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Behavior Therapy 42 (2011) 100 – 108

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The Effects of Behavioral Activation Therapy With Inpatient

Geriatric Psychiatry Patients
Melissa Snarski
Forrest Scogin
Elizabeth DiNapoli
Andrew Presnell
Jessie McAlpine
Jacquelyn Marcinak
University of Alabama

2006. In 2006, there were 37.3 million older adults,

This study examined the effects of Behavioral Activation
(BA) treatment on depressive symptoms and quality of life
among older adult patients in a geriatric psychiatry facility.
There were 50 participants with mild to moderate cognitive
impairment, each being 65 years of age or older. A 2
(between) × 3 (time of measurement) design was used in this
study comparing control (treatment-as-usual) and experi-
mental (BA) conditions at pre-, mid-, and posttreatment. BA
consisted of eight 30- to 60-minute sessions across 4 weeks.
Intent-to-treat analyses indicated a significant Group × Time
interaction on depressive symptoms, with this effect
remaining when only completer data were included. Further
analyses indicated that this effect was due to significant
change early in treatment in both the full and completer
samples. There was no evidence of a significant effect on the
quality-of-life measure. Cognitive status was not related to
change in depressive symptoms, suggesting that BA may be
useful across a range of older adults.
an increase of 3.2 million or 9.4% since 1995. In
the next 30 years, the number of individuals over 85
years of age will more than double, from 4.2 million
in 2000 to 8.7 million in 2030 (Administration on
Aging, 2008). Therefore, research on the important
issues that will affect older adults is critical.
Finding effective treatments for older adults is an
ever-evolving process. In particular, there is a lack
of research examining effective psychological treat-
ments for older adults in inpatient settings. This
includes patients with both acute and chronic
mental disorders. An additional challenge is iden-
tifying appropriate psychotherapies for older adults
with cognitive limitations. The current study was
conducted to address this gap in the literature and
examine the feasibility and effectiveness of applying
a brief behaviorally oriented therapy with an
inpatient geriatric psychiatry population.

Mental Disorders in Older Adults

OLDER ADULTS ARE THE fastest-growing U.S. age
group. Since 1900, the percentage of older Amer-
icans has tripled, from 4.1% in 1900 to 12.4% in
Address correspondence to Forrest Scogin, Ph.D., Dept. of
Psychology, University of Alabama, Box 870348, Tuscaloosa, AL;
e-mail: fscogin@as.ua.edu.
0005-7894/10/100–108/$1.00/0
© 2010 Association for Behavioral and Cognitive Therapies. Published by
Elsevier Ltd. All rights reserved.
It is estimated that almost 20% of older adults
experience mental disorders (Surgeon General's
Report of Mental Health, 1999). More specifically,
11.4% of adults age 55 and over meet the criteria
for an anxiety disorder, 2.7% for major depression,
and .1% for bipolar disorder (Narrow, Rae,
Robins, & Regier, 2002). Additionally, older
white male adults have up to a 6-fold higher suicide
rate than their younger counterparts (Hoyert,
Kochanke, & Murphy, 1999).
 effects of behavioral activation
Depression and anxiety are not the only disorders
that influence these statistics. Many older adults
suffer from severe mental illness (SMI) such as
chronic bipolar affective disorder, schizophrenia,
and other mental illnesses that are not as exten-
sively discussed in the literature. The 1993 appro-
priations bill for the Department of Health and
Human Services defined SMI as including “dis-
orders with psychotic symptoms such as schizo-
phrenia, schizoaffective disorder, manic depressive
disorder, autism, as well as severe forms of other
disorders such as major depression, panic disorder,
and obsessive-compulsive disorder” (as cited in
Narrow et al., 2000). Although the prevalence rates
of SMI are lower than in young adults, it is still a
significant problem in the geriatric population.
Among individuals 55 and older, .8% meet criteria
for SMI (Kessler et al., 1996), and these numbers
are predicted to more than double by the year 2030
(Jeste, Alexopoulos, & Bartels, 1999). These
numbers suggest the need for treatments that are
effective across a broad range of symptoms yet are
practicable for consumers to apply and therapists to
provide. Behavioral activation is an emerging
intervention that may prove beneficial to older
adults with SMI.
Behavioral Activation (BA)
Since the 1970s, radical behavior theorists have
proposed that depression was a result of not having
sufficient positively reinforced experiences in the
environment (Ferster, 1973; Lewinsohn, 1974;
MacPhillamy & Lewinsohn, 1972). Consequently,
previous behavioral therapy for depression was
aimed at increasing positive events and reinforcers,
as well as decreasing negative events and conse-
quences (Lewinsohn & Graf, 1973). BA expands
on Lewinsohn's work and is a more idiographic
and functional approach. BA is constructed around
the goal of keeping patients active and engaged in
life's activities, rather than leading inactive, with-
drawn, and avoidant lifestyles. BA encourages the
patient to explore how meaningful, reinforcing
activities influence their mood (Martell, Addis, &
Jacobson, 2001).
The utility of BA was first evaluated in a
component analysis. Some clients received BA
alone, some received BA in addition to techniques
intended to address automatic thoughts, while
others received full cognitive behavioral therapy
(CBT; Jacobson et al., 1996). Results suggested that
full CBT did not add benefits over receiving BA
alone. More recently, a randomized treatment trial
found BA to be comparable to antidepressant
medication and more effective than cognitive
101
therapy, among more severely depressed adult
patients (Dimidjian et al., 2006).
BA treatment as developed by Jacobson and his
colleagues (Jacobson et al., 1996; Martell et al.,
2001) has been modified by Hopko and colleagues
into a shorter, simpler approach (Lejuez, Hopko, &
Hopko, 2001) based on behavioral matching
theory (Lejuez, Hopko, LePage, Hopko, & McNeil,
2001). Hopko's adaptation predicts that increased
reinforcement for healthy, nondepressed behaviors
will decrease depressed behavior and increase
healthy, nondepressed behavior (Hopko, Lejuez,
Ruggiero, & Eifert, 2003). Hopko's brief BA
treatment for depression (BATD) modifies the
original BA protocol by adhering more closely to
behavioral techniques. It does not incorporate
mindfulness or other cognitive-based techniques
that may be used in BA (Hopko, Lejuez, Ruggiero,
et al., 2003). BATD patients are asked to rate their
life goals and values on a chart, after which patients
create an activity hierarchy with 15 activities that
are rated from “easiest” to “most difficult”
(Hopko, Bell, Armento, Hunt, & Lejuez, 2005).
The patient progresses through therapy from the
easy to the more challenging tasks. The final goal is
to see a change in the frequency and duration of the
activities. The activity hierarchy and final goal
setting are collaborative processes between the
patient and the therapist.
Brief BA has been used to successfully treat
anxiety and depressive symptoms (Hopko, Lejuez,
& Hopko, 2004) and in combination with phar-
macotherapy (Hopko, Lejuez, McNeil, & Hopko,
1999). Daughters et al. (2008) investigated the
effectiveness of BATD for depression in standard
inpatient substance abuse treatment. In this study,
patients who received BATD evidenced significantly
greater improvements in symptoms and severity of
depression than patients who received treatment-as-
usual (Daughters et al.).
An inpatient study conducted by Hopko and
colleagues is of particular relevance to the current
investigation. Patients (mean age = 30.5y) were ran-
domly assigned to brief BA (n = 10) or supportive
psychotherapy (SP; n = 15; Hopko, Lejuez, LePage,
Hopko, & McNeil, 2003) for a period of 2 weeks.
Patients in the experimental group received Hopko's
BA, while patients in the control group received
nonguided supportive conversation. This investiga-
tion revealed a large and significant effect between
treatment groups (d = .73; Hopko, Lejuez, LePage,
et al., 2003). Several areas suggested for future
research included measures of quality of life and
treatment satisfaction, as well as measures of
clinician treatment adherence, competency, and
patient compliance. In addition, it was suggested
102 snarski et al.
that this treatment may be useful in certain
populations, such as older adults, due to its
simplicity and brevity. The current project incorpo-
rates many of these suggestions.
Therapy With Dementia Patients
There have also been behavior therapies used to
treat older adults with dementia. Teri and collea-
gues taught caregivers of depressed and demented
family members to use behavioral techniques (Teri,
Logsdon, Uomoto, & McCurry, 1997). Such
techniques included increasing the patient's pleas-
ant events and helping with problem solving.
Significant decreases in depression were found in
both patients and the caregivers. Although this
intervention did not take place with the demented
individual directly, it suggests that behavioral
treatments could be useful when treating a de-
pressed and demented population.
Brief BA may have additional advantages in
demented populations because it is a short-term
therapy and may be easier to understand due to its
adherence to basic behavioral techniques. Treat-
ment may begin with 60-minute sessions and
gradually shorten to 15- to 30-minute sessions as
the client progresses. In addition, brief BA is made
simpler by using, but not focusing on, functional
analysis. Functional analysis is the process of
establishing the relations of stimuli and responses,
and in the current circumstance the relations
between activities and mood. Some research find-
ings suggest that an accurate functional analysis is
an arduous task for even the most skilled clinicians
(Hayes, Wilson, Gifford, Follette, & Strosahl,
1996). The therapist conducts a functional analysis,
but the client is not required to conduct one on his or
her own. These simplifications may make Hopko's
BA particularly useful in populations of older
adults, inpatients, or those with limited cognitive
ability.
Effective therapies for older adults with cognitive
impairment are largely absent in the literature.
Some studies report up to 20% of demented older
adults are also depressed (Ballard, Bannister, &
Oyebode, 1996). An earlier study suggested that
this number is even larger for demented individuals
who experience depressive symptoms but do not
meet diagnostic criteria for major depression (Teri
& Reifler, 1987). Although there is high comorbid-
ity between dementia and depression, there has
been limited treatment research in this area. The
relation between the two is complex and may make
treatment difficult. Behavioral and cognitive behav-
ioral therapy with demented individuals is a newly
studied area and has typically focused on treating
depression (Kasl-Godley & Gatz, 2000). Although
some may argue that memory impairments impede
therapy, there is very little data available to support
or refute this issue. Moreover, the point at which a
person is too demented to benefit from psychother-
apy has yet to be determined (Scholey & Woods,
2003). Therefore, the feasibility and usefulness of
various psychological treatments in older adults
merits further exploration.
The hypotheses of the current study were that
older individuals receiving BA therapy will demon-
strate significant decreases in depressive symptomol-
ogy compared to participants in the treatment-as-
usual control group. Furthermore, older individuals
receiving BA therapy will significantly improve on a
measure of quality of life compared to participants in
the treatment-as-usual control group. A secondary
aim was to explore the potential influence of
cognitive ability on the effectiveness of BA treatment.
Because BA therapy is often assumed to require less
cognitive ability than other psychotherapies, it was
expected that Mini-Mental State Examination
(MMSE) score would not be related to change in
depression severity score.
Method
participants
The following inclusion criteria were used: (a) 65
years of age or older; (b) a score of 18 or above on
the MMSE; (c) deemed competent to sign a consent
form by their psychiatrist; (d) deemed not actively
psychotic by their psychiatrist or attending mental
health care provider; (e) a score of 3 or higher on the
Geriatric Depression Scale–Short Form (GDS-S); (f)
and residence in the hospital for at least a 5-day
acclimation period. The MMSE cutoff score of 18
was selected to include those with mild to moderate
cognitive impairment. A GDS-S pretreatment score
of 3 or higher was selected to indicate at least mild
depressive symptomology. Additionally, this score
permitted inclusion of more participants. If the
participant was deemed capable and appropriate to
participate in the study, informed consent was
received from both the participant and psychiatrist.
The consent form was approved by the University of
Alabama's Institutional Review Board (IRB) and
described the procedures of the study as well as
informed clients that their participation was volun-
tary and would not influence their treatment (e.g.,
length of stay and quality of care).
The participants in this study were residents of the
state of Alabama who were committed by the
probate court to receive mental health services at the
Mary Starke Harper Geriatric Psychiatry Facility.
This is a state-supported facility for Alabama
 effects of behavioral activation 103

Table 1 sex, race, and diagnosis. Treatment usually involves

Demographics of Sample (N = 50) pharmacological therapy as well as casework, group
Variable M, SD or % therapy, and recreational therapy. The minimum
Sex length of stay is 20 to 30 days.
Male 40% The participants were recruited within a 1-year
Female 60% period and ranged in age from 63 to 87, with a
Age 71.67 (5.85) mean age of 71.67. Most of the participants were
Ethnicity Caucasian (62%), had been or were currently
Caucasian 60% married (84%) and completed high school (80%).
African-American 32% The sample had fairly equal representation of the
American Indian 2% sexes, with 30 women and 20 men. In the current
Other 6%
sample of 50 participants, 24% had a primary
Marital Status
Single 16%
diagnosis of schizophrenia, 18% bipolar disorder,
Married 20%
18% dementia, 16% schizoaffective disorder, 10%
Divorced 32% psychotic disorder, 6% major depressive disorder,
Widowed 32% and 2% each for mood disorder NOS, obsessive-
Education compulsive disorder, impulse control disorder, and
High School or below 66% delusional disorder. These diagnoses were derived
Some College 34% from chart review. For some patients this was their
MMSE 24.80 (2.91) first and only acute psychiatric hospitalization,
Note. Table includes 50 participants who completed pretreatment whereas other, more chronically ill patients reside
assessment. MMSE = Mini-Mental State Examination. there permanently. This was the first psychiatric
admission for 24% of the sample and 54% self-
residents age 65 and over. The facility contains four reported having good or excellent health. MMSE
units, each with approximately 25 residents. In most scores in the current study ranged from 18 to 30,
cases, the commitments are involuntary and involve with an average score of 24.80 and 61% of the
a prior incident in the community, such as sample scoring higher than 24. Further information
inappropriate suspicious behaviors toward their on the sample is presented in Table 1.
neighbors, neglecting their residence, or disturbing Participation was encouraged by offering incen-
the peace. Patients at the Harper Center vary in age, tives for the participants to begin and continue the

FIGURE 1 Flow of participants through study. "Time 1" represents the pretreatment session,
"Time 2" represents midtreatment and "Time 3" represents posttreatment. "Withdrew" indicates
that the individual discontinued participation, due to hospital release, prior to final session. One
individual voluntarily terminated participation, citing resistance to all treatments.
104 snarski et al.
study. The incentives offered were vouchers that
have monetary value at the hospital's daily snack
bar. The vouchers also served as an honorarium for
their time. Incentive vouchers were given to each
participant after their pre-, mid-, and posttreatment
assessments, regardless of their random group
assignment.
Figure 1 shows the flow of participants through
the study. Fifty individuals completed the pretreat-
ment session and agreed to participate in the study.
Twenty-five were randomly assigned to the exper-
imental group and 25 were randomly assigned to
the control group. Twenty-nine of the 50 indivi-
duals completed both pretreatment and posttreat-
ment assessment sessions; 13 were in the control
group and 16 were in the experimental group. Forty
individuals of the 50 completed both pre- and mid-
assessment sessions. Of these 40, 19 were in the
control group and 21 were in the experimental
group. One participant prematurely terminated the
study voluntarily. This participant remained hospi-
talized, but became resistant to all treatments,
including BA therapy. The remaining 20 noncompl-
eters resulted from patients being released from the
hospital prior to their last session.
materials
Mini Mental State Examination (MMSE)
The MMSE (Folstein, Folstein, & McHugh, 1975)
is an instrument that can be used to assess mental
status. It is a 30-item measure that tests five areas of
cognitive function: orientation, registration, atten-
tion and calculation, recall and language. The
maximum score is 30. A score of 23 or lower
indicates probable cognitive impairment (Folstein
et al., 1975). Scores of 24 to 30 are in the normal
range, 21 to 23 indicate mild impairment, 10 to 20
indicate moderate impairment, and scores below 9
are considered profound impairment (Folstein et
al., 1975). The MMSE takes only 10 to 15 minutes
to administer and is therefore practical to use
routinely with this population.
In this study, the MMSE was used to assess
overall cognitive ability and determine whether a
participant was eligible to participate in the study.
The traditional cutoff level of eligibility in a study is
a score of 23 or above (Wetherell, Gatz, & Craske,
2003). However, in the current study the eligibility
cutoff was a score of 18 or higher, thereby including
individuals with lower cognitive abilities. A score of
18 was chosen to include participants with mild to
moderate impairment and is often used as the
education-corrected cutoff score.
Geriatric Depression Scale–Short Form (GDS-S)
The GDS-S (Sheikh & Yesavage, 1986) is a self-
report depression scale used with older adults. It
was used as both a screening and outcome measure.
Patients needed a score of 3 or higher to be included
in the study. The GDS-S consists of 15 yes/no
questions from the original Geriatric Depression
Scale–Long Form (GDS-L; Brink et al., 1982). The
Short Form is particularly useful in working with
older adults because its brevity minimizes fatigue. A
score of 0 to 4 indicates no depression, 5 to 10
indicates mild depression, and a score above 10
indicates severe depression.
Quality of Life Inventory (QOLI)
The QOLI (Frisch, Cornell, Villanueva, & Retzlaff,
1992) is a self-report measure of life satisfaction. It
assesses 16 life domains at a sixth-grade reading
level (Frisch, 1994). Each item on the QOLI is
scored on a scale ranging from –6 to +6, with a
score of 0 being equivalent to an average quality of
life on that domain. After a participant's total score
is summed, this number is then translated into a
T-score statistic.
The QOLI is reliable as indicated by a test-retest
reliability coefficient of .73 over an interval of 2
weeks and an internal consistency coefficient of .79
(Frisch, 1994). Additionally, the QOLI is sensitive
to clinical change in individuals from pre- to
posttreatment and thus is a good outcome measure
(Scogin et al., 2007).
Treatment Fidelity Monitoring Measurements
Lichstein, Riedel, and Grieve (1994) proposed a
psychotherapy treatment implementation model
that includes three components that help determine
whether a valid clinical trial has been conducted.
These three components are delivery, receipt, and
enactment. Delivery refers to the appropriate
administration of the selected treatment to the
client. Receipt refers to the client's comprehension
of the treatment techniques and enactment refers to
the client's application of those techniques to daily
life. The therapists delivering the treatment were the
lead author (MS) and clinical psychology graduate
students trained in delivering BA treatment by the
research team over three sessions to ensure proper
treatment delivery. Weekly supervision meetings
were held, following the format of similar studies
(Hopko et al., 2005; Scholey & Woods, 2003).
Audiotaped sessions were randomly selected for
analysis and were evaluated with treatment adher-
ence checklists by a trained research assistant.
Ratings were made on a 0 (no adherence/compe-
tence) to 8 (complete adherence/competence) point
Likert scale (Hopko et al., 2005).
It was particularly important that the participant
understood the treatment techniques reviewed in
 effects of behavioral activation
each session because of the high frequency of
cognitive impairment. Therefore, brief “quizzes”
were randomly given in which the participant was
requested to explain the material being covered, as
suggested by Lichstein et al. (1994). For example,
the participant was asked what a pleasant event is
and what the purpose of an activity list is in treatment.
It was also important that the participants were
implementing BA techniques outside of the sessions.
Therefore, homework assignments were given and
completion of these assignments was checked and
recorded. Patient adherence was identified as
percentage of homework completed. Completion
was measured by the participant's self-report. The
participant also had an opportunity to discuss
whether they had used any of their learned skills
over the course of the week. Some examples of a
homework assignment included attendance in a
recreation therapy group three times per week, 30
minutes of exercise per day, or engagement in social
interactions with other patients.
design and procedure
This study used a two-group comparison design
with an experimental group and a treatment-as-
usual control group. A 2 (between) × 3 (within)
experimental design was used to measure depres-
sive symptoms and quality of life at pre-, mid-, and
posttreatment among experimental and control
group participants. Participants were randomly
assigned to either the treatment as usual plus BA
therapy (experimental group) or the treatment as
usual only (control group).
A power analysis was conducted to determine an
appropriate sample size for this study. A large effect
size was predicted based on findings of a similar
study (Hopko, Lejuez, LePage, et al., 2003). Fifty
participants were needed in the current study; 25 in
each condition, to have power = .80 using an a = .05.
Participants were recruited by the lead author after
treatment was suggested by a psychologist or other
mental health care provider. The investigator
requested that participants complete a consent form
to screen, as well as a release form to talk with the
referring psychiatrist and to gain access to their chart.
Information in the patients’ charts included primary
and comorbid diagnoses, as well as date of admission,
previous admissions, and length of stay. The partici-
pant next completed the screening battery. Screening
batteries were administered by research assistants. If
an interested patient was eligible based upon our
selection criteria, they were admitted to the study.
Once participants completed their pretreatment
assessment battery, they were randomly assigned to
either the experimental (treatment as usual plus BA)
or the treatment-as-usual control group.
105
Participants in the treatment group received eight
BA sessions over the course of 4 weeks. Biweekly
sessions of 30 minutes allowed for the patient to
work on a given homework assignment a few times
before moving on to the next treatment goal. Eight
sessions over 4 weeks was the chosen therapy
schedule. The sessions followed suggested guide-
lines set forth by Lejuez, Hopko, and Hopko (2001)
and were audiotaped. During sessions, experimen-
tal participants were asked to rate their life goals on
a chart, which included but were not limited to items
such as spirituality, physical health, volunteering,
and family relationships. In collaboration with the
therapist, participants created an activity hierarchy
and worked through the tasks from easiest to most
difficult. The goal was to increase the frequency and
duration of the activity in each session. Therapists
were persons different from research assistants who
remained blinded to the participant's group.
Some modifications were made to further simplify
treatment due to the potential cognitive limitations
of the participants. Contracts with family and
friends were not used due to the inpatient status of
the patients. Also, daily diaries were omitted, as they
would be too burdensome for the patients. A
homework log for each session was completed and
percentages of homework were tabulated by thera-
pists. As in both BA versions, the focus was to
meaningfully activate the patient.
Results
A MANOVA was conducted to examine the
differences between participants in the control and
experimental groups. There were no significant
differences found among the demographic (age,
health, previous hospitalizations) or outcome mea-
sures (GDS, QOLI, MMSE) at pretreatment be-
tween the two groups, suggesting that the
randomization was successful. Similarly, a second
MANOVA included the same dependent variables,
but examined completion status (e.g., those who
completed all three assessment points and those
who did not) as the independent variable. There
were no significant differences, suggesting that
attrition was largely nonsystematic.
Repeated measures analyses of variance (ANOVA)
were conducted to test the main hypotheses with
each of the outcome measures (GDS-S, QOLI) as
dependent measures and the group assignment as the
independent factor with the repeated factor of time.
Analyses examined the interaction between time and
group assignment across the three assessment
periods (pre-, mid-, and posttreatment) with an
α = .05. Carry forward end-point analyses were used
to address missing data due to participant attrition.
In this procedure, the last observation is substituted
106 snarski et al.
Table 2
Outcome Data by Assessment Time and Condition
T1 T2 T3
Mean (SD) Mean (SD) Mean (SD)
GDS-S score
Control Group 5.00(2.24) 5.16(3.21) 4.40(2.97)
Experimental 6.20(3.15) 4.60(3.15) 4.04(2.89)
Group
QOLI score
Control Group 46.71(15.06) 46.58(14.36) 49.71(13.92)
Experimental 44.84(15.19) 47.88(16.90) 49.04(15.25)
Group
Note. T1 = pretreatment; T2 = midtreatment; T3 = posttreatment;
GDS-S = Geriatric Depression Scale-Short Form; QOLI = Quality
of Life Inventory.
for future data, for example, midtreatment data
would be carried forward to represent posttreatment
data in the event of attrition between mid- and
posttreatment assessments. This approach to missing
data is considered more scientifically conservative
than eliminating cases due to missing data. On the
GDS-S, the interaction effect was significant and the
effect size was medium, F(2, 96) = 3.73, p =.03,
eta 2 = .07. We elected to further examine this
interaction to determine where this change occurred
by comparing pre- to mid- and mid- to postmeasure-
ments. The interaction of group and time (pre- to
mid-) was statistically significant, again with a
medium effect size, F(1, 48) = 5.20, p = .03,
eta2 =.10. There was no interaction of the two
groups between the mid- and posttreatment assess-
ments, F(1, 48) = .17, p =.69. Both Table 2 and
Figure 2 display the mean carried-forward GDS-S
scores for the control and experimental groups
across the three assessment times.
Repeated measures analysis of the QOLI scores
showed that there was not a significant interaction
between the two groups over the three assessment
periods, F(1, 48) = .36, p = .70. No further analyses
of these data were undertaken.
An exploratory analysis was undertaken of only
those participants who completed all three assessment
points. The completer group consisted of 13 partici-
pants in the control group and 16 participants in the
experimental group. A MANOVA was completed
examining the differences between completers and
noncompleters at pretreatment. There were no
significant differences found among the demographic
or outcome measures between the two groups,
suggesting that the completers and noncompleters
were not significantly different. Nonetheless, these
completer analyses should be interpreted with cau-
tion. The Time × Treatment interaction on the GDS-S
was statistically significant and showed a large effect
size, F(2, 54)= 6.74, p b .01, eta2 = .20. Although there
was a statistically significant interaction and large
effect size of groups between pre- and midtreatment, F
(1, 27) = 11.60, p b .01, eta2 = .30, there was no
statistically significant differences between the GDS
scores of the groups between mid- and posttreatment,
F(1, 27) = .53, p = .48. This was the same pattern
observed with the intent-to-treat analyses.
The Reliable Change Index (RCI; Jacobson et al.,
1984) was designed to measure clinical significance
of therapeutic change (Jacobson, Follette, &
Revenstorf, 1984). The RCI tests whether an
individual's observed change is greater than that
which would be expected by random measurement
error. Twenty-four percent of participants receiving
BA treatment experienced a clinically significant
positive change in depressive symptoms. The
control group had 12% experience clinically
significant positive change in depressive symptoms,
while another 12% had significant negative change.
Cognitive status may influence the efficacy of
treatment. To examine this question, a correlation
was run between the GDS-S change score and the
MMSE score of individuals in the BA treatment
group. A nonsignificant correlation resulted (r =
-.17, p = .42), suggesting that overall cognitive
ability did not influence treatment effectiveness in
a meaningful way.
Treatment enactment was excellent as indicated
by homework completion rates averaging 81%.
Treatment receipt measures averaged 61% correct
on session quizzes. This somewhat low average may
be the result of participants in the study with
dementia who had difficulty remembering details
from session to session. We also examined therapist
adherence to the treatment protocol. Independent
raters (undergraduate research assistants) listened to
and scored tapes. Results indicate an average rating
of 84% on adherence and 85% on competency.
FIGURE 2 Geriatric Depression Scores by condition across
assessment times.
 effects of behavioral activation
Discussion
BA treatment was associated with improved GDS
scores compared to treatment as usual in a sample
of older adults with serious mental disorders. If
BA's effect is primarily in the early phase of
treatment, as seen in this study, it may be a
beneficial therapy for an older, hospitalized popu-
lation, in which there is often a very brief period of
time to implement treatment. In support of BA's
rapid treatment effect, the majority of the improve-
ment in depressive symptoms occurred between
pre- and midtreatment sessions. Brief BA may be a
cost-effective therapy option. Clinical significance
was examined in this study by calculating the
Reliable Change Index (RCI). Approximately a
quarter of the BA participants achieved reliable
change in depressive symptoms, about double the
rate seen in the control participants. We believe this
is an impressive figure given the clinical character-
istics of this sample of older adults.
The finding regarding the other hypothesis was
not as promising. Measured quality of life revealed
no significant differences between BA and control at
pre- to midtreatment or mid- to posttreatment.
Perhaps quality of life is a global construct that may
not show change in the short-term. This then may be
a case of desynchrony (Rachman & Hodgson,
1974), where perhaps improvement in quality of
life occurs after changes in depression and after the
end of our assessment period. Also, our measure
included aspects of quality of life, such as neighbor-
hood and community, that may have been a poor
match for the circumstances of our participants.
Further analysis suggested that cognitive ability,
as assessed by the MMSE, was not a significant
correlate of change in depressive symptoms. This
suggests that BA may be useful for some older
adults that heretofore may have been seen as poor
candidates for individual psychotherapy treatment.
limitations and future directions
Due to the nature of the population, attrition was a
problem. The average stay for a resident at the
Harper Center is about 4 to 5 weeks. Because BA
requires a minimum of 4 weeks to complete, and
participants had a 5-day acclimation period before
entering the study, it was often difficult for
participants to complete the treatment protocol.
Attrition in the second half of the BA protocol could
be a reason for the lack of a significant treatment
effect on the GDS during the mid- to postassessment
phase. Although participants seemed to be moti-
vated to continue, many were released before the
study was over. Follow-up was not feasible due to
the wide range of participant geographic locations
107
after discharge. Possible solutions for the attrition
issues are to make the therapy shorter or increase
the frequency or intensity of sessions (e.g., three
sessions per week for 2 weeks). Patients would then
receive the maximum amount of treatment in the
shortest period of time.
Another problem was related to sample size. The
current study included a small sample size and a
heterogeneous group of participants with a range of
primary diagnoses. For the purpose of this study, a
cutoff of three depressive symptoms was chosen to
maximize participant inclusion, while still allowing
room for potential improvement. However, this
resulted in a wide range of depression severity
within the study. While this range enabled findings
to be generalizable, future studies could be more
specific in their sampling. To this end, it would be
helpful to include both individuals with mild
depressive symptoms and those with major depres-
sive disorder, to compare and contrast treatment
effectiveness in both groups.
It is also suggested that future researchers
perform follow-up assessments after they have
been released from the hospital. This would be an
extremely difficult task and probably only feasible
with external funding but worth the rich data it
would provide. Follow-up assessments would help
with understanding the long-term effects of BA
therapy on depressive symptoms and may also
reveal gradual changes in quality of life.
Further investigations of BA should substantiate
and build upon the current findings. Replication
with similar results would further strengthen our
findings and may lead to BA being an evidence-
based and cost-effective therapy option for cogni-
tively impaired geriatric inpatients as well as
depressed patients across the lifespan.
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R E C E I V E D : October 9, 2009
A C C E P T E D : May 3, 2010
Available online 20 November 2010