Behavioral ActivationBehavioral Activationfor Depression and PTSD for Depression and PTSD

Amy Wagner, Ph.D.Amy Wagner, Ph.D.Portland VAMCPortland VAMC

Key Collaborators:Key Collaborators:

Matthew Jakupcak, Ph.D. (Seattle VA)Matthew Jakupcak, Ph.D. (Seattle VA)

Christopher Martell, Ph.D. (UW)Christopher Martell, Ph.D. (UW) Sona Dimidjian, Ph.D. (UC Boulder)Sona Dimidjian, Ph.D. (UC Boulder) Miles McFall, Ph.D. (Seattle VA)Miles McFall, Ph.D. (Seattle VA)

Behavioral Activation is well-Behavioral Activation is well-established as a treatment for established as a treatment for

depression:depression: BA by increasing pleasant events for the BA by increasing pleasant events for the

treatment of depression treatment of depression (e.g., Lewinsohn, 1974)(e.g., Lewinsohn, 1974)

BA as the behavioral component of cognitive BA as the behavioral component of cognitive therapy treatment for depression therapy treatment for depression (Beck, 1976)(Beck, 1976)

BA as an independently effective intervention BA as an independently effective intervention for depression for depression (e.g., Jacobson et al., 1996(e.g., Jacobson et al., 1996))

BA as a stand-alone behavioral treatment for BA as a stand-alone behavioral treatment for Major Depressive Disorder Major Depressive Disorder (Martell, Addis and (Martell, Addis and Jacobson, 2001; Addis & Martell, 2004; Dimidjian et Jacobson, 2001; Addis & Martell, 2004; Dimidjian et al., 2006; Dobson et al., 2008)al., 2006; Dobson et al., 2008)

What is Behavioral Activation?What is Behavioral Activation?

Structured, brief psychosocial approachStructured, brief psychosocial approach

Based on premise that problems in Based on premise that problems in vulnerable individuals' lives and vulnerable individuals' lives and behavioral responses reduce ability to behavioral responses reduce ability to experience positive reward from their experience positive reward from their environmentsenvironments

What is Behavioral Activation?What is Behavioral Activation?

Aims to systematically increase Aims to systematically increase activation such that patients may activation such that patients may experience greater contact with sources experience greater contact with sources of of reward in their livesreward in their lives and and solve life solve life problemsproblems

Focuses directly on activation and on Focuses directly on activation and on processes that inhibit activation, such processes that inhibit activation, such as escape and avoidance behaviors as escape and avoidance behaviors and ruminative thinkingand ruminative thinking

Key Elements of BAKey Elements of BA

Behavioral case conceptualizationBehavioral case conceptualization Functional analysisFunctional analysis Activity monitoring and schedulingActivity monitoring and scheduling Emphasis on avoidance patternsEmphasis on avoidance patterns Emphasis on routine regulationEmphasis on routine regulation Behavioral strategies for targeting worry or Behavioral strategies for targeting worry or

ruminationrumination Goals are specific to the individual (not Goals are specific to the individual (not

necessarily pleasant events)necessarily pleasant events)

There is empirical and theoretical There is empirical and theoretical support for applying BA to PTSD:support for applying BA to PTSD:

High rates of co-morbidity of depression High rates of co-morbidity of depression and PTSDand PTSD

Conceptual overlap in the factors related Conceptual overlap in the factors related to the maintenance of both depression to the maintenance of both depression and PTSD (i.e. AVOIDANCE)and PTSD (i.e. AVOIDANCE)

Preliminary data support BA for the Preliminary data support BA for the treatment of PTSDtreatment of PTSD

BA may be particularly well-suited for BA may be particularly well-suited for the OIF/OEF Population:the OIF/OEF Population:

Significant proportion of OIF/OEF veterans Significant proportion of OIF/OEF veterans report PTSD and/or depression on their report PTSD and/or depression on their returnreturn

There are limitations to current treatments There are limitations to current treatments and models of careand models of care– Little is known about effective early interventionLittle is known about effective early intervention– Less data to support exposure-based Less data to support exposure-based

treatments for veteranstreatments for veterans– Stigma against mental health treatmentStigma against mental health treatment– Veteran preferences toward Veteran preferences toward

present-focused/skill-based interventionspresent-focused/skill-based interventions

BA may be particularly well-suited for BA may be particularly well-suited for the OIF/OEF Population:the OIF/OEF Population:

Majority of Iraq and Afghanistan veterans Majority of Iraq and Afghanistan veterans first diagnosed with PTSD in non-MH first diagnosed with PTSD in non-MH settings (Seal et al., 2007)settings (Seal et al., 2007)

BA is adaptable to primary care contextBA is adaptable to primary care context– Simple principlesSimple principles– Straightforward strategiesStraightforward strategies– Evidence for brief versionsEvidence for brief versions– May be easily disseminated and combined with May be easily disseminated and combined with

pharmacotherapypharmacotherapy

BA Case Conceptualization: BA Case Conceptualization: DepressionDepression

Life Events

Less Rewarding Life

Sad, tired, worthless, indifferent, etc.

Stay home, stay in bed, watch TV, withdraw, ruminate, etc.

Loss of friendships, conflict with supervisor at work, financial stress, poor health, etc.

BA Case Conceptualization: BA Case Conceptualization: PTSDPTSD

TraumaWithdraw from usual activities (fear, pain, functional limitations)

Increased fear (sadness, anger)

Stay home, stop socializing, ruminate, etc.

Loss of friendships, conflict with supervisor at work, financial stress, poor health, etc.

Preliminary data support BA as a Preliminary data support BA as a treatment for PTSD:treatment for PTSD:

Clinical case study: BA improves PTSD and co-morbid major Clinical case study: BA improves PTSD and co-morbid major depression among veteran with chronic PTSD depression among veteran with chronic PTSD (Mulick & Naugle, (Mulick & Naugle, 2004)2004)

Small open trial: BA improves PTSD among veterans with Small open trial: BA improves PTSD among veterans with chronic PTSD chronic PTSD (Jakupcak, Roberts, Martell, Mulick, Michael, Reed, (Jakupcak, Roberts, Martell, Mulick, Michael, Reed, Balsam, Yoshimoto, & McFall, 2006)Balsam, Yoshimoto, & McFall, 2006)

Pilot randomized trial: BA improves PTSD among recently Pilot randomized trial: BA improves PTSD among recently injured trauma survivors, compared to treatment as usual injured trauma survivors, compared to treatment as usual (Wagner, Zatzick, Ghesquiere, & Jurkovich, (Wagner, Zatzick, Ghesquiere, & Jurkovich, 2007)2007)

Small open trial: BA improves PTSD among OIF/OEF Small open trial: BA improves PTSD among OIF/OEF veterans in primary care setting veterans in primary care setting (Jakupcak, Wagner, Paulson, (Jakupcak, Wagner, Paulson, Varra, & McFall, 2010)Varra, & McFall, 2010)

BA for PTSD among VeteransBA for PTSD among Veterans(Jakupcak, Roberts, Martell, et al. (Jakupcak, Roberts, Martell, et al.

2006)2006)

Pre-post open trialPre-post open trial 11 outpatients with PTSD, most Vietnam-11 outpatients with PTSD, most Vietnam-

eraera Mean age 51.2 (12.6)Mean age 51.2 (12.6) Mean education 15 (2)Mean education 15 (2) 10 men10 men All whiteAll white BA delivered in 16 sessionsBA delivered in 16 sessions

Most participants had combat-Most participants had combat-related trauma and co-morbid related trauma and co-morbid

conditions:conditions: Trauma typeTrauma type

– 8 VN Vets-Combat8 VN Vets-Combat– 1 VN Vet-Training Accident 1 VN Vet-Training Accident – 1 Female-Military Sexual Assault1 Female-Military Sexual Assault– 1 Post VN era Vet-Peace Keeping (sniper fire; 1 Post VN era Vet-Peace Keeping (sniper fire;

mass graves)mass graves) Depression, Pain Symptoms, and Depression, Pain Symptoms, and

CompensationCompensation– 4 Major Depression/3 dystymia/1 etoh 4 Major Depression/3 dystymia/1 etoh

dependence, remissiondependence, remission– 7 Chronic pain7 Chronic pain– 7 Actively seeking service connection for PTSD7 Actively seeking service connection for PTSD

(Jakupcak et al., 2006)

Outcome MeasuresOutcome Measures

Clinician Administered PTSD Scale (CAPS) Clinician Administered PTSD Scale (CAPS)

The PTSD Checklist (PCL) The PTSD Checklist (PCL)

Beck Depression Inventory (BDI) Beck Depression Inventory (BDI)

Quality of Life Inventory (QOLI)Quality of Life Inventory (QOLI)

(Jakupcak et al., 2006)

AttritionAttrition

Dropped out (n = 1; travel)Dropped out (n = 1; travel)

Completed 15 of 16 sessions; Completed 15 of 16 sessions; lost to follow up (n = 1)lost to follow up (n = 1)

(Jakupcak et al., 2006)

Symptom Severity Symptom Severity One-tailed Paired t-testOne-tailed Paired t-test

PrePre PostPost tt (df) (df) H’s H’s gg

MM (sd)(sd) MM (sd)(sd)

CAPSCAPS 75 75 (22)(22) 6060 (24)(24) 2.47 (8)2.47 (8) .58.58

PCLPCL 5252 (13)(13) 4848 (20)(20) 1.00 (9)1.00 (9) .38.38

BDIBDI 2626 (15)(15) 2222 (17)(17) 0.86 (9)0.86 (9) .30.30

QOLIQOLI -.88-.88 (1.6)(1.6) .11.11 (1.4)(1.4) -2.10(8)-2.10(8) -.61-.61

*p < .05

*

(Jakupcak et al., 2006)

BA for PTSDBA for PTSDamong Injured Trauma among Injured Trauma

SurvivorsSurvivors(Wagner, Zatzick et al., 2007)(Wagner, Zatzick et al., 2007)

Randomized controlled trial (pilot)Randomized controlled trial (pilot) 8 physically injured trauma survivors, 8 physically injured trauma survivors,

recruited from surgical wardrecruited from surgical ward Met criteria for PTSD 1-mo post-injuryMet criteria for PTSD 1-mo post-injury Minimized exclusion criteriaMinimized exclusion criteria BA delivered in 6 sessionsBA delivered in 6 sessions

Sample (N=8)Sample (N=8)

BA (n=4)BA (n=4) TAU (n=4)TAU (n=4)

Age (mean, Age (mean, sd)sd)

28 (15.4)28 (15.4) 39 (16.2)39 (16.2)

# male# male 33 00

# > high # > high schoolschool

22 33

# minorities# minorities 33 11

# married# married 11 22

MDD diagnosisMDD diagnosis 22 22

(Wagner et al., 2007)

PTSD Outcome (PCL)PTSD Outcome (PCL)

17

22

27

32

37

42

47

52

57

62

BA TAU

PrePost

t = 2.85; p < .05; d = 1.19

(Wagner et al., 2007)

Depression Outcome (CESD)Depression Outcome (CESD)

05

101520253035404550

BA TAU

PrePost

no statistical difference; d = .55

(Wagner et al., 2007)

Physical Functioning (SF-12)Physical Functioning (SF-12)

Physical Fx: t = 1.86; p < .11; d = 1.27(Wagner et al., 2007)

BA for the Treatment of PTSD among BA for the Treatment of PTSD among OIF/OEF VeteransOIF/OEF Veterans

(Jakupcak, Wagner, Paulson, et al., 2010)(Jakupcak, Wagner, Paulson, et al., 2010)

Open trial, pre-post and 3-mo follow-upOpen trial, pre-post and 3-mo follow-up Brief BA (8 sessions)Brief BA (8 sessions) Integrated mental health and primary care Integrated mental health and primary care

settingsetting 6 veterans completed at least 4 sessions6 veterans completed at least 4 sessions All Caucasian All Caucasian Mean age 28 (sd = 5)Mean age 28 (sd = 5) 4 of 6 had co-morbid MDD4 of 6 had co-morbid MDD 5 of 6 had alcohol abuse5 of 6 had alcohol abuse

Results: Repeated Measures ANOVAs: Results: Repeated Measures ANOVAs: CAPSCAPS

FF(2,3)=10.66, (2,3)=10.66, pp<.05, <.05, dd=1.44=1.44(Jakupcak et al., 2010)

Results: Repeated Measures ANOVAs: Results: Repeated Measures ANOVAs: PCL-MPCL-M

FF(2,3)=24.97, (2,3)=24.97, pp<.01, <.01, dd=1.87=1.87 (Jakupcak et al., 2010)

Results: Repeated Measures ANOVAs:Results: Repeated Measures ANOVAs:BDIBDI

FF(2,3) = 3.49, (2,3) = 3.49, nsns, , dd=1.28=1.28(Jakupcak et al., 2010)

Results: Repeated Measures ANOVAs:Results: Repeated Measures ANOVAs:Quality of LifeQuality of Life

FF(2,3)=2.72, (2,3)=2.72, nsns, , dd=.62=.62(Jakupcak et al., 2010)

Summary and Future DirectionsSummary and Future Directions

BA may have potential as a treatment for PTSDBA may have potential as a treatment for PTSD

BA may be an appropriate, first line intervention as part of a BA may be an appropriate, first line intervention as part of a stepped care approach to treating PTSDstepped care approach to treating PTSD

BA may be more acceptable to some individuals and easier BA may be more acceptable to some individuals and easier to disseminate (e.g., primary care) than other ESTs for to disseminate (e.g., primary care) than other ESTs for PTSDPTSD

Grant-funded for dual-site randomized controlled trial of BA Grant-funded for dual-site randomized controlled trial of BA for recently returning veterans (Wagner, Jakupcak, McFall)for recently returning veterans (Wagner, Jakupcak, McFall)

Utilizing aspects of BA in NIMH-funded grant for recently Utilizing aspects of BA in NIMH-funded grant for recently injured adolescents (Zatzick, PI)injured adolescents (Zatzick, PI)

Course of BACourse 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 SessionsStructure of Sessions

Set collaborative agendaReview homeworkReview weekly activitiesTroubleshoot problem behaviorsAssign new homeworkAsk for feedback

Targets of BATargets 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 Individualizing Activation TargetsTargets

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) Functional (Behavioral) AnalysisAnalysis

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

Activity Chart: Central Tool in Activity Chart: Central Tool in BABA

Baseline assessment of activity and relationship with mood

Schedule activation On-going monitoring of activity and

mood Evaluate progress

TimeTime Day and Date:Day and Date:

6:00 am6:00 am

MoodMood

7:00 am7:00 am

MoodMood

8:00 am8:00 am

MoodMood

9:00 am9:00 am

MoodMood

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.

Practical Strategies toPractical Strategies toMaximize ActivationMaximize 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 ActivationMaximizing 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 AvoidanceBlocking 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/TRACTRAP/TRAC

T- Trigger T- Trigger (demands at work)(demands at work)

R- Response R- Response (depressed (depressed mood/hopelessness)mood/hopelessness)

AP- Avoidance AP- Avoidance Pattern Pattern (stay home in bed, (stay home in bed, don’t answer phone)don’t answer phone)

T-Trigger T-Trigger (demands at work)(demands at work)

R- Response R- Response (depressed (depressed mood/hoplesness)mood/hoplesness)

AC- Alternative AC- Alternative Coping Coping (approach (approach behaviors using behaviors using graded tasks)graded tasks)

Trigger Response Avoidance-Pattern

Trigger Response AlternativeCoping

Routine RegulationRoutine Regulation

Work with patient to develop regular routine for basic life activities

Implement, then evaluate– use activity logs– use the ACTION strategy

ACTION StrategyACTION Strategy AAssessssess How will my behavior affect my depression?How will my behavior affect my depression?

Am I avoiding? What are my goals in thisAm I avoiding? What are my goals in this

situation?situation?

CChoosehoose I know that activating myself will increase myI know that activating myself will increase my

chances of improving my life situation and chances of improving my life situation and mood. mood.

Therefore, if I choose not to self-activate, I Therefore, if I choose not to self-activate, I am choosing am choosing

to take a break.to take a break.

TTryry Try the behavior I have chosen.Try the behavior I have chosen.

IIntegratentegrate Integrate any new activity into my daily routine.Integrate any new activity into my daily routine.

OObservebserve Observe the result. Do I feel better or worse?Observe the result. Do I feel better or worse?

Did this action allow me to take steps Did this action allow me to take steps toward improvingtoward improving

my situation?my situation?

NNowow Now evaluate; OR Never give up. Now evaluate; OR Never give up.

Targeting RuminationTargeting Rumination

Rumination can function as avoidance, can maintain depression

Focus on context and consequences of rumination, not content

A Focus on the A Focus on the ContentContent of of Thinking:Thinking:

““I was depressed all day yesterday because I I was depressed all day yesterday because I was thinking about how my sister really was thinking about how my sister really

doesn’t love me.”doesn’t love me.”

* What is the evidence that this thought is accurate?* What is the evidence that this thought is accurate?

* What would it mean if it were true?* What would it mean if it were true?

* Can you think of another way to interpret what your * Can you think of another way to interpret what your sister said?sister said?

* Why must everyone love you?* Why must everyone love you?

A Focus on the A Focus on the Context and Context and ConsequencesConsequences of Thinking: of Thinking:

“I was depressed all day yesterday because I “I was depressed all day yesterday because I was thinking about how my sister really was thinking about how my sister really

doesn’t love me.”doesn’t love me.”

* When did you start thinking that?* When did you start thinking that?

* How long did it last?* How long did it last?

* What were you doing while you were thinking that?* What were you doing while you were thinking that?

* How engaged were you with the activity, context, * How engaged were you with the activity, context, etc.?etc.?

* What were consequences of thinking about that? * What were consequences of thinking about that?

Targeting RuminatingTargeting Ruminating

Attention to experience strategies– notice colors, smells, noises, sights, etc.– participate in task

Select high engagement activities

ResourcesResources Depression in ContextDepression in Context (Martell, Addis, (Martell, Addis,

Jacobson, 2001), NY: WW Norton & Company, Jacobson, 2001), NY: WW Norton & Company, Inc.Inc.

Overcoming Depression One Step at a TimeOvercoming Depression One Step at a Time (Addis & Martell, 2004), Oakland, CA: New (Addis & Martell, 2004), Oakland, CA: New Harbinger, Inc.Harbinger, Inc.

Behavioral Activation for Depression: A Behavioral Activation for Depression: A Clinician’s GuideClinician’s Guide (Martell, Dimidjian, Herman- (Martell, Dimidjian, Herman-Dunn & Lewinsohn, 2010), NY: Guilford PressDunn & Lewinsohn, 2010), NY: Guilford Press

Behavioral Activation: Distinctive FeaturesBehavioral Activation: Distinctive Features (Kantor, Busch, & Rusch, 2009), Routledge(Kantor, Busch, & Rusch, 2009), Routledge