‘Pushmi-pullyu’: Developing interventions that address both mental and physical health and wellbeing

Dr Paul Farrand

Interventions for Mental and Physical Health and Wellbeing?

Rationale for Treating Mental and Physical Health Symptoms of depression impact on physical health

Sustained inactivity, poor self-care, poor diet etc Depression and a range of poor health behaviours

often coexist (Gagnes et al, 2002; Simon et al, 2008)

Depression associated with a range of health related conditions Cardiovascular risk (Frasure-Smith et al, 2005) Diabetes (Peyrot & Rubin, 1999) Stroke (Jonas & Mussolino, 2000)

Causality remains undetermined

Association between Depression and Health Risk Behaviour in Middle Aged Women (Simon et al, 2008)

Depression

Limited Physical Activity

High Calorific Intake

Problems with a Dualist Approach

Target Physical Health

Depression Gets in Way

ProblemsFailure/difficulty to recruit

Unrepresentative recruitment/narrow

appeal

Target DepressionLittle Long Term Impact on Physical

Health/Worsening Medical Condition

ProblemsRelapse (both physical health outcomes and

depression)

(Clark et al, 1996; Sherwood et al, 1992; Werrij et al, 2006)

Cognitive and/or

Behavioural Therapies

Physical Activity

Limited general appeal even when supported by a PA specialist (TREAD Chalder et al, 2012)

Limited reach of conventional structured approach (Donaghy & Taylor, 2010)

Depressive symptoms get in way (Ussher at al, 2007)

Depressive relapse (BA alone over 60% relapse at 12 months (Dobson et al, 2008)

Lack of long term focus on physical health outcomes results in little health benefits /worsening health condition

Example – Depression and Physical Activity

Striking the Balance: BAcPAc

Solution: Integrate behavioural activation (BAc) with physical activity promotion (PAc)

Initially treat the symptoms of depression with BAc Evidence based intervention (Ekers et al, 2008) Functional analysis of PAc related activities enabled

during assessment Enables integration of PAc into BAc at beginning of

treatment even though emphasis on BAc

Striking the Balance: BAcPAC As depressive symptoms lift identify opportune

moment to promote PAc PAc intervention informed by evidence (Michie et al, 2009)

Self monitoring combined with at least one other technique from control theory (Carver & Scheier, 1981,

1982) – prompt intention formation, prompt specific goal setting, provide feedback on performance, prompt review of behavioural goals) – most effective

PAc alone may reduce relapse when continued over time (Babyak et al, 2000)

BAcPAc

IllnessIllness: Relapse

PreventionWellness/Wellbeing

Challenges Identifying the opportune moment to introduce PAc Required adaptations to BAc

Tensions with PAc approaches eg MI Cognitions?

Increasing staff confidence to address wider perspective Challenging over confidence (PWP survey)

Workforce? Mental health, physical health, other?

Wider Challenges Specifying 1-2 primary outcomes (CONSORT, 2010)

Multiplicity of analyses (Schultz & Grimes, 2005)

Choice of primary outcomes Eg MUS – treatment of depression and anxiety more

likely to be effective with physical symptom outcomes (Farrand & Woodford, submitted)

Identifying appropriate target population Diagnostic threshold for mental and physical health/risk

behaviour Often reach one or other, not both (Farrand & Woodford,

submitted)

Prevention and treatment being confused (Coyne, 2006)