Transcript Follow-Up - Collaborative Family Healthcare Association

Is a Brief Behavioral Activation Intervention
Effective in Reducing Depressive Symptoms?
Jennifer Funderburk, Ph.D.1,2,3
.
Collaborative Family Healthcare Association
October 5th, 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
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.
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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
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Detailed report of the initial presentation,
treatment, and follow-up of an individual
patient.
Presentation
Detailed Description
Signs & Symptoms
MD Impressions
Treatment
Thorough & Full
Explanation of
Tx Process
Follow-Up
Symptom Course
Tx Response
Follow-ups
Case Report
Case Report
Case Report
Case Report
Case Report
Case Report
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A study describing the outcomes of multiple
patients who were given a similar
treatment.
Patients
Demographics
Select Diagnoses
Common
Treatment
Shared Features
&
Individualized
Adaptations
Outcomes
% Positive Change
# Adverse Events
Follow-ups
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Decide on clear criteria
◦ Examples:
 Treatment used
 Condition shows up in chart
 Symptoms above a certain threshold
 Demographic Characteristic (e.g.,
Gender; Age)
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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
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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
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ELECTRONIC MEDICAL RECORD/CHART REVIEW
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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
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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
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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
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Syracuse University Health Clinic
◦ Serves Syracuse University (total
enrollment approx. 20,000)
◦ ̴9,464 patients per semester, 1
̴ 46
patients per day
◦ 2 physicians, 7 nurse practitioners, 4 per
diem practitioners
Integrated Behavioral Healthcare (IBHC)
◦ Regular screening
◦ Behavioral Health Providers
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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)
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All BHPs received additional training and
supervision by the first author
◦ Lejuez et al. (2011) manual as a guide
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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
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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 1st
Session (n=42)
◦ Came back for a second session (n=14)
and a second PHQ-9 score was recorded
11 charts met criteria
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Patient Characteristics
◦ 8 Female
◦ 8 White
◦ Age 19-27 (M= 20.9)
◦ 3 Upperclass; 2 Graduate
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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)
◦ PHQ-9: Mean=12.82; SD= 3.55
◦ 5 marked suicidal screening item on PHQ9 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
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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 3rd session, no PHQ-9 data
though
◦ Other interventions were also given depending
on problem complexity (e.g., stimulus control for
sleep problems)
25
20
15
10
5
0
time 1
time 2
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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
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2nd 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
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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
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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