Title: Community-based Behavioural Activation Training (ComBAT) for Depression in Adolescents
Funder: Department of Health and Social Care

Abstract: 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 &ldquo;usual care&rdquo; 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.

Lay abstract: Depression affects children of all ages, but it is more likely to start and escalate in adolescence. Feeling persistently sad or irritable, losing interest in activities and people, and feeling tired most of the time, are the first three symptoms which clinicians look out for, during an assessment for depression. Child and Adolescent Mental Health Services (CAMHS) offer interventions for depression, but their resources are prioritised for severe, complex or high-risk depression. What follows is that, adolescents who experience mild-to-moderate depression, and do not reach the &quot;threshold&quot; for entry into CAMHS, are supported in the community, such as in schools and in youth organisations. Community-based support for depression focuses on general advice about wellbeing and is inconsistent. Behavioural Activation (BA) is a brief psychological intervention recommended for adults with depression. BA's premise is that depression improves through purposeful, rewarding, pleasurable and meaningful activities in our day-to-day life; the more we engage in such activities, the better our mood, our relationships with other people, and our energy levels. The unique feature of BA is that, for adults, it has been successfully delivered by non-specialists in the community. BA has also shown promising results for adolescents, but only when delivered in specialist clinics and evaluated in small research projects. We need to find out whether BA can be effectively used on a large scale in the community to tackle mild-to-moderate depression in adolescents before they deteriorate and need to enter CAMHS. Our research aims to first develop a standardised community-based behavioural activation training (ComBAT) programme for depression, in consultation with adolescents, their parents, and professionals from the NHS, schools and charities. Second, we will evaluate, with a large group of secondary school young people (12-18 year olds), whether ComBAT improves depression more, and leads to a better experience of care and to less CAMHS referrals, than usual care. Third, we will estimate whether ComBAT is good value for money, immediately after the intervention and long-term. Finally, we will make recommendations about how to roll out ComBAT successfully and avoid pitfalls in its wider implementation. Our research is led from the North of England, where there is more need, but less investment, in mental health. We have discussed with young people, parents, and professionals working in the NHS, schools and charities, how we can best raise awareness about depression and potentially engage them in our research. We have consulted with clinicians, service managers and commissioners about how we can make best use of available NHS resources to support ComBAT, so that we can potentially reduce CAMHS referrals. We will involve the NHS, schools, colleges, charities and social care agencies in the interpretation and wider dissemination of our findings as appropriate.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH