Implementing Behavioral Activation and Life-Steps for Depression and HIV Medication Adherence in a Community Health Center

Abstract

Antiretroviral therapy to treat HIV/AIDS has substantially improved clinical outcomes among patients living with HIV/AIDS, but only in the presence of very consistent adherence. One of the most prevalent and impactful individual-level predictors of poor adherence is depressive symptoms, even at subthreshold levels. Evidence-based cognitive behavioral interventions exist to address improvements in depressive symptoms and adherence in this population, yet these techniques have largely been designed and tested as individual treatments for delivery in mental health settings. This presents a significant challenge when transporting these techniques to medical settings where other formats for delivery may be more appropriate (i.e., groups, less frequent visits) and few hands-on resources exist to guide this process. As such, primary aims of this study were to adapt and implement evidence-based cognitive behavioral techniques for depression (behavioral activation; BA) and HIV medication adherence (Life-Steps) that have potential for dissemination in an outpatient community health center. The intervention incorporated feedback from health center staff and utilized a modular, group format that did not rely on sequential session attendance. Feasibility was examined over 8 weeks (n = 13). Preliminary effects on depression, health-related quality of life, and medication adherence were examined and exit interviews were conducted with a subset of participants (n = 4) to inform future modifications. Treatment descriptions and recommendations for effective clinical implementation based on patient and clinician feedback are provided along with case material of two individual patients and an example group session. Current efforts are an important next step for disseminating evidence-based techniques for depression and HIV medication adherence to community health center or AIDS service organization settings.

Keywords: CBT; HIV medication adherence; behavioral activation; community health center; depression.

Figure 1

Depiction of BA treatment rationale reviewed at the start of each session. This was based upon the BA treatment rationale depicted in Act Healthy (Daughters et al., 2010). Specifically, this figure is introduced to patients step-by-step illustrating how the treatment is meant to break the negative cycle (i.e., where the “x” is) and start a new more positive cycle.

Figure 2

Activity monitoring and scheduling forms introduced and reviewed at each session. This form was adapted from Lejuez et al. (2011).

Figure 3

Life Areas, Goals, and Activities Inventory. Note that only one table per life area is depicted here due to space constraints; however, participants could work on more than one goal in each life area.