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UNITED STATES DEPARTMENT OF LABOR

Behavioral activation therapy for return to work in medication-responsive chronic depression with persistent psychosocial dysfunction (Hellerstein et al., 2015)

Review Guidelines

Causal Evidence Guidelines

Absence of conflict of interest. 

Citation

Hellerstein, D. J., Erickson, G., Stewart, J. W., McGrath, P. J., Hunnicutt-Ferguson, K., Reynolds, S. K., O’Shea, D., Chen, Y., Withers, A. & Wang, Y. (2015). Behavioral activation therapy for return to work in medication-responsive chronic depression with persistent psychosocial dysfunction. Comprehensive Psychiatry, 57, 140-147. http://dx.doi.org/10.1016/j.comppsych.2014.10.015

Highlights

  • The study's objective was to examine the impact of Behavioral Activation therapy with a goal of returning to work (BA-W) on employment and health outcomes. 
  • The study used an interrupted time series design. Data sources were self-reported work hours per week including paid work, work-related activity, and instruments measuring depressive symptoms. The authors used statistical models to evaluate changes in outcomes from baseline to week 24, adjusting for baseline depression.  
  • The study found a statistically significant relationship between BA-W and increased work-related hours per week as well as increased paid hours per week.  
  • This study received a low causal evidence rating. This means we are not confident that the estimated effects are attributable to BA-W; other factors are likely to have contributed. 

Intervention Examined

Behavioral Activation Therapy

Features of the Intervention

Behavioral Activation (BA) is a time-limited, manualized therapy that can be used to treat depression. It includes problem-solving, assessment of goals and values, activity scheduling, skills training, relaxation training, contingency management, and targeting verbal behaviors and avoidance. BA therapy was tailored to address unemployment for persons with depression who had some improvement in symptoms but had remaining functional impairment. The goal of the intervention was to return to work. 

Once a week for 12 weeks, program participants met with a therapist for 50 minutes. Booster sessions were provided at weeks 18 and 24. Therapists were bachelor's level or masters students, psychiatry residents, or PhD or MD practitioners. All therapists received a 2-day training from BA experts. During the therapy sessions, therapists provided explanations for symptoms and how patient behaviors maintain disability. Program participants were taught to use problem-solving to change behavior or situations that may maintain depressive symptoms and work-related outcomes. The primary focus of BA-W sessions was work dysfunction and employment related goals. 

Features of the Study

The study took place at New York State Psychiatric Institute. The authors used an interrupted time series design to understand change in outcomes between baseline and week 24. Participants were identified from clinical trials of antidepressant medication at New York State Psychiatric Institute between April 2009 and December 2012 and were offered study participation. The study eligibility criteria included: age 20-75; primary diagnosis of Dysthymic Disorder, Chronic Major Depressive Disorder, or double depression; >50% decrease in 17-item Hamilton Rating Scale for Depression (HRSD-17) score and a final HRSD-17 score ≤ 10 with an adequate antidepressant trial; a rating of "very much improved" or "much improved" on the Clinical Global Impressions-Improvement scale; continued functional impairment; and unemployment (jobless and looking and available for work). 

The sample included 9 men and 7 women who were an average age of 44 years. The majority (81%) were White. The duration of unemployment among the sample ranged from 2 to 200 months, with an average of 44.4 months. Data sources were self-reported work hours per week including paid work and work-related activity (paid work, job training, job searching, volunteer work, or schoolwork) and reported depressive symptoms measured through instruments (HRSD-17, Cornell Dysthymia Rating Scale, Beck Depression Inventory). The authors used statistical models to evaluate change in outcomes over time.  

Findings

Employment

  • The study found a statistically significant relationship between BA-W and increased work-related hours per week. The study also found a statistically significant relationship between BA-W and increased paid hours per week.  

Health

  • The study did not find a statistically significant relationship between BA-W and depression.  

Considerations for Interpreting the Findings

The authors compared the outcomes of participants measured before and after they participated in the intervention. For these types of designs, the authors must observe outcomes for multiple periods before the intervention to rule out the possibility that participants had increasing or decreasing trends in the outcomes examined before enrollment in the program. That is, if participants who had increasing work hours tended to enroll in the program, we would anticipate further increases over time, even if they did not participate in the program. Without knowing the trends before program enrollment, we cannot rule this out. Therefore, the study receives a low causal evidence rating. 

Causal Evidence Rating

The quality of causal evidence presented in this report is low because the authors did not account for trends in outcomes before the intervention. This means we are not confident that the estimated effects are attributable to BA-W; other factors are likely to have contributed. 

Reviewed by CLEAR

January 2024

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