1. ‘ Pushmi-pullyu’: Developing interventions that address both mental and physical health and wellbeing Dr Paul Farrand

2. Interventions for Mental and Physical Health and Wellbeing?

3. Rationale for Treating Mental and Physical Health Symptoms of depression impact on physical health  Sustained inactivity, poor self-care, poor diet etc Depression and a range of poor health behaviours often coexist (Gagnes et al, 2002; Simon et al, 2008)Simon et al, 2008 Depression associated with a range of health related conditions  Cardiovascular risk (Frasure-Smith et al, 2005)  Diabetes (Peyrot & Rubin, 1999)  Stroke (Jonas & Mussolino, 2000) Causality remains undetermined

4. Association between Depression and Health Risk Behaviour in Middle Aged Women (Simon et al, 2008) Depression Limited Physical Activity High Calorific Intake

5. Problems with a Dualist Approach Target Physical Health Depression Gets in Way Problems Failure/difficulty to recruit Unrepresentative recruitment/narrow appeal Target Depression Little Long Term Impact on Physical Health/Worsening Medical Condition Problems Relapse (both physical health outcomes and depression) (Clark et al, 1996; Sherwood et al, 1992; Werrij et al, 2006)

6. Cognitive and/or Behavioural Therapies Physical Activity Limited general appeal even when supported by a PA specialist (TREAD Chalder et al, 2012) Limited reach of conventional structured approach (Donaghy & Taylor, 2010) Depressive symptoms get in way (Ussher at al, 2007) Depressive relapse (BA alone over 60% relapse at 12 months (Dobson et al, 2008) Lack of long term focus on physical health outcomes results in little health benefits /worsening health condition Example – Depression and Physical Activity

7. Striking the Balance: BAcPAc Solution: Integrate behavioural activation (BAc) with physical activity promotion (PAc) Initially treat the symptoms of depression with BAc  Evidence based intervention (Ekers et al, 2008)  Functional analysis of PAc related activities enabled during assessment Enables integration of PAc into BAc at beginning of treatment even though emphasis on BAc

8. Striking the Balance: BAcPAC As depressive symptoms lift identify opportune moment to promote PAc  PAc intervention informed by evidence (Michie et al, 2009) Self monitoring combined with at least one other technique from control theory (Carver & Scheier, 1981, 1982) – prompt intention formation, prompt specific goal setting, provide feedback on performance, prompt review of behavioural goals) – most effective  PAc alone may reduce relapse when continued over time (Babyak et al, 2000)

9. BAcPAc Illness Illness: Relapse Prevention Wellness/Wellbeing

10. Challenges Identifying the opportune moment to introduce PAc Required adaptations to BAc  Tensions with PAc approaches eg MI  Cognitions? Increasing staff confidence to address wider perspective  Challenging over confidence (PWP survey) Workforce?  Mental health, physical health, other?

11. Wider Challenges Specifying 1-2 primary outcomes (CONSORT, 2010)  Multiplicity of analyses (Schultz & Grimes, 2005) Choice of primary outcomes  Eg MUS – treatment of depression and anxiety more likely to be effective with physical symptom outcomes (Farrand & Woodford, submitted) Identifying appropriate target population  Diagnostic threshold for mental and physical health/risk behaviour  Often reach one or other, not both (Farrand & Woodford, submitted) Prevention and treatment being confused (Coyne, 2006)