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. Author manuscript; available in PMC: 2023 May 1.
Published in final edited form as: Behav Ther. 2021 Nov 26;53(3):458–468. doi: 10.1016/j.beth.2021.11.005

“Do More, Feel Better”: Pilot RCT of Lay-Delivered Behavioral Activation for Depressed Senior Center Clients

Patrick J Raue 1, Matt Hawrilenko 1, Mariah Corey 1, John Lin 1, Shiyu Chen 1, Brittany A Mosser 1
PMCID: PMC9046684  NIHMSID: NIHMS1780740  PMID: 35473649

Abstract

This pilot randomized control trial (RCT) tested “Do More, eel Better” (DMFB), a lay-delivered Behavioral Activation intervention for depressed senior center clients. The study examined: 1. the feasibility of training older lay volunteers to fidelity; and 2. the acceptability, safety, and impact of the intervention. Twenty-one lay volunteers at four senior centers were trained in DMFB. Fifty-six depressed clients were randomized to receive 9 sessions of DMFB or Behavioral Activation delivered by social workers (MSW BA). Research assessments of overall client activity level (BADS) and depression severity (HAM-D) were conducted at baseline and weeks 3, 6, and 9. Eighty-one percent of lay volunteers who underwent training were formally certified in DMFB. Depressed clients receiving each intervention reported high levels of satisfaction and showed large and clinically significant changes in 9-week activity level (d ≥ 1.35) and depression severity (d ≥ 3.34). Differences between treatment groups were very small for both activity level (dMSW = 0.16; 95% CI, −0.70 to 1.02) and depression (dMSW = 0.14; 95% CI, −0.63 to 0.91). Increases in activity level were associated with decreases in depression (β = −0.42; 95% CI, −0.55 to −0.30). Both interventions appeared to work as intended by increasing activity level and reducing depression severity. “Do More, Feel Better” shows the potential of evidence-based behavioral interventions delivered by supervised lay volunteers, and can help address the insufficient workforce available to meet the mental health needs of community-dwelling older adults.

Keywords: older adults, depression, lay-delivered interventions, behavioral activation, aging care settings

Older community-dwelling individuals who attend senior centers have high rates of depression and are underserved. Senior center clients represent large numbers of mid to low-income older adults across the country with multiple social service needs, nutritional insecurity, and financial vulnerability (Aging, 2016; Mabli et al., 2017; Pardasani, 2004; Turner, 2004). Reports have documented that 10-25% of these individuals experience clinically significant depression (Berman & Furst, 2014; Raue, Dawson, et al., 2019a; Sirey et al., 2020). Senior centers do not typically offer mental health services, nor are older depressed adults likely to accept a referral or engage in evidence-based treatment (Gum et al., 2014; Sirey, 2013). Compounding this unmet need is the dearth of existing mental health providers trained to serve older adults (Bartels & Naslund, 2013; Eden et al., 2012). Untreated depression among older adults, even at milder levels, has been linked to a variety of poor health, mental health, and quality of life outcomes (Alexopoulos, 2005; Friedrich, 2017; Gallo et al., 2013; Jia & Lubetkin, 2017; Lyness et al., 2006).

The U.S National Council on Aging (NCOA) and the Substance Abuse and Mental Health Services Administration (SAMSHA) have promoted the importance of integrating mental health programs into aging service settings (NCOA, 2007; SAMSHA, 2012). Given the lack of a geriatric mental health workforce, lay health providers have been identified as a viable solution (Bartels & Naslund, 2013; Eden et al., 2012; Raue, Dawson, et al., 2019a; Raue, Sirey, et al., 2019b). Behavioral interventions delivered by lay providers in aging care settings may be less costly than professionally-delivered interventions, may be equally or more acceptable to older adults, and may show similar effectiveness in improving target and clinical outcomes. Multiple reports have demonstrated that a variety of lay-delivered behavioral interventions are feasible and effective in community and residential settings (Barnett et al., 2018; Bryant et al., 2020; Chartier & Provencher, 2013; Ekers et al., 2011; Quijano et al., 2007).

Toward this end, the study team developed a 9-session Behavioral Activation intervention called “Do More, Feel Better” that matches the skill set of lay providers (hereafter termed DMFB). DMFB was designed to tap into the hundreds of thousands of older adults who serve as volunteers across the national aging network (Aging, 2016). Further enhancing the potential sustainability of DMFB is a culture of health promotion and socialization within senior centers, and existing staff that can be drawn on to support both depression screening and supervision of volunteer activities. Also of note are the health and mental health benefits volunteers themselves may experience from participating in such a program (Anderson et al., 2014; Gruenewald et al., 2016; Tang et al., 2010). Behavioral Activation was chosen as the basis for DMFB given its straightforward nature and fit for older adults, including for those with low education level or mild cognitive impairment (Blazer, 2002; Porter et al., 2004). Numerous studies have documented the effectiveness of Behavioral Activation for depression among both adults (Coffman et al., 2007; Dimidjian et al., 2011; Mazzucchelli et al., 2009) and older adults (Cernin & Lichtenberg, 2009; Chartier & Provencher, 2013).

Early pilot work with New York City senior centers helped refine DMFB and supported the feasibility of training lay volunteers to rigorous fidelity standards (Raue, Sirey, et al., 2019b). A partnership with four Seattle-area senior centers documented the acceptability of DMFB from a variety of stakeholders prior to implementation of the current randomized controlled trial. In particular, 81% of clients would consider participating in DMFB if depressed and 59% of existing volunteers expressed interested in serving as coaches for the intervention (Raue, Dawson, et al., 2019a).

The aims of the current randomized controlled pilot trial were to examine: 1. the feasibility of training lay volunteers to fidelity in DMFB; and 2. the acceptability, safety, and preliminary impact of DMFB, in comparison to Behavioral Activation as delivered by master’s-prepared social workers (hereafter termed MSW BA). The study explored changes in overall activity level (target variable; Behavioral Activation Scale; BADS)(Kanter et al., 2006) and depression severity (Hamilton Depression Rating Scale; HAM-D)(Hamilton, 1960) over 9 weeks, but did not conduct formal null hypothesis significance testing due to this study’s primary purpose as a feasibility trial.

Methods

Participants

Lay Volunteers.

Senior center staff described the study and the DMFB intervention to volunteers whom they believed possessed good interpersonal skills. Investigators followed up with a structured interview guide which used behavioral examples (e.g., “Can you give me an example of how your experience has helped you to help another person going through depression, or having a difficult time emotionally?”) that reflected key competencies (e.g., “Experience/Service to Others”). Eligibility criteria were: age≥60 years; senior center participants; English-speaking; Mini-Mental State Examination (MMSE) ≥ 24 (Folstein et al., 1975); and satisfactory global ratings from the interview guide. Exclusion criteria were: current elevated depressive symptoms (PHQ-9 scores≥10)(Kroenke et al., 2001); or current manic, hypomanic, or psychotic symptoms (SCID IV probes)(First MB, 1995).

Social Workers (MSWs):

Eligibility criteria for social workers were: Master’s of Social Work degree; and English-speaking.

Clients.

Referral to study (stage 1): age≥ 60 years; attended a senior center; and PHQ-9 score ≥10 via routine screening by senior center staff or Research Assistants. Research assessment (stage 2): clinically assessed Hamilton Depression Rating Scale (HAM-D)≥ 14 and ≤25; MMSE ≥ 24 (Folstein et al., 1975); English-speaking; and capacity to consent. Client exclusion criteria: current passive or active suicidal ideation (HAM-D item and Raue Suicide Risk Protocol (Raue et al., 2006)); presence of psychiatric diagnoses other than unipolar, non-psychotic major depression or generalized anxiety disorder (SCID IV); current weekly psychotherapy; or severe or life-threatening medical illness.

Procedures

Four Seattle senior centers participated in the study. The study’s design was to certify 3 lay volunteer coaches and 1 social worker per center, each of whom would see 3 clients.

To keep the research team blinded to client’s randomization status, the study statistician randomized clients using blocked randomization with randomly selected block sizes. A total of 56 eligible clients were randomized at a 3:1 allocation ratio to DMFB (n=42) or MSW BA (n=14). This ratio was chosen to prioritize gaining experience providing DMBF via lay volunteers, as procedures for Behavioral Activation delivery via professionals are already well established.

Research Assistants (RAs) enrolled participants, and the PI assigned them to intervention condition. External mental health referrals were offered to clients in both arms. RAs repeated assessments at weeks 3, 6, and 9 weeks. RAs were blinded to study aims and randomization status at baseline assessment, but were not kept blinded following the baseline. Research interviews and interventions were designed to be delivered in-person when possible. Due to COVID-19 precautions, recruitment, intervention, and assessments with the study’s final eight participants were conducted via telephone.

The study was approved by the University of Washington Institutional Review Board (IRB). All client, volunteer, and MSW participants provided informed consent. Recruitment ran 3/2018-7/2020.

Intervention

Do More, Feel Better (DMFB).

The DMFB manual instructs coaches in using structured agendas and in-session worksheets for each of 9 meetings (see Raue (2019b) for more detailed description). Meeting 1 involved: 1. Introduction of the DMFB program and the role of a coach (i.e., structure of meetings, how coaches facilitate the program, confidentiality); 2. Review of PHQ-9 symptoms (i.e., probes for client perspective on most distressing symptoms, interference with functioning, life context); 3. Psychoeducation about depression and the rationale for DMFB; 4. Compilation of a list of pleasant and rewarding activities, each rated for their current difficulty level by clients (easy, medium, hard); and 5. Daily activity scheduling for the week. Follow-up meetings involved: 1. Monitoring symptom severity via the PHQ-9; 2. Homework review and troubleshooting; and 3. Ongoing daily activity scheduling for the week.

Social Worker Behavioral Activation (MSW BA).

Social workers followed the Brief Behavioral Activation for Depression - Revised Treatment Manual (Lejuez et al., 2011) and offered 9 sessions.

Training and supervision.

Investigators trained eligible volunteers in four 2-hour sessions over 1 month, consisting of didactic on late-life depression, the DMFB intervention, and step-by-step demonstration and role play experiences. Training incorporated discussion of confidentiality, scope of role as coaches, interpersonal boundaries, handling client distress, and procedures for detection of clinical deterioration. At the 4th session trainees role-played a full initial client meeting, and they achieved certification if investigators rated them ≥3 (satisfactory) on DMFB Fidelity forms (Raue, Sirey, et al., 2019b). Ratings were made on a 6-point scale ranging from “very poor” to “very good”. Individual items reflect key elements of the intervention: symptom review, homework review, activity scheduling, agenda setting and time management, and communication and interpersonal skills, with a final global rating integrating all sets of skills. If trainees did not achieve certification after a maximum of 5 simulated role plays, they did not serve as coaches for the trial. Following successful certification, coaches were approved to see depressed clients. Investigators provided 30-minute individual supervision to each coach every week they held an active caseload. Social workers separately underwent two 2-hour training sessions, and they followed the same certification and supervision structure.

Assessment and management of clinical deterioration.

Interventionists in both arms administered the PHQ-9 at the start of every client meeting. Client endorsement of suicidal ideation on PHQ-9 item 9, or total scores that increased by >30% for 2 consecutive meetings triggered an assessment by study investigators and mental health referrals as indicated. Clients with active suicidal ideation were removed from the study and followed up by study investigators to ensure connection to care. Interventionists continued to meet with clients reporting passive suicidal ideation or increased depressive severity, and they provided ongoing support for clients’ engagement in formal mental health care.

Measures

Interventionist fidelity.

An external expert in Behavioral Activation who was not a member of the research team assessed fidelity to each intervention using fidelity forms (Lejuez et al., 2011; Raue, Sirey, et al., 2019b) on one randomly selected audiotaped session per case.

Client measures.

Clients scoring PHQ-9 ≥10 via routinely screening by senior center staff or Research Assistants (RAs) were referred to the study. Two master’s-level students in clinical psychology doctoral programs served as study RAs. Investigators trained and certified RAs in the SCID IV and HAM-D by having them observe standard training videotapes, role play, observe assessment administration, and conduct recorded interviews for supervision and feedback. Following consent of clients who screened positive, RAs assessed cognitive functioning with the MMSE, psychiatric symptoms using the Structured Clinical Interview for DSM IV, depression severity with the HAM-D, and overall activity level with the Behavioral Activation Scale (BADS)(Kanter et al., 2006). In regular meetings, the PI reviewed RA judgments and descriptions of symptom presentation and pervasiveness and then assigned final SCID IV diagnoses. RAs repeated the HAM-D and BADS at weeks 3, 6, and 9. They assessed client satisfaction at week 9 using the 3-item Client Satisfaction Scale (CSQ)(Larsen et al., 1979), a 4-point scale ranging from 0 (strongly disagree) to 4 (strongly agree).

Volunteer measures.

Volunteers completed the following scales at baseline and 12 months later: the 13-item Generativity Scale (Carlson et al., 2015) to assess perceptions of generative desire and achievement; the 10-item General Self-Efficacy Scale (Schwarzer & Jerusalem, 1995) to assess belief in one's competence to cope with stress; and the SF-12 (Ware et al., 1996) to assess overall functioning.

Analytic Plan

The sample size was chosen for pragmatic reasons, and the study was not powered to conduct formal null hypothesis significance testing. Instead, probability that the point estimate of the difference between DMFB vs MSW BA would be within a margin was calculated. With 36 DMFB and 12 MSW-BA participants, there was >77% probability that the mean difference in HAM-D would be within a margin of 2 HAM-D points (Cohen’s d ≤ 0.5) assuming the true difference to be <1 point and a standard deviation of 4 points. A point estimate falling within this margin would provide preliminary information suggesting that the treatments were similar enough to proceed with a fully powered non-inferiority trial. With 36 DMFB participants, there was > 80% power, at an alpha=0.05, to detect a correlation r > 0.44 between improvement in BADS and improvement in HAM-D.

To estimate intervention effects, a two-level mixed effects model with repeated observations (level-1) nested within clients (level-2) was used. Models included a random intercept, random linear slope, and separate fixed effect indicator variables for the 3, 6, and 9- week time points to allow for curvilinear change over time. Condition-by-time interaction terms were included to estimate the adjusted difference between DMFB and MSW BA at each time point. To estimate provider outcomes a similar multilevel model was used, but only the main effect of time was included as only providers in the DMFB condition were analyzed. To estimate the association between activity level and depression, activity level was decomposed into time-invariant baseline scores and time-varying change scores, and these were included as covariates in the mixed effects model (Curran & Bauer, 2011). Consistent with intent-to-treat analysis, all available data were included in the models, regardless of client dropout status. Because the study was not powered for null hypothesis significance testing, inferential tests were not conducted but instead point estimates and 95% confidence intervals were presented for all parameters. Cohen’s d effect sizes were calculated by dividing point estimates by the pooled baseline standard deviation. All analyses were performed in R (R Core Team, 2013) using the lme4 package (Bates, 2007).

Results

Client participant flow and characteristics

The Consort chart (Figure 1) depicts client flow through the study. The study identified 73 clients scoring PHQ-9≥10 by senior center staff or Research Assistant. Of 72 baselines conducted, 56 clients met study eligibility criteria while 16 were excluded for low symptom severity or other psychiatric diagnoses. Eligible clients were randomized to receive DMFB (n=42) versus MSW BA (n=14). Table 1 presents client characteristics by study condition. The mean age for the full sample was 70 (sd=6.1); 80% were female; 70% White, 23% African-American or Black, 7% other race, and 1.8% Hispanic. 86% met SCID IV criteria for major depression, with the remainder endorsing subthreshold symptoms. Nine-week data were available for 33 (79%) DMFB and 11 (79%) MSW BA clients.

Figure 1:

Figure 1:

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Consort Flowchart

Table 1.

Baseline Characteristics of Enrolled Clients

Overall
(N = 56)
 DMFB
(N = 42)
 MSW BA
(N = 14)
N % N % N %
Gender
 Female 45 80.4 34 81.0 11 78.6
 Male 10 17.9 7 16.7 3 21.4
 Other 1 1.8 1 2.4 0 0.0
Race
 White 39 69.6 29 69.0 10 71.4
 African American 13 23.2 11 26.2 2 14.3
 Asian 2 3.6 1 2.4 1 7.1
 Native American 1 1.8 1 2.4 0 0.0
 Other 1 1.8 0 0.0 1 7.1
Hispanic = Yes 1 1.8 0 0.0 1 7.1
SCID Diagnosis Major Depression = Yes 48 85.7 35 83.3 13 92.9
Current Antidepressant Medication = Yes 28 51.9 23 57.5 5 35.7
Mean SD Mean SD Mean SD
Age 70.3 6.1 67.0 5.4 71.5 8.1
Years Education 15.7 2.8 15.7 2.9 15.9 2.3
Duration of depressive symptoms (months) 30.2 96.3 18.4 27.5 64.6 185.7
HAM-D total 18.1 3.2 17.8 3.2 18.9 3.3
BADS total 76.6 21.5 78.4 22.4 71.2 18.4
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Volunteer participant characteristics

Across the four centers, 21 volunteers without a professional mental health background were trained. The mean age was 76.9 (sd=6.6; range=65-89); 85% were female; 65% White, 30% African-American, and 5% Asian. Their mean years of education was 16.8 (sd=2.6).

Feasibility: Lay volunteer certification and session fidelity

Seventeen of 21 volunteers (81%) met the study’s certification standards, while 3 dropped out prior to training completion due to competing time demands and 1 failed to certify. Fidelity ratings based on review of 36 sessions by an external expert revealed that all sessions meet criteria for “satisfactory” or higher fidelity (scores ≥3 on the “Do More, Feel Better” Fidelity form (Raue, Sirey, et al., 2019b).

Acceptability

Thirty-three clients (79%) assigned to DMFB completed 9-week follow-ups, as did 11 clients (79%) assigned to MSW BA. All but one client who were seen via telephone due to COVID precautions completed 9-week follow-ups. Nine-week satisfaction ratings were high for both DMFB (10.6 out of 12; sd=2.2) and MSW BA clients (mean=10.6; sd=1.7).

Clinical Impact

Clients evidenced large decreases in depression severity in both DMFB (B = −10.8; 95% CI, −12.4 to −9.2) and MSW BA (B = −11.4; 95% CI, −13.9 to −8.9; Table 2 and Figure 2). Clients also reported large increases in activity levels in both DMFB (B= 29.1; 95% CI, 20.1 to 38.8) and MSW BA (B = 32.1; 95% CI, 17.1 to 49.1); within group effect sizes for both outcomes all fell in the large to very large range (ds ≥ 1.35 for activity level and ds ≥ 3.34 for depression; Figure 2). Between-group differences were very small for both depression (BMSW = 0.50; 95% CI, −2.3 to 3.3) and activity level (BMSW = −3.0; 95% CI, −19.5 to 13.6), although wide confidence intervals meant that moderately sized effects in either direction could not be ruled out. Increases in activity level were moderately associated with decreases in depression (β = −0.57; 95% CI, −0.73 to −0.40).

Table 2.

Observed and Model-Adjusted outcome

DMFB MSW BA Treatment Comparison
Variable N Mean SD Adj.
Change		 se N Mean SD Adj.
Change		 se Adj.
Group
Diff.		 95% CI Cohe
n’s d 		95% CI Cohen’s d Effect
Size
Depression graphic file with name nihms-1780740-t0003.jpg
Baseline 42 17.8 3.2 --- 14 18.9 3.3 --- --- ---
3 Months 38 10.5 3.8 −7.5 0.6 11 11.9 3.2 −6.3 1.0 −1.16 −3.3-0.9 −0.36 −1.01-0.29
6 Months 34 8.2 4.4 −9.7 0.7 12 8.8 3.1 −9.3 1.1 −0.4 −2.7-1.9 −0.12 −0.83-0.59
9 Months 33 6.7 3.9 −10.8 0.8 11 6.8 3.7 −11.4 1.3 0.5 −2.3-3.3 0.16 −0.70-1.02
Activity Level
Baseline 42 78.4 22.4 --- 14 71.2 18.4 --- --- ---
3 Months 38 101.7 21.6 23.7 3.2 11 92.2 23.0 16.6 5.3 7.2 −4.5-18.8 −0.33 −0.88-0.21
6 Months 34 104.8 23.7 25.9 3.8 12 99.1 25.9 24.2 6.0 1.7 −11.7-15.0 −0.08 −0.70-0.54
9 Months 33 108.7 23.5 29.1 4.6 11 107.7 25.4 32.1 7.5 −3.0 −19.5-13.6 0.14 −0.63-0.91
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Note. DMFB = Do More, Feel Better. MSW BA = Behavioral Activation delivered by providers with a Master’s degree in social work. Adj. = Adjusted. Diff. = Difference. CI = Confidence Interval.

Figure 2.

Figure 2.

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Model-Adjusted Trajectories and Within-Group Effect Sizes

Note. Y-axes are scaled to 2 standard deviations to facilitate interpretation.

Safety

One client receiving DMFB and one receiving MSW BA reported active suicidal ideation on interventionist-administered PHQ-9. Study investigators conducted follow up risk assessments and connected clients to appropriate services.

Impact on Volunteer Coaches

At baseline, volunteer coaches had relatively high scores for Generativity (M = 62.2, sd = 7.1), General Self-Efficacy (M = 32.0, sd = 3.0), and overall functioning as assessed by the SF-12 (M = 37.7, sd = 4.9). Generativity and SF-12 scores did not change across 12 month follow-up (Generativity B = −1.2 ; 95% CI, −5.1 to 2.7; d = −0.17; SF-12 B = −0.1; 95% CI, −2.5 to 2.3; d = −0.01), whereas General Self-Efficacy had significant increases with the effect size in the moderate to large range (B = 2.1; 95% CI, 0.8 to 3.5; d = 0.71).

Discussion

Study data provide evidence for the feasibility and safety of “Do More, Feel Better.” Training procedures yielded success at certifying 81% of eligible older volunteers as coaches. This proportion compares favorably to an earlier pilot where only 64% of volunteers were certified (Raue, Sirey, et al., 2019b), and may reflect the current study’s use of more rigorous interview procedures to determine volunteer eligibility. From a dissemination perspective, aging organizations may expect that a small proportion of volunteers they screen either will not certify or will drop out prematurely. As another indicator of the feasibility of DMFB, all randomly selected sessions from coaches met “satisfactory” or higher fidelity criteria as determined by external audiotape review. One client participant from each treatment condition developed active suicidal ideation, which was detected by routine PHQ-9 screening and confirmed by study investigators. While this detection was an indicator of successful intervention safety precautions, organizations interested in implementing DMFB will be advised to develop suicide risk protocols if not already in place.

Study data also document that “Do More, Feel Better” was an acceptable intervention for depressed client participants, who demonstrated high attendance and satisfaction levels. The study was not powered to formally test non-inferiority hypotheses, yet DMFB showed large and clinically significant increases in activity level and decreases in depression severity at 9 weeks. These increases were akin to those achieved by MSW BA. Further, increases in client activity level on the BADS scale were associated with decreases in depression. This finding is in line with prior research on Behavioral Activation as delivered by professionals that has identified increased activity and decreased avoidance as mechanisms by which the intervention reduces depression (Kanter et al., 2006; Lewinsohn et al., 1980; MacPhillamy & Lewinsohn, 1982; Manos et al., 2010).

Lastly, study data showed that coaches reported significant increases in generalized self-efficacy following participation in the study at 12 months, but not generativity or overall functioning. While prior research has documented more widespread improvements in the psychological well-being, generativity, health, and functioning of older adults from their participation in volunteer activities (Anderson et al., 2014; Gruenewald et al., 2016; Tang et al., 2010), the current study may have had a greater selection bias for high volunteer baseline functioning. Namely, rigorous interview criteria selected older adults with high levels of interpersonal skills, organizational ability, and emotional functioning. It is encouraging that coaches nonetheless reported increased self-efficacy, perhaps reflecting greater confidence achieved by applying “Do More, Feel Better” coping strategies in their own lives.

Taken together, study data provide strong support for pursuit of a fully powered study to investigate the impact of DMFB on the clinical and functional outcomes of depressed clients. While prior initiatives have integrated psychotherapy into community-based organizations (Sirey et al., 2017), “Do More, Feel Better” is the first depression-specific, lay-delivered intervention to be formally evaluated within senior centers. DMFB thus has potential as an innovative lay health-delivered intervention that may help improve access to care and address the unmet mental health needs of older adults. DMFB is consistent with task sharing approaches tested in low- and middle-income countries whereby lay health workers have effectively provided “low intensity” psychosocial interventions for depressed individuals (Gureje et al., 2019; Singla et al., 2019). Research within the U.S. has just begun to address different task sharing models within the United States (Bryant et al., 2020; Choi et al., 2020; Stanley et al., 2014), but their potential is great given limited specialist availability and other access barriers. Growing the field of nontraditional providers in the United States also offers the opportunity to enhance the racial and ethnic diversity of the geriatric workforce, benefiting the growing population of culturally diverse older adults across the country.

Study limitations include a relatively small sample size of volunteers and clients across four senior centers. Secondly, Research Assistants were blind to study hypotheses but not to intervention condition at follow-up assessment points. And while an existing volunteer infrastructure at the national level supports the potential sustainability of DMFB, implementation challenges remain in the absence of research funding (Raue, Dawson, et al., 2019a). In light of these limitations, study findings support the value of “Do More, Feel Better” as delivered by supervised lay volunteers.

Conclusions

Depression detection has increased in many aging care settings due to screening initiatives, but without a corresponding capacity to offer acceptable services to those in need. “Do More, Feel Better” was designed to draw on existing volunteer resources that can address this workforce issue, and is a feasible and acceptable intervention for depressed senior center clients. “Do More, Feel Better” has the potential to be a sustainable intervention offered by senior centers throughout the country.

Supplementary Material

1

Highlights:

  • Lay volunteers delivered “Do More, Feel Better” to fidelity standards.

  • Clinical outcomes were comparable to professionally-delivered Behavioral Activation.

  • “Do More, Feel Better” can increase access to mental health care for older adults.

Footnotes

The authors have no conflict of interest to disclose.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Data Availability

The data generated during and/or analyzed in this study are available from praue@uw.edu on reasonable request or may be accessed via Synapse, an open access data repository, https://www.synapse.org/#!Synapse:syn25450629/files/.

References

  1. Administration on Aging. (2016). Fiscal year 2015 report to Congress: Older Americans Act. Washington, D.C. [Google Scholar]
  2. Alexopoulos GS (2005). Depression in the elderly. The Lancet (British edition), 365(9475), 1961–1970. 10.1016/s0140-6736(05)66665-2 [DOI] [PubMed] [Google Scholar]
  3. Anderson ND, Damianakis T, Kröger E, Wagner LM, Dawson DR, Binns MA, Bernstein S, Caspi E, & Cook SL (2014). The benefits associated with volunteering among seniors: a critical review and recommendations for future research. Psychological Bulletin, 140(6), 1505–1533. 10.1037/a0037610 [DOI] [PubMed] [Google Scholar]
  4. Barnett MA-O, Gonzalez A, Miranda J, Chavira DA, & Lau AS (2018). Mobilizing community health workers to address mental health disparities for underserved populations: A systematic review. Administration and Policy in Mental Health and Mental Health Services Research, 45(2), 195–211. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bartels SJ, & Naslund JA (2013). The underside of the silver tsunami — Older adults and mental health care. The New England Journal of Medicine, 368(6), 493–496. 10.1056/nejmp1211456 [DOI] [PubMed] [Google Scholar]
  6. Bates D, Sarkar D, Bates MD, & Matrix L (2007). The Ime4 package. R package version, 2(1), 74. [Google Scholar]
  7. Berman K, & Furst L (2014). Addressing the needs of depressed older New Yorkers: A public-private partnership: EASE-D and other interventions. Internal Report: NYC Department of Aging. [Google Scholar]
  8. Blazer DG (2002). Self-efficacy and depression in late life: a primary prevention proposal. Aging & Mental Health, 6(4), 315–324. 10.1080/1360786021000006938 [DOI] [PubMed] [Google Scholar]
  9. Bryant C, Brown L, Polacsek M, Batchelor F, Capon H, & Dow B (2020). Volunteer-led behavioural activation to reduce depression in residential care: A feasibility study. Pilot and Feasibility Studies, 6(95). 10.1186/s40814-020-00640-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Carlson MC, Kuo JH, Chuang YF, Varma VR, Harris G, Albert MS, Erickson KI, Karmer AF, Parisi JM, Xue QL, Tan EJ, Tanner EK, Gross AL, Seeman TE, Gruenewald TL, McGill S, Rebok GW, & Fried LP (2015). Impact of the Baltimore Experience Corps Trial on cortical and hippocampal volumes. Alzheimer’s & Dementia Journal, 11(11), 1340–1348. 10.1016/j.jalz.2014.12.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Cernin PA, & Lichtenberg PA (2009). Behavioral treatment for depressed mood: A pleasant events intervention for seniors residing in assisted living. Clinical Gerontologist, 32(3), 324–331. 10.1080/07317110902896547 [DOI] [Google Scholar]
  12. Chartier IS, & Provencher MD (2013). Behavioural activation for depression: Efficacy, effectiveness and dissemination. Journal Of Affective Disorders, 145(3), 292–299. 10.1016/j.jad.2012.07.023 [DOI] [PubMed] [Google Scholar]
  13. Choi NG, Marti CN, Wilson NL, Chen GJ, Sirrianni L, Hegel MT, Bruce ML, Kunik ME (2020). Effect of telehealth treatment by lay counselors vs by clinicians on depressive symptoms among older adults who are homebound: A randomized clinical trial. JAMA Network Open, 3(8), e2015648. 10.1001/jamanetworkopen.2020.15648 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Coffman SJ, Martell CR, Dimidjian S, Gallop R, & Hollon SD (2007). Extreme nonresponse in cognitive therapy: Can behavioral activation succeed where cognitive therapy fails? Journal of Consulting and Clinical Psychology, 75(4), 531–541. 10.1037/0022-006X.75.4.531 [DOI] [PubMed] [Google Scholar]
  15. Curran PJ, & Bauer DJ (2011). The disaggregation of within-person and between-person effects in longitudinal models of change. Annual Review of Psychology, (62), 583–619. 10.1146/annurev.psych.093008.100356 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Dimidjian S, Barrera M Jr., Martell C, Muñoz RF, & Lewinsohn PM (2011). The origins and current status of behavioral activation treatments for depression. Annual Review of Clinical Psychology, 7, 1–38. 10.1146/annurev-clinpsy-032210-104535 [DOI] [PubMed] [Google Scholar]
  17. Eden J, Maslow K, Le M, & Blazer D (2012). The mental health and substance use workforce for older adults: In whose hands? The National Academies Press. 10.17226/13400 [DOI] [PubMed] [Google Scholar]
  18. Ekers D, Richards D, McMillan D, Bland JM, & Gilbody S (2011). Behavioural activation delivered by the non-specialist: Phase II randomised controlled trial. British Journal of Psychiatry, 198(1), 66–72. 10.1192/bjp.bp.110.079111 [DOI] [PubMed] [Google Scholar]
  19. First MB, S. R., Williams JBW, et al. (1995). Structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-IV - patient version (SCID-P). American Psychiatric Press. [Google Scholar]
  20. Folstein MF, Folstein SE, & McHugh PR (1975). “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. 10.1016/0022-3956(75)90026-6 [DOI] [PubMed] [Google Scholar]
  21. Friedrich MJ (2017). Depression is the leading cause of disability around the world. JAMA:The Journal of the American Medical Association, 317(15), 1517–1517. 10.1001/jama.2017.3826 [DOI] [PubMed] [Google Scholar]
  22. Gallo JJ, Morales KH, Bogner HR, Raue PJ, Zee J, Bruce ML, & Reynolds CF (2013). Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care. The BMJ, 346, f2570–f2570. 10.1136/bmj.f2570 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Gruenewald TL, Tanner EK, Fried LP, Carlson MC, Xue QL, Parisi JM, Rebok GW, Yarnell LM, & Seeman TE (2016). The Baltimore Experience Corps trial: Enhancing generativity via intergenerational activity engagement in later life. The Journals of Gerontology: Series B, 71(4), 661–670. 10.1093/geronb/gbv005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Gum AM, Hirsch A, Dautovich ND, Ferrante S, & Schonfeld L (2014). Six-month utilization of psychotherapy by older adults with depressive symptoms. Community Mental Health Journal, 50(7), 759–764. 10.1007/s10597-014-9704-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Gureje O, Oladeji BD, Montgomery AA, Bello T, Kola L, Ojagbemi A, Chisholm D, & Araya R (2019). Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial. Lancet Global Health, 7(7), e951–e960. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Hamilton M (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23(1), 56–62. 10.1136/jnnp.23.1.56 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Jia H, & Lubetkin EI (2017). Incremental decreases in quality-adjusted life years (QALY) associated with higher levels of depressive symptoms for United States adults aged 65 years and older. Health and Quality of Life Outcomes, 15(1), 9–9. https://doi.org/10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Kanter JW, Mulick PS, Busch AM, Berlin KS, & Martell CR (2006). The Behavioral Activation for Depression Scale (BADS): Psychometric properties and factor structure. Journal of Psychopathology and Behavioral Assessment, 29(3), 191–202. 10.1007/s10862-006-9038-5 [DOI] [Google Scholar]
  29. Kroenke K, Spitzer RL, & Williams JB (2001). The Patient Health Questionnaire-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. 10.1046/j.1525-1497.2001.016009606.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Larsen DL, Attkisson CC, Hargreaves WA, & Nguyen TD (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning, 2(3), 197–207. 10.1016/0149-7189(79)90094-6 [DOI] [PubMed] [Google Scholar]
  31. Lejuez CW, Hopko DR, Acierno R, Daughters SB, & Pagoto SL (2011). Ten year revision of the brief behavioral activation treatment for depression: Revised treatment manual. Behavior Modification, 35(2), 111–161. 10.1177/0145445510390929 [DOI] [PubMed] [Google Scholar]
  32. Lewinsohn PM, Sullivan JM, & Grosscup SJ (1980). Changing reinforcing events: An approach to the treatment of depression. Psychotherapy: Theory, Research & Practice, 17(3), 322–334. 10.1037/h0085929 [DOI] [Google Scholar]
  33. Lyness JM, Heo M, Datto CJ, Ten Have TR, Katz IR, Drayer R, Reynolds CF, Alexopoulos GS, & Bruce ML (2006). Outcomes of minor and subsyndromal depression among elderly patients in primary care settings. Annals of Internal Medicine, 144(7), 496. 10.7326/0003-4819-144-7-200604040-00008 [DOI] [PubMed] [Google Scholar]
  34. Mabli J, Gearan E, Choen R, Niland K, Rederl N, Panzarella E, & Carlson B (2017). Evaluation of the effect of the Older Americans Act Title III-C Nutrition Services Program on participants' food security, socialization, and diet quality. Princeton: Mathematica Policy Research [Google Scholar]
  35. MacPhillamy DJ, & Lewinsohn PM (1982). The pleasant events schedule: Studies on reliability, validity, and scale intercorrelation. Journal of Consulting and Clinical Psychology, 50(3), 363–380. 10.1037/0022-006X.50.3.363 [DOI] [Google Scholar]
  36. Manos RC, Kanter JW, & Busch AM (2010). A critical review of assessment strategies to measure the behavioral activation model of depression. Clinical Psychology Review, 30(5), 547–561. 10.1016/j.cpr.2010.03.008 [DOI] [PubMed] [Google Scholar]
  37. Mazzucchelli T, Kane R, & Rees C (2009). Behavioral activation treatments for depression in adults: A meta-analysis and review. Clinical Psychology: Science and Practice, 16(4), 383–411. 10.1111/j.1468-2850.2009.01178.x [DOI] [Google Scholar]
  38. National Council on Aging. (2007). Annual Report: Improving the Lives of Older Americans [Google Scholar]
  39. Pardasani MP (2004). Senior centers: Increasing minority participation through diversification. Journal of Gerontological Social Work, 43(2-3), 41–56. 10.1300/J083v43n02_04 [DOI] [Google Scholar]
  40. Porter JF, Spates CR, & Smitham S (2004). Behavioral activation group therapy in public mental health settings: A pilot investigation. Professional Psychology: Research and Practice, 35(3), 297–301. 10.1037/0735-7028.35.3.297 [DOI] [Google Scholar]
  41. Quijano LM, Stanley MA, Petersen NJ, Casado BL, Steinberg EH, Cully JA, & Wilson NL (2007). Healthy IDEAS: A depression intervention delivered by community-based case managers serving older adults. Journal of Applied Gerontology, 26(2), 139–156. 10.1177/0733464807299354 [DOI] [Google Scholar]
  42. R Core Team. (2013). R: A language and environment for statistical computing. R foundation for statistical computing. [Google Scholar]
  43. Raue PJ, Brown EL, Meyers BS, Schulberg HC, & Bruce ML (2006). Does every allusion to possible suicide require the same response? The Journal of Family Practice, 55(7), 605. [PubMed] [Google Scholar]
  44. Raue PJ, Dawson A, Hoeft T, Russo J, Ferguson D, Green L, Petersky C, & Kaplan C (2019a). Acceptability of a lay-delivered intervention for depression in senior centers. Aging & Mental Health, 1–8. 10.1080/13607863.2019.1698515 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Raue PJ, Sirey JA, Dawson A, Berman J, & Bruce ML (2019b). Lay-delivered behavioral activation for depressed senior center clients: Pilot randomized control trial. International Journal of Geriatric Psychiatry, 34( 11), 1715–1723. 10.1002/gps.5186 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Substance Abuse and Mental Health Services Administration (SAMSHA). (2012). SAMHSA. Behavioral Health, United States, 2012. Rockville, MD: [PubMed] [Google Scholar]
  47. Schwarzer R, & Jerusalem M (1995). Generalized Self-Efficacy Scale. In Weinman J, Wright S, & Johnston M (Eds.), Measures in health psychology: A user's portfolio. Causal and control beliefs. (pp. 35–37). NFER-NELSON. [Google Scholar]
  48. Singla DR, Hollon SD, Fairburn CG, Dimidjian S, & Patel V (2019). The roles of early response and sudden gains on depression outcomes: Findings from a randomized controlled trial of behavioral activation in Goa, India. Clinical Psychological Science:A Journal of the Association for Psychological Science, 7(4), 768–777. 10.1177/2167702619825860 [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Sirey JA (2013). Engaging to improve engagement. Psychiatric Services, 64(3), 205–205. 10.1176/appi.ps.640301 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Sirey JA, Berman J, Halkett A, Giunta N, Kerrigan J, Raeifar E, Artis A, Banjeree S & Raue PJ (2017). Storm impact and depression among older adults living in Hurricane Sandy–affected areas. Disaster Medicine and Public Health Preparedness, 11(1), 97–109. 10.1017/dmp.2016.189 [DOI] [PubMed] [Google Scholar]
  51. Sirey JA, Raue PJ, Solomonov N, Scher C, Chalfin A, Zanotti P, Berman J, & Alexopoulos GS (2020). Community delivery of brief therapy for depressed older adults impacted by Hurricane Sandy. Translational Behavioral Medicine, 10(3), 539–545. 10.1093/tbm/ibz145 [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Stanley MA, Wilson NL, Amspoker AB, Kraus-Schuman C, Wagener PD, Calleo JS, Cully JA, Teng E, Rhoades HM, Williams S, Masozera N, Horsfield M, & Kunik ME (2014). Lay providers can deliver effective cognitive behavior therapy for older adults with generalized anxiety disorder: a randomized trial. Depression & Anxiety, 31(5), 391–401. 10.1002/da.22239 [DOI] [PubMed] [Google Scholar]
  53. Tang F, Choi E, & Morrow-Howell N (2010). Organizational support and volunteering benefits for older adults. The Gerontologist, 50(5), 603–612. 10.1093/geront/gnq020 [DOI] [PubMed] [Google Scholar]
  54. Turner KW (2004). Senior citizens centers: What they offer, who participates, and what they gain. Journal of Gerontological Social Work, 43(1), 37–47. 10.1300/J083v43n01_04 [DOI] [Google Scholar]
  55. Ware J Jr., Kosinski M, & Keller SD (1996). A 12-item short-form health survey:construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220–233. 10.1097/00005650-199603000-00003 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS1780740-supplement-1.doc (218KB, doc)

Data Availability Statement

The data generated during and/or analyzed in this study are available from praue@uw.edu on reasonable request or may be accessed via Synapse, an open access data repository, https://www.synapse.org/#!Synapse:syn25450629/files/.

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