Behavioural Activation for Depression in Long Term Conditions: Developing a Behavioural Activation Guided Self-Help Intervention for Depression in Dementia

Abstract

Depression is common in people with long term conditions (LTCs) and is associated with worse quality of life, higher degrees of functional disability and increased risk of mortality. Treating comorbid depression in people with LTCs is therefore important. Meta-analyses have shown improvements in depression in people with LTCs associated with psychological therapies. However, treatment effect sizes have generally been small to moderate suggesting the need for continued development in psychological therapy for people with LTCs. Behavioural activation (BA) techniques have been recommended for the treatment of mild to moderate depression in people with LTCs, and with the simplicity of BA making it suitable for a broad range of populations it is an approach for further consideration. Informed by the revised MRC framework (2008) for developing and evaluating complex interventions, the overall aim of this dissertation was to develop a BA intervention for depression in people with a LTC. First, a systematic review (Study One) examining BA for the treatment of depression in people with LTCs was conducted to identify the evidence base, examine effectiveness across LTCs and identify adaptations made to BA to accommodate LTCs. In total 18 studies were included in the review with effectiveness reviewed from eight randomised controlled trials. Studies reported improvements in depression and significant findings were reported compared to control in studies involving participants with dementia, stroke and nursing home residents. Across the studies common adaptations to the interventions included the involvement of others in the delivery or support of the BA intervention, additional treatment components and ensuring psychoeducation, materials and inventories were appropriate for the LTC. With the majority of significant findings reported for neurological disorders, and informed by current policy priorities, the decision was made to develop a BA intervention for depression in dementia. Next, a BA guided self-help intervention (involving a workbook, practitioner support and carer involvement) was developed, with development informed by the findings from Study One, literature, contact with experts and guidance co-produced by people with dementia. Interviews with people with dementia and carers (n=12) were then conducted to discuss the suitability of the intervention and (if necessary) to inform modifications to the workbook. Comments suggested the design and layout of the workbook may be acceptable, but potential difficulties with reading the workbook and completing worksheets were also identified. Based on comments from participants, example worksheets were included in the workbook and additional diaries were created. Finally, a preliminary feasibility case series was conducted. This study investigated key uncertainties to inform further development of the intervention and future research. Difficulties were experienced recruiting dyads to receive the intervention alongside challenges delivering the intervention as currently developed, such as difficulties keeping sessions to time and a lack of engagement with the workbook. Some positive comments were however made about the therapist, workbook and telephone support, but participants still experienced difficulties understanding and completing the workbook. The findings from the case series were used to inform potential intervention modifications, including simplification, a separate carer workbook and flexible delivery. Overall, more development is needed to make the intervention more acceptable and feasible, and more research is needed to investigate the suitability of BA guided self-help for depression in dementia.