September/October 2013

Behavioral Activation Targets Depression

By Michael B. Friedman, LMSW; Lisa Furst, LMSW, MPH; and Kimberly A. Williams, LMSW
Today’s Geriatric Medicine
Vol. 6 No. 5 P. 24

This short-term, inexpensive intervention requiring minimal training to administer has been proven effective in treating mild, moderate, or severe depression.

Ethel, an 83-year-old with diabetes controlled by diet alone, remained profoundly sad and withdrawn many months after her husband died suddenly from a heart attack. Ordinarily quite sociable, she rarely left the house except for doctor visits or when one of her children insisted that she visit and spend some time with her grandchildren. Friends stopped inviting her over for dinner or to go out with them because she always declined their invitations.

Visitors were few and far between. Ethel watched TV to kill time, much of which she spent thinking about—and blaming herself for—her husband’s death. If only she had insisted that he eat well, get some exercise, and lose weight, she was sure she could have saved him.

Ethel had always been a big talker, even a bit of a gossip; now she was mostly silent, even when asked questions or when one of her daughters told her a juicy tidbit about someone she knew. Eventually, her physician noticed that her intense grief had lasted a long time. He suspected that she was depressed, prescribed an antidepressant, and referred her to a psychiatrist. She never called the psychiatrist and discontinued the medication within a week because she didn’t like the way it made her feel.

Patients like Ethel are not uncommon. Geriatricians, primary care physicians, and other specialists who treat older adults likely have a significant number of patients who experience a depressed mood, if not a major depressive disorder (MDD). The one-year rate of MDD among older adults in outpatient medical care is between 5% and 10%. Rates are even higher for people with serious physical conditions.1 In addition, about 15% of older adults have minor depression or clinically significant symptoms of depression in any given year, and there is evidence that minor (subsyndromal) depression can have a negative impact on health and functioning similar to MDD.2

Untreated depression—both major and minor—can cause considerable suffering in patients’ and families’ lives. It also increases the risk of disability and premature mortality.2 So it’s important for physicians and other health care providers to be able to identify depression and either provide or arrange for appropriate treatment.

The purpose of this article is to acquaint physicians and other health care providers with behavioral activation therapy,3 a form of treatment for depression that has a strong evidence base, including evidence that it may be more effective than either antidepressant medications or the more common forms of psychotherapy.4,5

Identifying and Treating Depression
Although many physicians believe they can identify depression in their patients, the fact is that physicians usually cannot know whether their patients are depressed unless they screen for depression either directly or with a screening instrument such as the PHQ-9.6

Like many physical disorders, depression often is invisible, and patients who are quite depressed may appear friendly and happy in conversations with their health care providers. Keep in mind that 70% of older adults who complete suicides have seen their physicians within 30 days of taking their own lives.7 Their physicians did not and could not anticipate their patients’ actions.

There is substantial evidence that depression can be treated effectively with antidepressant medications, various forms of psychotherapy, or both.9 However, recent studies call into question the effectiveness of antidepressants for mild to moderate MDD, suggesting that these medications are more effective than placebo only when the depression is relatively severe.9 In addition, a recent study indicates that for older adults, antidepressant medications can increase the risk of developing or exacerbating several serious physical health risks, including falls, fractures, gastrointestinal bleeding, and heart attacks.10-12

Psychotherapies such as cognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy also can be effective. However, most primary care physicians and geriatricians have neither the training nor the time to engage in psychotherapy. Therefore, many prefer to refer patients to mental health professionals, who are more likely to be clinically competent in the treatment of depression and have more time to provide psychotherapy than primary care physicians.13

Unfortunately, competent geriatric psychotherapists generally are in short supply, and those who are available often do not accept Medicare.14 In addition, many older adults who are referred to mental health professionals do not follow up on these referrals or do not become or remain engaged in treatment even if they initially follow up.15

Behavioral Activation Therapy
Over the past one to two decades, behavioral activation therapy has emerged as an evidence-based alternative to other forms of psychotherapy. A short-term, inexpensive intervention that does not require extensive training to administer, it has been shown to be effective with mild, moderate, or severe depression.5 Physicians, social workers, nurses, mental health counselors, other health care professionals, and even paraprofessionals can provide behavioral activation. In addition to primary care practices, behavioral activation can be provided in senior centers, senior housing, naturally occurring retirement communities, and other settings where older adults live or congregate.

Although behavioral activation is effective among a broad range of people with major or minor depression, it is not for everyone because patients must be able to make and follow a schedule of planned activities. However, even people with dementia may benefit if their caregivers are engaged.3,16

Rooted in behavioral psychology, behavioral activation is based on the belief that changing behavior can result in improved mood. It has much in common with cognitive and cognitive behavioral therapies, but it is based on research that has found the cognitive component of these therapies is unnecessary to reduce or overcome depression.17

As we know, when people are depressed, they tend to withdraw from relationships and activities that had previously given them pleasure and/or a sense of meaning. This contributes to a vicious cycle: The more people who are depressed withdraw, the more depressed they become and the more they withdraw.

Behavioral activation helps people reestablish routines of engaging in vocational, social, recreational, or physical activities they have been avoiding and that could provide them some pleasure, contribute to their “valued life directions,” and help achieve their personal goals.3

Through engaging in these activities and interests, an individual gradually will experience increased pleasure in activities, diminished depressed mood and, over time, increased motivation to engage in valued activities. Behavioral activation essentially creates an upward spiral.

Behavioral activation is not just a treatment technique; it is a skill that people learn and build into their lives. The core of behavioral activation therapy involves creating and completing a schedule of feasible activities. This schedule is individualized, arising from a conversation to elicit sources of pleasure from the past, individualized valued life directions, and an individual’s personal goals. This conversation includes identifying current avoidant behavior (including mental behavior such as rumination) and the undesired outcomes of avoidance.3,4

It is critical for the scheduled activities to be realistic. For example, Ethel, who is deeply depressed after her husband’s death, blaming herself for his passing, spends a significant amount of time ruminating about what she could have done to prevent his death. This behavior obviously serves no useful purpose and keeps her from potentially pleasurable activities.

Perhaps her wish for the impossible could be translated into creating external memories of her husband, such as establishing a pew in her church in his memory, organizing a memorial, or collecting some of his most valued possessions and either displaying them at home or giving them away to grandchildren or local charities.

Of course, it may be more helpful for Ethel to throw away her husband’s belongings or she may acknowledge her feelings of loneliness and admit that she has stopped calling the friends she feels have abandoned her. Making a phone call or two might be added to Ethel’s schedule. Perhaps she is unhappy about the weight she has gained while living like a couch potato. Scheduling walks or an exercise group at the local Y might be helpful.

Again, it is critical that patients themselves choose activities that are valuable and/or pleasurable to them. There are no specific activities or group of activities that work for everyone.

Behavioral activation unfolds in 10 to 24 sessions that last between 30 and 45 minutes.3,4,18 The first session includes psychoeducation about depression and behavioral activation; a formal assessment of the degree of depression, often using the PHQ-9; and identification of current behaviors that reinforce and/or exacerbate depression. It is particularly important to identify activities a patient is avoiding, especially those he or she had found pleasurable or meaningful in the past, such as contact with old friends. Undesired consequences of avoidant behavior must be identified to help patients develop the motivation to change behaviors.

Finally, an activities schedule is developed for the next week. It must be specific regarding the activities and when they will be performed. It may involve as little as five minutes of pleasurable activity per day or it may be more ambitious. The key lies in identifying and scheduling activities that are doable. Anticipating barriers to completing tasks and designing alternate plans, if necessary, also are critical elements of the initial session(s).

To determine whether a patient’s mood is improving, each subsequent session begins with a formal assessment of the degree of depression using the same instrument used for the initial screening. Then a review of the week’s activities takes place. The patient reports on what he or she accomplished, how it felt, any barriers that materialized, and how they were (or weren’t) resolved. Helping the patient note whether the activities were satisfying and correlating his or her engagement in activities with improvement in depression symptoms is of particular importance. If patients fail to adhere to the schedule or find no mood improvement, providers can initiate discussions to determine the reasons the therapy isn’t working and modify the schedule for the next week.

Over time, patients usually experience improved mood and learn to incorporate into their lives the principles of behavioral activation, including scheduling.

It is important to note that behavioral activation therapy can be used in conjunction with antidepressant medication, although recent findings about the risks of these medications for older adults should give pause before they are used. It is probably preferable to first try nonpharmacological interventions alone before adding a medication, particularly in cases of mild to moderate depression.12

Advantages of Behavioral Activation
Behavioral activation therapy is not the only form of nonpharmacological treatment effective in treating depression, but it does have several possible advantages that should be considered in choosing treatment modalities, including the following:

• Professionals or paraprofessionals who administer it do not have to be licensed mental health providers.

• Treatment generally works quickly, within about 12 to 24 weeks.

• Treatment sessions can be as brief as 30 minutes.

• It can be administered in inpatient or outpatient settings, in person or, if necessary, over the phone.

• It can be used in conjunction with medications and other types of support therapies if they are being given.

• It can be incorporated into care management models of treating depression, such as IMPACT*.1

• It helps individuals acquire skills that can be used outside a provider’s office as an effective form of self-care.

• It is a good treatment starting point. If the patient doesn’t respond to or is unable to engage in behavioral activation or his or her condition deteriorates, other therapies can be tried.

Financing Behavioral Activation
Whatever the effectiveness of behavioral activation therapy, it is unlikely to be used in medical practices without financial feasibility, which may not include solo practices because reimbursement for psychotherapy sessions—even if the physician has been trained—does not fit with the rapid services or specialized interventions that are the economic core of solo practice.

But in group practices, it probably is feasible. Behavioral activation is a form of psychotherapy, which is covered by Medicare when provided by Medicare-approved mental health providers, who can include personnel who earn far less than physicians, such as nurse practitioners, physician assistants, social workers, and psychologists. (The allowable services each category of approved professionals can legally provide vary based on state law.) Medicare and some other insurance plans cover personnel who are not licensed mental health service providers but who work in the context of a physician’s practice.

Providing behavioral activation therapy can help a practice meet the criteria for recognition as a medical home, which has certain financial advantages. This is true for both private group practices and federally qualified health centers.

In addition to funding behavioral activation therapy via direct reimbursement, medical practices can incorporate this service into their practices via partnerships with behavioral health providers. This includes paying a behavioral health organization to provide on-site staff at the medical practice and billing for the services they provide, establishing a formal satellite so that the behavioral health provider can bill for services themselves, or sharing space with or renting space to a mental health professional in private practice.

Financial model selection must be evaluated on a case-by-case basis, and we hasten to note that we are not providing advice in this article about the legalities of health care finance that apply to a practice or organization. You must consult with a qualified attorney or consulting firm.

Final Thoughts
Behavioral activation therapy can be useful in treating depression in medical settings. It is not the only effective form of treatment, but it is at least as effective as other forms of treatment, including antidepressant medications, and may be easier to administer and less expensive than other types of psychotherapy.

*Over the past 20 years or so, several models for treating depression in older adults have emerged in which a care manager on the medical staff, such as a nurse or social worker, follows up with the patient. Care managers check that the patient is taking medication as prescribed and also helps patients cope with side effects and other concerns. One such model that has become fairly popular and is recommended by Centers for Disease Control and Prevention19 is called IMPACT. In this model, care managers sometimes provide problem-solving therapy. Although it’s an effective form of treatment, it is somewhat more difficult to learn than is behavioral activation therapy. As a result, some medical providers who use the IMPACT model now are using behavioral activation instead of or in combination with problem-solving therapy.

— Michael B. Friedman, LMSW, is an adjunct associate professor at Columbia University School of Social Work.

— Lisa Furst, LMSW, MPH, is director of training for the Geriatric Mental Health Alliance of New York.

— Kimberly A. Williams, LMSW, is the director of the Center for Policy, Advocacy, and Education of the Mental Health Association of NYC.

References
1. Fiske A, Wetherell JL, Gatz M. Depression in older adults. Annu Rev Clin Psychol. 2009;5:363-389.

2. Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003;58(3):249-265.

3. Veale D. Behavioural activation for depression. Adv Psych Treat. 2008;14:29-36.

4. Dimidjian S, Martell CR, Addis ME, Herman-Dunn R. Behavioral activation for depression. In: Barlow DH, ed. Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual. 4th ed. New York, NY: Guilford Press; 2008:328-364.

5. Dimidjian S, Hollon SD, Dobson KS, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. J Consult Clin Psychol. 2006;74(4):658-670.

6. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

7. Conwell Y. Suicide in older adults: management and prevention. Psychiatric Times website. http://www.psychiatrictimes.com/articles/suicide-older-adults-management-and-prevention. January 1, 2007.

8. Bartels SJ, Dums AR, Oxman TE, et al. Evidence-based practices in geriatric mental health care. Psychiatr Serv. 2002;53(11):1419-1431.

9. Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010;303(1):47-53.

10. Coupland C, Dhiman P, Morriss R, Arthur A, Barton G, Hippisley-Cox J. Antidepressant use and risk of adverse outcomes in older people: population-based cohort study. BMJ. 2011;343:1-15.

11. Harrison P. Depression in older adults increases mortality risk. Medscape News website. http://www.medscape.com/viewarticle/717663. 2010.

12. Friedman M. Antidepressants for older adults? Be careful! The Huffington Post website. http://www.huffingtonpost.com/michael-friedman-lmsw/antidepressants-and-older-adults_b_921904.html. August 10, 2011.

13. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):629-640.

14. Abrams R, Young R. Crisis in access to care: geriatric psychiatry services unobtainable at any price. Public Health Rep. 2006;121(6):646-649.

15. Trude S, Stoddard JJ. Referral gridlock: primary care physicians and mental health services. J Gen Intern Med. 2003;18(6):442-449.

16. Sturmey P. Behavioral activation is an evidence-based treatment for depression. Behav Modif. 2009;33(6):818-829.

17. Jacobson NS, Dobson KS, Truax PA, et al. A component analysis of cognitive-behavioral treatment for depression. J Consult Clin Psychol. 1996;64(2):295-304.

18. LeJuez CW, Hopko DR, Hopko SD. A brief behavioral activation treatment for depression. Behav Mod. 2001;25(2):255-286.

19. Centers for Disease Control and Prevention, National Association of Chronic Disease Directors. The State of Mental Health and Aging in America Issue Brief 2: Addressing Depression in Older Adults: Selected Evidence-Based Programs. Atlanta, GA: National Association of Chronic Disease Directors; 2009.