Behavioral Activation for Depression and PTSD Amy Wagner, Ph. D Behavioral Activation for Depression and PTSD Amy Wagner, Ph.D. Portland VAMC

Key Collaborators: Matthew Jakupcak, Ph.D. (Seattle VA) Christopher Martell, Ph.D. (UW) Sona Dimidjian, Ph.D. (UC Boulder) Miles McFall, Ph.D. (Seattle VA)

Behavioral Activation is well-established as a treatment for depression: BA by increasing pleasant events for the treatment of depression (e.g., Lewinsohn, 1974) BA as the behavioral component of cognitive therapy treatment for depression (Beck, 1976) BA as an independently effective intervention for depression (e.g., Jacobson et al., 1996) BA as a stand-alone behavioral treatment for Major Depressive Disorder (Martell, Addis and Jacobson, 2001; Addis & Martell, 2004; Dimidjian et al., 2006; Dobson et al., 2008) BA is not a new intervention, it’s just new to the treatment of PTSD; BA originated as a treatment of depression

What is Behavioral Activation? Structured, brief psychosocial approach Based on premise that problems in vulnerable individuals' lives and behavioral responses reduce ability to experience positive reward from their environments

What is Behavioral Activation? Aims to systematically increase activation such that patients may experience greater contact with sources of reward in their lives and solve life problems Focuses directly on activation and on processes that inhibit activation, such as escape and avoidance behaviors and ruminative thinking

Key Elements of BA Behavioral case conceptualization Functional analysis Activity monitoring and scheduling Emphasis on avoidance patterns Emphasis on routine regulation Behavioral strategies for targeting worry or rumination Goals are specific to the individual (not necessarily pleasant events)

There is empirical and theoretical support for applying BA to PTSD: High rates of co-morbidity of depression and PTSD Conceptual overlap in the factors related to the maintenance of both depression and PTSD (i.e. AVOIDANCE) Preliminary data support BA for the treatment of PTSD

BA may be particularly well-suited for the OIF/OEF Population: Significant proportion of OIF/OEF veterans report PTSD and/or depression on their return There are limitations to current treatments and models of care Little is known about effective early intervention Less data to support exposure-based treatments for veterans Stigma against mental health treatment Veteran preferences toward present-focused/skill-based interventions

BA may be particularly well-suited for the OIF/OEF Population: Majority of Iraq and Afghanistan veterans first diagnosed with PTSD in non-MH settings (Seal et al., 2007) BA is adaptable to primary care context Simple principles Straightforward strategies Evidence for brief versions May be easily disseminated and combined with pharmacotherapy

BA Case Conceptualization: Depression Less Rewarding Life Sad, tired, worthless, indifferent, etc. Stay home, stay in bed, watch TV, withdraw, ruminate, etc. Life Events Loss of friendships, conflict with supervisor at work, financial stress, poor health, etc.

BA Case Conceptualization: PTSD Withdraw from usual activities (fear, pain, functional limitations) Stay home, stop socializing, ruminate, etc. Increased fear (sadness, anger) Trauma Loss of friendships, conflict with supervisor at work, financial stress, poor health, etc.

Preliminary data support BA as a treatment for PTSD: Clinical case study: BA improves PTSD and co-morbid major depression among veteran with chronic PTSD (Mulick & Naugle, 2004) Small open trial: BA improves PTSD among veterans with chronic PTSD (Jakupcak, Roberts, Martell, Mulick, Michael, Reed, Balsam, Yoshimoto, & McFall, 2006) Pilot randomized trial: BA improves PTSD among recently injured trauma survivors, compared to treatment as usual (Wagner, Zatzick, Ghesquiere, & Jurkovich, 2007) Small open trial: BA improves PTSD among OIF/OEF veterans in primary care setting (Jakupcak, Wagner, Paulson, Varra, & McFall, 2010)

BA for PTSD among Veterans (Jakupcak, Roberts, Martell, et al. 2006) Pre-post open trial 11 outpatients with PTSD, most Vietnam-era Mean age 51.2 (12.6) Mean education 15 (2) 10 men All white BA delivered in 16 sessions

Most participants had combat-related trauma and co-morbid conditions: Trauma type 8 VN Vets-Combat 1 VN Vet-Training Accident 1 Female-Military Sexual Assault 1 Post VN era Vet-Peace Keeping (sniper fire; mass graves) Depression, Pain Symptoms, and Compensation 4 Major Depression/3 dystymia/1 etoh dependence, remission 7 Chronic pain 7 Actively seeking service connection for PTSD (Jakupcak et al., 2006)

Outcome Measures Clinician Administered PTSD Scale (CAPS) The PTSD Checklist (PCL) Beck Depression Inventory (BDI) Quality of Life Inventory (QOLI) (Jakupcak et al., 2006)

Attrition Dropped out (n = 1; travel) Completed 15 of 16 sessions; lost to follow up (n = 1) (Jakupcak et al., 2006)

Symptom Severity One-tailed Paired t-test Pre Post t (df) H’s g M (sd) CAPS 75 (22) 60 (24) 2.47 (8) .58 PCL 52 (13) 48 (20) 1.00 (9) .38 BDI 26 (15) 22 (17) 0.86 (9) .30 QOLI -.88 (1.6) .11 (1.4) -2.10(8) -.61 * *p < .05 (Jakupcak et al., 2006)

BA for PTSD among Injured Trauma Survivors (Wagner, Zatzick et al Randomized controlled trial (pilot) 8 physically injured trauma survivors, recruited from surgical ward Met criteria for PTSD 1-mo post-injury Minimized exclusion criteria BA delivered in 6 sessions

Sample (N=8) BA (n=4) TAU (n=4) Age (mean, sd) 28 (15.4) 39 (16.2) # male 3 # > high school 2 # minorities 1 # married MDD diagnosis 2 of the BA group had drug/alc abuse, none in the TAU Prior trauma was higher in the BA group than TAU (4.0[2.5] v. 2.3[.5]) BA group had higher injury severity according to the injury severity index (14.3[6.8] v. 8.8[5.9]) (Wagner et al., 2007)

PTSD Outcome (PCL) (Wagner et al., 2007) Group analyses were conducted on residualized change scores (regressing pre on post) in order to take into account pre treatment scores (don’t lose degree of freedom) **One subject in the BA condition was only half-way through treatment when his 3-mo interview happened; therefore, his last session PCL was used for his post-treatment score t = 2.85; p < .05; d = 1.19 (Wagner et al., 2007)

Depression Outcome (CESD) Group analyses were conducted on residualized change scores (regressing pre on post) in order to increase power. no statistical difference; d = .55 (Wagner et al., 2007)

Physical Functioning (SF-12) Group analyses were conducted on residualized change scores (regressing pre on post) in order to increase power. Physical Fx: t = 1.86; p < .11; d = 1.27 (Wagner et al., 2007)

BA for the Treatment of PTSD among OIF/OEF Veterans (Jakupcak, Wagner, Paulson, et al., 2010) Open trial, pre-post and 3-mo follow-up Brief BA (8 sessions) Integrated mental health and primary care setting 6 veterans completed at least 4 sessions All Caucasian Mean age 28 (sd = 5) 4 of 6 had co-morbid MDD 5 of 6 had alcohol abuse Mention 8 were recruited, 1 withdrawn from protocol at session 6 due to substance dependence (earlier under-reporting); 1 discontinued after session 3 due to change in work schedule

Results: Repeated Measures ANOVAs: CAPS F(2,3)=10.66, p<.05, d=1.44 (Jakupcak et al., 2010)

Results: Repeated Measures ANOVAs: PCL-M F(2,3)=24.97, p<.01, d=1.87 (Jakupcak et al., 2010)

Results: Repeated Measures ANOVAs: BDI F(2,3) = 3.49, ns, d=1.28 (Jakupcak et al., 2010)

Results: Repeated Measures ANOVAs: Quality of Life F(2,3)=2.72, ns, d=.62 (Jakupcak et al., 2010)

Summary and Future Directions BA may have potential as a treatment for PTSD BA may be an appropriate, first line intervention as part of a stepped care approach to treating PTSD BA may be more acceptable to some individuals and easier to disseminate (e.g., primary care) than other ESTs for PTSD Grant-funded for dual-site randomized controlled trial of BA for recently returning veterans (Wagner, Jakupcak, McFall) Utilizing aspects of BA in NIMH-funded grant for recently injured adolescents (Zatzick, PI)

Course of BA Orient to treatment rationale and approach Develop treatment goals Behavioral analyses Repeated application of activation and engagement strategies Troubleshooting Treatment review and relapse prevention

Structure of Sessions Set collaborative agenda Review homework Review weekly activities Troubleshoot problem behaviors Assign new homework Ask for feedback

Targets of BA Avoidance behaviors (inertia, withdrawal, isolation, ruminating, etc.) Routine disruptions, connection between routine and mood Individual environments and relationship between activity and mood

Individualizing Activation Targets What are you doing more or less of since (you were assaulted)? What are your goals/values? What is the relationship between specific activities/life contexts/problems and mood? Conduct detailed examination of what is getting in the way of acting differently or feeling better.

Functional (Behavioral) Analysis “A step-by-step assessment of a problematic behavior or target, focusing on all aspects and circumstances of the behavior, including the antecedents and consequences.”

Activity Chart: Central Tool in BA Baseline assessment of activity and relationship with mood Schedule activation On-going monitoring of activity and mood Evaluate progress

Time Day and Date: 6:00 am Mood 7:00 am 8:00 am 9:00 am In each box, write the activities you engaged in during the hour and how you felt. Rate your feelings on a scale of 1-10, with 1 being the least intensity of feeling and 10 being the most. Time Day and Date: 6:00 am Mood 7:00 am 8:00 am 9:00 am

Practical Strategies to Maximize Activation Plan specific strategy for implementation (what, when, where, etc.) Troubleshoot Write it down Monitor progress, highlight consequences Adopt a scientific/experimental attitude Be alert to the “just do it” approach

Maximizing Activation Take an “outside – in” approach Break tasks into manageable components Aim for activities that have a high likelihood of natural reinforcement Consider help from significant others

Blocking Avoidance Orient patient to avoidance (how it works in short run and long run) Identify behaviors that function as avoidance Help patient engage in alternative behaviors

TRAP/TRAC T- Trigger (demands at work) R- Response (depressed mood/hopelessness) AP- Avoidance Pattern (stay home in bed, don’t answer phone) T-Trigger (demands at work) R- Response (depressed mood/hoplesness) AC- Alternative Coping (approach behaviors using graded tasks)

TRAP Trigger Response Avoidance- Pattern

TRAC Trigger Response Alternative Coping

Routine Regulation Work with patient to develop regular routine for basic life activities Implement, then evaluate use activity logs use the ACTION strategy

ACTION Strategy Assess How will my behavior affect my depression? Am I avoiding? What are my goals in this situation? Choose I know that activating myself will increase my chances of improving my life situation and mood. Therefore, if I choose not to self-activate, I am choosing to take a break. Try Try the behavior I have chosen. Integrate Integrate any new activity into my daily routine. Observe Observe the result. Do I feel better or worse? Did this action allow me to take steps toward improving my situation? Now Now evaluate; OR Never give up.

Targeting Rumination Rumination can function as avoidance, can maintain depression Focus on context and consequences of rumination, not content

A Focus on the Content of Thinking: “I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.” * What is the evidence that this thought is accurate? * What would it mean if it were true? * Can you think of another way to interpret what your sister said? * Why must everyone love you?

A Focus on the Context and Consequences of Thinking: “I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.” * When did you start thinking that? * How long did it last? * What were you doing while you were thinking that? * How engaged were you with the activity, context, etc.? * What were consequences of thinking about that?

Targeting Ruminating Attention to experience strategies notice colors, smells, noises, sights, etc. participate in task Select high engagement activities

Resources Depression in Context (Martell, Addis, Jacobson, 2001), NY: WW Norton & Company, Inc. Overcoming Depression One Step at a Time (Addis & Martell, 2004), Oakland, CA: New Harbinger, Inc. Behavioral Activation for Depression: A Clinician’s Guide (Martell, Dimidjian, Herman-Dunn & Lewinsohn, 2010), NY: Guilford Press Behavioral Activation: Distinctive Features (Kantor, Busch, & Rusch, 2009), Routledge