The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 4
4 - Usable
The intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components
Usability
Core Components
Behavioural Activation (BA) is an approach to improving mental health that involves engagement in behaviours, and the influence of these on emotional state. In the treatment of depression, BA recognises the relationship that exists between depression and inactivity, and the need to apply proactive measures to break out of this cycle and feel better again. BA therefore involves an outside-in approach of completing activities according to a planned schedule in order to lift the mood, as opposed to an inside-out approach of completing activities based on internal emotional state. It also involves reduced engagement in activities that sustain depression or increase depression risks.
At its core, BA components for depression treatment include;
- Understanding the cycle between depression and inactivity: Addresses the effect of emotions on behaviours (including avoidance, isolation), how these behaviours fuel depression, and the use of activating to reinforce positive context contingencies
- Activity monitoring: Involves the use of an activity monitoring chart to record activities through the day, and the corresponding mood while completing these activities. This improves awareness of activities that enhance or depress mood, and the promotes understanding of the relationship between activity and mood
- Identifying our values and goals: Involves exploration of the things that are important to the individual and make life meaningful. Values are unique to individuals and guide the goal-oriented activities that are founded on these values
- Simple activation: Involves scheduling activities that increase pleasure (e.g. social activities or hobbies) or mastery (e.g. sports or work). Enjoyment of these activities can increase positive emotions and improve mood
- Problem solving: Addresses potential barriers to activation, and looks into measures that can be taken to address problems, which can include acceptance.
BA is a highly personalised treatment approach that can be delivered as a standalone intervention, i.e. outside of other CBT skills, or with other components of CBT e.g. cognitive restructuring.
Fidelity
Practitioners delivering BA should receive training prior to programme delivery. BA should be delivered in line with the BA treatment manual, along with handouts and worksheets that support its delivery. Standardised quality criteria instruments can be used to assess practitioner competence in BA delivery such as the Quality of Behavioural Activation Scale (Dimidjian, Hubley, Martell, and Herman, unpublished measure).
Modifiable Components
BA is typically delivered in individual format, but can also be delivered in group format to offer additional cost effectiveness. BA can be delivered in person, remotely, or as a self-guided intervention (using self-help books or smart phone apps like Moodivate or Behavioural Apptivation). BA is typically delivered weekly over 20-24 sessions, but can also be delivered in 10-12 sessions as a brief behavioural activation treatment for depression (BATD-R).
Supports - Rating: 5
5 - Well Supported
Comprehensive resources are available to support implementation, including resources for building the competency of staff and organisational practice as a standard part of the intervention
Support for Organisation / Practice
Implementation Support
Implementation support is provided mainly by trained supervisors who support the application of BA within each clinician’s practice. Support for implementing BA is available through the NES Psychology Adult Mental Health and CAMHS workstreams with a national training plan for behavioural activation which has close links with the programme developers. BA training is offered annually to all Scottish health boards including BA for depression and BA in groups (Martell model), Brief BA for depression revised (Lejuez and Hopko model) and Brief Behavioural Activation for Depressed Adolescents (https://learn.nes.nhs.scot/32788). Training is supported nationally by emodules (BA e-learning modules on TURAS Learn and BA for Adolescents https://learn.nes.nhs.scot/32788), coaching, supervisor training and locally through a training for trainers model.
Start-up Costs
There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations.
Building Staff Competency
Qualifications Required
Staff will usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine). Other mental health workers (with neither professional mental health qualifications nor formal training in psychological therapies) have also effectively delivered BA.
Training Requirements
Behavioural Activation (BA) training is included in the Enhanced Psychological Practice (CYP and Adult) programmes, CYP and adult MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Training in BA for a wide range of professionals is available through the NES Psychology Behavioural Activation Learning Programme (https://learn.nes.nhs.scot/507) and CAMHS (Brief Behavioural Activation for Depressed Adolescents https://learn.nes.nhs.scot/32788).
Supervision Requirements
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision (minimum 1 hour a month) with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions such as the NES Generic supervision competences training or equivalent. There is an additional training module available that specifically supports supervision skills for psychological interventions such as BA (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/).
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Evidence
Theory of Change
BA is guided by the behavioural model of depression. It identifies depression as a behavioural issue associated with the lack of positive reinforcement, and the engagement in unhealthy behaviours to achieve temporary relief. BA therefore aims to change patients’ behaviours for the purpose of reinforcing positive context contingencies, and ending negative behaviours that maintain depression or increase its risks. The proactive measures adopted are expected help patients break the cycle of depression and inactivity, translating to increased positive emotions and improved mood.
CYP Evidence
Some of the best available evidence for BA in children and adolescents with depressed mood includes one meta-analytic study and 3 RCTs. These have been described below.
The first was a meta-analytic study that evaluated the effectiveness of BA in young people aged 18 years and below (1). Three RCT were included in the meta-analysis. Participants were experiencing depression or depressive symptoms as established by a validated screening measure or diagnosis. Interventions were considered BA if they were based on either operant conditioning principles or comprise techniques fundamental to behavioural treatments of depression (activity scheduling, self-monitoring, goal setting). No restrictions were placed on comparator or control group types. One of the included RCTs, (2) evaluated a transdiagnostic BA group for 12-14yr olds with depression or anxiety (2) compared to waitlist control. The participants (sample size 35) represented an ethnically diverse sample and the intervention was delivered across 10 group sessions and two individual .
Three RCTs evaluate the effectiveness of BA in late adolescent university students Gawrysiak et al., (2008); McIndoo et al., (2016); Takagaki et al., (2016). The Gawrysiak et al. (2008) paper involved 30 depressed students in the USA randomised to BA or no treatment control group (3). McIndoo et al. (2016) involved 50 college students in the USA randomised to 4 sessions of BA, a mindfulness based intervention or a control group (4). Takagaki et al, (2016) involved 118 participants in Japan, aged 18–19 years, with subthreshold depression were randomised to the BA or no treatment control group. BA was delivered over 5 weeks in 60-min sessions (5).
CYP Outcomes
Compared to the control or comparator groups, the following outcomes were observed;
- Significantly reduced depression scores/ symptoms at post-treatment (1, 3, 4,5)
- Symptom outcomes were not significantly different at post-treatment or 4 month follow up in the paper (2) but there was significant improvements in Clinical Global impairment and remission rates in primary and secondary diagnoses.
- Significantly improved quality of life and behavioural characteristics at post-treatment (5).
Adult Evidence Overview
Some of the best available evidence for BA in the treatment of depression in adults include meta-analytic studies and an RCT. These have been described below.
A recent meta-analytic study (6) evaluated the effectiveness of BA for depression in adults. The analysis included 22 RCTs with 819 participants. The focus was BA delivered to individuals and included waitlist, usual care or other control conditions. This review also summarised outcomes where only studies with low risk of bias were included.
Another meta analysis of BA on depressed mood in adults (≥18 years) (7). The study included 28 RCTs with 1853 participants. BA was defined as a time-limited treatment, delivered individually, by a trained clinician, and in which the primary treatment components were activity scheduling and self-monitoring. All types of control comparison conditions were included.
The third was a meta-analytic study that evaluated the effectiveness of group BA in the treatment of depression (8). The meta-analysis included 19 RCTs involving adults (≥18 years) with a depressive disorder or elevated symptoms of depression. Interventions were considered BA if they delivered a purely behavioural treatment. Group size was a minimum of three participants, and there was no limit on treatment duration. Comparators included any passive control, treatment as usual (TAU) or active treatment.
The fourth was a meta-analytic study that evaluated the effectiveness of BA in adults (≥16years) with a primary diagnosis of depression, ranging from mild to severe (9). The study included 25 RCTs with 1088 participants. BA was delivered in individual, group or self-help formats, with specialist or non-specialist therapist involvement. Number of sessions offered in the included studies ranged from 1 to 16.
The fifth was a meta-analytic study the compared BA to other psychological interventions, including cognitive-behavioural, psychodynamic, humanistic and integrative therapies (10). The study included 25 trials (n=955 participants) that were mainly of parallel-group, individually randomised design.
Another is an RCT that compared the clinical efficacy of BA to CBT in adults with depression (11). The study included 440 participants, aged ≥18 years, who met diagnostic criteria for major depressive disorder in primary care and psychological therapy services in England. The interventions were delivered in a maximum of 20 sessions over 16 weeks, with the option of four additional booster sessions if required. Sessions were delivered face to face, and lasted for 60 minutes. This RCT investigated outcomes at long -term (12 month follow up).
Adult Outcomes Achieved
Compared to psychological therapies or other control conditions (e.g. treatment as usual, waiting list, and psychological placebo), the following outcomes were observed;
- Significantly reduced depression symptoms (compared to inactive controls) at post-treatment (6-..,8), 9). Effects were maintained at follow-up (i.e. at 8-weeks or the closest possible time point) (8)
- Significant improvements in anxiety and activation at post-intervention (7)
- Comparable effects with other psychological interventions on depression outcomes at post-treatment (8,10) and at 12-months follow-up (11)
- Comparable effects with CBT on anxiety outcomes at 12 months (11)
Need
Comparable Population
BA has been delivered to children, adolescents, and adults with subthreshold depression, or those meeting the diagnostic criteria for depressive disorder.
Desired Outcome
BA is associated with significant improvements across several outcomes including depression, anxiety, and quality of life.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
Behavioural Activation (BA) is an approach to improving mental health that involves engagement in behaviours, and the influence of these on emotional state. BA recognises the relationship that exists between depression and inactivity, and the need to apply proactive measures to break out of this cycle and feel better again. BA is guided by the behavioural model of depression.
Priorities
BA aims to change patients’ behaviours for the purpose of reinforcing positive context contingencies, and ending negative behaviours that maintain depression or increase its risks. The proactive measures adopted are expected help patients break the cycle of depression and inactivity, translating to increased positive emotions and improved mood. BA can be delivered to children, adolescents, and adults, in delivery formats that include face-to-face, remote, individual and groups.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
Staff will usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine). Junior mental health workers (with neither professional mental health qualifications nor formal training in psychological therapies) have also effectively delivered BA. Practitioners undergo training to support its delivery. BA is typically delivered weekly over 20-24 sessions, but can also be delivered in 10-12 sessions as a brief behavioural activation treatment.
Technology Support
BA can be delivered without access to technology but access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision.
Administrative Support
BA can be delivered in individual or group formats. It can also be delivered in-person, remotely, or as a self-guided intervention. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.
Financial Support
There is typically limited financial costs when training in BA through NHS. Costs may apply when implementing BA through private organisations. What financial supports does your organisation require?
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
