Genevieve Riebe, MD, Department of Family and Community Medicine, University of Arizona
|TIPS FOR INCORPORATING ACTIVITY SCHEDULING (AS) INTO PRIMARY CARE TREATMENT OF DEPRESSION
Most older adults with depression initially present to a primary care clinician, and up to 10% of the older adults seen in primary care practice are affected by depression. Many factors can influence the severity of depression, one of which is social isolation. Addressing social isolation can improve outcomes for older adults who have depression.
Activity Scheduling (AS) is an effective behavioral treatment that addresses social isolation in patients with depression. It is an approach that actively involves patients by increasing the number of daily activities in which they participate. Activity scheduling is an established core component of evidence-based depression treatment that has been shown to be just as effective as other forms of cognitive behavioral therapy (CBT). Research shows a strong association between AS and both self-reported activities and depression improvement over the course of 12 months.
AS can take many forms in depression treatment, but the goal is the same - to increase contact with the environment in a positively reinforcing way. Traditionally, AS involves scheduling "pleasant" activities, defined as activities that are pleasurable to patients and which elevate their mood. However, any activity that includes the intention to socialize is associated with better depression outcomes.
In an analysis of behavioral management in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program, it was shown that a wide variety of activities can be effective, and not all of these activities need to be considered "pleasant" activities in the typical sense. Nonetheless, participation in any of them (Table 1) can improve depression outcomes. Even activities such as organizing medications and reflecting on symptom improvement related to medications may reduce stress and lessen symptoms of depression.
Table 1. Examples of "Activity Scheduling" Activities Associated with Improvements in Depression
Incorporating Activity Scheduling Into Practice
Incorporation of activity scheduling into clinical practice involves five steps: diagnosis, discussion, homework, motivation, and reassessment.
Step 1 Diagnosing Depression The U.S. Preventive Services Task Force recommends screening adults for depression when resources are in place to assure accurate diagnosis, treatment, and follow-up. The American Geriatrics Society also supports depression screening for older adults in primary care settings.
Several tools are available for depression screening. The 9-item Patient Health Questionnaire (PHQ-9) is well-validated for use in geriatric populations. The questionnaire takes just a few minutes to administer, can be self-administered, and is available at no cost. Another option is the Geriatric Depression Scale (GDS), a well-validated instrument for which a short form is also available. Both instruments can be easily located with an Internet search.
Step 2 Discuss Activities Once the diagnosis of depression has been confirmed and the patient is felt to be stable (e.g., not suicidal or needing psychiatric hospitalization), AS is initiated by discussing with patients the various activities in which they currently participate, activities they enjoy or think they might enjoy, and activities in which it is realistic for them to participate. These activities can range from traditional pleasurable activities to others, such as those shown in Table 1.
Step 3 Give the Patient Homework Patients should be assigned the task of scheduling and completing the selected activities. Scheduling can be as strict as having a daily calendar that details a specific time for each activity (Table 2). Or, it can be a more relaxed approach of simply jotting activities down in a planner or even making a mental note of the activities that need to occur. Either way, the point is for the patient to actually complete the activities. There is a strong association between discussing and planning activities and self-reported activity engagement at 12 months, lending support to the importance of working with patients to generate an activity plan.
Step 4 Motivate and Encourage AS often means a change in individual daily routines. Changing routines is best done in supportive environments.
Step 5 Reassess Depression severity should be reassessed at intervals, using instruments such as the PHQ-9 or GDS that were used at the time of diagnosis. Comparison of PHQ-9 or GDS scores to scores at the time of diagnosis can help determine if depression is improving. Depending on the patient's progress, changing or adding activities may be appropriate, as might additional therapeutic measures including modifying medication regimens or using other behavioral interventions.
Who are the Best Candidates for Activity Scheduling?
AS is appropriate for a variety of older adults who suffer from depression. There is particular benefit for individuals who spend long periods of time in bed, who are physically inactive, or who have been avoiding family and friends.
AS can also be an adjunct to treatment of individuals whose depression has led them to feel suicidal. These individuals may see their lives as having no meaning or purpose. Giving them activities that engage them in life can help alleviate profound depression and focus their thoughts on constructive activities.
Activity Scheduling and Interprofessional Care
The best late-life depression outcomes come from a collaborative, interprofessional approach to treatment. While activity scheduling is a core component of such an approach, it should not be viewed as an isolated treatment. Pharmacotherapy, other forms of psychological counseling, social service support when needed, and physical therapy (especially for individuals who have become home bound) are all part of what constitutes good depression care. Although not all clinical facilities have the personnel and infrastructure needed to institute a wide variety of effective interprofessional treatments for depression, individual clinicians can still include AS as one component of the treatment they provide to older adults with depression.
|Table 2. Sample Activity Scheduling Calendar|
|8-9 AM||Call daughter||Meet with Fran in park||Balance checkbook|
|9-10 AM||Go for walk||Go for walk|
|10-11 AM||Therapy appt||Food shopping||Write letter to son|
|11 AM - NOON||Lunch w/Sal||Lunch||Lunch|
|NOON - 2 PM||Reading time||Reading time||Reading time|
|2-3 PM||Piano||Piano||Dr. appointment|
|3-4 PM||Garden work||Computer class||Dr. appointment|
|4-5 PM||Garden work||Computer class||Dr. appointment|
|6-8 PM||Cook and eat||Cook and eat||Cook and eat|
|8-9 PM||Watch TV||Watch TV||Watch TV|
References and Resources
- Arean P, Hegel M, Vannoy S, Fan M, Unützer, J. Effectiveness of problem solving therapy for older, primary care patients with depression: Results from the IMPACT project. Gerontologist. 2008;48(3): 311-323.
- Cuijpers P, van Straten A, Warmerdam L. Behavioral activation treatments of depression. Clin Psych Rev. 2007;27: 318-326.
- Kanter J, Manos R, Bowe W, et al What is behavioral activation? A review of the empirical literature. Clin Psych Rev. 2010;30:608-620.
- Riebe G, Fan M, Unützer, J, Vannoy S. Activity Scheduling as a core-component of effective care management for late-life depression. Int J Geriatr Psych. 2012;27: 1298-1304.
- San Francisco Bay Area Center for Cognitive Therapy. Activity scheduling for depressed clients.
- Strawbridge WJ, Deleger S, Roberts RE. Physical activity reduces the risk of subsequent depression for older adults. Am J Epidemiol. 2002;156: 328-334.
- Solomonov N, Bress JN, Sirey JA, et. al. Engagement in socially and interpersonally rewarding activities as a predictor of outcome in "Engage" behavioral activation therapy for late-life depression. Am J Geriatr Psychiatry. 2019. Jun;27(6) 571-578.