A new study sug­gests mood-en­hanc­ing pur­suits such as danc­ing or walk­ing the dog could be the lat­est weapon in the war against de­pres­sion. And, writes Linda Moon, such ‘be­havioural ac­ti­va­tion’ is sim­ple and cost-ef­fec­tive.

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Like many, 50-year-old Jane Curnow cred­its over­com­ing de­pres­sion to an ab­sorb­ing hobby. Curnow was di­ag­nosed with clin­i­cal de­pres­sion at the age of 32 and had made two at­tempts on her life.

“I had spent my en­tire adult life in and out of ther­apy,” she says, ex­plain­ing that her de­pres­sion stemmed from life cir­cum­stances and low self-worth.

Curnow had al­ways en­joyed fit­ness and at 46 took up body-build­ing, which grew into a pas­sion. “My hobby not only cured my de­pres­sion but saved my life. Af­ter four years of body-build­ing I de­clared my­self fully re­cov­ered and cel­e­brated my 50th birth­day on stage to de­clare my re­cov­ery to the world.”

De­scrib­ing her cure as ac­ci­den­tal, Curnow is now a Syd­ney-based health and life­style coach and fit­ness model and has writ­ten a book about her ex­pe­ri­ences, Find­ing My­self from the Out­side In.

Like Curnow, many suf­fer­ers of de­pres­sion stum­ble accidentally on the ther­a­peu­tic ad­van­tages of ac­tiv­i­ties. But what if health prac­ti­tion­ers be­gan pre­scrib­ing them as a con­scious treat­ment for de­pres­sion? It’s a tan­ta­lis­ing propo­si­tion gain­ing trac­tion in Bri­tain. Thanks to a 2016 Lancet study, the ther­apy (dubbed “be­havioural ac­ti­va­tion” or BA for short), is of­fi­cially be­ing pro­moted as a le­git­i­mate treat­ment for de­pres­sion by Bri­tain’s Na­tional In­sti­tute for Health and Care Ex­cel­lence (NICE).

In the big­gest trial of BA to date, and the largest psy­cho­log­i­cal study for de­pres­sion ever con­ducted, Pro­fes­sor David Richards and his team at the Univer­sity of Ex­eter ran­domly con­signed 440 par­tic­i­pants to ei­ther BA or cog­ni­tive be­havioural ther­apy (CBT), the “gold-stan­dard” treat­ment for de­pres­sion. What they dis­cov­ered was that BA (a ther­apy re­vived from the 1950s) was as ef­fec­tive in treat­ing de­pres­sion as CBT. In both groups the re­cov­ery rate was about 65 to 70 per cent. To put this into per­spec­tive, rou­tine Bri­tish health ser­vices have a re­cov­ery rate of about 45 per cent, Richards ex­plains.

Where this gets ex­cit­ing is that BA re­quires far less train­ing than CBT. “It’s 20 per cent cheaper than CBT,” Richards says. “That means we can get more men­tal-health bang for our men­tal-health buck. The sec­ond ar­gu­ment for this is its sim­plic­ity rel­a­tive to other treat­ments avail­able.” Be­havioural ac­ti­va­tion is easy for peo­ple of all ages and cul­tures to un­der­stand and im­ple­ment. “We’ve got peo­ple us­ing BA in ado­les­cence and for peri­na­tal de­pres­sion.”

“What hap­pens when you’re feel­ing de­pressed is you stop in­ter­act­ing with the world in quite the same way,” Richards says. “They’re kind of shrink­ing into a small world which is re­ally de­void of op­por­tu­ni­ties for that pos­i­tive re­in­force­ment whether it be fun or ac­com­plish­ment or what­ever. It’s a re­ally iso­lat­ing dis­or­der. If you stop do­ing stuff, then you get mis­er­able.”

In essence, the ther­apy in­volves work­ing with a coun­sel­lor to con­struct a pro­gram of ac­tiv­i­ties de­signed to cre­ate pos­i­tively re­in­forc­ing, re­ward­ing ex­pe­ri­ences iden­ti­fied as mean­ing­ful to the client. These can be as sim­ple as pre­par­ing a cooked meal or read­ing a book, Richards says. “Even just a small walk or clear­ing up, do­ing a bit of wash­ing, stupid lit­tle things like that, can ac­tu­ally make you go, ‘Okay, that’s great, my place isn’t a mess any­more.’ These things re­ally mat­ter to peo­ple. You get a sense of pride, you get a sense of achieve­ment, and a sense of I’ve re­ally done some­thing now.”

In ef­fect, BA com­bines stud­ies on ac­tiv­i­ties that help de­pres­sion (for ex­am­ple, gar­den­ing, ex­er­cise, cre­ative arts, so­cial clubs) and places them un­der one um­brella term. It’s also help­ful for coun­ter­ing life changes that con­trib­ute to de­pres­sion, such as sep­a­ra­tion, par­ent­ing young chil­dren or chronic ill­ness. While most psy­cho­log­i­cal treat­ments for de­pres­sion try to change our in­ter­nal world, BA works from the “out­side in” Richards ex­plains.

Af­ter a stroke five years ago at the age of 49, She­lagh Bren­nand was un­able to per­form her job as a pri­vate in­ves­ti­ga­tor. She spi­ralled into de­pres­sion. “It was a huge life change for me,” Bren­nand re­calls. “It’s a griev­ing process. You lose your iden­tity and your life.”

Anti-de­pres­sants gave Bren­nand some re­lief but left her feel­ing flat. She turned to writ­ing po­etry and colour­ing in to cope. “It makes me feel re­laxed when

I do a poem no mat­ter if it’s sad or happy. I go into a bit of a zone.” Bren­nand, who lives on the Sun­shine Coast, started post­ing her po­ems on­line to help other stroke sur­vivors. This led to a colour­ing-in book, A Stroke of Po­etry, and char­ity work in­clud­ing be­com­ing an am­bas­sador for the Stroke Foun­da­tion. Like Curnow, Bren­nand in­ci­den­tally dis­cov­ered the ben­e­fits of ex­er­cise. She hired a per­sonal trainer to lose weight and then took up moun­tain climb­ing. Thanks to her ac­tiv­i­ties, her de­pres­sion was short-lived. “It’s prob­a­bly a com­bi­na­tion of all the three things re­ally – the colour ther­apy, the po­etry, the ex­er­cise, and know­ing you’re help­ing oth­ers with what you do. It’s given me that fo­cus, that pur­pose back in life that I lost.”

Richards points out that BA isn’t merely about hav­ing fun but about meet­ing what­ever needs are con­sid­ered im­por­tant to an in­di­vid­ual. “You’re do­ing things be­cause of words such as achieve­ment, self­sat­is­fac­tion, ac­com­plish­ment,” he says. “It’s about who you are and you feel­ing good about it.”

De­pres­sion and anx­i­ety af­fect about 10 per cent of the global pop­u­la­tion, ac­cord­ing to a 2016 World Health Or­gan­i­sa­tion state­ment. And Aus­tralian Bureau of Sta­tis­tics fig­ures from 2016 show sui­cide, closely linked to de­pres­sion, kills more Aus­tralians in the 15 to 44 age bracket than any other cause.

Richards views BA as “an ex­cit­ing prospect for re­duc­ing wait­ing times and im­prov­ing access to high­qual­ity de­pres­sion ther­apy world­wide. [It] of­fers hope for coun­tries that are cur­rently strug­gling with the im­pact of de­pres­sion on the health of their peo­ples and economies.”

He be­lieves train­ing generic health work­ers and vol­un­teers in BA could in­crease the preva­lence of treat­ment in those with less access to health ser­vices – the un­de­vel­oped world, ru­ral pop­u­la­tions and the eco­nom­i­cally dis­ad­van­taged within the de­vel­oped world. “A lot of peo­ple think ev­ery­body in de­vel­oped coun­tries gets good access,” Richards says. “That’s not the case.”

“It’s now defini­tively shown that we have an­other ef­fec­tive treat­ment that should be pro­vided to pa­tients. It’s also about pa­tients say­ing, ‘I want be­havioural ac­ti­va­tion.’”

Ac­cord­ing to Aus­tralian prac­tis­ing clin­i­cal psy­chol­o­gist and re­search fel­low at Black Dog In­sti­tute, Dr Ja­nine Clarke, a key strength of BA is it is less stig­ma­tis­ing. “When de­pres­sion is ad­dressed in be­havioural terms, that is, some­thing that you ‘do’ and not some­thing that you ‘have’, many clients feel lib­er­ated from the stigma of men­tal ill­ness. BA is an ex­tremely palat­able treat­ment ap­proach that makes in­tu­itive sense to pa­tients.”

Its sim­plic­ity makes it more ac­ces­si­ble for those with lan­guage dif­fi­cul­ties and in­tel­lec­tual im­pair­ments, she adds. It may also ap­peal more to men. “Men are at high risk of sui­cide and of­ten re­luc­tant to seek help,” Clarke says. “Re­search by Black Dog In­sti­tute shows that men view par­tic­i­pat­ing in en­joy­able and re­ward­ing ac­tiv­i­ties as im­por­tant for stay­ing well and pre­vent­ing de­pres­sion. Be­cause BA is po­ten­tially less ‘touchy-feely’ than some other psy­chother­a­pies, it may pro­vide an at­trac­tive treat­ment ap­proach for de­pres­sion in this hard-to-reach group.

“It’s time ef­fi­cient and trans­portable – able to be de­liv­ered via the in­ter­net us­ing dig­i­tal and hand­held tech­nolo­gies. Hence, much of the ap­peal of BA lies in its po­ten­tial for de­liv­ery on a broad scale.” How­ever, Clarke is keen not to dis­miss the mer­its of CBT. “We cer­tainly do not want to pit one ther­apy against the other,” she says.

“It’s about pa­tient choice,” Richards con­cludes, al­though he stresses that for those with se­ri­ous men­tal-health con­di­tions, such as bipo­lar dis­or­der, treat­ment de­ci­sions should not be made with­out con­sult­ing their doc­tor.

When dealing with mild to moder­ate de­pres­sion, he says, “Many peo­ple would pre­fer not to take med­i­ca­tion. I think there’s an ar­gu­ment as well for the per­se­ver­ance of this treat­ment. You get much less re­lapse in psy­cho­log­i­cal treat­ments than you do with drugs. Be­cause ob­vi­ously peo­ple have learnt to be­have or think dif­fer­ently. It’s an old-fash­ioned tech­nol­ogy and, • guess what, it still works.”

Life­line 13 11 14; SANE 1800 187 263; be­yond­blue 1300 224 636

Pro­fes­sor David Richards, of the Univer­sity of Ex­eter Med­i­cal School.

LINDA MOON is a free­lance health and life­style writer.

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