Integrating Behavioural Activation for Depression Into Community Drugs and Alcohol Treatment: A Randomised Controlled Trial

RATIONALE Over 50% of treatment-seeking substance users present with clinically significant depression symptoms (Johnson, Neal, Brems, & Fisher, 2006). This combination of problems tends to complicate treatment (e.g. Carroll et al., 1993) resulting in greater functional impairment (Johnson et al., 1995) and poor health outcomes (Hasin et al., 2002). Treatment protocols for co-occurring mental health and substance misuse have traditionally focused on treating these issues separately, however there is now increasing consensus that integrated approaches to treatment are more effective (Davidson et al., 2010) and subsequently a growing interest into how targeted mental health support can be incorporated into standard drug and alcohol treatment.

CBT is deemed to be one of the most effective psychological treatments for depression, though may be too complex and time-consuming for effective delivery in routine CDAT. Emerging evidence suggests that a more suitable intervention in this context may be Behavioural Activation (BA); a brief, manualised intervention which targets depression symptoms by increasing engagement in rewarding, values-based activities (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011). Indeed, previous studies have found that BA is associated with reductions in both depression symptoms and substance use (Daughters et al., 2018; Daughters et al., 2008; Delgadillo et al., 2015), as well as improved treatment retention among substance misuse service users with comorbid depression (Magidson et al., 2011). The only known trial of BA in UK Community Drugs and Alcohol Treatment (CDAT) was conducted by Delgadillo and colleagues (2015), however this study was under-powered and employed qualified mental health practitioners to deliver the intervention which may be too costly or unfeasible to implement in routine practice. More research is needed to establish the efficacy of BA in CDAT services, and given that BA may be delivered effectively with minimal training by staff who are not formally trained as psychological therapists (Ekers et al., 2008), it seems that the most suitable and cost-effective way of integrating BA into routine drug and alcohol treatment would be to upskill the existing workforce.

Accordingly, given the high prevalence and impact of comorbid depression among addiction service users, along with evidence to suggest that BA is an effective and acceptable intervention for treating this population, the present study will expand on previous research by conducting a trial to evaluate the efficacy of BA delivered by trained drugs and alcohol workers in a sample of patients accessing treatment for substance use. The central research question is: How effective is Behavioural Activation for treating depression in substance users compared to treatment as usual in Community Drugs and Alcohol services?

AIMS

The proposed study aims to: