Behavioral Activation in Nursing Homes to Treat Depression (BAN-Dep): Results From a Clustered, Randomized, Single-Blinded, Controlled Clinical Trial


      • What is the primary question addressed by this study?
        Can we decrease the proportion of older adults living with depression in residential aged care facilities by training staff on how to use behavioral activation?
      • What is the main finding of the study?
        Training residential aged care staff on how to use behavioral activation has fleeting and nonsustainable effects on symptoms of depression and anxiety.
      • What is the meaning of the finding?
        Interventions that require activities to be added to usual routine practices of staff working in residential aged care facilities produce non-sustainable results, particularly in the context of competing demands such as the COVID-19 pandemic.



      To determine if behavioral activation (BA) delivered by trained staff decreases prevalence of clinically significant symptoms of depression among older adults living in residential aged care facilities (RACFs).


      Clustered, randomized, single-blinded, controlled trial of BA for adults aged over 60 years living permanently in a RACF with symptoms of depression (Patient Health Questionnaire, PHQ-9 ≥ 5). BA was delivered over 8–12 weeks using a structured workbook. The proportion of residents with PHQ-9 ≥ 10 at weeks 12, 26, and 52, as well as anxiety symptoms (GAD-7), physical (PCS), and mental (MCS) quality of life, loneliness, and loss to follow-up were main outcomes of interest


      We recruited 54 RACFs (26 intervention) and 188 of their residents (89 intervention). Participants were aged 61–100 years and 132 (70.2%) were women. PHQ-9 ≥ 10 interacted with BA at week 12 (OR = 0.34, 95%CI = 0.11–1.07), but differences between the groups were not statistically significant at any time-point. GAD-7 ≥ 10 interacted with BA at week 26 (OR = 0.12, 95%CI = 0.02–0.58), but not at any other time-point. Overall, the intervention had no effect on the scores of the PHQ-9, GAD-7, PCS, MCS, and loneliness scale. Loss to follow-up was similar between groups. Adherence to all stages of the intervention was poor (36.2%).


      Disruption by the COVID-19 pandemic and staffing issues in RACFs undermined recruitment and adherence. In such a context, a BA program delivered by RACF staff was not associated with better mental health outcomes for residents over 52 weeks.

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        • Kotynia-English R
        • McGowan H
        • Almeida OP
        A randomized trial of early psychiatric intervention in residential care: impact on health outcomes.
        Int Psychogeriatr. 2005; 17: 475-485
        • Seitz D
        • Purandare N
        • Conn D
        Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review.
        Int Psychogeriatr. 2010; 22: 1025-1039
        • McCabe MP
        • Karantzas GC
        • Mrkic D
        • et al.
        A randomized control trial to evaluate the beyondblue depression training program: does it lead to better recognition of depression?.
        Int J Geriatr Psychiatry. 2013; 28: 221-226
        • Hanlon JT
        • Handler SM
        • Castle NG
        Antidepressant prescribing in US nursing homes between 1996 and 2006 and its relationship to staffing patterns and use of other psychotropic medications.
        J Am Med Dir Assoc. 2010; 11: 320-324
        • Midlov P
        • Andersson M
        • Ostgren CJ
        • et al.
        Depression and use of antidepressants in Swedish nursing homes: a 12-month follow-up study.
        Int Psychogeriatr. 2014; 26: 669-675
        • Boyce RD
        • Hanlon JT
        • Karp JF
        • et al.
        A review of the effectiveness of antidepressant medications for depressed nursing home residents.
        J Am Med Dir Assoc. 2012; 13: 326-331
        • Banerjee S
        • Hellier J
        • Dewey M
        • et al.
        Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial.
        Lancet. 2011; 378: 403-411
        • Cuijpers P
        • van Straten A
        • Warmerdam L
        Behavioral activation treatments of depression: a meta-analysis.
        Clin Psychol Rev. 2007; 27: 318-326
        • Leontjevas R
        • Gerritsen DL
        • Smalbrugge M
        • et al.
        A structural multidisciplinary approach to depression management in nursing-home residents: a multicentre, stepped-wedge cluster-randomised trial.
        Lancet. 2013; 381: 2255-2264
        • Markle-Reid M
        • McAiney C
        • Forbes D
        • et al.
        An interprofessional nurse-led mental health promotion intervention for older home care clients with depressive symptoms.
        BMC Geriatr. 2014; 14: 62
        • Meeks S
        • Van Haitsma K
        • Schoenbachler B
        • et al.
        BE-ACTIV for depression in nursing homes: primary outcomes of a randomized clinical trial.
        J Gerontol B Psychol Sci Soc Sci. 2015; 70: 13-23
        • Gilbody S
        • Brabyn S
        • Mitchell A
        • et al.
        Can we prevent depression in at-risk older adults using self-help? The UK SHARD Trial of Behavioral Activation.
        Am J Geriatr Psychiatry. 2022; 30: 197-207
        • Gilbody S
        • Lewis H
        • Adamson J
        • et al.
        Effect of collaborative care vs usual care on depressive symptoms in older adults with subthreshold depression: The CASPER Randomized Clinical Trial.
        JAMA. 2017; 317: 728-737
        • Chew-Graham CA
        • Kitchen CEW
        • Gascoyne S
        • et al.
        The feasibility and acceptability of a brief psychological intervention for adults with long-term health conditions and subthreshold depression delivered via community pharmacies: a mixed methods evaluation-the Community Pharmacies Mood Intervention Study (CHEMIST).
        Pilot Feasibility Stud. 2022; 8: 27
        • Velasquez Reyes D
        • Patel H
        • Lautenschlager N
        • et al.
        Behavioural activation in nursing homes to treat depression (BAN-Dep): study protocol for a pragmatic randomised controlled trial.
        BMJ OPEN. 2019; 9e032421
        • Whooley MA
        • Avins AL
        • Miranda J
        • et al.
        Case-finding instruments for depression - two questions are as good as many.
        J Gen Intern Med. 1997; 12: 439-445
        • Kroenke K
        • Spitzer RL
        • Williams JB
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Mellor D
        • Kiehne M
        • McCabe MP
        • et al.
        An evaluation of the beyondblue Depression Training Program for aged care workers.
        Int Psychogeriatr. 2010; 22: 927-937
        • Lowe B
        • Kroenke K
        • Herzog W
        • et al.
        Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9.
        J Affect Disord. 2004; 81: 61-66
        • Spitzer RL
        • Kroenke K
        • Williams JB
        • et al.
        A brief measure for assessing generalized anxiety disorder: the GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097
        • Sanderson K
        • Andrews G
        The SF-12 in the Australian population: cross-validation of item selection.
        Aust N Z J Public Health. 2002; 26: 343-345
        • Gierveld JD
        • Van Tilburg T
        A 6-item scale for overall, emotional, and social loneliness - Confirmatory tests on survey data.
        Res Aging. 2006; 28: 582-598
        • Nasreddine ZS
        • Phillips NA
        • Bedirian V
        • et al.
        The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment.
        J Am Geriatr Soc. 2005; 53: 695-699
        • Almeida OP
        • Hankey GJ
        • Golledge J
        • et al.
        Depression and the risk of fractures in later life: the Health In Men Cohort Study.
        MATURITAS. 2021; 145: 6-11
        • Mahoney FI
        • Barthel DW
        Functional evaluation: The Barthel Index: a simple index of independence useful in scoring improvement in the rehabilitation of the chronically ill.
        Maryland State Med J. 1965; 14: 61-65
        • McGilton KS
        • Escrig-Pinol A
        • Gordon A
        • et al.
        Uncovering the devaluation of nursing home staff during COVID-19: are we fuelling the next health care crisis?.
        J Am Med Dir Assoc. 2020; 21: 962-965
        • Xu H
        • Intrator O
        • Bowblis JR
        Shortages of staff in nursing homes during the COVID-19 pandemic: what are the driving factors?.
        J Am Med Dir Assoc. 2020; 21: 1371-1377
        • Ekers D
        • Webster L
        • Van Straten A
        • et al.
        Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis.
        Plos One. 2014; 9e100100
        • Ekers D
        • Godfrey C
        • Gilbody S
        • et al.
        Cost utility of behavioural activation delivered by the non-specialist.
        Br J Psychiatry. 2011; 199: 510-511
        • Gilbody S
        • Littlewood E
        • McMillan D
        • et al.
        Behavioural activation to prevent depression and loneliness among socially isolated older people with long-term conditions: The BASIL COVID-19 pilot randomised controlled trial.
        PLoS Med. 2021; 18e1003779
        • Castle NG
        • Engberg J
        • Men A
        Nursing home staff turnover: impact on nursing home compare quality measures.
        Gerontologist. 2007; 47: 650-661

      Linked Article

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          Somewhere between 15% and 65% of elders living in nursing homes and residential care facilities have significant depression and anxiety1 and these symptoms have only intensified during the COVID-19 pandemic.2 Depression and anxiety are major contributors to decreased quality of life for older adults and are associated with poor health outcomes, social isolation, functional decline including premature death and increasing the burden on nursing home staff and caregivers.3,4 Mood disorders in late life are also often unrecognized clinically and more likely to have a complicated clinical course and incomplete recovery and.
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          Hundreds of randomized trials have shown that psychological interventions are effective in the treatment of depression.1 That is also true in older adults. Although the effects of psychological treatments are significantly less effective in children and adolescents, there are no significant differences in effects between age groups when patients have reached adulthood.2 Psychotherapy is as effective in older adults as it is in younger adults, and there is now enough evidence that it also works equally well in older old adults (75 and older).
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