An Initial Open Trial of a Brief Behavioral Activation Treatment for Depression and Medication Adherence in HIV-Infected Patients

Behavioral Activation, Depression, and Promotion of Health Behaviors: A Scoping Review

Diverse approaches to the treatment of depressive disorders are necessary to improve evidence-based practice and maximize treatment outcomes. As a result, a range of behaviors and other factors associated with the onset and course of depressive disorders should be examined more comprehensively. Behavioral activation (BA) is a treatment approach to these disorders that can be tailored to address certain health behaviors within the context of depression in an attempt to promote health behaviors whose adoption and maintenance can prove complementary in the treatment of depression. We conducted a scoping review of published studies in which BA-based interventions were used to promote certain health behaviors in individuals with depression. Our search of Medline and the Web of Science identified 336 potential candidate studies. Following screening and with the application of inclusion and exclusion criteria to isolate potentially eligible full-text records, we ultimately identified and evaluated 20 papers that report the nature and efficacy of these modified interventions. Across various domains, including substance use, exercise, medication adherence, and occupational and social success, we found evidence that many-but not all-of the studies we reviewed demonstrated that BA-based interventions were efficacious in promoting the health behavior of interest as well as reducing depressive symptomatology in participants. Implications for more widespread dissemination of such interventions, especially via mobile and web-based platforms due to their accessibility and affordability, are discussed. More research on the feasibility and efficacy of BA-based interventions tailored toward various determinants of health behavior and comorbidities of depressive disorders is warranted.

"You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment

BACKGROUND

Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment.

METHODS

The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis.

RESULTS

Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment.

CONCLUSION

Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.

Rumination influences the relationship between trauma and depression over time among youth living with HIV

BACKGROUND

Traumatizing events often result in long-term mental health symptoms. Identifying the features of the post-trauma experiences that can impact mental health symptoms is key to designing effective interventions.

METHODS

Youth living with HIV (YLH),1 predominantly sexual and gender minorities (SGM;2 84 % gay, bisexual, transgender, queer, pansexual identities), 78 % Black and Latino, (N = 170) were recruited in New Orleans, LA and Los Angeles, CA from 13 youth-serving agencies. They were assessed for trauma, rumination and depression, with 78 % reassessed for depression at 4 and 74 % at 8 months later. Relationships between these variables were examined using a Bayesian approach to structural equation modeling.

RESULTS

At recruitment, 78 % of YLH reported at least one traumatic event, and 21 % met the cut-off score indicating depression on the PHQ-9. Ruminations were reported by 41 % of YLH. While associations between trauma and depression were modest (rmean = 0.19), ruminations were moderately associated with depressive symptoms over time (rmean = 0.34). Ruminations were only modestly associated with trauma (rmean = 0.19) but had a robust negative association (λSTD = -0.29) with the slope of depressive symptoms such that the more ruminations YLH experienced, the smaller the decline in depression over time. The associations between trauma and depression were more modest (λSTD ≤ 0.12). Limitations The main limitations of this study are the lack of a scale to measure trauma and the use of a single item measure of rumination.

CONCLUSION

Ruminations appear to be associated with traumatic events for a large subset of young people, suggesting that future interventions should consider including components addressing ruminations.

CLINICALTRIALS

gov registration NCT03109431.

Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial

BACKGROUND

Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention.

METHODS

Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems.

RESULTS

Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040].

CONCLUSION

Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.

Improving functioning in HIV+ patients with chronic pain and comorbid depression: Protocol for a randomized clinical trial testing a collaborative behavioral health intervention based on behavioral activation

OBJECTIVE

Persons living with HIV (PWH) experience a disproportionate level of comorbid chronic pain and depression compared to individuals who do not have a diagnosis of HIV. Many PWH report pain that impairs daily function, is severe, and requires medical management. Depression alone is associated with HIV disease progression, medication non-adherence, and increased mortality. Given that numerous studies show that PWHs have chronic pain and depression despite pharmacologic treatment, there is a clear need for additional treatment modalities to address these conditions.

DESIGN

In this paper, we describe our protocol for a multisite, randomized controlled trial of the effectiveness of a collaborative behavioral intervention, called HIV-Pain and Sadness Support (HIVPASS), designed for PWH who endorse chronic pain and depressive symptoms, as compared to an attention matched Health Education (HE) condition. The HIVPASS intervention is based on Behavioral Activation and designed to target both pain and depression using an integrated model that promotes collaboration between HIV medical and psychological providers.

SETTING AND METHODS

We plan to (1) recruit PWH who endorse chronic pain and depression in three sites located in New England and the Midwestern United States and (2) compare our HIVPASS intervention to a full attention matched HE intervention with the primary outcome of pain interference, and secondary outcomes of depression, physical activity, HIV medication adherence, and health-related quality of life. Follow-up assessments will occur monthly for three months during the intervention phase and then during the post-intervention phase at months four, six, nine and twelve.

CONCLUSIONS

We provide descriptions of our protocol and interventions of our randomized controlled trial for comorbid chronic pain and depression in PWH.

TRIAL REGISTRATION

http://ClinicalTrials.govNCT02766751 https://clinicaltrials.gov/ct2/show/NCT02766751?term=stein%2C+michael&draw=2&rank=5.

The development and pilot testing of a behavioral activation-based treatment for depressed mood and multiple health behavior change in patients with recent acute coronary syndrome

BACKGROUND

Patients with acute coronary syndrome (ACS) with depressed mood demonstrate poor cardiovascular behavioral risk profiles and elevated risk for recurrent ACS and mortality. Behavioral Activation (BA) offers an intervention framework for an integrated treatment targeting both depression and critical health behaviors post-ACS. Behavioral Activation for Health and Depression (BA-HD) was developed and pilot tested in a multiphase iterative process.

METHODS

First, an initial treatment manual was conceptualized based on the team's prior work, as well as the extant literature. Second, qualitative interviews were conducted with target patients and target providers on the proposed BA-HD treatment rationale, content, and structure. Framework matrix analyses were used to summarize and aggregate responses. Third, an expert panel was convened to elicit additional manual refinements. Finally, patients with post-ACS depression and health behavior non-adherence were recruited to complete an open pilot trial to evaluate acceptability (Client Satisfaction Questionnaire [CSQ], exit interview) and treatment engagement (number of sessions attended; treatment completion was considered completion of 8 out of 10 possible sessions).

RESULTS

The initial BA-HD treatment manual expanded an existing treatment manual for post-ACS BA-based mood management and smoking cessation to target four health behaviors relevant to post-ACS patients (e.g., smoking cessation, medication adherence, physical activity, and diet). After the initial conceptualization, ten post-ACS patients and eight cardiac rehabilitation professionals completed qualitative interviews. Patients endorsed bi-directional interactions between mood and health behaviors post-ACS. Both patients and providers expressed general support of the proposed treatment rationale and values-guided, collaborative goal-setting approach. Patients, providers, and experts provided feedback that shaped the iterative manual development. After the BA-HD manual was finalized, eight participants were enrolled in a single-arm pilot trial. The mean CSQ score was 30.57 ± 2.23, indicating high satisfaction. Seven out of eight (88%) completed treatment. Pre- to post treatment improvements in depressed mood and health behaviors were promising.

CONCLUSIONS

BA-HD treatment is an acceptable approach to target both mood and health behaviors in post-ACS patients with depression. A future larger, controlled trial is needed to evaluate the efficacy of the BA-HD treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04158219.

Global Systematic Review of Common Mental Health Disorders in Adults Living with HIV

PURPOSE OF THE REVIEW

By reviewing the most recent common mental health disorders (CMHD) studies in people living with HIV (PLWH) (2018-2020), this review discusses the prevalence of CMHD, factors associated with CMHD in PLWH, mental health in PLWH from vulnerable groups, the impact of CMHD on HIV disease progression and adherence to antiretroviral therapy and the efficacy of different treatment approaches.

RECENT FINDINGS

After screening for eligibility 142 studies were included in the final systematic review. Only 27% of studies were conducted in Sub-Saharan Africa, which carries the highest burn of HIV disease globally. Despite the well-established increased risk of CMHD in PLWH, the current prevalence remains high, with studies reporting 28%-62% of PLWH having mental health symptoms.

CONCLUSION

Despite the significant challenges that CMHDs present to successful HIV treatment, there are many mental health treatments and interventions which can improve outcomes in PLWH and opportunities to task-shift and integrate mental health care with HIV care.

Interventions Addressing Depression and HIV-Related Outcomes in People with HIV

PURPOSE OF REVIEW

People with HIV (PWH) are more likely to experience depression than those without HIV. Depression is not only distressing and interfering in and of itself, but it is also consistently associated with non-adherence to antiretroviral treatment (ART). Accordingly, research and clinical priorities require updated knowledge about interventions that address depression in PWH.

RECENT FINDINGS

Twenty efficacy trials and nine pilot studies since a 2009 review emerged in the literature review search. Of these, 11 and 6 respectively had a depression-related inclusion criterion. The intervention strategies included individual psychotherapy (n=6), group therapy (n=6), telehealth (n=3), and antidepressant medication (n=5). Generally, these interventions demonstrated acute efficacy for improving depression symptoms in PWH, with some also addressing ART non-adherence. However, not all studies collected follow-up data. Furthermore, trials that addressed depression but did not specifically address non-adherence did not also show adherence improvements. Existing interventions for depression have demonstrated efficacy in PWH, and these may have both positive mental and physical health outcomes. Future trials should measure and boost longer-term effects. It would be useful to incorporate adherence interventions into depression treatment to improve self-care behaviors and health outcomes.

Behavioral and Physical Activity Interventions for HAND

Approximately 30-50% of persons living with HIV manifest some degree of neurocognitive impairment. Even mild-to-moderate forms of HIV-associated neurocognitive disorders (HAND) can result in difficulties with everyday functioning, such as suboptimal medication adherence and impaired driving. Despite the pervasive presence and consequences of HAND, there is a significant unmet need to develop effective behavioral strategies to reduce the incidence and consequences of HAND. Although there is an absence of evidence-based behavioral interventions specific to HAND, the literature reviewed in this chapter suggest the following modifiable lifestyle factors as intervention targets: physical activity, diet, sleep, and antiretroviral medication adherence. Adoption and maintenance of these healthy lifestyle factors may reduce inflammation and oxidative stress, which, in turn, may reduce the incidence and/or severity of HAND.

Demographic and Perioperative Factors Associated With Patient-reported Outcomes Measurement Information System (PROMIS) Survey Completion

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

To evaluate independent demographic and perioperative factors associated with lower Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF) survey completion rates after spine surgery.

SUMMARY OF BACKGROUND DATA

There has not been a study evaluating factors related to PROMIS PF survey completion following spine surgery.

METHODS

Patients undergoing spine procedures were retrospectively reviewed. The number of PROMIS PF surveys that were completed at each time period and the number of surveys that were completed in succession starting with the first survey were tabulated and reported using descriptive statistics. Independent preoperative and perioperative factors associated with full survey completion up to the 12-month period were identified using χ analysis and Poisson regression with robust error variance. A final multivariate model was created using a backward, stepwise multivariate regression.

RESULTS

A total of 713 patients were included. Variables positively associated with PROMIS survey completion were aged above 60 years and Patient Health Questionnaire (PHQ)-9≥10. African Americans and Hispanics were negatively associated with survey completion. Postoperative day 0 narcotic use ≥50 oral morphine equivalents was positively associated with survey completion, while outpatient surgical setting and high preoperative radicular arm/leg pain were negatively associated with survey completion. In the final multivariate model, depression was the only variable that was positively associated, while both outpatient surgical setting and high preoperative radicular arm/leg pain were negatively associated with survey completion.

CONCLUSION

This study identified demographic and perioperative variables associated with PROMIS survey completion and response rates. Patients who underwent surgery in the outpatient setting and those with high preoperative radicular limb pain were less likely to complete surveys. Interestingly, patients with clinical signs of depression were more likely to fill out surveys. Understanding variables associated with survey completion may provide the clinician with insight into which demographic groups are the most at-risk for not responding to surveys.

New directions in behavioral activation: Using findings from basic science and translational neuroscience to inform the exploration of potential mechanisms of change

Interest in behavioral activation treatments for depression has increased over the past two decades. Behavioral activation treatments have been shown to be effective in treating depression across a variety of populations and settings. However, little is known about the mechanisms of change that may bring about symptom improvement in behavioral activation treatments. Recent developments in the theoretical and empirical literature on behavioral activation treatments have coincided with advances in basic science and translational neuroscience regarding the mechanisms underlying individual differences in responsiveness to reward. Attenuated reward responsiveness has been associated with depression and related clinical outcomes at the self-report, behavioral, and neural levels of analysis. Given that behavioral activation treatments are focused on increasing individuals' contact and engagement with sustainable sources of reward in their environment, it is plausible that behavioral activation treatments bring about improvements in depression symptoms by targeting (low) reward responsiveness directly. This paper integrates findings from the clinical research literature on behavioral activation treatments with insights drawn from basic science and translational neuroscience in order to propose hypotheses about potential mechanisms of change in behavioral activation. Conceptual issues and recommendations for future research on behavioral activation treatments are discussed.

"Too much boredom isn't a good thing": Adapting behavioral activation for substance use in a resource-limited South African HIV care setting

South Africa has the largest HIV/AIDS burden globally. In South Africa, substance use is prevalent and interferes with HIV treatment adherence and viral suppression, and yet it is not routinely treated in HIV care. More research is needed to adapt scalable, evidence-based therapies for substance use for integration into HIV care in South Africa. Behavioral activation (BA), originally developed as an efficacious therapy for depression, has been feasibly used to treat depression in low- and middle-income countries and substance use in high-income settings. Yet, to date, there is limited research on using BA for substance use in low- and middle-income countries. Guided by the ADAPT-ITT framework, this study sought to adapt BA therapy for substance use in HIV care in South Africa. We conducted semistructured individual interviews among patients (n = 19) with moderate/severe substance use and detectable viral load, and HIV care providers and substance use treatment therapists (n = 11) across roles and disciplines at 2 clinic sites in a peri-urban area of Cape Town. We assessed patient and provider/therapist views on the appropriateness of the BA therapy model and sought feedback on isiXhosa-translated BA therapy components. Participants identified the central role of boredom in contributing to substance use and saw the BA therapy model as highly appropriate. Participants identified church and religious practices, sports, and yard/housework as relevant substance-free activities. These findings will inform adaptations to BA therapy for substance use and HIV medication adherence in this setting. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Using behavioral psychotherapy techniques to address HIV patients' pain, depression, and well-being

For persons with HIV (PWH), aims of psychotherapy can extend beyond HIV-related topics. Issues such as HIV stigmatization and disclosure and HIV-related self-care including treatment adherence might be ongoing concerns, but patients often need support to develop skills to manage other problems, whether functional or psychiatric. In the context of an ongoing randomized clinical trial, we delivered an individual, behavioral activation-based intervention to PWH with comorbid chronic pain and depression. Our primary treatment target was to reduce pain-related interference in physical and psychosocial functioning. Throughout the course of the 7-session intervention, clinicians used 4 core strategies to help patients improve a variety of domains related to their health and well-being: (a) teaching value-based goal setting, (b) developing skills to be an activated and informed patient, (c) focusing on changing behavior despite discomfort, and, (d) facilitating access to care (e.g., flexible scheduling and primarily phone sessions). The application of these strategies to HIV-related and non-HIV-related problems are presented to illustrate how and when clinicians can utilize these strategies. These practical lessons will inform a flexible approach to helping PWH address a myriad of health and functional issues related to their overall well-being. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

An Uncontrolled Open Trial of a Brief Behavioural Activation Treatment for Depression in Patients with Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) has been associated with depression and can have an impact on quality of life. Therefore, researchers have suggested the potential utility of psychological interventions for targeting depression among CSU patients. Psychological interventions that may hold the most promise are those that are brief and easily transportable, such as brief behavioural activation treatment for depression. We report results of a preliminary investigation of an uncontrolled open trial of a one-session behavioural activation treatment for depression designed for patients with CSU (BATD-CSU) at a university-based allergy and immunology clinic. Participants were 11 females with chronic, poorly controlled urticaria and symptoms of depression. Following the completion of pretreatment questionnaires, participants were administered BATD-CSU primarily by non-mental health professionals trained and supervised in its delivery. One month post-BATD-CSU, participants completed follow-up questionnaires. Participants exhibited significant reductions in depression severity, avoidance/rumination, and work/school impairment. BATD-CSU was also associated with improvements in urticaria control one month post-treatment. Moreover, five of nine patients reported reliable and clinically significant improvement on at least one outcome. Results demonstrate that BATD-CSU may have benefits for CSU patients even when consisting of one session and delivered by professionals with limited background in psychological interventions, thus speaking to its feasibility and transportability.

Evaluation of the contribution of values clarification to a brief mindfulness meditation intervention for anxiety

OBJECTIVE

Evaluate the incremental effects of a computerized values clarification (VC) activity on anxiety symptomology and quality of life over and above establishment of a mindfulness meditation (MM) practice.

METHOD

Anxious participants (N = 120, Female = 86; M_age  = 22.26) were randomly assigned to a 2-week, 10-min daily MM practice + control task or a 2-week, 10-min daily MM practice + VC task. Pre-assessments and post-assessments included well-established and ideographic self-report measures.

RESULTS

Overall decreases in past week and past 24-h anxiety symptom frequency, as well as increased quality of life during the previous 24-h cycle only. VC did not have a demonstrable impact on outcomes.

CONCLUSIONS

Though findings are preliminary, brief VC exercises may not enhance outcomes that follow from mindfulness practice. Additional research is needed to isolate specific and shared impacts of mindfulness-based and values-based treatment strategies on anxiety symptoms and quality of life.