Community-based Behavioural Activation Training (ComBAT) for Depression in Adolescents

Depression is the third leading cause of illness, disability and death among adolescents worldwide.

In the UK, nearly a quarter of all adolescent girls and one in ten adolescent boys self-report elevated depressive symptoms. We need to reach adolescents at the earliest point at which depression develops and warrants an intervention.

Most adolescents do not access timely and evidence-based psychological interventions, either because they do not meet the high threshold for entry to child and adolescent mental health services (CAMHS), or because professionals who work with adolescents in the community (schools, social care, charities) do not have the specialist skills to deliver such interventions.

Behavioural Activation (BA) is a psychological intervention with proven effectiveness for depression in adults and with promising results for depression in adolescents.

BA aims to restore and increase stable sources of positive reinforcement in a person s environment through purposeful and rewarding activities. BA has two advantages over other psychological interventions.

First, it is brief, as it requires fewer sessions with those who receive it and shorter training for those who deliver it. Second, it can be delivered by non-specialists because of its parsimonious approach.

In view of the limited capacity of professionals working with adolescents in the community, and the high dropout of adolescents from psychological interventions in general, the briefer and the simpler the intervention, the more likely that professionals and adolescents will adopt it and adhere to it.

Our proposed programme of work will adapt conventional BA, in consultation with adolescents, parents and professionals across different community settings, to produce a standardised intervention that can be delivered at scale by non-specialists in the community.

A fully-powered randomised controlled trial (RCT) will compare the effectiveness and acceptability of ComBAT against usual care with a sample of 236 adolescents (12-18-years). We will record and monitor what “usual care” means in different community settings. A 9-month internal pilot will monitor and report recruitment, randomisation, follow-up and adverse event rates.

Interviews with both adolescents and support workers will explore their experiences of ComBAT. An economic evaluation and modelling will estimate value for money within and beyond the RCT's duration.

A process evaluation will identify the contextual, implementation and mechanistic factors that are important for BA s future large-scale delivery in the community. We will monitor the impact of ComBAT on subsequent help-seeking and CAMHS referrals.

Our research is timely, because adolescent mental health is high on the policy agenda and mental health support teams in schools and colleges need to be trained in evidence-based interventions.

Our research has the potential to make an impact on the problem of rising numbers of young people with depression and the limitations of CAMHS to deal with this.

ComBAT will build on the experience of support workers in engaging adolescents, while upskilling them to deliver a clinically-informed intervention that can make a meaningful change in young people's depression trajectory.

The research could potentially reduce the need for CAMHS entry, if adolescents with depression can be effectively helped in the community.