Depression is set to become the leading mental health problem by 2030 (1). For some people, having one or more long-term health conditions puts them at an increased risk of experiencing depression. For those people this can result in lower quality of life and increased mortality. Therefore, The National Institute for Health and Care Excellence (NICE) guidance highlights the importance of looking after both physical and mental wellbeing using care that is patient centred (2).

In Spring 2020 the research team were preparing to run a study (a ‘pilot trial’) as part of the Managing Multiple Health Conditions in Older Adults (MODS) programme of research (funded by the National Institute for Health and Care Research, NIHR). MODS aimed to test a brief type of psychological support, called ‘Behavioural Activation’, which was adapted to help support older adults (65+ years) who have physical long-term health conditions (LTCs) (such as diabetes, asthma, heart problems and so on) and depression or low mood. You can learn more about Behavioural Activation support further down this webpage. The team wanted to look at how helpful this new form of support was compared with the usual care people might already receive. You can find out more about the MODS research here.

Unfortunately, like many research studies, the MODS study was not able to continue as planned due to the arrival of the Covid-19 pandemic. The Covid-19 restrictions (such as social distancing, or the need to self-isolate or shield) led to a disruption of daily routines and limited social contact for most people. This in turn increased the risk of depression, loneliness and social isolation, particularly for older people with existing health conditions. As this group of people were most likely to be impacted by Covid-19 restrictions and were the group of people we were interested in as part of the MODS study, the team decided to respond to the pandemic to support this isolated group.

The existing MODS Behavioural Activation support package was re-focussed to facilitate remote delivery and acknowledge Covid-19 restrictions to support older adults with physical and emotional wellbeing conditions to help reduce depression and loneliness during social isolation. This new programme of research was entitled BASIL (Behavioural Activation In Social Isolation). BASIL was awarded Urgent Public Health status by the NIHR (and was one of only two mental health studies to be awarded this status) enabling the research to be undertaken during the pandemic.

The aim of BASIL was to evaluate the effectiveness of the BASIL Behavioural Activation support in reducing depression and loneliness in older adults with multiple long-term health conditions during isolation. 

The BASIL research programme included three main elements.

1. Modifying the MODS Behavioural Activation support and training of Support Workers to account for Covid-19 restrictions and remote (telephone/video) delivery. 

2. Delivery of a small study (a pilot randomised controlled trial) to test recruitment, retention, and study procedures; and to explore people’s experiences of the BASIL Behavioural Activation support (‘BASIL-C19’). 

3. Delivery of a larger study (a fully powered randomised controlled trial) to evaluate the clinical and cost effectiveness of the BASIL Behavioural Activation support (‘BASIL+’). 

More information about each of these three elements is detailed below.

As part of the MODS programme, we had co-produced a bespoke support package for older adults with multiple health conditions based on Behavioural Activation (BA) (more information about BA can be found above). For BASIL we adapted this support package to specifically consider social isolation and Covid-19 restrictions, and the need to deliver the support remotely. We did this by holding an online co-design stakeholder workshop which comprised of experts by experience, caregivers, health and social care professionals and researchers. In addition, members of the existing MODS Patient and Public Involvement Advisory Group (PPI AG) agreed to continue to support the team with BASIL. The members met with the research team online to discuss the Behavioural Activation support materials. More information about how our PPI members were involved is available here. 

The BASIL Behavioural Activation support was designed to be delivered by trained ‘BASIL Support Workers’. The BASIL Support Worker and participant worked together to develop a collaborative support plan that sought to reinstate (or replace, if former activities were no longer possible because of social isolation and/or long-term conditions) behaviours that connect them to sources of positive reinforcement (valued activity). Behavioural Activation has the potential to address depression and loneliness in the presence of social isolation in this way and the simplicity of Behavioural Activation made it suitable for delivery in the context of Covid-19.

The Behavioural Activation support was delivered over up to 8 sessions. Older adults would work through the BASIL booklet with the support of their trained BASIL Support Worker. All sessions were delivered remotely via telephone or video call, according to participant preference. The first session was scheduled to last approximately one hour, with subsequent sessions lasting approximately 30 minutes. 

Training of support workers was adapted for BASIL to facilitate remote delivery. BASIL Support Workers completed a bespoke Behavioural Activation support training course delivered by Behavioural Activation support  training facilitators which included clinicians and Behavioural Activation experts. The training took place over three days spread out over approximately a two-week period (to allow for practice time between sessions) and was delivered remotely via Zoom. Break out rooms were used to allow for small group discussion and to enable trainees to practice delivering the Behavioural Activation support. Skills practice in breakout rooms could be observed and expert feedback was given.

The training also included access to training materials and study procedures. Presentations and example role-play sessions were developed and recorded. All trainees were required to successfully complete a run through of session one of the BASIL booklet over the telephone with a training facilitator before they could commence delivery of the BASIL Behavioural Activation support. BASIL Support Workers came from a variety of backgrounds including community psychiatric nurses and support workers, assistant psychologists, Age UK care coordinators, psychological wellbeing practitioners, research assistants, social prescribers and wellbeing link workers (see the below infographic for more). 

The BASIL pilot trial commenced in April 2020. Participants (older adults) were recruited via two GP practices based in the North East of England between June and October 2020 (18 weeks in total). Due to the ongoing pandemic and the need to deliver the trial remotely, we worked with a Research Ethics Committee (REC) to develop a flexible consent process which enabled older adults to provide their informed consent (their agreement to take part in the study) either online or over the telephone (or via video call) with a study researcher.

Older adults (65 years or over) with two or more physical long-term health conditions. Examples of long-term health conditions included respiratory conditions (such as asthma or chronic obstructive pulmonary disease (COPD)), diabetes, cardiovascular conditions (such as hypertension or coronary heart disease), stroke.

Eligible older adults were randomised (1:1) to either receive the BASIL Behavioural Activation support or to receive usual care as provided by their current NHS and/or third sector providers; older adults randomised to the usual care group were also signposted to reputable sources of self-help information about how to keep mentally and physically well.

A full list of our outputs can be found here.

• • 96 older adults were happy to join the study using remote methods, for example providing their consent over the telephone or online.

• • 47/96 older adults were offered the BASIL Behavioural Activation support; of these 44 older adults completed two or more sessions.

• • 49 older adults were allocated to usual care with signposting.

• • People were happy to stay in the study and complete the study questionnaires: 90 people (94%) completed their 1 month follow- up questionnaire, 86 people (90%) completed their 3 month follow up questionnaire, and 79 people (82%) completed their 12 month follow up questionnaire. 

• We found that it was feasible to deliver the study remotely using the telephone or video call.
  
  

• Older adults appeared happy to engage in the BASIL Behavioural Activation support over the telephone or via video call.
  
  

• Older adults were happy to complete the study questionnaires with a researcher over the telephone.
  
  

• The initial findings suggested that people who were offered the Behavioural Activation support felt less lonely three months after joining the study.
  
  

• There was also some suggestion that the Behavioural Activation support could benefit levels of depression.
  
  

• BASIL support workers and older adults who were offered the BASIL Behavioural Activation support found the support acceptable.

• One strength of the Behavioural Activation support was whilst it was structured in its approach it was also flexible in its delivery.

• It had a positive impact on mood and wellbeing for most older adults by motivating them to make small, subtle changes to their behaviour or daily routine.

• Nearly all the older adults we spoke to found using the telephone to conduct the behavioural activation support remotely acceptable, and some said it enabled them to be more open and honest with their support worker than they would have been face-to-face.

• The support needs to be person-centred and tailored to an individual’s needs.

• It had a positive impact on mood and wellbeing, suggesting that there is benefit to the older adults

• For some older adults, who initially had not felt they needed the Behavioural Activation support, they benefited from learning how to keep well and avoid deterioration associated with ageing.

You can read about the BASIL pilot trial in more detail in the following published articles

• BASIL Pilot main findings. Access it here. 

• BASIL Pilot - feedback findings. Access it here.

• BASIL Pilot - 12 month follow up findings. Access it here. 

Following the successful BASIL pilot trial, the BASIL Behavioural Activation support was tested in a much larger study (a ‘fully powered large scale randomised control trial’) (BASIL+).

We took some key learnings from the BASIL pilot trial in order to design the larger study. These changes included:

• Older adults who had one long-term health problem but met the 'Clinically Extremely Vulnerable' category in terms of Covid-19 risk were included.

• In addition to having long-term health conditions, older adults also needed to have symptoms of depression or low mood (according to the Patient Health Questionnaire 9) to be eligible to join the study.

• Other changes to the delivery of the trial are shown below.

The aim of the BASIL+ trial was to evaluate the clinical and cost effectiveness of the BASIL Behavioural Activation support for older adults to help with reducing depression and loneliness in older adults with long-term conditions. 

Older adults (65 years or over) with two or more long-term conditions, or a condition that indicated they were within a ‘clinically extremely vulnerable’ group in relation to Covid-19, with symptoms of low mood or depression (which was indicated by a score of 5 or more on the Patient Health Questionnaire (PHQ9).

Eligible older adults were randomised (1:1) to either receive the BASIL Behavioural Activation support or to receive usual care as provided by their current NHS and/or third sector providers; older adults randomised to the usual care group were also signposted to reputable sources of self-help information about how to keep mentally and physically well. 

• 435 older adults were eligible and happy to join the study (via written consent or remote options). 

• 218/435 older adults were allocated to the Behavioural Activation support group, and 217/435 were allocated to the usual care with signposting group

• When joining the study, older adults:

  • were on average 75.7 years old

  • included 270 females and 165 males 

  • mostly reported being White British (402/435)

• Cardiovascular conditions (66.2%) and arthritis (42.8%) were the most frequently reported long-term health conditions.

• Nearly half (46%) reported living alone

• Of the 218 older adults who were offered the Behavioural Activation Support:

  • 175 completed 2 or more support sessions

  • 80 completed all 8 support sessions

  • completed on average 5.2 out of 8 support sessions

• Older adults were happy to remain in the study and complete the study questionnaires: 

  • 358 (82%) completed their 1 month follow- up questionnaire

  • 359 (82%) completed their 3 month follow up questionnaire.

• Behavioural Activation positively impacted older adults’ wellbeing in the short-term (over 3 months)
  
  

• Older adults in the Behavioural Activation group:

• • showed larger (and significant) reductions in depression at 1 and 3 months, compared to older adults in the usual care with signposting group

  • were found to have significantly lower levels of emotional loneliness (but not social loneliness) at 3 months, compared to older adults in the usual care with signposting group

  • had improved quality of life relating to mental wellbeing at 3 months

• The positive impact of behavioural activation was greater for older adults who were experiencing more severe depression when joining the study 

• Larger (and significant) improvements in depression were found for older adults who engaged with 5 or more of the Behavioural Activation support sessions   

• Levels of anxiety were reduced over 3 months

• Early findings from qualitative feedback from older adults who received the Behavioural Activation support sessions and BASIL Support Workers suggest:

• • People responded to each of the Behavioural Activation support elements in different ways, with some drawing more heavily on certain aspects than others, enabling a flexible and person-centred approach.

  • Most older adults described the impact of the Behavioural Activation support  as having had a positive effect on their mood, marked by small or subtle changes to their behaviour. Many talked about feeling better and having a greater sense of self-reliance or independence after taking part in BASIL.

  • Some older adults felt they did not have low mood and found it difficult to engage with the Behavioural Activation support sessions  initially. However, those willing to give it a try went on to benefit, which suggests Behavioural Activation support could be used to prevent deterioration as well as to address low mood.

A full list of our outputs can be found here.

We are currently busy analysing our feedback data from BASIL+ and will be writing it up for publication, keep a look out on our Twitter page (@BASIL_research). 

All of our outputs from the BASIL research programme can be found on the ‘Outputs’ page. You can access this by using the navigation bar at the top of this webpage, or by clicking here.

Our future plans involve considering how the BASIL Behavioural Activation support might be scaled up for implementation within a range of health and care provider settings. This will involve speaking with stakeholders, including those who commission services, to begin to develop an implementation framework.

We are a team of researchers, clinicians and stakeholders. The research was led by the NHS (Tees, Esk and Wear Valleys NHS Foundation Trust, TEWV) and the University of York. Our partners included the Universities of Leeds, Keele and Manchester and Age UK.

The North East North Cumbria Clinical Research Network (NENC CRN) were the lead Clinical Research Network (CRN) for the  BASIL study.

The NIHR BASIL study aligns with the NIHR Yorkshire and Humber Applied Research Collaboration (ARC), where Professors Simon Gilbody and Andrew Clegg lead programmes of research into physical health and mental health, particularly among older people and those with frailty.

To find out more about the NIHR Yorkshire and Humber Applied Research Collaboration please click on the below link:

https://www.york.ac.uk/healthsciences/research/mental-health/projects/mental-and-physical-multimorbidity/

The BASIL programme of research is funded by the National Institute for Health Research Programme Grants for Applied Research (Reference number: RP-PG-0217-20006).

1.      Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. 2013;382(9904):1575-86.

2.      NICE. Multi-morbidity: clinical assessment and management. 2016.