The Full Spectrum of Behavioral Activation in Older Adults: A Scoping Review

Abstract

<h3>Introduction</h3> Mental health concerns are common in older adults, and include many symptoms that may not meet criteria for specific DSM-5 diagnoses but which nevertheless affect patients' overall functioning and quality of life. However, timely access to quality mental health care remains inadequate in many communities. Behavioral activation (BA) is a brief psychotherapeutic treatment modality that is gaining momentum as a readily deployable intervention for addressing mental health needs in older adults. Early in its development, BA was primarily conceptualized as a treatment for patients with depression. Since its inception, the intervention has found utility in a broad range of patient populations and conditions beyond what most clinicians and researchers originally imagined. BA has the advantage of being able to be implemented by a range of provider types—e.g., health educators, physicians, mental health providers, family caregivers and community volunteers. Although several reviews have summarized the literature on BA for depression in older adults, there has not been a comprehensive scoping review that has looked broadly at the full spectrum of BA in older adults (i.e., beyond its use for depression). Therefore, the primary objective of this scoping review is to provide a comprehensive overview of the literature on the use of behavioral activation with older adults. This overview includes a categorization of the target conditions (e.g., depression, anxiety), specific populations studied (e.g., caregivers, ethnic minorities, veterans), context or setting (e.g., outpatient vs. inpatient), modality of BA use (i.e., stand-alone vs. incorporated into a larger treatment protocol), and type of individuals delivering the intervention. The aim of this full spectrum review is to provide a comprehensive snapshot of the work done to-date while also highlighting areas of growth for targeted dissemination and knowledge gaps for future study. <h3>Methods</h3> In order to conduct a comprehensive, scoping review of the literature on BA, we utilized both a wide date range as well as broad search criteria. We searched for manuscripts published from 1980 to 2020 in PubMed, PsycInfo, Cochrane, and EMBASE. All types of literature were eligible for inclusion (e.g., reviews, randomized clinical trials, case studies, book chapters). The search strategy consisted of selected keywords and combinations of keywords, which were selected to be inclusive of most scholarly work in the field (e.g., behavio(u)ral activation, older adult, geriatric, depression, anxiety). We did not exclude any specific diagnoses or conditions, as we sought to paint as comprehensive a picture as possible of the landscape related to BA. <h3>Results</h3> The database search strategy yielded 3953 articles; after removing duplicates, 1335 unique publications remained (see attached Figure, PRISMA diagram). Selection of publications for the final scoping review consists of two stages of screening. Initial inclusion criteria were: 1) title or abstract included specific and clear reference to behavioral activation; AND 2) clear focus of article or mean age of participants ≥ 50, OR unclear age of participants (leading to a need for additional screening). These initial inclusion criteria resulted in 640 records which were identified as either: 1) meeting inclusion criteria; OR 2) in need of additional screening in the second stage. Our team is currently conducting the second stage of screening for final inclusion, by retrieving identified manuscripts and reviewing the full text to determine age of participants. The final number, scope, and nature of records/publications included in the scoping review will be presented in the poster. <h3>Conclusions</h3> By casting a very wide net with our search strategy, we have uncovered a collection of articles whose breadth and depth were eye-opening—even to the seasoned BA provider. This broad spectrum of work to date with older adults, as well as their caregivers, underscores the transdiagnostic applicability of BA; targets of intervention or study included mental health conditions (e.g., depression, anxiety, substance use, PTSD, OCD, complicated bereavement, eating and sleep disorders), physical conditions (e.g. high blood pressure, diabetes, obesity, frailty) and psychosocial issues (e.g. loneliness, isolation, grief and loss, spiritual connectedness). This broad search revealed a diverse and surprisingly extensive range of life challenges addressed, in an array of contexts (e.g., in-home, community based, outpatient and inpatient settings), and with adaptations to render BA appropriate for a multitude of languages and cultures. It is hoped that this scoping review will not only identify areas in need of further study, but will thoroughly document the state of the field, giving a boost to dissemination efforts aimed at addressing the growing mental health needs of older adults. <h3>This research was funded by</h3> N/A. Chart: https://apps.aagponline.org/abstracts/uploads/2022/08n7lpw0gg4oebo.pdf