The influence of therapy quality on outcomes from behavioural activation and guided self-help treatments for depression in adults with intellectual disabilities.

OBJECTIVES: We report the effect of quality of therapy delivery on outcomes in a randomized, controlled trial of behavioural activation (BA) and guided self-help (GSH) for depression in adults with intellectual disabilities. METHODS: A study specific measure of quality was used in a linear mixed effect model to determine the effects therapy and therapy quality on therapy outcome. RESULTS: There was a significant interaction between quality and treatment type, with lower quality therapy associated with better outcome for GSH but poorer outcome for BA, with little difference in outcomes at higher levels of therapy quality. CONCLUSIONS: Factors suggesting high quality in individualized BA may indicate problematic engagement for GSH. More research into processes in therapy for people with intellectual disabilities is required.

"Therapy without a therapist?" The experiences of adolescents and their parents of online behavioural activation for depression with and without therapist support.

Behavioural Activation (BA) is an established treatment for adults with depression, and research on BA for adolescents is promising. However, there is a knowledge gap in terms of the experiences of adolescents and their parents BA for depression delivered online. Furthermore, there have been no previous studies conducted on the experiences of respondents with regard to the role of the therapist in online treatment. Therefore, the primary aim of this study is to explore the experiences of online BA among adolescents with depression and how their parents experience supporting their adolescent through treatment. Second, the experiences of having online therapy with or without a therapist were explored. Semi-structured interviews were conducted with eight adolescents and nine parents (n = 17) who completed guided or self-guided online BA. Reflexive thematic analysis was used to identify aspects of the experience of treatment that were important to adolescents and their parents. Two main themes were generated: (1) opportunities or barriers to engaging in treatment and (2) parental involvement is valued and welcomed. This study contributes valuable information regarding user experiences of BA treatment, the importance of therapist support and parental involvement in treating adolescents with depression.Trial registration number: ClinicalTrials.gov Identifier NCT04117789, Date of registration: 07 October 2019.

Is behavioural activation an effective treatment for depression in children and adolescents? An updated systematic review and meta-analysis.

Behavioural Activation (BA)-a brief therapy based on the scheduling of enjoyable, purposeful and rewarding activities-is an effective and cost-effective treatment for depression in adults that shows promise for children and adolescents. We provide an update on a previous systematic review of evidence on BA-delivered in-person, telephone, or online-for depression and comorbid anxiety in children and adolescents. We conducted systematic literature searches in 6 databases up to February 2024. We included all study designs evaluating BA with participants up to 18 years old with diagnosable depression, as established by a validated screening tool or diagnostic manual. We used the Moncrieff Scale and the Cochrane Risk of Bias tool to assess study quality. We summarised the findings of all study types with a narrative synthesis and of randomised controlled trials (RCTs) with a meta-analysis. Overall, 24 studies (6 RCTs, 18 pre-post evaluations, n = 2,758) met our inclusion criteria. A meta-analysis of 4 RCTs (n = 156) showed that BA has a small effect of 0.24 (Hedge's adjusted g) in reducing depression symptoms compared to a waiting-list control, usual care and other therapies. Online and telephone-facilitated BA was shown to be feasible in 3 studies and effective in 1. Outcomes on comorbid anxiety were mixed. No economic evaluations met our inclusion criteria. BA shows sufficient promise as an intervention for reducing depression symptoms in children and adolescents to justify the need for further RCTs, providing that five conditions are met: studies are powered to detect a minimal clinically important difference; BA materials are fit-for-purpose to produce clinically meaningful change; follow-ups are longer than 6 months; primary outcomes are child-reported; and intervention costs, resource use and adverse events are reported.

A feasibility and pilot additive randomised control trial of attachment security priming during behavioural activation.

BACKGROUND: There is some initial evidence that attachment security priming may be useful for promoting engagement in therapy and improving clinical outcomes. AIMS: This study sought to assess whether outcomes for behavioural activation delivered in routine care could be enhanced via the addition of attachment security priming. METHOD: This was a pragmatic two-arm feasibility and pilot additive randomised control trial. Participants were recruited with depression deemed suitable for a behavioural activation intervention at Step 2 of a Talking Therapies for Anxiety and Depression service. Ten psychological wellbeing practitioners were trained in implementing attachment security priming. Study participants were randomised to either behavioural activation (BA) or BA plus an attachment prime. The diagrammatic prime was integrated into the depression workbook. Feasibility outcomes were training satisfaction, recruitment, willingness to participate and study attrition rates. Pilot outcomes were comparisons of clinical outcomes, attendance, drop-out and stepping-up rates. RESULTS: All practitioners recruited to the study, and training satisfaction was high. Of the 39 patients that were assessed for eligibility, 24 were randomised (61.53%) and there were no study drop-outs. No significant differences were found between the arms with regards to drop-out, attendance, stepping-up or clinical outcomes. CONCLUSIONS: Further controlled research regarding the utility of attachment security priming is warranted in larger studies that utilise manipulation checks and monitor intervention adherence.

Behavioural activation for depressive symptoms in adults with severe to profound intellectual disabilities: Modelling and initial feasibility study.

BACKGROUND: Almost no research has been published reporting on evaluations of the effectiveness of psychological interventions for people with severe to profound intellectual disabilities and depression. This paper describes the development and initial feasibility testing of an adapted Behavioural Activation therapy (BeatIt2) for this population. METHOD: Phase 1 of the study examined participant recruitment and willingness to be randomised in the context of a planned Randomised Controlled Trial (RCT). Phase 2 examined the feasibility of delivering the intervention. RESULTS: Twenty adults with a severe or profound intellectual disability and clinically significant depression were recruited to Phase 1 of the study. In Phase 2, there was 100% participant retention for those recruited to the study at 6-month follow-up. The BeatIt2 therapy was reported to be acceptable for participants. CONCLUSION: COVID disruption meant that it was not possible to complete the planned feasibility RCT. The positive findings suggest that additional evaluation of BeatIt2 is warranted.

Understanding the effects of a complex psychological intervention on symptoms of depression in Goa, India: findings from a causal mediation analysis.

BACKGROUND: Understanding how and under what circumstances a highly effective psychological intervention, improved symptoms of depression is important to maximise its clinical effectiveness. AIMS: To address this complexity, we estimate the indirect effects of potentially important mediators to improve symptoms of depression (measured with the Patient Health Questionnaire (PHQ-9)) in the Healthy Activity Program trial. METHOD: Interventional in(direct) effects were used to decompose the total effect of the intervention on PHQ-9 scores into the direct and indirect effects. The following indirect effects were considered: characteristics of sessions, represented by the number of sessions and homework completed; behavioural activation, according to an adapted version of the Behavioural Activation for Depression Scale - Short Form; and extra sessions offered to participants who did not respond to the intervention. RESULTS: Of the total effect of the intervention measured through the difference in PHQ-9 scores between treatment arms (mean difference: -2.1, bias-corrected 95% CI -3.2 to -1.5), 34% was mediated through improved levels of behavioural activation (mean difference: -0.7, bias-corrected 95% CI -1.2 to -0.4). There was no evidence to support the mediating role of characteristics of the sessions nor the extra sessions offered to participants who did not respond to the treatment. CONCLUSIONS: Findings from our robust mediation analyses confirmed the importance of targeting behavioural activation. Contrary to published literature, our findings suggest that neither the number of sessions nor proportion of homework completed improved outcomes. Moreover, in this context, alternative treatments other than extra sessions should be considered for patients who do not respond to the intervention.

Online behavioural activation during the COVID-19 pandemic decreases depression and negative affective bias.

BACKGROUND: The COVID-19 pandemic highlighted the need for mental health interventions that can be easily disseminated during a crisis. Behavioural activation (BA) is a cost-effective treatment that can be administered by non-specialists; however, it is unclear whether it is still effective during a time of lockdown and social distancing, when opportunities for positive activity are significantly constrained. METHODS: Between May and October 2020, we randomised 68 UK participants with mild to moderate low mood to either a 4-week online programme of non-specialist administered BA or to a passive control group. Before and after the intervention, we collected self-report data on mood and COVID-related disruption, as well as measuring emotional cognition as an objective marker of risk for depression. RESULTS: In comparison to the control group, the BA group showed a significant decrease in depression, anxiety and anhedonia after the intervention, as well as an increase in self-reported activation and social support. Benefits persisted at 1-month follow-up. BA also decreased negative affective bias on several measures of the Facial Emotion Recognition Task and early change in bias was associated with later therapeutic gain. Participants rated the intervention as highly acceptable. CONCLUSION: This study highlights the benefits of online BA that can be administered by non-specialists after brief training. These findings can help inform the policy response towards the rising incidence of mental health problems during a crisis situation such as a pandemic. They also highlight the use of objective cognitive markers of risk across different treatment modalities.

Behavioural Activation versus Treatment as Usual for Depressed Older Adults in Primary Care: A Pragmatic Cluster-Randomised Controlled Trial.

INTRODUCTION: Effective non-pharmacological treatment options for depression in older adults are lacking. OBJECTIVE: The effectiveness of behavioural activation (BA) by mental health nurses (MHNs) for depressed older adults in primary care compared with treatment as usual (TAU) was evaluated. METHODS: In this multicentre cluster-randomised controlled trial, 59 primary care centres (PCCs) were randomised to BA and TAU. Consenting older (≥65 years) adults (n = 161) with clinically relevant symptoms of depression (PHQ-9 ≥ 10) participated. Interventions were an 8-week individual MHN-led BA programme and unrestricted TAU in which general practitioners followed national guidelines. The primary outcome was self-reported depression (QIDS-SR16) at 9 weeks and 3, 6, 9, and 12-month follow-up. RESULTS: Data of 96 participants from 21 PCCs in BA and 65 participants from 16 PCCs in TAU, recruited between July 4, 2016, and September 21, 2020, were included in the intention-to-treat analyses. At post-treatment, BA participants reported significantly lower severity of depressive symptoms than TAU participants (QIDS-SR16 difference = -2.77, 95% CI = -4.19 to -1.35), p < 0.001; between-group effect size = 0.90; 95% CI = 0.42-1.38). This difference persisted up to the 3-month follow-up (QIDS-SR16 difference = -1.53, 95% CI = -2.81 to -0.26, p = 0.02; between-group effect size = 0.50; 95% CI = 0.07-0.92) but not up to the 12-month follow-up [QIDS-SR16 difference = -0.89 (-2.49 to 0.71)], p = 0.28; between-group effect size = 0.29 (95% CI = -0.82 to 0.24). CONCLUSIONS: BA led to a greater symptom reduction of depressive symptoms in older adults, compared to TAU in primary care, at post-treatment and 3-month follow-up, but not at 6- to 12-month follow-up.

Psychosocial interventions with art and music during stem cell transplantation: An integrative review.

OBJECTIVES: The objective of this study is to systematically review the literature with the following aims: to survey the art and music interventions offered to the stem cell transplant population; to define the interventions' beneficial properties by conceptualising themes; to analyse these themes using behavioural activation principles as a lens and explore their value in alleviating isolation-related distress. BACKGROUND: Patients undergoing stem cell transplant are at great risk of psychological morbidity, partly on account of prolonged hospital stays in protective isolation. This risk extends beyond discharge and into ambulatory care, negatively affecting quality-of-life and survival rates of the transplant recipients. DESIGN: Integrative review methodology. METHODS: A systematic search of 10 bibliographic databases was undertaken using terms relating to art, music and stem cell transplantation for the years 2012 to 2019. Records were assessed for quality and risk-of-bias using a critical appraisal tool and following the PRISMA Systematic Review checklist to guide reporting. Studies were analysed narratively and thematically. RESULTS: The 16 papers were of mixed quality. Findings and treatment effects differed between and within studies. The beneficial attributes of the treatments were clustered and divided into two groups. The first consisted of intrinsic, patient-focussed factors: (1) Creative outlet or acquisition of a new skill; (2) achievement of normality; (3) mutual or peer-support; (4) relationship-building and (5) meaningful recreation, distraction and diversion. The second group considered extrinsic factors: (6) Improved communication; (7) enhanced spiritual care and (8) better healthcare experience. CONCLUSIONS: Several art and music interventions have been attempted which were beneficial to patients and generated a sense of achievement, connection and enjoyment. The interventions appear to uphold the principles of person-centred holistic care and have potential to generate a high-quality, supportive healthcare and working environment. RELEVANCE TO CLINICAL PRACTICE: Psychosocial interventions with art and music have improved the care and experience of patients undergoing stem cell transplant.

Overcoming training bottlenecks: mixed-methods evaluation of digital training for non-specialists in postnatal depression self-help treatment.

OBJECTIVES: This mixed-methods study evaluated the feasibility, acceptability and preliminary effectiveness of an interactive digital training programme for non-specialist supporters providing a guided self-help intervention for postnatal depression (PND). METHODS: A total of 49 non-specialist trainees participated. Six digital training modules were flexibly delivered over a 5-week period. Training included a chatroom, moderated by a supervised assistant psychologist. Quantitatively, feasibility was assessed via participation and retention levels; acceptability was examined using course evaluation questionnaires; and effectiveness was measured pre-test-post-test quantitatively using a self-report questionnaire and pre-post using scenario questions. Participant focus groups explored feasibility, acceptability and effectiveness. RESULTS: The training was feasible; 41 completed the course and 42 were assessed at follow-up. Quantitative course evaluation and thematic analysis of focus group feedback demonstrated high training acceptability. RANOVAs indicated training significantly improved knowledge and confidence pre- to post-test. There were demonstrable increases in specific skills at post-test as assessed via clinical scenarios. CONCLUSION: This training is a feasible, acceptable and effective way to upskill non-specialists in supporting treatment for PND, however supervised practice is recommended to ensure participants embed knowledge competently into practice. The training offers an effective first step in upskilling non-specialist supporters to support women with PND treatment at scale.

A pilot trial of behavioural activation with a contingency management component: Preliminary examination of changes in smoking and alternative rewards among low-income individuals.

The heaviest smoking and burden of tobacco-related illness occurs among low-income individuals. Using a behavioural economics framework, this non-randomised pilot study examined the preliminary efficacy of behavioural activation (BA) with a contingency management (CM) component designed to encourage continued use of BA skills and reductions in cigarettes smoked. Eighty-four participants were recruited from a community centre. Data were collected at the start of every other group and at four different follow-up time points. Domains assessed included number of cigarettes smoked, activity level, and environmental rewards (i.e. alternative environmental reinforcers). Over time, cigarette smoking decreased (p < .001), environmental reward increased (p = .03), and reward probability and activity level were associated over time with cigarette smoking (p ≤ .03) above and beyond the effect of nicotine dependence. The continued use of BA skills was associated with greater environmental rewards (p = .04). While further research is needed to replicate this work, results suggest initial evidence for the utility of this intervention in a traditionally underserved community.

Preventing depression using a smartphone app: a randomized controlled trial.

BACKGROUND: There is evidence that depression can be prevented; however, traditional approaches face significant scalability issues. Digital technologies provide a potential solution, although this has not been adequately tested. The aim of this study was to evaluate the effectiveness of a new smartphone app designed to reduce depression symptoms and subsequent incident depression amongst a large group of Australian workers. METHODS: A randomized controlled trial was conducted with follow-up assessments at 5 weeks and 3 and 12 months post-baseline. Participants were employed Australians reporting no clinically significant depression. The intervention group (N = 1128) was allocated to use HeadGear, a smartphone app which included a 30-day behavioural activation and mindfulness intervention. The attention-control group (N = 1143) used an app which included a 30-day mood monitoring component. The primary outcome was the level of depressive symptomatology (PHQ-9) at 3-month follow-up. Analyses were conducted within an intention-to-treat framework using mixed modelling. RESULTS: Those assigned to the HeadGear arm had fewer depressive symptoms over the course of the trial compared to those assigned to the control (F3,734.7 = 2.98, p = 0.031). Prevalence of depression over the 12-month period was 8.0% and 3.5% for controls and HeadGear recipients, respectively, with odds of depression caseness amongst the intervention group of 0.43 (p = 0.001, 95% CI 0.26-0.70). CONCLUSIONS: This trial demonstrates that a smartphone app can reduce depression symptoms and potentially prevent incident depression caseness and such interventions may have a role in improving working population mental health. Some caution in interpretation is needed regarding the clinical significance due to small effect size and trial attrition.Trial Registration Australian and New Zealand Clinical Trials Registry (www.anzctr.org.au/) ACTRN12617000548336.

Behavioral Activation in Nursing Homes to Treat Depression (BAN-Dep): Results From a Clustered, Randomized, Single-Blinded, Controlled Clinical Trial.

OBJECTIVES: To determine if behavioral activation (BA) delivered by trained staff decreases prevalence of clinically significant symptoms of depression among older adults living in residential aged care facilities (RACFs). METHODS: Clustered, randomized, single-blinded, controlled trial of BA for adults aged over 60 years living permanently in a RACF with symptoms of depression (Patient Health Questionnaire, PHQ-9 ≥ 5). BA was delivered over 8-12 weeks using a structured workbook. The proportion of residents with PHQ-9 ≥ 10 at weeks 12, 26, and 52, as well as anxiety symptoms (GAD-7), physical (PCS), and mental (MCS) quality of life, loneliness, and loss to follow-up were main outcomes of interest RESULTS: We recruited 54 RACFs (26 intervention) and 188 of their residents (89 intervention). Participants were aged 61-100 years and 132 (70.2%) were women. PHQ-9 ≥ 10 interacted with BA at week 12 (OR = 0.34, 95%CI = 0.11-1.07), but differences between the groups were not statistically significant at any time-point. GAD-7 ≥ 10 interacted with BA at week 26 (OR = 0.12, 95%CI = 0.02-0.58), but not at any other time-point. Overall, the intervention had no effect on the scores of the PHQ-9, GAD-7, PCS, MCS, and loneliness scale. Loss to follow-up was similar between groups. Adherence to all stages of the intervention was poor (36.2%). CONCLUSIONS: Disruption by the COVID-19 pandemic and staffing issues in RACFs undermined recruitment and adherence. In such a context, a BA program delivered by RACF staff was not associated with better mental health outcomes for residents over 52 weeks.

Behavioural activation and trial-based cognitive therapy may be beneficial to reduce suicidal ideation in major depressive disorder: A post hoc study from a clinical trial.

WHAT IS KNOWN AND OBJECTIVE: The suicidality spectrum is a clinical challenge because of the difficulty of its management and its association with mortality. Few studies have investigated psychotherapies for reducing the components of suicidality. In this study, we compared the effect of behavioural activation (BA), trial-based cognitive therapy (TBCT) - both added to antidepressant (AD) treatment - and treatment as usual (TAU) in mitigating suicidal ideation in patients with major depressive disorder (MDD). METHODS: A post hoc study was conducted with data from a randomized clinical trial. Secondary analyses compared the treatments using scores from the items that evaluated suicidal ideation with the HAM-D (HAM-D-3) and BDI (BDI-9). A composite measurement was constructed by summing the scores from the two items (HAM-D-3 plus BDI-9). RESULTS AND DISCUSSION: Seventy-six patients were analysed (BA + AD = 24; TBCT + AD = 26 and TAU = 26). In HAM-D-3, the BA + AD group showed a statistically greater reduction than the TAU group. In BDI-9, the three groups did not show significant differences. In the HAM-D-3 plus BDI-9, TBCT + AD reduced ideations more than the TAU group. There were no differences among the psychotherapies in any of the measures. Sensitivity analyses showed improvement in suicidal ideation in both psychotherapies compared to TAU. WHAT IS NEW AND CONCLUSION: This is one of the few studies that evaluated the effect of BA and TBCT in lowering suicidal ideation. Adding these therapies to ADs seems to decrease suicidal ideation. We suggest the possible beneficial effects of BA and TBCT in the management of suicidal ideation in patients with recurrent MDD. Our findings need further studies to confirm these results.

A Mental Health Chatbot with Cognitive Skills for Personalised Behavioural Activation and Remote Health Monitoring.

Mental health issues are at the forefront of healthcare challenges facing contemporary human society. These issues are most prevalent among working-age people, impacting negatively on the individual, his/her family, workplace, community, and the economy. Conventional mental healthcare services, although highly effective, cannot be scaled up to address the increasing demand from affected individuals, as evidenced in the first two years of the COVID-19 pandemic. Conversational agents, or chatbots, are a recent technological innovation that has been successfully adapted for mental healthcare as a scalable platform of cross-platform smartphone applications that provides first-level support for such individuals. Despite this disposition, mental health chatbots in the extant literature and practice are limited in terms of the therapy provided and the level of personalisation. For instance, most chatbots extend Cognitive Behavioural Therapy (CBT) into predefined conversational pathways that are generic and ineffective in recurrent use. In this paper, we postulate that Behavioural Activation (BA) therapy and Artificial Intelligence (AI) are more effectively materialised in a chatbot setting to provide recurrent emotional support, personalised assistance, and remote mental health monitoring. We present the design and development of our BA-based AI chatbot, followed by its participatory evaluation in a pilot study setting that confirmed its effectiveness in providing support for individuals with mental health issues.

FACT effectiveness in primary care; a single visit RCT for depressive symptoms.

BACKGROUND: Patients with depressive symptoms are common in primary care. Brief, simple therapies are needed. AIM: Is a focussed acceptance and commitment therapy (FACT) intervention more effective than the control group for patients with depressive symptoms in primary care at one week follow up?Design and setting: A randomised, blinded controlled trial at a single primary care clinic in Auckland, New Zealand. METHODS: Patients presenting to their primary care practice for any reason were recruited from the clinic waiting room. Eligible patients who scored ≥2 on the PHQ-2 indicating potential depressive symptoms were randomised using a remote computer to intervention or control groups. Both groups received a psychosocial assessment using the "work-love-play" questionnaire. The intervention group received additional FACT-based behavioural activation activities. The primary outcome was the mean PHQ-8 score at one week. RESULTS: 57 participants entered the trial and 52 had complete outcome data after one week. Baseline PHQ-8 scores were similar for intervention (11.0) and control (11.7). After one week, the mean PHQ-8 score was significantly lower in the intervention group (7.4 vs 10.1 for control; p<0.039 one sided and 0.078 two sided). The number needed to treat to achieve a PHQ-8 score ≤6 was 4.0 on intention to treat analysis (p = 0.043 two sided). There were no significant differences observed on the secondary outcomes. CONCLUSION: This is the first effectiveness study to examine FACT in any population. The results suggest that it is effective compared with control, at one week, for patients with depressive symptoms in primary care.

A brief report informing the adaptation of a behavioural activation intervention for delivery by non-mental health specialists for the treatment of perinatal depression.

BACKGROUND: Behavioural activation (BA) is recommended by the National Institute for Health and Care Excellence guidelines for the treatment of perinatal depression; however, there is limited evidence about whether it is effective when delivered by non-mental health specialists (NMHS) in a perinatal setting in the UK. AIMS: This study aimed to adapt a BA intervention manual and guided self-help booklet intended for delivery by NMHSs for the treatment of perinatal depression. METHOD: Interviews were conducted with 15 women and 19 healthcare professionals (HCP) within the first study element. Four experience-based co-design (EBCD) workshops were held, with the involvement of 14 women and three HCPs, to modify the BA documents for the specific needs of perinatal women. Thematic analysis was used to analyse the data. FINDINGS: The findings from the study elements were presented with themes. The co-designers (women and HCPs) pointed out that having sleeping problems, changes in appetite, feeling exhausted and feeling emotional, may be experienced by non-depressed mothers as well during pregnancy or in the postpartum period, especially around the fourth day after giving birth. Therefore, it was important to differentiate these feelings from depression. The women also wanted to see an example for each activity before being asked to do it. Having examples would help them to see the possibilities before creating their own diary sheets or tables of activities. CONCLUSIONS: Aside of the tool adaptation, the findings of this study provide a foundation to assess the effectiveness of the adapted intervention in a subsequent feasibility trial.

Multiple mediation analysis of the peer-delivered Thinking Healthy Programme for perinatal depression: findings from two parallel, randomised controlled trials.

BACKGROUND: Low-intensity psychosocial interventions have been effective in targeting perinatal depression, but relevant mechanisms of change remain unknown. AIMS: To examine three theoretically informed mediators of the Thinking Healthy Programme Peer-delivered (THPP), an evidence-based psychosocial intervention for perinatal depression, on symptom severity in two parallel, randomised controlled trials in Goa, India and Rawalpindi, Pakistan. METHOD: Participants included pregnant women aged ≥18 years with moderate to severe depression, as defined by a Patient Health Questionnaire 9 (PHQ-9) score ≥10, and were randomised to either THPP or enhanced usual care. We examine whether three prespecified variables (patient activation, social support and mother-child attachment) at 3 months post-childbirth mediated the effects of THPP interventions of perinatal depressive symptom severity (PHQ-9) at the primary end-point of 6 months post-childbirth. We first examined individual mediation within each trial (n = 280 in India and n = 570 in Pakistan), followed by a pooled analysis across both trials (N = 850). RESULTS: In both site-specific and pooled analyses, patient activation and support at 3 months independently mediated the intervention effects on depressive symptom severity at 6 months, accounting for 23.6 and 18.2% of the total effect of THPP, respectively. The intervention had no effect on mother-child attachment scores, thus there was no evidence that this factor mediated the intervention effect. CONCLUSIONS: The effects of the psychosocial intervention on depression outcomes in mothers were mediated by the same two factors in both contexts, suggesting that such interventions seeking to alleviate perinatal depression should target both social support and patient activation levels. DECLARATION OF INTEREST: None.

How Does Behavioural Activation Work? A Systematic Review of the Evidence on Potential Mediators.

INTRODUCTION: Behavioural activation is an effective treatment for depression, but little is known about its working mechanisms. Theoretically, its effect is thought to rely on an interplay between activation and environmental reward. OBJECTIVE: The present systematic review examines the mediators of behavioural activation for depression. METHODS: A systematic literature search without time restrictions in Medline, EMBASE, PsycINFO, The Cochrane Library, and CINAHL resulted in 14 relevant controlled and uncontrolled prospective treatment studies that also performed formal mediation analyses to investigate their working mechanisms. After categorising the mediators investigated, we systematically compared the studies' methodological quality and performed a narrative synthesis of the findings. RESULTS: Most studies focused on activation or environmental reward, with 21 different mediators being investigated using questionnaires that focused on psychological processes or beliefs. The evidence for both activation and environmental reward as mediators was weak. CONCLUSIONS: Non-significant results, poor methodological quality of some of the studies, and differences in questionnaires employed precluded any firm conclusions as to the significance of any of the mediators. Future research should exploit knowledge from fundamental research, such as reward motivation from neurobiology. Furthermore, the use of experience sampling methods and idiographic analyses in bigger samples is recommended to investigate potential causal pathways in individual patients.

Internet-based behavioural activation to improve depressive symptoms and prevent child abuse in postnatal women (SmartMama): a protocol for a pragmatic randomized controlled trial.

BACKGROUND: Child abuse and postnatal depression are two public health problems that often co-occur, with rates of childhood maltreatment highest during the first year of life. Internet-based behavioural activation (iBA) therapy has demonstrated its efficacy for improving postnatal depression. No study has examined whether the iBA program is also effective at preventing child abuse. This study aims to investigate whether iBA improves depressive symptoms among mothers and prevents abusive behaviours towards children in postpartum mothers in a randomized controlled trial, stratifying on depressive mood status. The study also evaluates the implementation aspects of the program, including how users, medical providers, and managers perceive the program in terms of acceptability, appropriateness, feasibility, and harm done. METHODS: The study is a non-blinded, stratified randomized controlled trial. Based on cut-off scores validated on Japanese mothers, participants will be stratified to either a low Edinburgh Postnatal Depression Scale (EPDS) group, (EPDS 0-8 points) or a high EPDS group (EPDS ≥9 points). A total of 390 postnatal women, 20 years or older, who have given birth within 10 weeks and have regular internet-access will be recruited at two hospitals. Participants will be randomly assigned to either treatment, with treatment as usual (TAU) or through intervention groups. The TAU group receives 12 weekly iBA sessions with online assignments and feedback from trained therapists. Co-primary outcomes are maternal depressive symptoms (EPDS) and psychological aggression toward children (Conflict Tactic Scale 1) at the 24-week follow-up survey. Secondary outcomes include maternal depressive symptoms, parental stress, bonding relationship, quality of life, maternal health care use, and paediatric outcomes such as physical development, preventive care attendance, and health care use. The study will also investigate the implementation outcomes of the program. DISCUSSION: The study investigates the effectiveness of the iBA program for maternal depressive symptoms and psychological aggression toward children, as well as implementation outcomes, in a randomized-controlled trial. The iBA may be a potential strategy for improving maternal postnatal depression and preventing child abuse. TRIAL REGISTRATION: The study protocol (issue date: 2019-Mar-01, original version 2019005NI-00) was registered at the UMIN Clinical Trial Registry (UMIN-CTR: ID UMIN 000036864 ).