoms) using structural equation modeling based on maximum likelihood estimation using bootstrapping.

RESULTS

The exploratory model was found to be valid and to have a good fit with the data. The results indicate that value-based behaviors increase the frequency of goal-oriented and scheduled activities, which in turn increases the frequency of positive reinforcement in everyday life. Additionally, when self-compassion, value-based behavior, goal-oriented and scheduled activities, and positive reinforcement are considered together, self-compassion may be indirectly related to activation via value-based behavior.

CONCLUSION

From the perspective of preventing depressive symptoms, it is important to increase the frequency of value-based activities. Furthermore, adding self-compassion is effective in behavioral activation to increase value-based activities. However, to address the limitations of this study, future studies should investigate the relationship among behavioral characteristics during interventions.

Doing research in non-specialist mental health services for children and young people: lessons learnt from a process evaluation of the ICALM (Interpersonal Counselling for Adolescent Low Mood) feasibility randomised controlled trial

BACKGROUND

The rising prevalence of adolescent mild depression in the UK and the paucity of evidence-based interventions in non-specialist sectors where most cases present, creates an urgent need for early psychological interventions. Randomised controlled trials (RCTs) are considered the gold standard for obtaining unbiased estimates of intervention effectiveness. However, the complexity of mental health settings poses great challenges for effectiveness evaluations. This paper reports learning from an embedded process evaluation of the ICALM RCT which tested the feasibility of delivering Interpersonal Counselling for Adolescents (IPC-A) plus Treatment as Usual (TAU) versus TAU only for adolescent (age 12-18) mild depression by non-qualified mental health professionals in non-specialist sectors.

METHODS

A qualitative mixed methods process evaluation, drawing on Bronfenbrenner's socioecological model to investigate key influences on trial delivery across macro-(e.g. policy), meso-(e.g. service characteristics) and micro-(e.g. on-site trial processes) contextual levels. Data collection methods included 9 site questionnaires, 4 observations of team meetings, policy documents, and 18 interviews with stakeholders including therapists, heads of service and managers. Thematic analysis focused on understanding how contextual features shaped trial implementation.

RESULTS

The ICALM trial concluded in 2022 having only randomised 14 out of the target 60 young people. At a macro-level, trial delivery was impacted by the COVID-19 pandemic, with services reporting a sharp increase in cases of (social) anxiety over low mood, and backlogs at central referral points which prolonged waiting times for mild cases (e.g. low mood). An interaction between high demand and lack of capacity at a meso-service level led to low prioritisation of trial activities at a micro-level. Unfamiliarity with research processes (e.g. randomisation) and variation in TAU support also accentuated the complexities of conducting an RCT in this setting.

CONCLUSIONS

Conducting a RCT of IPC-A in non-specialist services is not feasible in the current context. Failure to conduct effectiveness trials in this setting has clinical implications, potentially resulting in escalation of mild mental health problems. Research done in this setting should adopt pragmatic and innovative recruitment and engagement approaches (e.g. creating new referral pathways) and consider alternative trial designs, e.g. cluster, stepped-wedge or non-controlled studies using complex systems approaches to embrace contextual complexity.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN82180413. Registered on 31 December 2019.

Resilience in Mild Cognitive Impairment (MCI): Examining the Level and the Associations of Resilience with Subjective Wellbeing and Negative Affect in Early and Late-Stage MCI

The current study examines the relationship between the cognitive state of participants [healthy-early mild cognitive impairment (MCI)-late MCI], some subjective wellbeing factors (positive emotions, engagement, positive relationships, meaning in life, accomplishment, and negative emotions), and negative psychological outcomes (depression, anxiety, stress), as well as psychological resilience. We expected that people with advanced MCI would perceive increased negative psychological outcomes, poorer psychological resilience, and lower levels of subjective wellbeing in contrast to early MCI and healthy participants. The study involved 30 healthy, 31 early, and 28 late MCI individuals. A series of questionnaires have been applied to assess the aforementioned constructs. To examine the hypotheses of the study, path analysis (EQS program) was applied. Results showed that early MCI persons maintain the same levels of positive emotions and feelings of accomplishment with healthy peers. Late-stage patients present those feelings in a diminished form, which adversely impacts psychological resilience. Individuals with early and late MCI exhibit negative emotions and stress that impact their resilience; however, those with early MCI experience greater stress, negative emotions, depression, and anxiety. These findings may be utilized to design psychological interventions for resilience enhancement and support brain health in elderly adults who are at risk of neurodegeneration.

Barriers and enablers for young people, parents and therapists undertaking behavioural activation for depression: A qualitative evaluation within a randomised controlled trial

BACKGROUND

Adolescent depression is common, long-lasting and debilitating. Behavioural Activation (BA) is a brief, evidence-based therapy for depression in adults with promising outcomes for young people.

OBJECTIVES

We sought to understand how young people, their parents and therapists experienced manualised BA for depression within Child and Adolescent Mental Health Services.

DESIGN

Participants in a randomised controlled trial aged 12 to17 with depression, their parents and therapists were invited to a semi-structured interview with a researcher to explore their experiences of receiving, supporting or delivering BA.

METHODS

Six young people, five parents and five therapists were interviewed. Verbatim interview transcripts were coded using thematic analysis.

RESULTS

Factors that may optimise delivery of BA were: boosting the young person's motivation, tailoring parental input to the young person's needs/wishes and developing a positive collaboration between the young person and therapist. Engagement with treatment may be hindered by a mismatch between BA delivery and young person's preferences, concurrent mental health comorbidities that are not addressed within a wider care package, lack of parental support and therapist preconceptions against manualised therapy or BA.

CONCLUSIONS

Manualised BA for young people requires flexibility and adjustment to meet individual and family needs. Therapist preparation could dispel hindering preconceptions about the suitability and potential value of this brief and simple intervention for young people with complex needs and different learning styles.