Community-based Behavioural Activation Training (ComBAT) for depression in adolescents

<ns5:p> <ns5:bold>Research Background      </ns5:bold> </ns5:p> <ns5:p>Young people with depression often feel low or irritable, and they may stop doing things they enjoy or find rewarding. Behavioural activation (BA) is a type of talking therapy. It aims to lift a young person’s mood by helping them take part in activities they enjoy and that matter to them. At the same time, BA aims to cut down on avoiding things, putting things off, going over the same negative thoughts and pulling away from other people, which are all common in depression.</ns5:p> <ns5:p/> <ns5:p> <ns5:bold>Research Aims</ns5:bold> </ns5:p> <ns5:p>ComBAT stands for Community based Behavioural Activation Training. It was a five year research programme that built and tested BA for young people aged 12-18 years with less severe depression. We tested whether BA helped depression more than usual care, and whether it gave better value for money. We also looked at what made BA easier or harder to deliver in health services and in the community, including schools, colleges and voluntary organisations. In these places, staff who are not mental health specialists often support young people with depression.</ns5:p> <ns5:p/> <ns5:p> <ns5:bold>What we did</ns5:bold> </ns5:p> <ns5:p>We ran a study with 260 young people across 22 sites: 12 schools and colleges, five NHS services and five voluntary organisations. We put each young person into one of two groups at random: one was offered BA, the other usual care. We trained community and NHS staff to deliver BA using a manual we wrote for this study, with five modules covered in 5-8 sessions. We measured symptoms of depression at the start of the study and again after 6 and 12 months. We also interviewed 48 young people (21 BA, 27 usual care) and 18 staff across different sites (7 BA, 5 usual care, 6 both).</ns5:p> <ns5:p/> <ns5:p> <ns5:bold>What we found</ns5:bold> </ns5:p> <ns5:p>BA was no better than usual care at reducing depression within a year. Usual care was an active, varied mix of support, such as counselling and help to challenge negative thoughts. Young people in both groups improved by a similar amount. The results were similar across different groups of young people. This included boys and girls, younger and older teenagers, and those with mild or moderate depression. </ns5:p> <ns5:p/> <ns5:p>Young people valued different things in each approach. With BA, they liked its clear structure, using the workbook as a guide, breaking the cycle of low mood and feeling a sense of achievement as they did more activities. In usual care, they valued the chance to get things off their chest and getting help with anxiety and overthinking.</ns5:p> <ns5:p/> <ns5:p>Young people in both groups went to a similar number of sessions: 6.5 on average for BA and 5.6 for usual care. We checked whether usual care used BA methods. This only happened in 4% of usual care sessions. Even so, young people in both groups took part in more enjoyable and useful activities by the same amount. BA and usual care had some common ingredients: both helped young people understand their problems, think about different solutions and build a relationship with the person who supported them. </ns5:p> <ns5:p/> <ns5:p>ComBAT was the first study to weigh the impact of BA on health and care costs against the extra health benefits it might bring for under 18s with depression. BA did not offer good value for money, because it cost more than usual care but worked no better. Running the BA sessions cost £460 per young person, whereas usual care cost £440. Setting up BA added another £760 per young person for training, supervision and manuals. This set-up cost was high because only 21 (16%) of the 132 staff we trained went on to deliver BA. Usual care did not have any set-up costs. In total, BA cost about £1,230 per young person, against £440 for usual care. Once we added up all the health, care and training costs, BA cost £580 more per young person than usual care. </ns5:p> <ns5:p/> <ns5:p>We can trust the results of ComBAT for several reasons. First, we recruited more young people than we planned: 260 against a target of 236. Our participants were a good match for the wider group of young people we wanted to reach. Second, the random split into BA or usual care worked as planned: the two groups were very similar in age, sex, ethnicity and how severe their depression was at the start. Third, young people stayed with the study to the end: we collected follow-up information from nearly 84% of them, and they went to around 88% of all planned therapy sessions, based on 1,583 session records. Fourth, staff delivered BA as planned, which we checked against audio recordings and written notes of sessions. Finally, we ran extra tests and reached the same answer. These tests allowed for missing information, adjusted for differences in follow-up times and included only those young people who completed their BA sessions as planned.</ns5:p> <ns5:p/> <ns5:p> <ns5:bold>What our findings mean</ns5:bold> </ns5:p> <ns5:p>Many young people with less severe depression can get substantial support from the services already on offer in the NHS, schools, colleges and voluntary organisations. Building on this support makes the best use of the skills and resources already in the community. We should offer training in a new therapy to those staff and services most likely to use it. </ns5:p> <ns5:p/> <ns5:p> <ns5:bold>How we involved young people, parents and professionals in the research      </ns5:bold> </ns5:p> <ns5:p>A young person with lived experience of depression was a full member of the research team from the start of the project through to sharing the findings. We also set up three advisory groups, each with 6 to 8 members: one with young people, one with parents/carers and one with professionals. These groups helped us develop the intervention, training materials and study documents, including a questionnaire that gathered information from young people about the health and care services and support they used outside the study. The advisory groups also suggested ways to improve recruitment and helped us understand and interpret the experiences shared by young people and professionals in interviews.</ns5:p>