Bounce Back, Reclaim Your Health

Creating community-based self-help strategies to improve the mental health of people with chronic health conditions

In this presentation, I will review why Bounce Back is needed, describe what the Bounce Back program offers to patients, and briefly discuss the evidence supporting the use of guided self-help to treat mild-moderate depression.

Why Bounce Back is needed

It is estimated that over 1 million adults in British Columbia live with chronic physical health conditions such as diabetes, congestive heart failure, hypertension, and asthma (BC Ministry of Health, 2006). These conditions can result in serious health complications which lead to high use of health care services and poor quality of life. Moreover, chronic disease patients often become discouraged due to failing health, dietary and activity restrictions, dependency on medications, and other medical treatments or procedures required to manage their conditions. Importantly, patients with chronic diseases are significantly more likely to experience symptoms of depression and/or anxiety than individuals without a chronic physical disease (Moussavi et al., 2007). The presence of mental health symptoms can interfere with the motivation to engage in self-care activities prescribed as part of a chronic disease management program and lead to further deterioration of health and quality of life (Katon, 2003).

Psychological adjustment to chronic illness can be enhanced when patients remain as active as possible, deal with emotions in a way to take control of their lives, engage in self-management, and are able to see potential positive outcomes of their illness (de Ridder et al., 2008). Consistent with this recommendation, the BC medical community has identified the need for mental health support for individuals living with chronic disease as a key issue.

Cognitive-behavioural therapy (CBT) has been shown to be effective in treating depression and anxiety. CBT is a psychosocial intervention based on the premise that how we think about situations is related to how we feel and behave. CBT-based interventions teach people skills to decrease unhelpful thinking and increase activity which improves how they feel and how they cope with new situations. Since CBT was developed in the 1950s by Dr. Aaron-Beck, a large body of research has accumulated demonstrating the effectiveness of CBT for a number of mental health conditions including depression and anxiety (Butler et al., 2006). However, in British Columbia, CBT services are available only on a limited basis through specially trained mental health professionals and are not readily accessible by primary health care practitioners for their patients.

To address this service gap, the Ministry of Health awarded a $6M grant to the Canadian Mental Health Association (CMHA) – BC Division to develop and deliver community-based, CBT informed self-help strategies to assist primary health care practitioners in meeting the mental health needs of their patients. One promising way to bridge this gap for individuals dealing with mild to moderate levels of depression has been the development of low intensity/high capacity CBT interventions such as bibliotherapy. Bibliotherapy is a self-education intervention in which participants are given reading materials in the form of manuals, and/or other take home materials such as audio/video recordings. These types of resources have proven to be effective in teaching individuals with a mild to moderate level of symptoms the key principles of CBT to help them self-manage their psychological symptoms (den Boer et al., 2004). This type of intervention can involve no contact with a therapist or, in the case of guided self-help, can involve minimal contact with a therapist, for example, in-person or via the telephone. Guided self-help has been shown to be more effective than self-help alone irrespective of whether the coaches are mental health specialists or non-specialists (Gellatly et al., 2007). Furthermore, for patients coping with chronic physical illness(es) and multiple medical appointments, the availability of telephone coaching can offer many advantages including privacy as well as accessibility and convenience, especially for those patients living in rural areas.

The Bounce Back Delivery Model: Overview

The Bounce Back delivery model depends on non-mental health specialist, community-based mental health infrastructure and support. The model has three key features. The first is immediate access for patients to a brief intervention for depression at the point of contact with their family doctor’s office. This intervention is the Living Life to the Full DVD described below. The second feature is the provision of tele-health or distance services that bring mental health coaching to patients in their own homes via telephone. Community coaches working through local CMHA branches help patients complete a structured, short-term mood improvement program using self-help materials. The telephone delivery model allows for branches to serve patients of primary care practices in local and outlying communities. The third critical feature is the provision of “coaching”. Coaching is not the same as counseling or therapy. The materials used in the program provide the benefits of therapy. The coaching enables patients to engage with and get the most out of the materials. These features combine to make Bounce Back a low-intensity but high capacity intervention that can reach a large number of individuals through a brief, easy to implement service.

What Bounce Back offers patients

Bounce Back has adapted resources from a program developed in Scotland by Dr. Chris Williams together with Media Innovations and Hodder Education.

1: Living Life to the Full DVD

The DVD is a 45-minute, professionally produced film that describes the Five Areas Approach using engaging examples from real individuals suffering from depression. Originally filmed in Scotland, the DVD has been edited to include individuals from, and segments filmed in, British Columbia to improve its relevance to the local population. It covers a number of the most common life skills most people can learn to get more enjoyment out of life.

The DVD is a good, first-line intervention for individuals who could benefit from learning about self-help strategies but don’t like to use workbooks or are not ready for a more structured intervention. For patients who may initially be overwhelmed by the self-management requirements around their chronic physical disease, Living Life to the Full can be an easy introduction to the topic of mental health, using engaging and actual examples from real people.

Contents include:

• Why do I feel like I do
• Problem solving
• Building confidence and activities
• Balanced thinking
• Dealing with unhelpful behaviours
• Sleeping better
• Healthy Living
• Assertiveness

2: Overcoming Depression, Low Mood and Anxiety

This resource is a series of structured self-help workbooks for use by people experiencing depression and anxiety. The course provides instruction in CBT strategies, known to be an effective intervention for anxiety and depression. With reading ages between 11 and 14 years, each workbook has been designed to offer essential jargon-free information and provides carefully sequenced series of questions designed to bring about change in how the person thinks and in what they do in order to improve how they feel. This course offers a clear model of intervention based on the Five Areas Approach developed by Dr. Chris Williams.

Contents include:

• Starting out (using the course materials)
• Understanding why I feel as I do?
• Understanding worry and generalized anxiety
• Understanding how we respond to physical health problems
• Practical problem solving
• Being assertive
• Building relationships
• Information for families and friends
• Noticing and changing unhelpful thinking
• Overcoming reduced activity and avoidance
• Using exercise to boost how you feel
• Helpful and unhelpful things we can do
• Alcohol, drugs and you
• Overcoming sleep problems
• Understanding and using antidepressant medication
• Planning for the future

3: Empirical Support

Overcoming Depression and Low Mood is one of the few self-help books available that has been evaluating using randomized controlled study designs (Williams et al., 2008). Findings indicate that people using the book with 3-4 short support sessions from a support worker were less depressed, more able to live their lives and had significantly higher well-being than those receiving usual treatment for low mood in general practice. The Canadian edition of Overcoming Depression, Low Mood and Anxiety is very similar to the UK edition with the addition of two additional anxiety related workbooks. Furthermore, minor adaptations (e.g., wording changes) were made to the workbooks to make them applicable to Canadian culture. Nevertheless, the Canadian edition has all the beneficial qualities of the original edition. The Canadian edition is designed be used in modular format where patients work through specific chapters, or modules, based on their individual needs.

4: Who is eligible for Bounce Back?

Bounce Back is designed to serve individuals who are living with a chronic physical condition such as diabetes, arthritis, hypertension, heart disease, chronic obstructive pulmonary disease or chronic pain and are also experiencing mild-moderate symptoms of depression or depression accompanied by anxiety. More recently, eligibility to enroll in the Bounce Back program has been broadened to include depressed caregivers. Thus, any patient with chronic disease, or chronic pain, or a depressed caregiver, that the primary care practitioner feels is experiencing depression or depression with anxiety is eligible for the DVD. No formal eligibility criteria are suggested.

For the Guided Self-Help program, eligible patients are adults aged 19 and older; experiencing mild to moderate symptoms of depression with or without anxiety (as defined by a score between 5 and 19 on the Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001); interested in acquiring new life skills to manage low mood and worry; functioning at least at a grade 6 literacy level; and, cognitively intact. Persons experiencing severe depression (greater than 19 on the PHQ-9); active suicidal ideation or intent; evident substance misuse disorder (chronic high alcohol intake or routine use of recreational drugs); a history of bipolar disorder or psychosis; or visual problems that interfere with reading are not appropriate for this program.

5: Access to Bounce Back

Access to Bounce Back is currently restricted to BC residents through their regular family physician in select communities. At present the program is not open to self-referrals or referrals from other agencies. Details of which communities currently offer Bounce Back and how to make a referral can be found at http://www.cmha.bc.ca/services/bounceback.

Coach’s Role

Bounce Back guided self-help is designed to be a short term intervention that empowers the individual to acquire and practice new skills that are outlined in a series of workbooks. The coach’s role in the provision of guided self-help is as follows:

• To encourage patients to use the self-help materials and retain a focus on the materials
• To negotiate areas for change and offer guidance on which workbooks may be most helpful
• To help tackle obstacles in using the materials
• To assist in patient plans for putting what they are learning into practice
• To review progress and reinforce skills

Coach training program

Coaches are required to attend a mandatory 3-day learning session prior to delivering services within their local community. The training is delivered by the BC Division project team and registered psychologists with CBT expertise and includes:

• Program delivery model
• Safe and effective working relationships
• Self-help approach
• Components of coaching
• Risk assessment
• Chronic disease management
• Communication with referral sources
• Community relations

On-going consultation

Formal training is followed by weekly telephone consultations sessions to reinforce knowledge and skill development, provide clinical support, and to reinforce the focus on the self-help materials. Both group consultation sessions and individual consultation sessions are used. In addition, coaches record telephone sessions with clients which can then be reviewed to help coaches improve their coaching skills and to ensure adherence to the protocol.

Conclusion

Bounce Back: Reclaim Your Health is the first program of its kind in British Columbia to offer mental health support to individuals suffering from depression and at least one chronic physical condition. The goal of this program is to improve patients’ emotional well-being and quality of life; increase patients’ capacity to engage in self-care activities that contribute to improved health outcomes; prevent complications associated with chronic health conditions; and, reduce avoidable use of hospital and/or emergency departments. Overall, initial feedback from patients, coaches and the community has been encouraging and positive. Referrals have generally been appropriate and a large majority of the referred patients have engaged with the program and derived benefit from the materials. A planned program evaluation will provide critical information regarding the process of implementing the program. In addition, a controlled evaluation of the Bounce Back program will help determine its cost-effectiveness.

references

1. BC Ministry of Health. (2006). Conversations On Health, Lets talk About…Chronic Disease Prevention and Management (November, 2006). http://www.llbc.leg.bc.ca/public/PubDocs/ bcdocs/407902/index.htm, accessed December 15, 2008.
2. Butler, A.C., Chapman, J.E., Forman, E.M., & Beck, A.T. (2005). The empirical status of cognitive-behavioral therapy: A review of meta-analysis. Clinical Psychological Review, 26(1), 17-31.
3. den Boer, P.C.A.M., Wiersma, D., & van den Bosch, R.J. (2004). Why is self-help neglected in the treatment of emotional disorders? A meta-analysis. Psychological Medicine, 34, 959-971.
4. de Ridder, D., Geenen, R., Kuijer, R., & van Middendorp, H. (2008). Psychological adjustment to chronic disease. The Lancet, 372(9634), 246 – 255.
5. Gellatly, J., Bower, P., Hennessy, S., Richards, D., Gilbody, S., & Lovell, K. (2007). What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression. Psychological Medicine, 307(9), 1217-1228.
6. Katon, W. (2003). Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Society of Biological Psychiatry, 54, 216-226.
7. Kroenke, K., Spitzer, R.L., & Williams, J.B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine,16(9), 606-613.
8. Moussavi, S., Chatterji, S., Verdes, E., Tendon, A., Patel, V., & Ustun, B. (2007). Depression, chronic diseases, and decrements in health: results from the World Health Survey. Lancet, 370, 851-858.
9. Williams, C.J. (2006). Overcoming Depression and Low Mood: A Five Areas Approach (2nd ed.). London: Hodder Arnold.
10. Williams, C.J., Wilson, P., Walker, A., Wallace, I., Morrison, J., Witfield, G., & McMahon, A. (2008). An evaluation of the effectiveness of the structured cognitive behaviour therapy self-help materials delivered by a self-help support worker within primary care. Unpublished manuscript.

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