1 Basic rationale of low intensity treatments 2 Understanding BA from the perspective of learning theory and neuroscience Tereza Ruzickova Psychopharmacology and Emotion Research Lab University of Oxford 12th April 2022 Lecture plan (some of it might change) 1. Basic rationale of behavioural activation (BA) and other low intensity treatments 2. Understanding BA from the perspective of learning theory and neuroscience 3. The practical methodology of BA and other low-intensity skills 4. Evaluating efficacy and areas of clinical application 5. Implementation and dissemination, challenges and solutions 6. Discussion, Q&A with a Psychological Wellbeing Practitioner from the UK Other low intensity interventions? • Problem solving • Worry management - Graded exposure • Sleep management • Motivational interviewing • Physical exercise interventions Problem solving • First outlined by D'Zurilla and Goldfried (1971) • Step-by-stem system to approach and solve problems • Aim to empower patients with skills adopted for the treatment of depression and anxiety across a variety of populations: older adults (Kirkham etal., 2016), veterans (Kasckow, etal., 2014), ethnic minorities (Unlu Ince et al., 2013) and patients with chronic-obstructive pulmonary disease (Lee et al., 2015) and cancer (Hopko et al., 2011) Problem statement: Over the last few months I have been feeling stressed and overwhelmed due to lots of pressures in everyday life. I have been working long hours to try to help this, but this has meant that I am constantly tired and irritable and I have been seeing much less of my family and spending less quality time with my children. I have also been avoiding addressing problems elsewhere. As a result, I have thoughts of 'I can't cope' and 'I'm a bad parent'. This is impacting on my relationships with others. Problem solving Explain problem solving Identify main problems Worksheet 16.2 Jamie's problem list Problem list Main problem area Main problem area Work Financial Specific problems Not getting on with colleagues Having to cover for two colleagues who are off on long-term sick leave Current project is behind Getting to work Specific problems Credit card payment is overdue Always running out of money towards the end of the month Car MOT Least difficult to solve Least difficult to solve Getting to work Having to cover for two colleagues who are off on long-term sick leave Most difficult to solve Most difficult to solve Current project is behind Not getting on with colleagues Always running out of money towards the end of the month Selected problem Having to cover for two colleagues who are off on long-term sick leave Medium difficulty solving Medium difficulty solving Credit card payment is overdue Car MOT Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions Problem-solving worksheet Identify the problem Having to cover for two colleagues who are off with long-term sickness Potential solutions (Generate as many as possible) Quit my job Continue as I am currently - do nothing Speak to manager and discuss difficulties managing workload Refuse to do the extra work Delegate more responsibilities Ask colleagues for help Organise a team night out to boost morale Book some annual leave Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons Solution: Quit my job Advantages Disadvantages Would no longer have the stress Would have lots of spare time Don't have another job to go to Would be more stressed due to financial issues Could lose house if we can't pay the mortgage Would miss my job as its something I am good at Solution: Speak to manager and discuss difficulties managing workload Advantages Disadvantages They may not know how much work I currently have to do They may be able to take some of the responsibilities from me They could help with some of the tasks themselves They may just expect me to continue working as I am I may be seen as less capable than colleagues Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons 5. Select the solution that seems best Chosen solution Implementation plan What are you going to do? When are you going to do it? Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons 5. Select the solution that seems best 6. Make a specific plan: what, where, when, with whom Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons 5. Select the solution that seems best 6. Make a specific plan: what, where, when, with whom 7. Attempt the solution Problem solving 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons 5. Select the solution that seems best 6. Make a specific plan: what, where, when, with whom 7. Attempt the solution 8. Review & problem solve Try it yourself! Problem: Your friend is losing motivation to finish their degree 1. Explain problem solving 2. Identify main problems 3. Generate potential solutions 4. Evaluate pros and cons 5. Select the solution that seems best 6. Make a specific plan: what, where, when, with whom 7. Attempt the solution 8. Review & problem solve Mynors-Wallis et al. (1995) • 90 patients with major depression • Randomised to 1) problem solving (6 short sessions over 12 weeks), 2) antidepressant or 3) placebo • No significant difference found between problem solving (60% recovered) and antidepressant (50% recovered) •High patient satisfaction after PS • 30% recovered on placebo The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis John M. Malouff *, Einar B. Thorsteinsson, Nicola S. Schutte The meta- analysis, encompassing 2895 participants, showed that PST is significantly more effective than no treatment (d = 1.37), treatment as usual (d = 0.54), and attention placebo (d = 0.54), but not significantly more effective than other bona fide treatments offered as part of a study (d = 0.22). How many of you have struggled or know someone who has struggled with insomnia? Digital LI treatment for insomnia cognitive distortions y/^All or nothings, thinking Jumping to conclusions 2 + 2 = 5 "If he doesn't text back quickly he's a bad boyfriend" "I'm sure he wants to break up with me" Disqualifying^N the positive /" Over- >^ generalizing 'fvtrythtpg >i always rubotsh' nothing y.Kx) ever ncftfiMl "He never texts me back quickly" "This always happens to me" f Labelling \ "I'm such an idiot" Personalization "this is my fault V J "He is probably mad at me" CBT model of insomnia Arousal • Emotional (fear, sadness) • Cognitive (thoughts, images) • Physiologic (pain, muscular tension) ft v \ \ \ \ \ \ N Beliefs and Attitudes • Worry over sleep toss • Rumination over consequences • Unrealistic expectations • Misattnbutions and amplifications Consequences • Fatigue • Performance impairments • Mood disturbances • Social discomfort Maladaptive Habits • Excessive time spent in bed • Irregular sleep schedule • Daytime napping • Sleep-incompatible activities • Inappropriate use of hypnotics CBT tools Examining sleep-related thoughts Correcting distortions Setting up realistic expectations Sleep restriction Sleep hygiene Arousal • Emotional (fear, sadness) • Cognitive (thoughts, images) • Physiologic (pain, muscular tension) ft v \ \ \ \ \ \ N Beliefs and Attitudes • Worry over sleep toss • Rumination over consequences • Unrealistic expectations • Misattnbutions and amplifications Consequences • Fatigue • Performance impairments • Mood disturbances • Social discomfort Maladaptive Habits • Excessive time spent in bed • Irregular sleep schedule • Daytime napping • Sleep-incompatible activities • Inappropriate use of hypnotics Sleepio is a 6 week online program designed by sleep experts and based on cognitive and behavioral techniques. Sleep Restriction The most powerful way to increase your sleep drive and reset your sleep schedule. lorzil Stimulus Control Rebuild a healthy association between your bed and sleep. Cognitive Tools Manage the worries and thoughts that make it difficult to sleep. Sleep Hygiene Review Optimize your environment and habits for better sleep. • Fully automated • Algorithms for personalised recommendations How would you like to improve your sleep? Select all that apply Get to sleep more easily Sleep right through the night without waking up Stop waking up too early Wake up feeling refreshed None of the above o Your lifestyle e Your bedroom o The truth about sleep o Challenging negative thoughts o The Weekly Quiz Espie et al. (2019) Over 1700 participants Randomised 12 weeks of Sleepio programme vs sleep hygiene education website (superiority trial) Espieetal. (2019) Over 1700 participants Randomised 12 weeks of Sleepio programme vs sleep hygiene education website (superiority trial) Significantly improved sleep, physical health, wellbeing Assessment3 Unadjusted, Mean (SD) Adjusted Difference (95% CI) Cohen d P Value SHE + TAU dCBT + TAU PROMIS-10 Week 4 32.52 (6.05) 33.84 (6.49) 0.90 (0.40 to 1.40) 0.16 <.001 Week 8 32.92 (6.18) 35.08 (6.65) 1.76 (1.24 to 2.28) 0.31 <.001 Week 24 33.10(6.10) 35.24 (6.88) 1.76 (1.22 to 2.30) 0.31 <.001 WEMWBS Week 4 44.72 (8.21) 46.03 (8.55) 1.04 (0.28 to 1.80) 0.13 .007 Week 8 45.16 (8.77) 48.12(8.82) 2.68 (1.89 to 3.47) 0.35 <.001 Week 24 45.31 (8.89) 48.62 (9.02) 2.95 (2.13 to 3.76) 0.38 <.001 GSIIb Week 4 69.80 (23.64) 60.69 (26.20) -8.76 (-11.83 to-5.69) -0.69 <.001 Week 8 65.68 (25.86) 46.78 (29.90) -17.60 (-20.81 to-14.39) -1.38 <.001 Week 24 63.33 (27.26) 43.78 (31.25) -18.72 (-22.04 to-15.41) -1.46 <.001 Abbreviations: dCBT, digital cognitive behavioral therapy; GSII, Glasgow Sleep Impact Index; PROMIS-10, 10-item Patient-Reported Outcomes Measure; SHE, sleep hygiene education; TAU, treatment as usual; WEMWBS, Warwick-Edinburgh Mental Well-being Scale. Integrating LI interventions into the healthcare system STEPS system - intervene early - support prevention - distribute resources efficiently STEPS system - intervene early - support prevention - distribute resources efficiently Podcasts, school workshops, media STEPS system - intervene early - support prevention - distribute resources efficiently STEPS system - intervene early - support prevention - distribute resources efficiently STEPS system - intervene early - support prevention - distribute resources efficiently STEPS system - intervene early - support prevention - distribute resources efficiently Indiv Group therapy with specialist / Groups practitioners Single session counselling / Sjng|e contacts Books, phone calls, digital interventions Non face-to-face work GPs, nurses, peer support, emergency services, psychological assistants / wellbeing practitioners Working with others Already existing services that could help signpost to or deliver LI treatment Podcasts, school workshops, media Population level Awareness raising; community STEPS system - intervene early - support prevention - distribute resources efficiently Individual therapy with specialist practitioners /lndivx Group therapy with specialist / Groups practitioners Single session counselling / Sjng|e contacts Books, phone calls, digital interventions / Non face-to-face work GPs, nurses, peer support, emergency SerViCwel^ '/ W0rking With °therS " /Already existing services that could help signpost to or deliver LI treatment Podcasts, school workshops, media ^ Population level Awareness raising; community Network Benefits Financial Legal Agencies David Clark & Richard Layard • In 2007, less than 5% of UK adults with anxiety and depression would access evidence-based psychotherapy • Waiting lists often over a year long • Survey showed public preferred psychological therapy to medication • Similar situation (or worse) all around the world |L| I ^ C National Institute for IN I LC Health and Care Excellence David Clark & Richard Layard Untreated depression and anxiety reduce GDP by 4% (absenteeism and presenteeism) •Increased access to psychological therapy will have a minimal net cost London School of Economics THE DEPRESSION REPORT A New Deal for Depression and Anxiety Disorders The Centre for Economic Performance's Mental Health Policy Group June 2006 = David Clark & Richard Layard On World Mental Health Day in October 2007 the UK Government announced an unprecedented, large-scale initiative for Improving Access to Psychological Therapies (IAPT) for depression and anxiety disorders within the English National Health Service I •Between 2008 and 2011 investment in psychological therapies would rise to £173 million per annum above existing expenditure •The extra investment would be used to train and employ at least 3600 new psychological therapists who will work in new IAPT clinical services offering evidence-based psychological therapies Clark et al. (2009) • Two pilot services in Doncaster and Newham during first 13 months • Patients seen within 21 days •Offering HI specialist therapy or LI (most commonly guided self-help) • Self-referral or GP-referral • Careful outcome monitoring •50-60% recovery if at least two or more sessions, compared with 20% spontaneous recovery • 4-10% increase in employment IAPT successes TalkingSpace) _PI I C_/ NHS Foundation Trust • Trained 10 000 therapists • Treats over 1 000 000 patients annually now • Aims for 50% patients recovering and 75% improving • Collects outcome data on 98% patients • Similar services now implemented in Australia, Israel, Norway, Sweden • Recent evaluation: https://youtu.be/T1 r3ZqZK4iq Digital ft 89.9% of referrals accessing IAPT within 6 weeks 8.1 sessions of treatment on average per referral OPINION For better mental-health care in Canada, look to Britain DAVID CRATZER AND DAVID COLDBLOOM Stye $cUi Jlork Simcs England's Mental Health Experiment: No-Cost Talk Therapy LONDON — England is in the midst of a unique national experiment, the world's most ambitious effort to treat depression, anxiety and other common mental illnesses. Therapy deficit Nature 489, 473-474 (2012) "This programme represents a world-beating standard thanks to the scale of its implementation." Understanding BA from the perspective of learning theory and neuroscience Behaviourists & depression • Science and human behaviour (Skinner, 1957) • Functional analysis of depression (Ferster 1973) "A depressed person may sit silently for long periods, or perhaps even stay in bed all day " Driving forces of behaviour ... according to behaviourists * Reinforcement = leads to increase in behaviour • Positive reinforcement behaviour => something good happens • Negative reinforcement behaviour => something bad doesn't happen • Punishment = leads to decrease in behaviour behaviour => something bad happens or something good doesn't happen Driving forces of behaviour ... according to behaviourists What driving force would explain this? 1. Rat presses a lever and gets an electric shock. 2. Wife doesn't get coffee with a male friend so that husband doesn't shout at her. 3. Shop assistant wears a face mask during a pandemic. 4. Man spends all day watching pornography. 5. Scientist works hard on his publication. Behaviourists & depression • Depression is characterised by: • Decrease in positive reinforcement • Increase in negative reinforcement • Increase in punishment • Examples? Behaviourists & depression Depression is characterised by: • Decrease in positive reinforcement: Less social connection, less work fulfilment, lower enjoyment from hobbies, exercise, lower income... • Increase in negative reinforcement: Avoidant behaviour - increase in watching TV, sleeping, substance use, social media scrolling, ignoring contact from friends... • Increase in punishment? Feeling like effort was wasted? Loss of a job, loss of a relationship, social rejection... Can be both a cause and a consequence of depression The mechanism of depression onset & maintenance Something difficult happens (that reduces positive reinforcement / increases negative reinforcement / increases punishment) 4, Sadness, lack of energy Interrupted routine Lower activity Anhedonia Lack of motivation The mechanism of depression onset & maintenance Something difficult happens (that reduces positive reinforcement / increases negative reinforcement / increases punishment) Sadness, lack of energy Interrupted routine Anhedonia Lack of motivation Lower activity (also reduces positive reinforcement / increases negative reinforcement / increases punishment) The mechanism of depression onset & maintenance Something difficult happens (that reduces positive reinforcement / increases negative reinforcement / increases punishment) 4 Sadness, lack of energy Interrupted routine Lower activity (also reduces positive reinforcement / increases negative reinforcement / increases punishment) Anhedonia Lack of motivation The mechanism of depression onset & maintenance Something difficult happens Primarv cause (that reduces positive reinforcement / increases negative reinforcement / increases punishment) 4, Secondary ^ cause Lower activity (also reduces positive reinforcement / increases negative reinforcement / increases punishment) Sadness, lack of energy Interrupted routine Anhedonia Lack of motivation The mechanism of depression onset & maintenance Seconda cause Something difficult happens PrimarV cause (that reduces positive reinforcement / increases negative reinforcement / increases punishment) Sadness, lack of energy Interrupted routine Anhedonia Lack of Lowecactivity (also reduces positive reinforcement / increases negative reinforcement / increases punishment) Primary cause John has recently gone through a breakup. Secondary cause John has become a lot more inactive. John has recently gone through a breakup. He misses all the pleasant activities Primary cause ne used to do witn nis girlfriend, like going to the park or dancing together. He started avoiding places that remind him of her as well as mutual friends to avoid the pain. The grief he's experiencing makes him feel like his investment in the relationship has been wasted. Secondary cause John has become a lot more inactive. Primary cause Secondary cause John has recently gone through a breakup. He misses all the pleasant activities he used to do with his girlfriend, like going to the park or dancing together. He started avoiding places that remind him of her as well as mutual friends to avoid the pain. The grief he's experiencing makes him feel like his investment in the relationship has been wasted. John has become a lot more inactive. He stopped going to the gym and doesn't put as much effort into his work, because he doesn't feel motivated. He started playing computer games and sleeping more to escape negative feelings. His boss is starting to get upset with him for making mistakes. Neuroscience of BA? BIS & BAS • Behavioural inhibition and activation (approach) systems •Gray (1987) two major neurobiological systems responding to reward and •Carver and White (1994) BIS/BAS scale development • Relate to personality factors like neuroticism and extraversion BIS & BAS Gray (1987) two major neurobehavioural systems responding to reward and punishment Carver and White (1994) BIS/BAS scale development 1. BIS If I think something unpleasant is going to happen I usually get pretty "worked up." I worry about making mistakes. Criticism or scolding hurts me quite a bit. I feel pretty worried or upset when I think or know somebody is angry at me. Even if something bad is about to happen to me, I rarely experience fear or nervousness. I feel worried when I think I have done poorly at something. •I have very few fears compared to my friends. 2. BAS Reward Responsiveness When I get something I want, I feel excited and energized. When I'm doing well at something, I love to keep at it. When good things happen to me, it affects me strongly. It would excite me to win a contest. When I see an opportunity for something I like, I get excited right away. 3. BAS Drive When I want something, I usually go all-out to get it. I go out of my way to get things I want. If I see a chance to get something I want, I move on it right away. When I go after something I use a "no holds barred" approach. 4. BAS Fun Seeking I will often do things for no other reason than that they might be fun. I crave excitement and new sensations. I'm always willing to try something new if I think it will be fun. I often act on the spur of the moment. Behavioural inhibition system * punishment (innate & learnt) * absence of expected reward (= disappointment, frustration) * can be triggered by novelty (hyponeophagia in rodents) * inhibits behaviour that may lead to negative outcomes * hyperactive in depression Sensitivity to punishment scale Reward predicted Reward occurs Reward predicted No reward occurs MMH mm -1 0 CS « s Schultz, Dayan, Montague Science, 1997 Behavioural activation * reward * absence of punishment (= relief) * hypoactive in depression -decreased approach towards rewarding behaviour (approach) system \0 Sensitivity to reward scale Pinto-Meza et al. (2006) • Participants with current MD, participants recovered from MD and healthy controls - Current and recovered MD showed hyperactive BIS and hypoactive BAS • Possible personality / physiological vulnerability marker that can be objectively measured • May explain the mechanism of BA treatment What else could we research to better understand the mechanism of depression and its treatment? Thank you! • Please fill in feedback forms: https://forms-gle/xDaPaTfGyHb4FDre7 • Any questions, email me at ruzickova-te@gmaiLcom