The Feasibility and Acceptability of a Behavioural Activation Intervention for Young People with Depression in Child and Adolescent Mental Health Services

Abstract

Depression in young people is common, resulting in morbidity and mortality. Behavioural Activation (BA) is a cost-effective and efficacious treatment for reducing depressive symptoms in adults. There is little published research relating to BA as a treatment option for young people with depression. Thus, the aim was to explore the feasibility of conducting a trial of BA for depression in Child and Adolescent Mental Health Services (CAMHS).

Stage I

The initial stage of the study comprised a focused ethnography, conducted over a six-month period. The purpose was to explore the CAMHS study site, with a view to pre-empting (and addressing) any difficulties that may be encountered during a planned trial. Participant observation (158 hours), staff interviews (n= 6) and document collection (n= 17) were used to gather data. Data were coded using thematic analysis and the resulting themes were verified by a second coder. Insights into the individual, practical and organisational boundaries of the service guided implementation of Stage II.

Stage II
The second stage involved a randomised controlled feasibility trial with an embedded qualitative component. Participants were identified via a case note review or self/clinician referral from three CAMHS over seventeen months. Young people (aged 12 to 17 years) displaying symptoms of depression were offered a structured diagnostic interview to confirm depression status. Additional measures of mood, functioning and self-esteem were recorded. Twenty-two patients were randomised to BA or usual CAMHS care.

Existing CAMHS staff were trained to deliver the 8-week manualised BA intervention. Following treatment, participants in the BA arm, their parents and clinicians were offered semi-structured interviews to explore their experiences of receiving or administering BA. Verbatim interview transcripts were coded using thematic analysis. At three months post-baseline, the diagnostic interview and outcome measures were repeated. At six months post-baseline, a telephone interview repeated selected outcomes.

Participant recruitment was successful but the trial suggests that the process used could be streamlined. Participants were 82% female, with a mean age of 15.7 (SD, 1.2) years. Qualitative feedback from patients and their caregivers supported the acceptability of BA treatment. Families also identified barriers to participating in the intervention. Most staff found the intervention acceptable, but some raised concerns about the manualised treatment delivery. Retention at three months was 68%, with higher loss to follow-up in the BA (4/11; 36%) vs. usual care (3/11; 27%). Although not powered to demonstrate statistical differences, preliminary quantitative data suggest BA treatment may result in improved outcomes compared to usual care, such as remission from depression. Fewer BA participants met depression criteria at three-month follow-up (3/7; 42.9%) than in usual care (7/8; 87.5%). However, the assessor was not blinded to treatment allocation, fidelity was not assessed and the number of sessions was not controlled for, which increases uncertainty relating to the results.

This research contributes valuable information about how a BA trial could be implemented in an adolescent mental health setting, and provides indications about the potential of the approach to treat depression in this context. However, outstanding questions relating to the feasibility of the intervention remain.