This research study is designed to investigate the effects of a brief psychological intervention for improving depressed mood in older individuals (65 years and older) in isolation during the Coronavirus (COVID-19) pandemic. The treatment is delivered by telephone and consists of four weekly individual sessions. Two therapeutic methods are used in combination during this intervention: Behavioral activation (BA) and Mental Imagery (MI). BA involves identifying and scheduling enjoyable and meaningful activities to improve mood and reduce social isolation. To enhance BA efficacy and adherence, MI is paired with BA as MI is known to activate emotion and motivation. The MI intervention in this study involves having participants imagine, in vivid sensory detail, engaging in some of the activities that are scheduled during BA. Approximately 154 individuals will participate in the study. Half of the participants will be randomised to start the intervention immediately, while the other half of the participants will be randomized to a control group receiving the intervention after 4 weeks. This procedure makes it possible to evaluate the effects of the treatment while not disadvantaging participants randomized to the control group. Participants will be asked to fill in questionnaires before, during (at the end of each intervention week), and after treatment (or waiting period for the control group). Questionnaires will also be sent 1-, 3- and 6 months after treatment to follow up on the results. A smaller group of participants (10-15) will be asked to participate in a more detailed interview about how they experienced the treatment.
Coronavirus (COVID-19) has become a worldwide pandemic. The mortality rates are highest in
the older age groups, particularly in those 70 years and older. In Sweden, the government
urges people 70 years and older to limit close contact with other people and to stay at home
as much as possible, a strategy called social distancing. From previous epidemics, such as
the SARS-epidemic, we know that quarantine and isolation leads to psychological symptoms such
as stress, irritability, depressed mood and sleep problems. About 30% of those subjected to
isolation and quarantine become depressed, and in a study from Hong Kong during SARS there
was a nearly 32% increase of suicide rates among individuals 65 years and older. In Sweden,
depression among the elderly was a major public health concern before the covid-19-pandemic -
Major depression occurred in 5-15 % of the older population in Sweden, and one third of the
women and a fifth of the men 65 years and older reported subclinical depressive symptoms.
Several mental health experts raise concerns that there will be an increase of psychiatric
illness during and after covid-19, particularly among the elderly.
Depression in older individuals can be treated with antidepressant medication, psychological
interventions and physical activity. However, the majority of the older individuals state
that they would prefer psychological treatments to medication, which poses a challenge during
COVID-19 as such treatments are often delivered face-to-face. Psychological treatments
delivered via the Internet are as efficacious as face-to-face, but only 3-4% of the
individuals 65 years and above in Sweden use digital applications that replace physical
healthcare visits.
Psychological treatments have been shown to work when delivered via telephone, and since
practically every household in Sweden has access to a telephone, the investigators believe
this could be a feasible option. Preferably, the treatment should be brief yet effective, and
easily accessible for healthcare professionals. One such treatment is brief behavioral
activation (BA), which is aimed at increasing enjoyable and meaningful activities to improve
mood. BA has been shown to be feasible in as few as four sessions. Depression is often
accompanied by low motivation and lack of energy, which can pose a problem when trying to
increase activities. One way of increasing motivation in BA and the likelihood of performing
the planned activities is to add mental imagery (MI), where some of these activities are
imagined in detail during the calls.
However, there are to the investigators knowledge no studies of telephone-delivered brief BA
for older individuals, no studies of the combination of BA and MI for depression in the
elderly, and no studies of either of these during pandemics with isolation or quarantine.
The aim of the present study is to investigate the feasibility, effect and experience of
telephone-delivered Behavioral Activation with Mental Imagery for the treatment of depressive
symptoms in individuals 65 years and older during the covid-19-pandemic.
Behavioral: Brief Behavioral Activation with Mental Imagery
Session 1:
Provide psychoeducation about depression; Provide treatment rationale for BA; Provide rationale and instructions for activity log; Plan activities for coming week.
Session 2:
Review activity log; Discuss life goals and values; Plan activities aligned with life goals and values for coming week; Provide rationale for Mental Imagery (MI); Go through MI-exercise for one of the planned activities.
Session 3:
Review activity log; Troubleshoot any problems carrying out activities; Plan activities aligned with life goals and values for coming week; Go through MI-exercise for one of the planned activities.
Session 4:
Review activity log; Troubleshoot any problems carrying out activities; Review treatment; Stress the importance of continuing to engage in activities aligned with life goals and values; Referral to additional services if necessary.
Behavioral: Minimal Attention Control Intervention
Weekly call with follow-up of psychiatric symptoms and assessment of suicide risk.
Inclusion Criteria:
- Residing in the County of Västmanland
- Access to telephone
- Fluent in written and spoken Swedish
- Reporting clinically significant depressive symptoms above cut-of on depression
measures and/or by structured clinical interview
Exclusion Criteria:
- Severe depression
- Elevated risk of suicide
- Current substance use disorder
- Current or previous manic/hypomanic episodes
- Current psychotic disorder
- Current diagnosis of dementia/major neurocognitive disorder
- Currently receiving psychological therapy
Adult Psychiatric Clinic
Västerås, Västmanland, Sweden
Mattias Damberg, MD, PhD, Principal Investigator
County of Vastmanland and Uppsala University