5 Implementation and dissemination of low intensity interventions: challenges and solutions Tereza Ruzickova Psychopharmacology and Emotion Research Lab University of Oxford 10th May 2022 But first, let’s catch up… Driving forces of behaviour • Reinforcement = ? • Positive reinforcement • Negative reinforcement behaviour => _________ ? behaviour => __________ ? … according to behaviourists • Punishment = ? behaviour => __________ ? Driving forces of behaviour • Reinforcement = leads to increase in behaviour • Positive reinforcement • Negative reinforcement behaviour => something good happens behaviour => something bad doesn't happen … according to behaviourists • Punishment = leads to decrease in behaviour behaviour => something bad happens or something good doesn’t happen 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 ful fi lment, 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 e ff ort was wasted? Loss of a job, loss of a relationship, social rejection… Can be both a cause and a consequence of depression Something di ffi cult happens (that reduces positive reinforcement / increases negative reinforcement / increases punishment) Sadness, lack of energy Interrupted routine Anhedonia Lack of motivation Lower activity The mechanism of depression onset & maintenance Something di ffi cult happens (that reduces positive reinforcement / increases negative reinforcement / increases punishment) Sadness, lack of energy Interrupted routine Anhedonia Lack of motivation Lower activity The mechanism of depression onset & maintenance (also reduces positive reinforcement / increases negative reinforcement / increases punishment) Sadness, lack of energy Interrupted routine Anhedonia Lack of motivation Lower activity The mechanism of depression onset & maintenance (also reduces positive reinforcement / increases negative reinforcement / increases punishment) Something di ffi cult happens (that reduces positive reinforcement / increases negative reinforcement / increases punishment) Sadness, lack of energy Interrupted routine Anhedonia Lack of motivation Lower activity The mechanism of depression onset & maintenance Primary cause Secondary cause (also reduces positive reinforcement / increases negative reinforcement / increases punishment) Something di ffi cult happens (that reduces positive reinforcement / increases negative reinforcement / increases punishment) Sadness, lack of energy Interrupted routine Anhedonia Lack of motivation Lower activity The mechanism of depression onset & maintenance Primary cause Secondary cause (also reduces positive reinforcement / increases negative reinforcement / increases punishment) Something di ffi cult happens (that reduces positive reinforcement / increases negative reinforcement / increases punishment) Primary cause Secondary cause John has recently gone through a breakup. 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. Primary cause Secondary cause John has become a lot more inactive. He stopped going to the gym and doesn’t put as much e ff ort 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. 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. Neuroscience of BA? • Behavioural inhibition and activation (approach) systems •Gray (1987) two major neurobiological systems responding to reward and punishment •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 BIS & BAS Behavioural activation (approach) system • reward • absence of punishment (= relief) • hypoactive in depression - decreased approach towards rewarding behaviour Sensitivity to reward scale 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 Schultz, Dayan, Montague Science, 1997 • 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 Pinto-Meza et al. (2006) Back to the topic of implementation & dissemination… What issues might come up if we tried implementing these interventions? • B-G: younger and older age groups What issues might come up if we tried implementing these interventions? What issues might come up if we tried implementing these interventions? • B-G: younger and older age groups • H-J: non-western cultures, cultural, religious and sexual minority groups What issues might come up if we tried implementing these interventions? What issues might come up if we tried implementing these interventions? • B-G: younger and older age groups • H-J: non-western cultures, cultural, religious and sexual minority groups • L-M: groups with low socioeconomic status and low income countries What issues might come up if we tried implementing these interventions? What issues might come up if we tried implementing these interventions? • B-G: younger and older age groups • H-J: non-western cultures, cultural, religious and sexual minority groups • L-M: groups with low socioeconomic status and low income countries • N-S: patients with physical illness or addiction comorbidity What issues might come up if we tried implementing these interventions? What issues might come up if we tried implementing these interventions? • B-G: younger and older age groups • H-J: non-western cultures, cultural, religious and sexual minority groups • K-M: groups with low socioeconomic status and low income countries • N-S: patients with physical illness or addiction comorbidity • Š-V: current Czech mental healthcare system What issues might come up if we tried implementing these interventions? What issues might come up if we tried implementing these interventions? Implementation and dissemination - important factors • Robust clinical & economic evidence • Lobbying - Lord Layard writing and speaking to ministers for years + coalition of mental health charities “We Need To Talk” • Strategic political timing & consistency with broader government policy around social care and evidence-based treatment provision Political influence • Involving service users and carers in key decision making • Creating a legislative framework • Creating a management framework • E ff ective leadership & its consensus (politics, healthcare, professional bodies) • Measuring change to supply evidence of e ffi cacy • Long-term technical and fi nancial sustainability Change management • Involving service users and carers in key decision making • Creating a legislative framework • Creating a management framework • E ff ective leadership & its consensus (politics, healthcare, professional bodies) • Measuring change to supply evidence of e ffi cacy • Long-term technical and fi nancial sustainability Change management Take the long term view! • Crucial to understand individual situation and needs of each target group • Developing new systems collaboratively to make a change rather than just telling people what to do • Inner context: leadership, organisational culture, individual attitudes • Outer context: policy, insurance, public attitudes • Ongoing support rather than one-time training is ideal Change management Developing new types of education • Client and healthcare workers awareness & preference • Not viewing LI interventions as “second choice” • Media outreach • Strong partnership with charities & community groups • Creating a new language? Public awareness Wulsin et al. (2002) • Many panic disorder patients get misdiagnosed with a physical health condition at emergency services • A screening measure and 5min structured interview increased panic disorder diagnosis and relevant referral GP awareness 73% of those seeking psychological help turn to their GPs (OECD, 2011) Private investment Continuation of care Ali et al. (2017) • Longitudinal cohort of over 400 patients • 50% participants found to relapse within 1 year, particularly if they had residual symptoms at the end of treatment • Recommend that patients are treated until residual symptoms are gone and follow-up care is provided “We suggest taking the long view, recognising that problems like depression often have to be managed as recurrent long-term conditions.” STEPS system Podcasts, school workshops, media GPs, nurses, peer support, emergency services, psychological assistants / wellbeing practitioners Specialist practitioners Books, phone calls, digital interventions Network Overwhelmed? Lobby politicians? Lobby politicians? Economic measurements? Lobby politicians? Economic measurements? Media campaigns? Lobby politicians? Economic measurements? Media campaigns? Public awareness campaigns? Lobby politicians? Economic measurements? Media campaigns? Train GPs? Public awareness campaigns? Lobby politicians? Economic measurements? Media campaigns? Train GPs? Public awareness campaigns? Train teachers in BA? Lobby politicians? Economic measurements? Media campaigns? Train GPs? Public awareness campaigns? Train teachers in BA? Build a low intensity intervention app? Lobby politicians? Economic measurements? Media campaigns? Train GPs? Public awareness campaigns? Train teachers in BA? Build a low intensity intervention app? Create a BA center in Afganistan? Lobby politicians? Economic measurements? Media campaigns? Train GPs? Public awareness campaigns? Train teachers in BA? Build a low intensity intervention app? Create a BA center in Afganistan? Build software for easier continuation of care? Lobby politicians? Economic measurements? Media campaigns? Train GPs? Public awareness campaigns? Train teachers in BA? Build a low intensity intervention app? Create a BA center in Afganistan? Build software for easier continuation of care? Establish a new masters course? National Cancer Act (1971) 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 speci fi c plan: what, where, when, with whom 7. Attempt the solution 8. Review & problem solve 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 speci fi c plan: what, where, when, with whom 7. Attempt the solution 8. Review & problem solve 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 speci fi c plan: what, where, when, with whom 7. Attempt the solution 8. Review & problem solve Thank you for your attention! Don’t forget fi lling in your anonymous feedback: https://forms.gle/xDaPaTfGyHb4FDre7