Behavioral activation in acute inpatient psychiatry: A multiple baseline evaluation

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Highlights

  • Behavioral Activation was integrated into acute psychiatric wards.

  • A multiple baseline design was used for six adult inpatients.

  • Outcomes improved and process measures changed at the onset of treatment.

  • At least four participants showed clinically reliable improvements.

  • Behavioral Activation appears feasible in acute psychiatric settings.

Abstract

Background and objectives

The present study employed a multiple baseline study design with repeated measures to explore clinical outcomes, therapy mechanisms, and feasibility of Behavioral Activation for persons admitted to inpatient psychiatry.

Methods

Six adult inpatients with depressive symptoms and different psychiatric disorders were randomized to different lengths of baseline standard inpatient treatment. Subsequently a 5-day, 10-session Behavioral Activation protocol was added. Daily self-report outcome and process measures were administered and supplemented with hourly self-reports and clinician assessments before and after each study phase.

Results

After a relatively stable baseline, at least four participants showed marked gradual improvements both in terms of outcome as well as activation and avoidance as Behavioral Activation was initiated. The temporal relation between process and outcome differed somewhat across metrics. In most instances however, change in activation and avoidance either coincided or preceded decreased depression.

Limitations

We did not include some relatively common disorders, did not control for the effects of increased attention, did not investigate treatment integrity, and did not conduct follow-up after discharge. Raters were not blind and measures were mainly focused on depressive symptoms. All received concurrent medical treatment.

Conclusions

This preliminary study further supports the promise of Behavioral Activation as an inpatient treatment for persons with a variety of psychiatric disorders. Results also lends preliminary support for the purported mechanisms of Behavioral Activation.

Introduction

Over the last decades the number of beds (Fakhoury & Priebe, 2002) and length of admissions (Watanabe-Galloway & Zhang, 2007) in inpatient psychiatric care have reduced drastically. Current inpatient services are frequently criticized for being socially disengaging (Sharac et al., 2010), not being guided by empirical research (Goldman, 2011), and staff report high levels of job dissatisfaction and burn out (Gilbody et al., 2006). Meta-analytic studies indicate inpatients benefit from psychological treatment (Cuijpers et al., 2011, Kösters et al., 2006, Stuart and Bowers, 1995, Xia et al., 2011) but access to such therapy is restricted.

Behavioral Activation (BA) is a well-established treatment for major depression (Mazzucchelli, Kane, & Rees, 2009), with effects comparable to gold standard Cognitive Behavior Therapy (CBT) and antidepressant medication (Dimidjian et al., 2006, Moradveisi et al., 2013). The treatment is aimed at engaging clients in personally meaningful behavior and at reducing avoidant coping strategies. BA originates from early behavioral models proposing that depression results from low levels of reinforcement and over-reliance on avoidant coping (Ferster, 1973, Lewinsohn, 1974). There are currently two BA versions being implemented widely, the Behavioral Activation Treatment for Depression (BATD) developed by Lejuez, Hopko, and Hopko (2001) and the version developed by Jacobson, Martell, and Dimidjian (2001).

BA has been proposed to be particularly well suited for inpatient environments (Curran et al., 2007, Folke et al., in press). Hopko, Lejuez, Lepage, Hopko, and McNeil (2003) conducted a pilot randomized trial of the BATD for depressed inpatients (N = 25). Results indicated a restricted number of BATD sessions were significantly more effective in reducing depression scores than a control supportive therapy condition. Gollan et al. (2014) developed a milieu-based approach for heterogeneous inpatient populations called Behavioral Activation Communication (BAC). In a non-randomized comparison with an otherwise similar treatment ward BAC showed a greater increase in activity engagement and positive affect. Two studies have investigated BA for depressed geriatric inpatients (Brand and Clingempeel, 1992, Snarski et al., 2011) with equivocal but promising results. Magidson et al. (2011) adapted BATD for inpatient substance users with depressive symptoms and found significantly better substance use treatment retention and increased activation for BATD in a randomized comparison to supportive counseling. Folke et al. (in press) reported in a small open trial that BA was feasible when initiated during inpatient care and continued in outpatient care after discharge. Taken together, BA appears to be a promising and feasible treatment for diverse inpatient populations but research is preliminary. Studies so far have been small, conducted in varied settings with different levels of acuteness.

The empirical research regarding BA's purported mechanism, that increased activation behavior results in increased environmental rewards and decreased symptoms, is sparse (Dimidjian et al., 2011, Manos et al., 2010). In a single subject study by Gaynor and Harris (2008), activation appeared to mediate outcomes in 50% of participants. Collado, Castillo, Maero, Lejuez, and MacPherson (2014) found, in a small pilot trial, that depression improved in tandem with activation and was preceded by environmental reward. In another case study by Manos, Kanter, and Luo (2011) activation preceded depression improvement in one client and was concurrent with improvement in the other. No studies have investigated the temporal relation between BA mechanisms and outcome in inpatient contexts. Gollan et al.(2014) did administer an inpatient specific activation and avoidance measure at admission and discharge. A significantly greater degree of activation was found in the BA group relative to the control group. However, demonstration of temporal relations requires repeated assessments throughout treatment.

The aim of the current study was to investigate the mechanisms and efficacy of inpatient BA for depressive symptoms in patients with different psychiatric disorders. As an initial test we used a Single Case Experimental Design (SCED) with six inpatients. A multiple baseline study design was employed so that participants received BA after differing lengths of standard treatment. This design has considerable advantages in the preliminary stages of research. As opposed to open trials the multiple baseline study offers an experimental control condition. Compared to the gold standard Randomized Controlled Trial (RCT) it requires fewer participants as every participant acts as their own control. In the busy and unpredictable inpatient environment it is challenging to obtain larger samples and conduct stringent RCTs, instead a restricted number of participants can be studied in greater detail as they are present round the clock. Several researchers have also argued that the intensive SCED is particularly well suited for studying mechanisms of change (Gaynor and Harris, 2008, Manos et al., 2010).

Section snippets

Participants

Six patients from three acute general psychiatric inpatient wards in Dalarna, Sweden, were included. Eligible patients scored ≥20 on the self-report version of the Montgomery–Åsberg Depression Rating Scale (MADRS-S; Svanborg & Åsberg, 1994), did not suffer significant confusion (due to dementia, intoxication, acute psychosis, etc.), and were able to read and speak Swedish. The study protocol required patients to participate in an intensive assessment and treatment program for 6–11 days. Thus,

Results

All admitted patients at the three wards (N = 55) were screened for eligibility. The majority were non-eligible due to the study- and inpatient ward characteristics (n = 33) and only 10 due to patient characteristics (see Fig. 1). None declined to participate in the study. Only one participant (P4) failed to attend two sessions. An overview of missing data is provided in Table 3. No clinician ratings were missing but occasional daily assessments were missing for P4 and P6. The number of diary

Discussion

The current study examined the efficacy, mechanisms of change, and feasibility of a brief team-based BA intervention added to the standard acute inpatient psychiatric treatment.

In relation to efficacy, the baseline period did not appear to improve symptoms. The only exceptions were a temporary improvement in P4 on the MADRS-S, an improvement in the hourly diary mood measures for P3, and a minor improvement trend in the mood diary for P2. The lack of improved symptoms and activation/avoidance

Acknowledgments

We wish to thank the patients taking part in the study and the participating staff on the wards in Dalarna, Sweden. This study was supported by the Center for Clinical Research Dalarna.

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