Health

Just Do It

A simple strategy is proving as effective as more complex therapies in helping people with depression. David Hughes look at Behavioural Activation

Those of us past our athletic prime might have less use than hitherto for Nike products, but the company's slogan could have been tailor-made for the latest trend in managing depression.

Behavioural Activation, rapidly gaining attention in psychological circle, involves scheduling pleasurable and responsible activities into our daily lives, and sticking to the schedule whether we feel like it or not. "Just do it" is the buzz phrase.

Although originally short on evidence, BA has preformed favourably in recent studies with more established therapies like Cognitive Behavioural Therapy (CBT). And crucially in our cash strapped health services, results are not only comparable, say researchers- they're also cheaper to deliver.

This is important both financially and psychologically. Three million people in Britain are thought to be suffering with depression, and 60 million antidepressant medicines were dispensed in 2015. CBT has been show to be as effective as antidepressants, yet there are long waiting lists to see qualifies CBT practitioners on the NHS. Proponents point out that it is easier to train a BA therapist, and the program is cheaper to deliver.

How it works

CBT analyses how we think. and develop skills to void being overwhelmed by thoughts or feelings of hopelessness. It;s been described as an 'inside out' therapy. Behavioural Activation, on the other hand, uses an 'outside in' approach to depression. It identifies which activities we associate with feeling good, and then encourages us to engage in them in a structured way.

The evidence now suggests both approaches seem to work equally well. Avoiding negative and depressing thought patterns will lead to engaging in more enjoyable and purposeful activity; and deliberately identifying and engaging in such activity will lead to a decline in depressing thoughts and feeling. 

Isolation

Depression can very often cause people to become passive and lethargic, and withdraw from social activities. Telephone calls go unanswered, previously attended pubs , social events and clubs go uninvited, and a spiral of unhappiness can develop where nothing that we do makes us feel any better; so we avoid doing anything at all. 

Behavioural Activation encourages us to make a list of activities that we enjoy, used to enjoy, however simple or mundane- going for a short walk, visiting the library, talking to a friend- and schedule those activities in our diary. And, says Peter McEvoy, associate professor of clinical psychology at Australia's Curtin University, if the activity is in the diary, we should do it, no matter how we are feeling.

"The essence of BA is that if we behave as if we are depressed, then we will continue to be depressed. Behaviour needs to change before emotions and motivation will improve, not the other way around" 

Indeed, he points out feelings can be one of the first casualties of depression, and as it progresses, we may have little or no feelings about anything, and so little to no motivation to do anything.

"Just a few of us would turn up for work with out a financial reward, it can be difficult to turn up for life without an emotional reward," he says

So people with depression will characteristically tell themselves they will do something "when they get around to it", or when they feel like it. Yet the condition means that such a time is unlikely to arrive. 

BA recognises that, and overcomes the problem by training us to follow a schedule regardless of the presence or absence of motivation.

And if plans for a particular day seem a bit challenging, do something less ambitiouss, suggests Prof McEvoy but still do something. "Starting slow is better than not starting at all."

People starting out BA are shown how to make a note of their moods, and to notice which activities are associated with a low mood, and which with a more upbeat one. At first, there are likely to be more periods of low moods, but as time goes  on, and our schedule is filled with positive activities, the balance will change.

Prof McEvoy recommends balancing purely pleasure-inducing activities, such as having coffee with a friend, or dancing , with a healthy dose of achievement-related ones, like cleaning the house or going to work.

Accomplishing something challenging or difficult is a source of happiness and confidence in itself, whereas avoiding such things will be a source of further anxiety and guilt. With an increase in achievements, and a renewal of social interaction, BA can help people take back control of their lives with a renewed sense of purpose. 

BA is  now recommended bu NICE (the National Institute for Clinical Excellence) and is widely offered by NHS trusts. Courses involve sessions with a therapist and then 'homework' with further sessions to review progress. South London and Maudsley NHS Trust, for example offers BA courses based on 9 short booklets, supported by six weekly face-to-face or telephone sessions, plus a review and ideas to try out between sessions.

And with the evidence mounting as to its effectiveness for both mild and severe forms of depressions, it is likely to be a treatment we are going to be hearing a lot more of.

Obtaining BA

Your local GP surgery will know which Improving Access to Psychological Treatment (IATP) services, including Behavioural Activation, may be available throughout the NHS in your area.

"The main route for psychological therapies, would be to go and discuss the matter with your GP", says Dr Stephen Pilling, consultant clinical psychologist at University College, London.

"Some people may not feel comfortable doing that. Some people may feel they haven't a good enough relationship with their doctor to do that. In that case, people can refer themselves directly."

And if thinking of approaching your GP, he adds, the first thing to remember is that you're not alone.

"Psychological problems are very common," he reminds us. "They are thought to affect about one in six of the population. And GPs are very used to dealing with these problems, and the treatments that people can get are going to work."

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