Study could pave the way for a lean and scalable treatment for adolescent depression using behavioural activation

A national study at Hull York Medical School is embracing a simple yet powerful concept to help adolescents facing depression: engaging in enjoyable and purposeful activities can serve as a catalyst for healing.

The study, known as ComBAT, is exploring the transformative potential of a type of therapy known as behavioural activation.

Against the backdrop of a mounting mental health crisis amongst teenagers, this ground-breaking research aims to help adolescents to use meaningful experiences and connections to help treat mild to moderate depression.

ComBAT, which stands for Community-Based Behavioural Activation Training, targets the less severe forms of adolescent depression and takes place in community settings such as schools, charities, and non-specialist primary care mental health services.

Funded by a £2.1 million grant from the National Institute for Health Research (NIHR), the ComBAT study is a pivotal moment in adolescent mental health research.

This innovative study aims to empower young people, instilling a renewed interest in life and vitality through behavioural activation techniques.

Why do we need to address young people’s mental health?

In the UK, nearly a quarter of all adolescent girls and one in ten adolescent boys report depressive symptoms. It is important to provide timely support to young people who experience mild to moderate symptoms of depression.

Professor Lina Gega, Professor of Mental Health at Hull York Medical School and the Inaugural Director of the Institute of Mental Health Research at the University of York, as well as an honorary Nurse Consultant in Psychological Therapies, is at the forefront of this transformative initiative that holds immense potential for young people struggling with depression.

Professor Gega recognises that the urgency to tackle depression in young people stems from two critical challenges.

Firstly, mental health issues often emerge during adolescence, but intervention frequently occurs much later, leaving young people grappling with prolonged struggles. By intervening earlier in the trajectory of mental health problems, the ComBAT study aims to disrupt this cycle and pave the way for long-term wellbeing.

Secondly, specialised child and adolescent mental health services face overwhelming demand, resulting in lengthy waiting lists and limited treatment capacity. The ComBAT initiative seeks to alleviate the strain on these services by empowering a diverse workforce comprising youth workers, teaching assistants, and primary care providers.

Professor Gega said, “Professionals who support young people may help contain the problem and for some of these young people the problem may get better with time, but for many [young people] it just gets worse. And this is when they reach the threshold for specialist services and can access treatment.

“We're trying to decongest the specialist system by upskilling the workforce who helps adolescents anyway to enable them change the trajectory of depression.”

Equipped with evidence-based skills, these professionals will be at the forefront of making a meaningful change for young people’s mental health, providing timely and clinically-informed interventions that can transform lives.

What is behavioural activation?

Behavioural activation is a brief psychological therapy that breathes new life into individuals by giving them positive reinforcement through scheduled activities.

Behavioural activation aims to lift young people’s mood, energise and motivate them. It aims to restore their interest and pleasure in life through enjoyable, purposeful and meaningful activities.

At the same time, behavioural activation aims to counteract avoidance, procrastination, rumination and social withdrawal, all of which feed into depression.

Behavioural activation goes beyond a standard menu of activities, emphasising the significance of doing things that truly resonate with each young person’s individual preferences and meaningful connections.

Professor Gega said, "We do not have robust evidence about the use of behavioural activation for children and adolescents from large clinical trials or economic studies.

“ComBAT is the first definitive study that will give us evidence about the impact and cost effectiveness of behavioural activation for addressing depression among young people.”

About the trial

ComBAT is a 5-year research programme (started in August 2021) and involves a randomised control trial, comparing behavioural activation versus usual care.

The trial involves approximately 240 young people aged 12 to 18, who are being recruited via schools and their wellbeing and pastoral teams, the NHS Single Point of Access (SPA), charitable organisations, and youth services.

The study team, through the Tees, Esk and Wear Valleys NHS Foundation Trust, have provided training to in-house pastoral teams and contracted mental health support workers in delivering the behavioural activation intervention.

The young people who randomly allocated to the intervention will typically receive between 5 and 8 sessions with a trained ComBAT practitioner, and the young people are followed by the study team for a year.

This study will also include interviews with participants, parents, and professionals involved in the study, ensuring a holistic understanding of the outcomes and experiences.

Alongside the trial, the study team will also conduct an economic evaluation to estimate whether the intervention is good value for money. It will compare the cost consequences and cost-effectiveness of the intervention against usual care for NHS and non-NHS agencies.

ComBAT babies

As a result of the work done so far, the ComBAT team have developed two additional, smaller projects – ComBAT Digital and ComBAT Cultural - affectionately referred to as 'ComBAT babies' in the study.

Through their work delivering behavioural activation sessions, the study team have discovered that culture and value-driven activities play a significant role in ComBATing adolescent depression. They have observed that in certain families – due to ethnic, cultural, socioeconomic or other factors - parents’ influence can be strong, both helpful and unhelpful, for their children's scheduled activities.

Professor Gega explained, “For instance, if a family highly values academic achievement or family commitments, but the depressed young person needs to spend more time doing things for fun or being in their own company or being with friends, it becomes essential to schedule fun activities that balance out the time they spend studying to lift their mood. However, this may require negotiation and support from their parents.”

The team is now focusing on developing strategies to make behavioural activation more adaptable and agile, allowing it to be customised to different family contexts, as part of the ComBAT Cultural project.

The study team have also introduced ComBAT Digital. The researchers found that, after young people had completed their sessions with the ComBAT practitioner, young people typically do not maintain their scheduled activities for behavioural activation.

To bridge this gap and help young people remain motivated, the researchers are developing a digital tool, in collaboration with the School of Arts and Creative Technologies and the Department of Computer Science at the University of York.

Professor Gega said, “Young people told us that it can feel like facing a ‘cliff edge’ after they stop seeing their practitioner, despite having new skills and knowing what they have to do to remain well in themselves.

"This new online tool will allow young people to continue practicing the therapy skills they learned during their sessions, ensuring they do not feel like they are suddenly left without guidance. The aim is to prevent relapse and encourage them to maintain their progress by actively engaging with their therapy skills.”

Future outlook

Professor Lina Gega expressed her aspirations for the study, stating, "I hope the results of our study demonstrate that behavioural activation works better than usual care. Not only do we aim for it to be more clinically effective, but also cost-effective, offering good value for money while requiring only a modest investment."

She continued, “The other hope is that the all the people who supported behavioural activation as part of this study, whether they are teachers or wellbeing workers, or charity youth workers, are willing to continue providing this even after the research ends– to have a legacy beyond the duration of the study would be the biggest achievement of all.”

End notes

This project is funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research (PGfAR) Programme (Grant Reference Number NIHR201174). 

A ComBAT Massive Open Online Course (MOOC) ‘Introduction to Behavioural Activation’ has been developed by the ComBAT team in collaboration with the IMPACT team (Professor Najma Siddiqi, Professor of Psychiatry at Hull York Medical School). It uses lay language and is free to access. It is recommended as a primer for professionals before they attend ComBAT workshops.

For more information about the ComBAT study please visit the ComBAT website or contact Professor Lina Gega. Please visit the Mental Health and Addiction Research Group pages for more research in behavioural activation.