Behavioral Activation Between Acute Inpatient and Outpatient Psychiatry: Description of a Protocol and a Pilot Feasibility Study

    Behavioral Activation Between Acute Inpatient and Outpatient Psychiatry: Description of a Protocol and a Pilot Feasibility Study Fredrik Folke, Timo Hursti, Stefan Tungstr¨om, Per S¨oderberg, Lisa Ekselius, Jonathan W. Kanter PII: DOI: Reference:

S1077-7229(14)00044-3 doi: 10.1016/j.cbpra.2014.03.006 CBPRA 529

To appear in:

Cognitive and Behavioral Practice

Received date: Revised date: Accepted date:

7 October 2013 23 February 2014 24 March 2014

Please cite this article as: Folke, F., Hursti, T., Tungstr¨ om, S., S¨oderberg, P., Ekselius, L. & Kanter, J.W., Behavioral Activation Between Acute Inpatient and Outpatient Psychiatry: Description of a Protocol and a Pilot Feasibility Study, Cognitive and Behavioral Practice (2014), doi: 10.1016/j.cbpra.2014.03.006

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INPATIENT TO OUTPATIENT BA

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Contains Video

Behavioral Activation Between Acute Inpatient and Outpatient Psychiatry: Description of a

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Protocol and a Pilot Feasibility Study

Fredrik Folke, Center for Clinical Research, Dalarna, Sweden, Uppsala University, and Uppsala

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University Hospital

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Timo Hursti, Uppsala University Stefan Tungström and Per Söderberg, Center for Clinical Research, Dalarna, Sweden

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Lisa Ekselius, Uppsala University

Jonathan W. Kanter, University of Washington

Continuing Education Quiz located on p. xx

ACCEPTED MANUSCRIPT INPATIENT TO OUTPATIENT BA

2 Abstract

Gaps in the continuity of care between acute inpatient and outpatient psychiatric services are

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common and potentially detrimental for service users. In this paper we provide the rationale for

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and description of a 12-session behavioral activation intervention for acute inpatients with depression and comorbid psychiatric disorders. The intervention was tailored to be initiated

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during acute inpatient care and to continue after discharge into outpatient services. We also

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describe a small pilot investigation (N = 13) of the intervention’s preliminary feasibility. Treatment retention, self-ratings, and participants’ adherence to treatment principles indicate

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preliminary feasibility of behavioral activation in this complex context. Self-rated activation and avoidance improved during the intervention. The value of a parsimonious inpatient therapy that

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can bridge the gap between services is discussed along with the limitations of this study.

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Keywords: continuity of care, acute, inpatient, behavioral activation

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The period after discharge from around-the-clock acute psychiatric inpatient services to less

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frequent community outpatient follow-up is associated with increased risk for suicide (Qin &

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Nordentoft, 2005), noncompliance, relapse, and rehospitalization (Walker, MinorSchork, Bloch,

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& Esinhart, 1996). Engaging inpatients in outpatient treatment programs before discharge has been found to increase adherence to outpatient services (Boyer, McAlpine, Pottick, & Olfson,

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2000). However, serious gaps in the continuity of care have been recurrently reported (Adair et al., 2003) and many patients receive no immediate or much delayed outpatient aftercare (Boyer et

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al., 2000).

Psychological treatments for inpatients are not readily available on acute inpatient units

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(Mullen, 2009). When such treatments are available, they rarely span over the critical transition period between inpatient and outpatient services. The lack of psychological services in acute

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inpatient settings is perhaps explained by complicating features of the ward milieu such as short and unpredictable admission lengths, diverse and preliminary diagnoses, high symptom severity, behavioral disturbance, lack of relevant staff training, and occasional staff skepticism towards psychotherapy (Curran, Lawson, Houghton, & Gournay, 2007; Mullen, 2009). Research indicates that cognitive and behavioral therapies (CBTs) can be successfully adapted for inpatients with depression (Cuijpers et al., 2011) as well as mixed diagnostic groups (Durrant, Clarke, Tolland, & Wilson, 2007; Lynch, Berry, & Sirey, 2011; Veltro et al., 2008). The research is however preliminary and the magnitude of psychotherapy effects may be smaller than the ones observed in other contexts (Cuijpers et al., 2011). The effectiveness of CBTs for depressed inpatients has been argued to improve if outpatient sessions are scheduled after discharge as it ensures consolidation of skills learned during admission (Stuart, Wright, Thase, & Beck, 1997; Thase &

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Wright, 1991). There is promising data from inpatient depression trials where CBTs start during inpatient treatment and continue after discharge (Miller, Bishop, Norman, & Keitner, 1985;

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Miller, Norman, & Keitner, 1989; Scott, 1992; Whisman, Miller, Norman, & Keitner, 1991).

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Behavioral activation (BA) has been proposed to be particularly well suited to deal with the challenges of the inpatient milieu (Curran, Lawson, Houghton, & Gournay, 2007). We will

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highlight a few arguments for this and for why we believe it could serve as a treatment to bridge

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the gap between inpatient and outpatient services. First, data from a large clinical trial (Dimidjian et al., 2006) suggested that BA was more effective than cognitive therapy (CT) in the acute

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treatment of severe depression. BA was also equally effective to pharmacotherapy and evidenced superior retention. In a reanalysis of the data, Coffman and colleagues (2007) found that BA did

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not evidence the same nonresponse pattern as did CT for a subset of patients with functional

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impairment, problems in the primary support group, and severe depression.

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Second, Hopko and colleagues (2003) reported that their brief protocol Behavioral Activation Treatment for Depression (BATD; Lejuez et al., 2001) evidenced significantly larger improvements from baseline to posttreatment in depression compared to supportive therapy. In another recent open trial BA was implemented as a nurse-driven milieu therapy called Behavioral Activation Communication (BAC; Gollan et al., in press) on an acute ward. Inpatients in the BAC milieu demonstrated significantly greater changes in self-reported positive affect and avoidance from admission to discharge compared to a nonrandomized control group. Third, BA has been proposed to be easier to learn than the extensive CT package (Jacobson et al., 1996). Actually, data do suggest that BA can be learned and effectively executed by nontherapists after only 5 days of training (Ekers, Richards, McMillan, Bland, & Gilbody, 2011). The parsimonious nature of BA is of particular value for the inpatient context as the majority of staff involved in such treatment is nontherapists. Finally, BA also appears well suited to deal with

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the heterogeneous inpatient population with diverse and preliminary diagnoses. Successful adaptations of BA have been reported for a wide variety of diagnoses and populations

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(Dimidjian, Barrera, Martell, Munoz, & Lewinsohn, 2011).

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In summary, BA is an efficacious, easy-to-learn, parsimonious therapy that can be successfully adapted to both a variety of diagnoses as well as treatment contexts. This has led us

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and others to conclude that BA is plausible therapy for further evaluation in inpatient settings

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and, we assert, a promising therapy to bridge the gap in the transition from inpatient to outpatient

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care.

The Present Study

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In this pilot study we sought to adapt a BA protocol to bridge the gap in the transition from

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inpatient to outpatient care for acutely admitted patients with depression and other psychiatric

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comorbid disorders. The primary aim of the pilot study was to examine the intervention’s feasibility and to provide empirical data from the treatment process (i.e., activation, avoidance, homework adherence, working alliance) as BA is implemented between inpatient and outpatient services. A secondary aim was to report the uncontrolled outcomes and investigate possible relations between outcomes and treatment process variables.

The BA Model BA has its roots in early behavioral models of depression (Ferster, 1973; Lewinsohn, 1974). The models assert the role of decreased levels of positive reinforcement and increased aversive control for understanding depression and pleasant activity scheduling as a primary treatment strategy. Contemporary BA arose in the 1990s and it exists in two different widespread versions: BA developed by the late Jacobson and colleagues (Jacobson, Martell, & Dimidjian, 2001;

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Martell, Dimidjian, & Herman-Dunn, 2010) and BATD (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011). They share many features but they also differ in content, emphasis, complexity,

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and structure (Kanter et al., 2010). BATD provides a simple structure with fewer components and greater emphasis on formal values assessment. BA, on the other hand, relies more on the

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therapist’s ability to conduct ideographic functional analysis and to structure therapy accordingly.

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The model used in our study was based on the synthesis of the two versions, developed by

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Kanter, Busch, and Rush (2009). It capitalizes on the simplicity and structure of BATD while it

Overview of the Adapted BA Protocol

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retains BA’s emphasis on ideographic functional analysis.

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The first author produced a therapist manual and patient workbook with input from one of

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the authors (J. W. Kanter). An overview of the BA protocol is outlined in Figure 1.

General Adaptations

The complex treatment context required some adaptations of therapy structure and content. First, inpatient diagnoses are often preliminary as admission to acute psychiatric wards is reserved for persons with severe, and often unusual, symptoms and pronounced behavioral disturbance. The manual thus had to address a wide range of problems beyond the scope of typical major depression. As a result, patient materials used the term depression interchangeably with other words that denote emotional problems. Exposure techniques were added to the protocol based on our clinical observation that anxiety and avoidance is highly common in the inpatient population. We consider exposure a logical extension of BA given that both approaches are rooted in the behavioral tradition, apply a similar functional understanding of avoidance, and foster approach behaviors to counter avoidance. The kinship between BA and exposure therapy has been noted by

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other researchers (Jacobson et al., 2001; Kanter et al., 2010) and the two have been integrated before (Chu, Colognori, Weissman, & Bannon, 2009). We also encouraged therapists to be

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flexible regarding session length and amount of content covered each session given many

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inpatients’ hampered ability to focus attention. Instead of specifying the exact content of each session, we defined three phases of therapy (i.e., early, middle, and late phases). Sessions were

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scheduled twice a week whenever possible to increase the amount of support during the critical

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time period and to work intensively on achieving behavior change. The protocol also needed to take into account that wards are artificial milieus with few similarities to patients’ home

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environments. The function of an event on the ward may not be the same at home and some reinforcers may simply not be available on the ward. Sessions were scheduled at the outpatient

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facilities closest to home whenever possible, to increase contact with positively reinforcing

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events in patients’ communities, to counter possible negative reinforcement for staying on the

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ward, and to introduce the patient to the outpatient facility.

Early Phase (Approximately Sessions 1–3) Treatment starts with history taking. Therapists are particularly interested in gaining knowledge about the relation between the patient’s behavior (what the person has stopped doing, does instead, avoids, etc.), the context (when, where, with whom, etc.), and mood and emotion. The information is used to provide the patient with a rationale for how mental health problems develop and are maintained. The therapist explains how negative life events elicit aversive emotional reactions and how avoidant coping maintains and exacerbates problematic emotions and life situations. Specific attention is paid to rumination. In BA rumination and worry are understood functionally (Jacobson et al., 2001), as is avoidance behavior (e.g., avoidance of the anxiety that is associated with active problem solving). Therapists were carefully trained to

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deliver the rationale in a nonconfrontational and validating manner. This is particularly important when working with inpatients who often feel they have lost support from family and friends. A

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rationale is then provided for how to break the vicious cycle and improve mental health from “the

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outside in.” This refers to changing avoidant coping responses first and not attempting direct control of emotional reactions. It is achieved using structured graded activation and problem-

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solving strategies. Therapists were trained to deal with common negative reactions to the

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rationale in a normalizing, validating, and educational fashion. Assessment is then further refined by initiating self-monitoring of moment-to-moment activities and mood, emotion, and sense of

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mastery. After behavioral assessment of history and present-moment monitoring, attention is then turned to the future. The patient’s values in different life domains are assessed. Values and

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activity monitorings are then used as the foundation from which the therapist aids the person to

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develop behavioral goals. Specific values- and goal-related behaviors are listed according to their

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expected difficulty in an activity hierarchy functioning as a treatment plan. Low-difficulty activities are planned early on and problem solving of anticipated obstacles are performed (Video 1 provides an example of activity scheduling). Therapists were trained to approach activation with an empirical interest (i.e., never assume that an activity will function as an antidepressant but rather to model curiosity and willingness to try before drawing conclusions). Activation was defined in a broad sense, as pleasant activities (e.g., doing something one used to enjoy) as well as problem-solving activities (e.g., settle a conflict with someone). Activation was also performed in the form of exposure to feared situations. Therapists were trained to conduct exposure within the framework of the simple BA rationale, without the addition of other exposure models or rationales. Finally, in accordance with the BATD protocol (Lejuez et al., 2011), activation assignments were derived from personal values (e.g., doing something in the service of a personal value as opposed to achieving a feeling). Using values as a basis for activation is very similar to

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Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999). In fact, ACT and BA share many common features, both practical and theoretical (Kanter, Baruch, & Gaynor,

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2006). For example, both treatments emphasize the importance of functional analysis, targeting

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avoidance, not attempting direct change of cognition, and immediate attention to experience.

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Middle Phase (Approximately Sessions 3–10)

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After attempts at simple activation, therapists evaluate if it has been sufficiently effective in terms of improved mood, and if so, therapy continues to progress through the activation

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hierarchy. If, on the other hand, simple activation does not achieve its intended effects for some reason, the therapist works together with the patient to assess the reasons for nonadherence and

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tailor interventions accordingly. Nonadherence is categorized using functional categories

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corresponding to the behavioral ABC model: (A) stimulus control deficits, (B) behavioral skills

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deficits, and (C) environmental consequences (public and private). Stimulus control deficit barriers reflect whether the environment effectively supports activation (e.g., reminders) and whether the rationale has been appropriately understood and remembered. To investigate stimulus control deficits, the therapist asks questions like, “Did you remember the assignment?” “Did you remember why it was important?” (See Video 2 for an example.) Stimulus control interventions involve using “reminder strategies” or revisiting and expanding the rationale. Behavioral skill deficit barriers reflect nonadherence due to not having the skills necessary to perform the activity. To investigate skills deficits the therapist asks questions like, “Did you have to use certain skills that you find difficult?” “Would you know how to do it hadn´t you been so anxious?” (See Video 2 for an example.) Tailored skills training interventions are initiated using traditional skills training procedures. Identifying and targeting skills deficits is standard procedure in BA (Martell et al., 2010). Public environmental consequence barriers reflect

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observable, external disruptions (e.g., the partner did the activity) or competing distractions (e.g., computer games). To investigate if public consequences contribute to nonadherence the therapist

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asks questions like, “How did others react to your trying to do the assignment?” “Did you think

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the assignment was less fun than whatever it was you did instead?” (See Video 2 for an example.) Public consequences are addressed with contingency management techniques such as

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making behavioral contracts with self and others. Private environmental consequences barriers

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reflect avoidance of internal experiences (e.g., aversive thoughts and feelings). To investigate if private consequences contribute to nonadherence the therapist asks questions like, “Did thinking

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about the homework cause distress?” “How do you feel if you imagine your self doing the assignment now?” (See Video 2 for an example.) Such barriers are addressed with explicit

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training of functional assessment of avoidance patterns and problem solving to come up with

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alternative coping strategies, training attention to experience, and using exposure.

Late Phase (Approximately Sessions 10–12) Therapy ends with traditional relapse prevention. Work is focused on generalizing the skill of activating as a response to negative life events and emotions broadly into everyday routines and into different situations, especially outside the inpatient unit. The therapist gradually fades the use of instructions to see if the patient is able to respond with activation and problem-solving strategies without therapist prompts. Patients are encouraged to identify potentially difficult situations in the future and apply problem solving. Early-warning signs of depression, anxiety, and increased avoidance are discussed and an activation relapse plan is defined.

Case Illustration

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Monica was a 44-year-old single, unemployed woman with a longstanding history of depressive episodes and severe health anxiety. She did fulfill the criteria for generalized anxiety

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disorder but her outpatient psychiatrist considered dependent personality disorder a better

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diagnosis given her pervasive behavioral pattern of interpersonal worrying and reassurance seeking. Monica was brought by her daughter and ex-husband to the acute ward because they had

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seen her become increasingly housebound and had expressed plans to commit suicide. On the

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ward Monica was perceived to be depressed, anxious, restless, and she repeatedly asked the same questions about her medications. She gave her verbal and written informed consent to participate

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in the study after 4 days on the unit. She was on antidepressant and antipsychotic medication

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Session 1

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when admitted and dosages were increased after a few days.

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The first session was on the ward as Monica was reluctant to leave. During history taking she stated that she had been somewhat depressed for all her life and occasionally had worse episodes. She thought one reason for this was that she never made any decisions on her own and always consulted others in everyday situations. During her marriage she got reassurance and advice from her husband but since the divorce a few years ago she had felt abandoned and disoriented. She frequently called her daughter or mother to ask for their advice on ordinary every day decisions. Whenever she had tried to make up her own mind in the past she had felt like a failure and she ruminated over being incompetent. Her father died when she was young and she had been worried about her health ever since. She visited the emergency room or primary care physician frequently and was occasionally convinced that she was dying from a medical disease. Whenever she was declared fit she was first angry for not being taken seriously and then relieved. She did not leave home without a phone and she always stayed within reach of others so that she could

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receive help in case of a medical emergency. She had gradually become less engaged in activities and relationships. She no longer asked her daughter to come stay with her, she had stopped going

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for coffee with her two girlfriends, and she had also quit her long-time commitment in the choir.

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Monica avoided going outside but managed to get groceries as she lived next door to the store. She spent most of the time trying to sleep, watching TV, and ruminating about her life situation.

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She was unemployed and was on disability pension due to her psychiatric condition.

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The therapist spent the last part of the session providing Monica with the rationale for how her emotional problems could be understood. Negative events (being lonely, difficult

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everyday decisions, bodily symptoms) were listed. The related aversive emotional responses (feeling sad and worthless, uncertain about decisions and afraid of symptoms) were also listed

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and validated as normal and understandable given her history. Her behavioral responses

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(ruminating, making suicide plans, not going out, staying in bed, seeking everyday and medical

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advice) were validated as sincere attempts at coping that had actually provided her some shortterm relief. Monica agreed that her coping attempts could be labeled avoidance and she could see that they had worsened her depression.

Session 2

This session was also conducted at the inpatient unit. The therapist asked Monica to review the rationale from last session, provided Monica with a whiteboard pen, and stood by her side to signal that they would work collaboratively on repeating the rationale. Afterward, the therapist described how the vicious cycle could most effectively be broken from “the outside in.” In response Monica stated that she had tried previously and did not think it was possible to make behavioral changes. The therapist acknowledged that this concern was both common and understandable, especially given her history of trying. She was also reassured that this treatment

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had helped many others with similar problems and that it would contain different elements from her own previous change attempts (e.g., exploring many different coping behaviors, detailed

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gradual activation towards specific goals, coaching and support). The therapist then reviewed in detail activities that Monica had used to enjoy but had stopped doing. First she denied ever

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having liked anything. After being prompted with highly specific questions (e.g., “Did you ever

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enjoy anything in your bathroom?” “Looking back at last year, was there an evening you

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remember particularly well?”), she came up with a wide variety of activities, including taking baths, having dinner with her daughter, going to choir practice, and having coffee with friends.

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At the end of the session Monica was introduced to the self-monitoring procedure and asked to complete 1 day of self-monitoring before next session. The therapist also asked if Monica would

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be willing to explore what would happen if she went to the outpatient unit for the next session.

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Monica understood the purpose of doing so (investigating the effect of new behaviors) and felt

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nervous about it at the same time. The assignment was planned in detail and obstacles (e.g., being too fatigued and too afraid) were problem solved.

Session 3

The therapist started with letting Monica know that he really appreciated her coming to the outpatient clinic despite fatigue and fears. She was asked in detail about the experience of doing so (“What did you feel?” “How did you get started?” “How did you persist when feelings got really intense?” “Did you learn anything from this experience?”). Her accomplishment was then discussed in the context of the treatment rationale (“So you managed to act in accordance with your goal even though your feelings were telling you otherwise and that provided you with some new insights about how things work”). If Monica would not have come to the outpatient facility the therapist was prepared to use that experience to gain more knowledge about her emotional

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and behavioral responses and being careful to frame it as an important learning experience rather than a failure. Her self-monitoring form was reviewed and it showed that she had been staying in

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bed on the ward with a low mood for most of the time, except for an instance of talking to a

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fellow patient that had improved her mood somewhat. Monica was then asked about values and she emphasized the importance of her relationship to her daughter, getting routines, being

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outside, working (which she did not think was possible), and that she wanted to be a person who

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made her own decisions in life. The therapist then encouraged her to come up with specific goals in line with these values. Examples of Monica’s goals were making dinner for her daughter,

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going grocery shopping in different stores, taking up choir practice, choosing things (e.g., food, clothes) based on her own preferences, and to start talking about the possibility of working in the

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future. The therapist was careful to ask about goals that could be targeted during the inpatient

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admission and Monica mentioned talking to fellow patients, abstaining from asking ward staff

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about medications and planning her near future. Activities listed so far in therapy were inserted into Monica’s activation hierarchy and graded in terms of expected difficulty. She was then encouraged to choose two activities to complete before next session. She scheduled talking to fellow patients at least twice a day and calling her daughter every other day. She predicted that she would perhaps be discouraged by different emotions and to overcome this she came up with the idea of telling someone in the staff about her homework so that they could encourage and support her.

Session 4 Monica’s mood was significantly improved. She felt proud for having accomplished most of her scheduled assignments except for one day, when she experienced strange bodily symptoms and she had spent the day in bed. The therapist reviewed the experience of both completing the

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assigned activities and the experience of staying in bed. This was connected to the rationale and Monica had noticed that staying in bed had been somewhat relieving but on the other hand had

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made her even more worried and depressed as nothing else occupied her mind. Monica and the

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therapist agreed that when bodily symptoms and pain were very intense, social activities became too demanding for her. Instead they scheduled nonsocial activities that were outside her ward

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room (away from bed) and that required her to focus on things other than worrying. She also

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scheduled making dinner for her daughter during a short leave from the ward (see Video 1 for an

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excerpt of that activity planning).

Session 5

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Monica came to the session feeling ashamed for not having completed the planned dinner with

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her daughter. The therapist first normalized and validated the emotions that had stopped her from

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doing the assignment and also the feelings of shame that she brought into the session. The therapist also noted that she had come to the session even though she had intense feelings of shame and strong urges to stay at the hospital. The therapist then assessed the functional reasons for not completing the assignment (see Video 2 for a shortened version of that assessment). Their mutual understanding was that she had avoided the assignment due to intense feelings of hopelessness. They worked on making the assignment less overwhelming by including fewer demanding elements. She instead scheduled inviting her daughter to watch a movie together. She also scheduled a few less challenging outside activities.

Session 6 Monica completed the homework and felt a significant improvement in mood. Her daughter had persisted in requesting that they go out for coffee the next day, and she went along. She had a

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panic attack on the way there but was surprised to find that it was a different experience when she was on an adventure with her daughter and doing something in the service of improving their

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relationship. Inspired by this experience, Monica was willing to try some new activities outside

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her home further up in the hierarchy. She was discharged from the hospital after this session.

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Sessions 7–10

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These sessions included continued activity scheduling. For Monica, the most prevalent obstacle to completing activities was avoidance of private consequences. The therapist was, in many

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instances, able to counter such avoidance by breaking down tasks into more manageable parts or coming up with emotional reminders of why it was important for Monica to persist at the task

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(e.g., writing down the assignment on the back of a photo of her daughter and specifying how the

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task was related to their relationship). The therapist made Monica more aware of her tendency to

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ask for advice as it happened during sessions. Monica tried different ways of deciding for herself while observing what happened to her feelings of uncertainty.

Session 11–12

Monica and the therapist worked collaboratively on fitting the activities she now mastered into a routine so that they would not have to be scheduled every time. She met with her daughter every Tuesday and she went shopping twice a week. She had not called her friends yet but listed that as an activity to do within the week after ending therapy. She also decided to schedule an appointment with her case manager at the outpatient clinic to talk about returning to some kind of work in the future. In order to improve Monica’s ability to discriminate activation from avoidant responses without much aid, the therapist gradually started asking questions like, “What do you think my response would have been to that?” She identified that staying in bed more and not

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going outside for a whole day should be considered an early warning sign of relapse that she should attended to with increased activation. She also decided to share her relapse prevention

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plans with her daughter, ex-husband, and the case manager at the outpatient facility.

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At the end of therapy Monica was significantly less depressed and anxious and had started going out more. She was still worried when bodily symptoms got intense. However the

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symptoms seemed less frequent and she was less inclined to stay in bed and to present at the

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emergency room.

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The Pilot Study Overview of Study Methods

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Approval was obtained from the Regional Ethics Committee. Participants (N = 13) were

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admitted to general psychiatric acute inpatient wards in Dalarna, Sweden. We included

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individuals with significant depression (≥ 20 on the Montgomery-Åsberg Depression Rating Scale) if they had no ongoing psychotic disorder, manic symptoms, confusion, primary substance abuse, anorexia nervosa, or mental retardation. Verbal and written informed consent was obtained before baseline assessments were administered. BA treatment included 8 to 12 sessions conducted once to twice a week independently of whether the patient was continuously admitted or discharged. Baseline assessments were repeated following treatment termination. Therapists were outpatient psychiatric professionals (nurses or psychologists) with a basic university degree in CBT and previous experience with BA. Therapist training for study purposes consisted of a 3day training program led by the first author who was trained and supervised by one of the other author’s lab (J. W. Kanter). Case conferences were conducted during the pilot treatment period.

Measures

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Feasibility Measures The Treatment Credibility Scale (TCS; Borkovec & Nau, 1972) was administered at

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Session 3 when all clients had been presented with the rationale. It contains 5 items each rated from 0 (not at all) to 10 (very much) and total scores range from 0–50 with high scores

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representing higher credibility. Participants’ satisfaction with treatment was measured following

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treatment using Client Satisfaction Questionnaire (CSQ-8; Larsen, Attkisson, Hargreaves, &

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Nguyen, 1979). It contains 8 items each rated from 1 to 4 and total scores range from 8–32 with high scores representing higher satisfaction. Furthermore, participants were interviewed about

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Process Measures

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with the answers in the results section).

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their perception of the treatment using open-ended questions (the questions are reported along

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The self-report measure (short form version) Behavioral Activation for Depression Scale (BADSSF; Manos, Kanter, & Luo, 2011) was used to assess activation and avoidance at baseline, Session 3, 6, 9, and posttreatment. It contains 9 items each rated from 0 (not at all) to 6 (completely) and total scores ranges from 0–54 with high scores representing more activation and less avoidance. The BADS-SF has good psychometric properties (Manos et al., 2011). The therapeutic alliance was measured using the Working Alliance Inventory (WAI; Tracey & Kokotovic, 1989) 12-item (each item ranging from 1–7) self-report version. The WAI has good psychometric properties (Horvath & Greenberg, 1989). At every session therapists recorded the number and types of assignments from the previous session (e.g., activity monitoring or activity scheduling) and the degree of assignment adherence on a categorical scale ranging from 0 (made no effort to begin assignment) to 3 (fully completed assignment). This was done using the procedure outlined by Busch, Uebelacker, Kalibatseva, and Miller (2010). Therapists also used

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functional assessment to establish the reason for assignment noncompletion after every session (this procedure has been described in detail above; please revisit the section “Overview of the

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Adapted BA Protocol”). Acceptable interrater reliability was achieved during training of the

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procedure (Fleiss’ Kappas = .82 – .91; ICC = .92).

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Outcome Measures

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The well-established Montgomery-Åsberg Depression Rating Scale (MADRS-S; Svanborg & Asberg, 1994) was used to assess depressive symptoms at baseline, Session 3, 6, 9, and

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posttreatment. It contains 9 items each rated from 0 (not at all) to 6 (completely) and total scores ranges from 0–54 with high scores representing more depressive symptoms. The clinician rated

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version was used before and after treatment (MADRS; Montgomery & Asberg, 1979). Other

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outcomes were assessed using the The Sheehan Disability Scale (SDS; Leon, Olfson, Portera,

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Farber, & Sheehan, 1997), the self-report version of the Global Assessment of Functioning (GAF; Ramirez, Ekselius, & Ramklint, 2008) and Clinical Global Impression Scales (CGI; Guy, 1976).

Diagnostic Assessments

Psychiatric diagnoses were assessed at baseline using the Mini-International Neuropsychiatric Interview (M.I.N.I.; Sheehan et al., 1998) and the general diagnostic criteria from Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II; First et al., 1995). Self-reported criteria for borderline personality disorder (BPD) and avoidant personality disorder (APD) were assessed with the SCID-Screen (Ekselius, Lindstrom, Von Knorring, Bodlund, & Kullgren, 1994).

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Statistical Analysis Feasibility is reported using the descriptive statistics of the credibility and satisfaction

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measures for treatment completers. Changes in BADS-SF in the completers sample were examined using repeated measures ANOVAs. Descriptive statistics for the clinician-rated

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homework compliance measure are reported for treatment completers. Correlations (Spearman’s

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Rho) between process and outcome measures are conducted according to the procedure outlined

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by Steketee and Chambless (1992) using residualized gain scores. Preliminary outcomes were analyzed with repeated measures ANOVAs and paired samples t tests for both treatment

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completers and intention-to-treat (ITT) sample (using the Last Observation Carried Forward

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procedure).

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Pilot Study Results

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The Sample and the Treatment Received A total of 61 patients were screened for eligibility. The characteristics of the included sample are reported in Table 1. The most common reasons for noneligibility were age and acute psychosis. All participants (N = 13) were prescribed concurrent psychiatric medications and n = 1 was treated with ECT parallel to BA. Of the 13 participants that started treatment n = 10 completed the minimum of 8 sessions. A total of n = 9 completed 11 or 12 sessions. Three patients dropped out prematurely at Session 1 (n = 1) or 2 (n = 2). One participant stated that she dropped out due to significant memory loss following the ECT. The mean duration of BAtreatment for completers was 9.3 weeks (SD = 3.1). The mean number of sessions received during hospital admission were 3.5 (SD = 2.4). The mean duration of inpatient admission was 20.4 days (SD = 14.4). One participant was rehospitalized during the treatment period but was discharged prior to the last session.

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21

Feasibility Measures

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Results from the TCS after Session 3 (M = 40.5, SD = 6.2) indicated high credibility and

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expectancy for change. The CSQ-8 after treatment (M = 28.2, SD = 3.3) indicated high satisfaction. Results from the WAI at Session 3 (M = 66.2, SD = 11.2), Session 6 (M = 70.6, SD

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= 7.3), and Session 9 (M = 75.40, SD = 7.1) indicated a good working alliance. A one-way

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repeated measures ANOVA indicated that it improved over the course of treatment, F(2, 18) = 4.912, p = .02.

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Following treatment participants were also asked open-ended questions about their

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experience of therapy. Below we report the answers that did not overlap each other:

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1. What did you think about initiating therapy while admitted on the inpatient unit?

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“I wouldn’t have coped with being discharged if I had not had the scheduled sessions with my therapist”; “I am not sure I would have gone to the outpatient clinic if I had only been offered follow-up after a few weeks”; “It was a different kind of support than the medicines I received at the ward—it helped me handle my feelings and myself”; “I really appreciated seeing the same person both on the ward and after discharge—she knew what I had gone through.”

2. What did you think about the amount and pacing of therapy? “Twelve sessions is not much. Maybe it would have been better to have twenty”; “Twelve sessions was good. I knew what to do after that”; “Twice a week was good, otherwise I wouldn’t have been able to use the diary so much. I would have forgotten it.”

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3. What was most and least helpful in therapy? “I learned a lot about my self”; “We were able to talk about everything and still come back to the same way of working with it. That made sense”;

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“I learned how to handle one thing at a time”; “I learned what to do instead of starting arguments

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and fights—I could back away instead.”

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4. Did you do any specifically important changes or observations during therapy? “It became

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clear to me that my ruminating only ended up increasing my anxiety”; “I understood that I wasn’t the only one with these kinds of problems”; “I gained some control over how I chose to respond

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in certain situations, that was really important as my life is just upside down”; “I learned to stop ruminating just by doing something completely different”; “I became more observant on the

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things around me”; “If I had a problem I learned I could write it down on a piece of paper and list

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possible solutions to it, and if it was too difficult I could just start with a small part of it”; “I

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really liked that I didn’t have to do all at once—I liked setting short-term goals”; “I like that I learned just how to stop what ever stupid things I was doing and do something else.”

5. Was there something about therapy you’d wished had been different? “Maybe more sessions”; “It would have been good to figure out more about my diagnosis.”

6. What made you end therapy early? “I was too busy as I started working the day after discharge. Also, it seemed to me that the focus of therapy was going to be on present thing. I feel the need to process things from my childhood instead”; “I couldn’t get there once I was discharged”; “I didn’t remember my therapist or even being in therapy from session to session due to the ECT treatment.”

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Process Measures The BADS-SF total score improved gradually over the course of treatment from baseline

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(M = 16.20, SD = 6.4), Session 3 (M = 20.8, SD = 6.2), Session 6 (M = 25.4, SD = 6.1), Session

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9 (M = 29.1, SD = 5.6) to posttreatment (M =33.10, SD = 10.6). A one-way repeated measures ANOVA for BADS-SF indicated a significant time effect, F(4, 48) = 10.367, p < .001.

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Descriptive statistics for participants’ homework compliance are reported in Table 2.

Outcome Measures

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Significant improvements and large effect sizes were indicated for MADRS-S, F(4, 36) = 18.79, p < .001, d = 2.60), clinician rated MADRS, t(9) = 6.292, p < .001, d = 2.43, self reported

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GAF, t(9) = -4.525, p < .001, d = 2.11, and the clinician-rated GAF, t(9) = -5.628, p < .001, d =

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2.21. No significant improvements were observed in the SDS, t(9) = 2.101, p = .065, d = .63. The

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above pattern of significance and effect size magnitude was repeated when looking at the intention-to-treat sample using last observation carried forward.

The Relation Between Process Measures and Depressive Symptoms Changes in BADS-SF from baseline to posttreatment were significantly correlated with depressive symptom improvements over the course of treatment on the MADRS-S (r = -.681, p = .01). Residualized gain scores for BADS-SF from baseline to Session 6 were used to analyze if early change in this process measure was related to depression scores posttreatment. There was a significant correlation between the early change in BADS-SF and clinician-rated MADRS posttreatment (r = -.637, p = .04) but not the MADRS-S. There was no significant correlation between working alliance on the WAI and depression outcome on the MADRS-S (r = .219). Each participant’s average homework compliance score was calculated and related to depression

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outcome (residualized gain scores for MADRS-S), producing a correlation of .487

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(nonsignificant).

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Discussion

This paper describes a BA intervention starting after admission into acute psychiatric

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inpatient units with the goal of continuing after discharge to bridge the critical gap between

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services. BA was chosen for evaluation on the basis of being parsimonious, flexible, and promising for severe and diverse populations. The treatment context required significant

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adaptations of the contents and format of therapy. We also reported preliminary data regarding feasibility, therapy processes, and their relation to outcome in a small sample of depressed

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inpatients with psychiatric comorbidity.

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Multiple sources of data from the pilot study provided encouraging preliminary support for

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the feasibility of the BA protocol in the current context. First, none of the approached patients declined the invitation to participate, indicating that initiating a brief treatment during inpatient admission was experienced as a credible idea. Second, treatment retention was high and participants attended sessions both in the inpatient and the outpatient setting. The low dropout rate is very encouraging given how common treatment disengagement is after discharge from hospital care (Boyer et al., 2000). Third, patients rated credibility (at Session 3) and satisfaction (posttreatment) highly. Fourth, participants had a positive experience of the working alliance as indicated by repeated ratings. A fifth indicator of the acceptability of BA was the positive comments following treatment. And finally, participants were able to agree on and largely adhered to homework, indicating that the core purpose of BA (i.e., activation) was experienced as meaningful.

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It is noteworthy that credibility and acceptability of our BA protocol was high in this sample with such wide variety of comorbidity, complexity, and problem behaviors. Although BA

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was initially developed for depression, there are many adaptations for different groups of patients

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(Dimidjian et al., 2011). Our study lends further preliminary support for the feasibility of BA for both severe problems and heterogeneous populations.

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The quick and gradual improvement of activation/avoidance observed in our pilot study

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lends preliminary support to the hypothesized mechanisms of BA. Furthermore, these findings are of particular interest for the inpatient milieu where social disengagement prevails (Sharac et

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al., 2010) and attenuates outcomes (Wing & Brown, 1970). A parsimonious intervention that achieves increased engagement within a few sessions does seem to fit well into the inpatient

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context. Furthermore, our data suggest that participants experienced the active and goal-directed

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approach as credible and working alliance was maintained. This may be of particular interest for

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inpatient nurses who may feel uncomfortable in persevering at the importance of some activity in the face of noncompliance. BA may thus provide staff with a useful model for how to be assertive without compromising the working alliance. This study was the first to use the BA model outlined by Kanter and colleagues (2009; 2011) in a clinical sample. A main characteristic of this model is to tailor the interventions according to the function of nonadherence (i.e., the reasons for not completing activation assignments). The study provided preliminary validity to that model as all the reasons for nonadherence proposed by the model were indicated at some point. Private consequences were the most common of reasons for noncompliance. Our decision to add explicit focus on exposure to counter avoidance thus seems to be warranted in this context. Given the uncontrolled nature of our study design, reporting effectiveness was only a secondary aim of the pilot study. However, a quick benchmark with previous inpatient depression

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studies of behavioral (Hopko et al., 2003) and cognitive therapy (Miller et al., 1989; Whisman et al., 1991) roughly suggests a 50% average reduction in depressive symptoms. This appeared

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consistent with the improvement magnitude in our current pilot trial.

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This study had several methodological limitations. First, our pilot sample was limited in size and some patient groups were excluded (e.g., acute psychosis and mania) and thus our

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findings regarding feasibility cannot be generalized across the inpatient population at large.

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Second, our pilot study design lacked a control group, did not apply long-term follow-up, and assessments were not blind. We are thus unable to draw any conclusions about the effectiveness

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of BA and what it adds to standard care in terms of outcome. Overall, the present study provides a detailed description of and preliminary support for the

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feasibility of BA in the transition between acute inpatient and outpatient services. Our study

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indicates that inpatients with acute and heterogeneous psychiatric problems may experience BA

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as a credible and helpful treatment to bridge the gap after inpatient treatment. Furthermore, adherence to the principles of BA appears to be the rule and may have a positive effect on outcome.

Future research using rigorous methods (e.g., multiple baseline and randomized controlled study designs) will be necessary to study the efficacy of adding BA to standard care. Such research will present a significant challenge for researchers given the difficulty to control the context of acute care and the organizational boundaries between inpatient and outpatient services.

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4-year follow-up study. Journal of Psychiatric Practice, 14, 281–288.

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Author Note

Address correspondence to Fredrik Folke, Center for Clinical Research, Nissers väg 3, 791 82 Falun,

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Sweden; e-mail: [email protected]

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Assessment: Review of client life history, current behaviour and context

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Activity Monitoring: Self monitoring of moment to moment activities, mood and sense of mastery

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Early sessions (1-3)

Rationale: Depression and treatment is described using a simple model

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Values/goals: Values are assessed and behavioural goals are derived

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Activity hierarchy: Activities derived from assessment are listed according to difficulty

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Activity scheduling: A few activities from the hierarchy are scheduled and planned in detail between every session

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Middle sessions (3-10)

If activation is successful: activity scheduling continues

If activation fails: functional assessment is conducted and activation is tailored accordingly

Functional reason for non-adherence

Interventions

Antecedent failure - forgetting - Rationale

- Develop reminders - Target rationale

Last sessions (10-12)

Behavioural deficits - Social skills (SS) - Problem solving (PS) - Other skills (OS)

- SS training - PS training - OS training

Public consequences

- Contingency Management

Private consequences

- Target avoidance

Relapse prevention: Interventions to prevent relapse and maximize generalization of gains

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Figure 1. Overview of the components of the BA treatment

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Table 1.

n

%

10/3

76.92

8

61.54

3

23.08

2

15.38

2

15.38

5

38.46

3

23.08

Unemployed

1

7.69

Disability Pension

2

15.38

7

53.85

9-12 years

3

23.08

> 12 years (University)

3

23.08

13

100.00

Sex (female/male)

Married/cohabiting

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Living with parents Employment Status

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≤ 9 years

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Employed. full-time

Education

8.81

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Single/Divorced

High-School senior

28.85

SC

Marital Status

Employed. part-time

SD

RI

Age

M

PT

Characteristics of Study Participants (N=13)

Number of diagnoses

3.31

1.70

(Pre-treatment M.I.N.I. interview) Major Depression Number of depressive episodes

3.77

2.39

ACCEPTED MANUSCRIPT INPATIENT TO OUTPATIENT BA

38 6

46.15

Anxiety Disorder

10

76.92

Asperger Syndrome. ADHD or ADD indicated by

4

30.77

4

30.77

10

76.92

9

69.23

7

53.85

9

69.23

3

23.08

1

7.69

Suicide Attempt (lifetime)

9

69.23

Deliberate Self-harm (lifetime)

6

46.15

11

84.62

Previous admission/s

6

46.15

History of drug use

8

61.54

PT

Chronic Depression

RI

treating psychiatrist Pain diagnoses indicated by treating psychiatrist

SC

Personality disorder

Borderline PD according to SCID-Screen

MA

Avoidant PD according to SCID-Screen Reason for admission

TE

AC CE P

Aggressive Behavior

D

Elevated Suicide Risk Suicide Attempt

NU

According to General Criteria interview

SAD persons scale

Specialized mental health care user (for >1 year prior

3.15

1.68

admission)

Note. M.I.N.I. = Mini-International Neuropsychiatric Interview; PD = Personality Disorder; SCID-Screen = Structured Clinical Interview for DSM-IV Personality Disorders Screening instrument.

ACCEPTED MANUSCRIPT INPATIENT TO OUTPATIENT BA

39

Table 2.

PT

Descriptive Statistics for Homework (HW) During Therapy

Total Homework

209

Percentage -

- Made no attempt

23

11.5%

- Made an attempt

NU

SC

Completion of HW (N=200)

RI

Frequency

8

4%

32

16%

137

68.5%

44

22.0%

69

34.5%

- Repeated activity

46

23.0%

- Activity if situation occurs

6

3.0%

- Abstinence/limitation

-

-

- Other (e.g. completing

44

22.0%

Forgetting

13

21.0%

Rationale

5

8.1%

Social skills

1

1.6%

Problem solving skills

11

17.7%

MA

- Partial completion - Fully completed

AC CE P

- One time activity

TE

- Self-monitoring

D

Type of homework (N=209)

workbook material) Reason for non adherence (n=62)

ACCEPTED MANUSCRIPT INPATIENT TO OUTPATIENT BA

40 7

11.3%

Private consequences

25

40.3%

PT

Public consequences

RI

Note. These are the assignments from 96 session of the completers (n = 10). The first session was not assigned a homework. Participants that dropped out early are not included as they

AC CE P

TE

D

MA

NU

SC

were only given n = 2 assignments.

ACCEPTED MANUSCRIPT INPATIENT TO OUTPATIENT BA

41

Highlights

BA adapted for the transition between inpatient and outpatient psychiatry is described.



Results from a small feasibility study indicated high acceptability and credibility.



A case is reviewed in detail.



BA may be a feasible intervention for improving continuity of care between services.

AC CE P

TE

D

MA

NU

SC

RI

PT

