Behavioral Activation for the Treatment of Depression in Older Adults

In Sweden, depression among the elderly is a major public health concern. Major depression occurred in 5-15 % of the older population in Sweden, and one third of the women and a fifth of the men 65 years and older reported subclinical depressive symptoms. Several mental health experts raise concerns that there will be an increase of psychiatric illness during and after COVID-19, particularly among the elderly.

Depression in older individuals can be treated with antidepressant medication, psychological interventions and physical activity. However, the majority of the older individuals state that they would prefer psychological treatments to medication, which poses a challenge during COVID-19 as such treatments are often delivered face-to-face. Psychological treatments delivered via the Internet are as efficacious as face-to-face, but only 3-4% of the individuals 65 years and above in Sweden use digital applications that replace physical healthcare visits.

The purpose of this randomised controlled multicenter study is to evaluate the effects and outcomes of a telephone-delivered Behavioral Activation-treatment for older adults with depression in primary care within the framework of the research project DepActive. Our study specifically aims to: 1. investigate the effect of a telephone-delivered BA-treatment for older adults with depression in primary care with regards to a. depressive symptoms (primary outcome measure) b. depression diagnosis c. anxiety symptoms d. quality of life e. activity level f. functional ability g. cognitive function h. loneliness i. self-efficacy j. cost effectiveness k. care consumption including pharmacological treatment 2. explore patients' and therapists' experiences of the treatment 3. investigate to which extent the BA-treatment corresponds to person-centered care 4. investigate the mediating role of type of activity and level of physical activity with regards to improvement in depressive symptoms 5. investigate whether the intervention impacts the need for community healthcare services for participants utilizing such services.

The study is a multi-center randomised controlled clinical trial in primary care in the Swedish county councils of Vastmanland, Uppsala and Sormland.

Participants will be recruited from multiple primary care centers in each region. If the participant is enrolled in the study, the study therapist performs the randomisation by using an online randomisation software with a 1:1, random-blocks sequence. The participants are randomised consecutively to two arms: control group or intervention group. The control group will receive treatment as usual (TAU) in primary care, and the intervention group will receive TAU with the addition of a five-session telephone-based BA-intervention over an eight-week period.

Inclusion criteria

• Participants should fulfill criteria for current major depressive episode or sub-threshold depressive episode.
• Eligible participants should be 65 years or older, should be fluent in spoken and written Swedish to understand the treatment materials, have access to telephone, and be interested in participating in the trial.

Exclusion criteria

• Severe depression, elevated suicide risk, current substance use disorder, current or previous manic or hypomanic episodes, current psychotic disorder, and current diagnosis of minor or major neurocognitive disorder or suspected neurocognitive disorder with < 24 points on the Mini Mental State Examination number 3, MMSE-NR3.
• ongoing psychotherapy