Presentation on theme: "Behavioral Activation for Depression and PTSD Amy Wagner, Ph. D"— Presentation transcript:
1Behavioral Activation for Depression and PTSD Amy Wagner, Ph. D Behavioral Activation for Depression and PTSD Amy Wagner, Ph.D. Portland VAMC
2Key Collaborators: Matthew Jakupcak, Ph.D. (Seattle VA) Christopher Martell, Ph.D. (UW)Sona Dimidjian, Ph.D. (UC Boulder)Miles McFall, Ph.D. (Seattle VA)
3Behavioral Activation is well-established as a treatment for depression: BA by increasing pleasant events for the treatment of depression (e.g., Lewinsohn, 1974)BA as the behavioral component of cognitive therapy treatment for depression (Beck, 1976)BA as an independently effective intervention for depression (e.g., Jacobson et al., 1996)BA as a stand-alone behavioral treatment for Major Depressive Disorder (Martell, Addis and Jacobson, 2001; Addis & Martell, 2004; Dimidjian et al., 2006; Dobson et al., 2008)BA is not a new intervention, it’s just new to the treatment of PTSD; BA originated as a treatment of depression
4What is Behavioral Activation? Structured, brief psychosocial approachBased on premise that problems in vulnerable individuals' lives and behavioral responses reduce ability to experience positive reward from their environments
5What is Behavioral Activation? Aims to systematically increase activation such that patients may experience greater contact with sources of reward in their lives and solve life problemsFocuses directly on activation and on processes that inhibit activation, such as escape and avoidance behaviors and ruminative thinking
6Key Elements of BA Behavioral case conceptualization Functional analysisActivity monitoring and schedulingEmphasis on avoidance patternsEmphasis on routine regulationBehavioral strategies for targeting worry or ruminationGoals are specific to the individual (not necessarily pleasant events)
7There is empirical and theoretical support for applying BA to PTSD: High rates of co-morbidity of depression and PTSDConceptual overlap in the factors related to the maintenance of both depression and PTSD (i.e. AVOIDANCE)Preliminary data support BA for the treatment of PTSD
8BA may be particularly well-suited for the OIF/OEF Population: Significant proportion of OIF/OEF veterans report PTSD and/or depression on their returnThere are limitations to current treatments and models of careLittle is known about effective early interventionLess data to support exposure-based treatments for veteransStigma against mental health treatmentVeteran preferences toward present-focused/skill-based interventions
9BA may be particularly well-suited for the OIF/OEF Population: Majority of Iraq and Afghanistan veterans first diagnosed with PTSD in non-MH settings (Seal et al., 2007)BA is adaptable to primary care contextSimple principlesStraightforward strategiesEvidence for brief versionsMay be easily disseminated and combined with pharmacotherapy
10BA Case Conceptualization: Depression Less Rewarding LifeSad, tired, worthless, indifferent, etc.Stay home, stay in bed, watch TV, withdraw, ruminate, etc.Life EventsLoss of friendships, conflict with supervisor at work, financial stress, poor health, etc.
11BA Case Conceptualization: PTSD Withdraw from usual activities (fear, pain, functional limitations)Stay home, stop socializing, ruminate, etc.Increased fear (sadness, anger)TraumaLoss of friendships, conflict with supervisor at work, financial stress, poor health, etc.
12Preliminary data support BA as a treatment for PTSD: Clinical case study: BA improves PTSD and co-morbid major depression among veteran with chronic PTSD (Mulick & Naugle, 2004)Small open trial: BA improves PTSD among veterans with chronic PTSD (Jakupcak, Roberts, Martell, Mulick, Michael, Reed, Balsam, Yoshimoto, & McFall, 2006)Pilot randomized trial: BA improves PTSD among recently injured trauma survivors, compared to treatment as usual (Wagner, Zatzick, Ghesquiere, & Jurkovich, 2007)Small open trial: BA improves PTSD among OIF/OEF veterans in primary care setting (Jakupcak, Wagner, Paulson, Varra, & McFall, 2010)
13BA for PTSD among Veterans (Jakupcak, Roberts, Martell, et al. 2006) Pre-post open trial11 outpatients with PTSD, most Vietnam-eraMean age 51.2 (12.6)Mean education 15 (2)10 menAll whiteBA delivered in 16 sessions
14Most participants had combat-related trauma and co-morbid conditions: Trauma type8 VN Vets-Combat1 VN Vet-Training Accident1 Female-Military Sexual Assault1 Post VN era Vet-Peace Keeping (sniper fire; mass graves)Depression, Pain Symptoms, and Compensation4 Major Depression/3 dystymia/1 etoh dependence, remission7 Chronic pain7 Actively seeking service connection for PTSD(Jakupcak et al., 2006)
15Outcome Measures Clinician Administered PTSD Scale (CAPS) The PTSD Checklist (PCL)Beck Depression Inventory (BDI)Quality of Life Inventory (QOLI)(Jakupcak et al., 2006)
16Attrition Dropped out (n = 1; travel) Completed 15 of 16 sessions; lost to follow up (n = 1)(Jakupcak et al., 2006)
18BA for PTSD among Injured Trauma Survivors (Wagner, Zatzick et al Randomized controlled trial (pilot)8 physically injured trauma survivors, recruited from surgical wardMet criteria for PTSD 1-mo post-injuryMinimized exclusion criteriaBA delivered in 6 sessions
19Sample (N=8) BA (n=4) TAU (n=4) Age (mean, sd) 28 (15.4) 39 (16.2) # male3# > high school2# minorities1# marriedMDD diagnosis2 of the BA group had drug/alc abuse, none in the TAUPrior trauma was higher in the BA group than TAU (4.0[2.5] v. 2.3[.5])BA group had higher injury severity according to the injury severity index(14.3[6.8] v. 8.8[5.9])(Wagner et al., 2007)
20PTSD Outcome (PCL) (Wagner et al., 2007) Group analyses were conducted on residualized change scores (regressing pre on post) in order to take into account pre treatment scores (don’t lose degree of freedom)**One subject in the BA condition was only half-way through treatment when his 3-mo interview happened; therefore, his last session PCL was used for his post-treatment scoret = 2.85; p < .05; d = 1.19(Wagner et al., 2007)
21Depression Outcome (CESD) Group analyses were conducted on residualized change scores (regressing pre on post) in order to increase power.no statistical difference; d = .55(Wagner et al., 2007)
22Physical Functioning (SF-12) Group analyses were conducted on residualized change scores (regressing pre on post) in order to increase power.Physical Fx: t = 1.86; p < .11; d = 1.27(Wagner et al., 2007)
23BA for the Treatment of PTSD among OIF/OEF Veterans (Jakupcak, Wagner, Paulson, et al., 2010) Open trial, pre-post and 3-mo follow-upBrief BA (8 sessions)Integrated mental health and primary care setting6 veterans completed at least 4 sessionsAll CaucasianMean age 28 (sd = 5)4 of 6 had co-morbid MDD5 of 6 had alcohol abuseMention 8 were recruited, 1 withdrawn from protocol at session 6 due to substance dependence (earlier under-reporting); 1 discontinued after session 3 due to change in work schedule
27Results: Repeated Measures ANOVAs: Quality of Life F(2,3)=2.72, ns, d=.62(Jakupcak et al., 2010)
28Summary and Future Directions BA may have potential as a treatment for PTSDBA may be an appropriate, first line intervention as part of a stepped care approach to treating PTSDBA may be more acceptable to some individuals and easier to disseminate (e.g., primary care) than other ESTs for PTSDGrant-funded for dual-site randomized controlled trial of BA for recently returning veterans (Wagner, Jakupcak, McFall)Utilizing aspects of BA in NIMH-funded grant for recently injured adolescents (Zatzick, PI)
29Course of BA Orient to treatment rationale and approach Develop treatment goalsBehavioral analysesRepeated application of activation and engagement strategiesTroubleshootingTreatment review and relapse prevention
30Structure of Sessions Set collaborative agenda Review homework Review weekly activitiesTroubleshoot problem behaviorsAssign new homeworkAsk for feedback
31Targets of BAAvoidance behaviors (inertia, withdrawal, isolation, ruminating, etc.)Routine disruptions, connection between routine and moodIndividual environments and relationship between activity and mood
32Individualizing Activation Targets What are you doing more or less of since (you were assaulted)?What are your goals/values?What is the relationship between specific activities/life contexts/problems and mood?Conduct detailed examination of what is getting in the way of acting differently or feeling better.
33Functional (Behavioral) Analysis “A step-by-step assessment of a problematic behavior or target, focusing on all aspects and circumstances of the behavior, including the antecedents and consequences.”
34Activity Chart: Central Tool in BA Baseline assessment of activity and relationship with moodSchedule activationOn-going monitoring of activity and moodEvaluate progress
35Time Day and Date: 6:00 am Mood 7:00 am 8:00 am 9:00 am In each box, write the activities you engaged in during the hour and how you felt. Rate your feelings on a scale of 1-10, with 1 being the least intensity of feeling and 10 being the most.TimeDay and Date:6:00 amMood7:00 am8:00 am9:00 am
36Practical Strategies to Maximize Activation Plan specific strategy for implementation (what, when, where, etc.)TroubleshootWrite it downMonitor progress, highlight consequencesAdopt a scientific/experimental attitudeBe alert to the “just do it” approach
37Maximizing Activation Take an “outside – in” approachBreak tasks into manageable componentsAim for activities that have a high likelihood of natural reinforcementConsider help from significant others
38Blocking AvoidanceOrient patient to avoidance (how it works in short run and long run)Identify behaviors that function as avoidanceHelp patient engage in alternative behaviors
39TRAP/TRAC T- Trigger (demands at work) R- Response (depressed mood/hopelessness)AP- Avoidance Pattern (stay home in bed, don’t answer phone)T-Trigger (demands at work)R- Response (depressed mood/hoplesness)AC- Alternative Coping (approach behaviors using graded tasks)
42Routine RegulationWork with patient to develop regular routine for basic life activitiesImplement, then evaluateuse activity logsuse the ACTION strategy
43ACTION Strategy Assess How will my behavior affect my depression? Am I avoiding? What are my goals in thissituation?Choose I know that activating myself will increase mychances of improving my life situation and mood.Therefore, if I choose not to self-activate, I am choosingto take a break.Try Try the behavior I have chosen.Integrate Integrate any new activity into my daily routine.Observe Observe the result. Do I feel better or worse?Did this action allow me to take steps toward improvingmy situation?Now Now evaluate; OR Never give up.
44Targeting RuminationRumination can function as avoidance, can maintain depressionFocus on context and consequences of rumination, not content
45A Focus on the Content of Thinking: “I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.” * What is the evidence that this thought is accurate? * What would it mean if it were true? * Can you think of another way to interpret what your sister said? * Why must everyone love you?
46A Focus on the Context and Consequences of Thinking: “I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.” * When did you start thinking that? * How long did it last? * What were you doing while you were thinking that? * How engaged were you with the activity, context, etc.? * What were consequences of thinking about that?
47Targeting Ruminating Attention to experience strategies notice colors, smells, noises, sights, etc.participate in taskSelect high engagement activities
48ResourcesDepression in Context (Martell, Addis, Jacobson, 2001), NY: WW Norton & Company, Inc.Overcoming Depression One Step at a Time (Addis & Martell, 2004), Oakland, CA: New Harbinger, Inc.Behavioral Activation for Depression: A Clinician’s Guide (Martell, Dimidjian, Herman-Dunn & Lewinsohn, 2010), NY: Guilford PressBehavioral Activation: Distinctive Features (Kantor, Busch, & Rusch, 2009), Routledge