Transcript

Dr. Frank Domino:
SL, is a 38-year old female who presents with difficulty falling asleep and staying asleep all night. She also reports she has no energy, and on chatting with her, you find out she's lost interest in doing the things she liked to do and being with her friends. She seems to feel guilty about everything, in particular, of caring for her family. You get the sense she is depressed and want her to consider going on medication and going for counseling. Knowing the long delay to get her into a therapist in your area, what can you say to do that might help this patient start the healing process? Joining me today is Susan Feeney, assistant professor and coordinator of the Family Nurse Practitioner Program at the University of Massachusetts Medical School. Welcome to the show, Susan.

Susan Feeney:
Thanks, Frank. So Frank, this is a very common problem and it is quite a burden for our patients. What kinds of things are available to help SL besides medication that we can do in our offices?

Dr. Domino:

Well, I agree with you completely, Susan. Time and time again, I make the diagnosis of depression, I want to initiate treatment, and I believe strongly that patients get better when they have an opportunity to work through whatever it is that's making them depressed, if there is some external factor and use medication when appropriate. I don't just like to use medicine, but 

we have so little time, and access to behaviorist is challenging. The paper I wanted to discuss today is about behavioral activation. Behavioral activation recognizes that when patients get depressed, two things occur. The first is that, they withdraw a bit from their family and their friends, they become isolated. And that isolation actually, reinforces and worsens the depression. The other thing that happens is that they become less and less interested and motivated to do things that they might enjoy. Behavioral activation helps patients, in a very systematic manner, address those two things. It requires investigating with the patient, one or two small things they could do, that they aren't doing now that they used to enjoy, and likewise, it encourage them to identify and start adding to their daily routines one or two things that they've done to isolate themselves from their peers.

Susan Feeney:
Well, that's really interesting and it sounds like a really great tool for us and for our patients, but what's the literature say about behavioral activation and then how could we use it in primary care effectively?

Dr. Domino:
So the concept of behavioral activation has been around for quite a while and therapists have used it themselves. The paper that I'm discussing today was a randomized controlled trial comparing having behaviorist used cognitive behavioral therapy, something that requires years to study to implement versus mental health workers who had a short training in behavioral activation, folks without advanced degrees, and do the fundamentals of behavioral activation, query about isolation and try to change it, query about loss of interest in doing things and try to change that. And have found that they were both equally effective. Not only were they equally effective, using the non-graduate degree cognitive behavioral approach, which is wonderful, is quite expensive. And doing this with community workers who have a limited training is far more cost effective.

Susan Feeney:
That is so exciting, because I know getting patients, regardless of their ability to pay and their reimbursement plan, getting them in to see a cognitive behavioral therapist or a licensed psychiatrist or a psychologist can take months and people become dysfunctional, so this is very exciting.

Dr. Domino:
So, I think what it means to me is two things. One is, we as practitioners can start the process of doing this in the office. We can ask our patients, "So, what are things you used to do that you're not doing now that you enjoyed?" Cooking for your family, reading a book, taking a walk every day. Try to find out things that they've stopped doing and ask them how they might incorporate in their day, and in fact, even diary it or chart it to follow it. Likewise, we... It only takes a minute or two to ask a patient. "So, what can you do to get out and be with your friends more?" or, "What are you doing that's making you not engage with the community?" That could be something as simple as going to the grocery store or taking a shower everyday or whatever. And just ask them to again, chart those changes in behavior on a daily basis, help them set a goal. And this study had them see patients once a week with the behavioral activation person for an hour for two months. Now, we can't do that with our patients but we can start this process and maybe follow, with our first follow-up, have them bring in what they've been charting and doing, and remind them that when they see their social worker or their therapist, that they continue this discussion with them. I think it works as a good starting point. What's really quite interesting is that there's a variety of electronic tools that can help with this.

So, there are a number that we'll post on the website, that help patients identify those areas where they might be isolating themselves and help them set goals to address it. And likewise, helps them list the things that they enjoy doing or that they enjoy doing but they're not doing and incrementally getting more exposure to them. So, this is a process we start and then we can refer them to the proper provider as well as to some digital tools.

Susan Feeney:
Well, it's very exciting to think that we can have a fairly simple low tech way to interact with our patients to improve outcomes with or without medications. And to also engage people in our practice who don't have the advanced degrees but could have the ability to do this and we could all help our patients. So how would you explain this to SL, if you were... When you go back to talk to her?

Dr. Domino:
Well, I might begin the explanation by querying those aspects of her life. What she's not doing and what she used to do that she enjoyed. And then explain... Help her to understand that part of the healing process requires her to change her behavior a little bit. And I think whenever we talk with patients who have severe anxiety or severe depression, they always are looking for the external world to change. So we have to bring that locus of control back and say, "The healing process starts from within, you have to make some changes in what you're doing." And help her to pick one or two things, chart them, I even put them in my note and when she does follow up, if especially if I've started medication. When I follow her up within that two week span, I come right back to it and I bring it to her that way. And so it becomes very real, very concrete, sometimes I'll even write it out on paper and say, every day I want you to check off that you've done X or done Y. And that's how I encourage her to do so.

I think one of the important aspects of behavioral activation is it both consciously and subconsciously empowers the patient to make themselves better. It's not a pill, it's not going to see the therapist. And likewise, I love the therapists I refer to, they do wonderful work with patients. I wish I had 20 more of them. And make the patient understand this is not a replacement for that, but this is something that's going to be part of what they're going to be doing going forward.

Susan Feeney:
Right. And I think that's really important, the empowerment, is because depression causes hopelessness and powerlessness to give that control back to the patient and help them see that they can have some power over this. It's so powerful. Well, thank you Frank.

Dr. Domino:
Great Susan, thanks so much for discussing this with me.

Susan Feeney:
My pleasure.

Dr. Domino:
Practice pointer, helping patients recognize that part of the cure of their depression is changing their behavior, is a concept associated with behavioral activation. Something we can easily use in our clinical day to day practice. Join us next time when we talk about the new direct acting oral anticoagulants and their role in the management of atrial fibrillation.