Can We Prevent Depression in At-Risk Older Adults Using Self-Help? The UK SHARD Trial of Behavioral Activation

Treatment of established depression is the dominant approach to care of older adults, but prevention holds much promise. Self-help interventions are a feasible preventive approach, since they are scalable and low cost. There are few trials in this area. Behavioral Activation (BA) is a credible candi... Full description

Treatment of established depression is the dominant approach to care of older adults, but prevention holds much promise. Self-help interventions are a feasible preventive approach, since they are scalable and low cost. There are few trials in this area. Behavioral Activation (BA) is a credible candidate psychological approach, which has been shown to work in therapist led care but not been trialled in a self-help form. To test the effectiveness of an unguided self-help intervention based on BA for older adults. We compared a self-help intervention based on BA for older people (n = 172) to usual care (n = 160) in a pragmatic randomized controlled trial. Outcomes were depression status and severity (PHQ9) and health related quality of life (SF12). The primary timepoint of the primary outcome was depression at 4 months, with longer term follow up at 12 months to test sustained impact of the primary outcome. At 4 months adjusted PHQ-9 scores for BA self-help were 0.79 lower (95% CI: -1.70 to 0.13; p = 0.09) and the proportion of participants with case-level depression was significantly reduced (BA 31/137 (22.6%) versus usual care 41/141 (29.1%); Odds Ratio 0.48; 95% CI: 0.26–0.92; p = 0.03). There was no PHQ-9 difference at 12 months or for health related quality of life at any point (4 or 12 months). Self-help using BA for older people at risk of depression is a feasible and scalable intervention with potential short-term benefits in preventing depression. •What is the primary question addressed by this study?—can we treat lower severity depressive symptoms and prevent the onset of depression in at risk older adults using a low-technology self-help approach based on behavioural activation.•What is the main finding of this study?—Older people readily engaged with self-help (using bibliotherapy) based on behavioural activation principles. There was evidence of benefit in reducing the severity and incidence of depression in the short term, but this was not sustained at 12 months.•What is the meaning of the finding?—Low intensity self-help interventions are a feasible intervention to potentially mitigate short term risk of depression in older adults. Low intensity self-help interventions can increase access to care and expansion of provision of evidence-supported models of psychological therapy.