1. Is a Brief Behavioral Activation Intervention Effective in Reducing Depressive Symptoms?. Jennifer Funderburk, Ph.D. 1,2,3 Collaborative Family Healthcare Association October 5 th, 2012 Austin, Texas 1 Clinical Research Psychologist, Center for Integrated Healthcare, Syracuse VAMC 2 Department of Psychiatry, University of Rochester 3 Department of Psychology, Syracuse University

2. Jennifer Funderburk does not have any relevant financial relationships during the past 12 months. The views expressed in this article are those of the authors and do not reflect the official policy of the Veterans’ Affairs’ department or other departments of the U.S. government. Thanks to Robyn Fielder, M.S. & Spiro Tzeztsis, M.D. who are instrumental in helping to obtain the data presented in this presentation as an example. Thanks to Dev Crasta for helping me to organize the information.

3.  Understand the fundamental components of a clinical case study/series research design  Describe our application of the design to the implementation of a brief behavioral activation intervention for depressive symptoms  Discuss how this approach can provide preliminary data on interventions providers are using regularly within primary care

4.  Detailed report of the initial presentation, treatment, and follow-up of an individual patient. Presentation Detailed Description Signs & Symptoms MD Impressions Presentation Detailed Description Signs & Symptoms MD Impressions Treatment Thorough & Full Explanation of Tx Process Treatment Thorough & Full Explanation of Tx Process Follow-Up Symptom Course Tx Response Follow-ups Follow-Up Symptom Course Tx Response Follow-ups

5. Case Report

6.  A study describing the outcomes of multiple patients who were given a similar treatment. Patients Demographics Select Diagnoses Patients Demographics Select Diagnoses Common Treatment Shared Features & Individualized Adaptations Common Treatment Shared Features & Individualized Adaptations Outcomes % Positive Change # Adverse Events Follow-ups Outcomes % Positive Change # Adverse Events Follow-ups

8.  Decide on clear criteria ◦ Examples:  Treatment used  Condition shows up in chart  Symptoms above a certain threshold  Demographic Characteristic (e.g., Gender; Age)

9.  Decide on a clear definitions of outcomes. ◦ Examples:  Patient drops below a certain symptom threshold  Symptoms drop a measurable amount  Patient experiences ANY symptom reduction  ABSENCE of negative outcomes or complications  Measurable restoration of patient functioning

10.  Best Practice: Do this prospectively so you can make sure you collect all the data you would like to have  Consider talking to your IRB if you plan on sharing this information through publication in the future  However, you may already have the data already  ELECTRONIC MEDICAL RECORD/CHART REVIEW

11.  Quick and Simple  Systematic Method for Evaluating Clinical Experience  Provides a Way to Evaluate Things as a Clinician Without Funding  Provides a Way to Evaluate Things Diffucult to Evaluate Other Ways

12.  Selection criteria and outcome definitions must be used consistently.  Keep track of relevant treatment differences for each patient.  Remember, the results suggest implications but are not conclusive. This is not a way to determine cause and effect and a limitation is that the findings may not generalize.  CONSIDER MULTIPLE ASSESSMENTS PRIOR TO INTERVENTION AND AT FOLLOW-UP

14.  Depressive symptoms especially common in college students ◦ High Risk for Suicide  Evidence mixed for antidepressants in: ◦ Sub-threshold depressive symptoms ◦ Suicide management  Brief Behavioral Activation (BA) ◦ Effective in a wide range of populations ◦ Easily implemented in Primary Care

15.  Syracuse University Health Clinic ◦ Serves Syracuse University (total enrollment approx. 20,000) ◦ ̴9,464 patients per semester, ̴146 patients per day ◦ 2 physicians, 7 nurse practitioners, 4 per diem practitioners  Integrated Behavioral Healthcare (IBHC) ◦ Regular screening ◦ Behavioral Health Providers

16.  BHPs encouraged to use BA with patients reporting depression because: ◦ Research demonstrating its effectiveness in reducing depressive symptoms (Cuijpers, van Straten & Warmerdam, 2007; Mazzucchelli, Kane & Rees, 2009)  All BHPs received additional training and supervision by the first author ◦ Lejuez et al. (2011) manual as a guide  Modifications needed to adjust to brief sessions was necessary ◦ Education about depression and the link between thoughts, behaviors, and mood ◦ The importance of increasing pleasurable activities

17.  All charts reviewed for patients in: ◦ Aug. 2009 –May 2010 ◦ Aug. 2010– Dec. 2010  Charts selected if: ◦ Presented with depressive symptoms(n=102) ◦ Behavioral Activation discussed in 1 st Session (n=42) ◦ Came back for a second session (n=14) and a second PHQ-9 score was recorded  11 charts met criteria

18.  Patient Characteristics ◦ 8 Female ◦ 8 White ◦ Age 19-27 (M= 20.9) ◦ 3 Upperclass; 2 Graduate

19.  Presentation ◦ Reason for Referral to BHP:  Depression/Positive PHQ-9 screen (8)  Depression and Sleep (2)  Depression and Anxiety (1) ◦ Diagnosis on Encounter:  Major Depressive Disorder: unspecified (1), mild (2), moderate (1)  Depressive Disorder N.O.S. (2)  Adjustment Reaction (2)  No Diagnosis (3)

20. ◦ PHQ-9: Mean=12.82; SD= 3.55 ◦ 5 marked suicidal screening item on PHQ- 9 as greater than 0  3 indicated experiencing thoughts of death/hurting oneself several days  2 indicated experiencing thoughts of death/hurting oneself more than ½ the days in the past 2 weeks

21.  At All Sessions ◦ BA was used ◦ BHP provided educational info about depression ◦ Additional educational materials were provided  Avg. 13 days (SD=6.99) --session 1 & 2  Extra Components ◦ 3 Referred for extra treatment (long-term psychotherapy, medication management) ◦ 2 were seen for a 3 rd session, no PHQ-9 data though ◦ Other interventions were also given depending on problem complexity (e.g., stimulus control for sleep problems)

23.  Intake ◦ 5 marked suicidal screening item on PHQ-9 as greater than 0  3 indicated experiencing thoughts of death/hurting oneself several days  2 indicated experiencing thoughts of death/hurting oneself more than ½ the days in the past 2 weeks  2 nd Session ◦ Only one individual continued to report suicidal ideation and it was maintained at the level of experiencing thoughts several days across the past 2 weeks

25.  Disadvantages ◦ No way to determine cause/effect relationships ◦ Hard to generalize ◦ Possible biases in data collection and interpretation  Advantages ◦ Makes some studies possible ◦ Easier to implement ◦ Rich data ◦ Good way to examine innovative ideas

26.  Lejuez, C., Hopko, D.R., Acierno, R., Daughters, S., and Sherry, L. (2011). Revised Treatment Manual Ten Year Revision of the Brief Behavioral Activation Treatment for Depression. Behavioral Modification, 35, 111-161. DOI: 10.1177/0145445510390929