Child and Adolescent Mental Health 27, No. 2, 2022, pp. 131–137 doi:10.1111/camh.

12474

Feasibility study of a new behavioural activation

programme for young people with depressed mood
Bernadka Dubicka1,2 , Susanne Marwedel3, Sabah Banares4,
Amy McCulloch1, Taghrid Tahoun5, Jasmine Hearn4 & Leo Kroll1
1
Young People’s Mental Health Research Unit, Pennine Care NHS Foundation Trust Headquarters, Ashton-under-Lyne, UK
2
Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
3
Lancashire and South Cumbria, NHS Foundation Trust, Preston, UK
4
Manchester Metropolitan University, Manchester, UK
5
Manchester University NHS Foundation Trust, Manchester, UK

Background: Behavioural activation (BA) is effective in adults with depression but the evidence for young peo-
ple (YP) is less clear. We therefore developed and tested a new coproduced BA programme. Method: In phase
one (2014 to 2015 inclusive), we codeveloped with young people attending specialist child and adolescent
mental health service (CAMHS) an 8-session BA workbook. In Phase two (2019 to 2020 inclusive), we ran an
uncontrolled feasibility study in two specialist CAMHS, with BA being offered to YP by less specialised staff.
Results: In phase one, we tested the workbook with 15 YP with depression and other comorbidities. Satisfac-
tion was good from both YP and staff, and 9 YP reported improvement in mood. In phase two, 51 YP were
offered BA; 15 declined to take part. 36 consented with three dropping out after consent. 33 YP (mean age
14.6, 12 males, 24 females) continued treatment attending a mean of 6.6 sessions. At the end of treatment,
youth-rated Mood and Feeling Questionnaire (MFQ) mean score decreased from 43.2 to 27.6, difference 14.6
(95% CI 8.7 to 20.2; n = 28), and Clinician Global Assessment Score (CGAS) mean score increased from 52.3 to
69.8, difference 18.0 (95% CI 11.9 to 24.2; n = 29). Of the 33 YP who participated in therapy, 12 (36%) recov-
ered and were discharged. Conclusions: This programme demonstrated preliminary evidence for effectiveness
and utility. Less specialised staff were able to use BA, and this may reduce secondary waits for more specialist
therapy. More research is needed about the role of BA in specialist CAMHS.

Key Practitioner Message

• A standardised and comprehensive behavioural activation (BA) programme was coproduced with a group
of young people with high levels of depressive symptoms and complexity attending CAMHS.
• Less specialised clinicians delivered the BA programme with high fidelity within CAMHS.
• Two thirds (22/33) of young people who started the BA programme completed it fully (all 8 sessions) and a
third of those recruited recovered and were discharged.
• This BA programme provides eight workbooks, training, a fidelity measure and digital materials for future
clinical and research use.

Keywords: Adolescence; depression; behaviour therapy; implementation; qualitative methods; service develop-
ment

Behavioural activation is an intervention with a theo-

Introduction
Adolescent depression is common (Sadler et al., 2018),
and cost-effective first-line psychological treatments are
needed to meet the demand for services in the United
Kingdom (Children’s Commissioner, 2020). There is an
urgent need to train practitioners with less specialist
experience to deliver interventions to increase access to
therapy and reduce waiting times for more specialist
care (Health Education England, 2017). Behavioural
activation (BA) may be an intervention that could provide
both an effective intervention and be delivered by less
specialised clinicians. At present, there is a dearth of BA
outcome research with young people using manualised
BA programmes.
retical framework that proposes that increasing engage-
ment in meaningful activity results in improved mood.
Key parts include:- socialisation to the model to under-
stand the ‘depression trap’ and how activities aligned to
values helps recovery; values and goal clarification;
planned stepwise activity scheduling that is supported
by key family, peer and professionals (e.g. staff in
school); and dealing with avoidance (barriers) to activity
scheduling. BA shows promise for young people with
depression but has not yet been tested in large ran-
domised controlled trials (RCTs). In contrast, a large
RCT with adults showed that BA (delivered by less spe-
cialised clinicians) was as effective in improving out-
comes, and more cost-effective, than cognitive

© 2021 Association for Child and Adolescent Mental Health


132 Bernadka Dubicka et al.
behavioural therapy (CBT) with a follow-up period of
18 months (Richards et al., 2017). A recent meta-
analysis detailed that BA for adults is likely to be as
effective as CBT (Stein, Carl, Cuijpers, Karyotaki, &
Smits, 2020).
The BA evidence base for young people is summarised
in two systematic reviews (Martin & Oliver, 2018; Tindall
et al., 2017). The combined effect size of four RCTs was
0.7, suggesting good efficacy of BA. However, this was
derived from a small sample (n = 160 for four collated
RCTs), with considerable variation of focus (group versus
individual), site (schools versus clinics) and young peo-
ple’s clinical characteristics between these studies (Mar-
tin & Oliver, 2018). A variety of published and
unpublished researcher-developed BA manuals and
programmes were detailed in both systematic reviews.
Research is thus needed to address the slim evidence
base for effectiveness of BA in specific groups of young
people.
Our first aim was to codevelop, with young people and
clinicians, a BA programme for use in specialist child
and adolescent mental health service (CAMHS) and
develop a training programme for less specialised clini-
cians such as assistant psychologists (nonclinical psy-
chology graduates) or newly qualified nurses. Our
second aim was to conduct an uncontrolled feasibility
mixed methods study with further development of the
training programme including a website, training videos
and a fidelity measure. This was in preparation for a pro-
posed future RCT.
At the time of the studies, researchers had not devel-
oped a fidelity measure though a new fidelity measure
for the Reynolds BA package (2020) has been developed
recently (Hodgson, 2019).
The two qualitative studies of clinicians’ experiences
of implementation, beliefs and attitudes about BA and
young peoples’ experiences of BA are reported elsewhere
(Shenton, Redmond, Kroll, & Parry, 2020; Whittenbury,
Eve, Kroll, & Bull, 2020).
Methods
Our research started before the BA systematic reviews, and two
BA manuals (McCauley, Schlordt, Gudmundsen, Martell, &
Dimidjian, 2016; Reynolds et al., 2020) were published. Our
focus was on young people with moderate to severe depression
attending specialist CAMHS. In the United Kingdom, specialist
CAMHS services consist of psychiatrists, psychologists, nurses,
social workers and other allied health professionals who see
young people with a range of mental health problems, usually
referred by general practitioners, schools or via self-referral. On
examining the other available BA programmes in 2019, we found
substantial differences in delivery from our package such as cul-
tural use of language and metaphors to explain BA. Also, our pro-
gramme is shorter in length than the McCauley package and
each of our workbooks has an integral risk assessment and
review process, session feedback and goal-based outcomes. The
other BA programmes use handouts for young people whereas
we chose to develop workbooks, which was young peoples’ prefer-
ence. These differences are important to young people and pro-
fessionals, for example, feedback in 2020 was that the workbook
format was preferred compared to the handout format of other
BA packages. Our training guide is comprehensive and illus-
trated with vignettes of young people with complex problems; we
also developed a fidelity rating scale for the eight workbooks.
Our package also provides clinicians and researchers with
additional choice, allowing clinicians to choose a BA program
that suits their needs and context.
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Child Adolesc Ment Health 2022; 27(2): 131–7
For both phase one and phase two studies, we used the same
inclusion and exclusion criteria. We excluded those with sub-
stance addiction, anorexia nervosa, psychosis and those who
had already completed a course of psychological therapy. We
included complex presentations, comorbidity and young people
presenting with self-harm, if risk (clinician risk assessment)
was deemed manageable by the outpatient team.
Phase one: Workbook development
B.D. and S.M. reviewed the available adult BA workbooks at the
time of development in 2014 (e.g. Lejuez, Hopko, Acierno,
Daughters, & Pagoto, 2011). A decision was made to develop a
BA package spanning eight sessions based on clinical experi-
ence and the developing evidence that young people do not stay
in therapy for depression for longer than about 8 sessions.
(Goodyer et al., 2017). There is also evidence now that the opti-
mal number of sessions may be fewer than that reported in the
adult literature (O’Keeffe, Martin, Goodyer, et al., 2019).
Each of the eight workbooks (Figure 1) have a title page, over-
view, session agenda, symptom and risk check, homework
review, session content, session summary (feedback and goals
review) and a parent information sheet. The first four sessions
focus on socialisation to the model, goals and values and activ-
ity scheduling. The following three address avoidance and over-
coming barriers to activation. A final session covers planning for
relapse prevention.
The different components were developed over a 12-month
period using a coproduction approach encouraging young peo-
ple to be involved and influence (Stacey et al., 2015) the develop-
ment of the workbooks. The workbooks were trialled and
changed iteratively with a convenience sample of four young
people (three females and one male aged 14–16) from S.M.’s
clinical case load. Feedback was collected verbally, and from
feedback questionnaires developed for the project, using Likert
scale ratings and free text questions. All feedback was influen-
tial in improving the visual design of the workbook and lan-
guage used. To our knowledge, handouts and visual design of
other BA programmes have not involved young people in influ-
encing the development of BA handouts and explanatory texts.
Once the workbooks were developed, a one-day training
workshop was delivered by S.M. and B.D. and a supervising
clinical psychologist. We trained four less specialised clinicians,
who then used the workbooks in three specialist CAMHS in
Lancashire. Additional feedback from clinicians was used to
further develop a clinician’s guide to the workbooks. We
recruited 15 adolescents aged 11–17, referred to CAMHS with
low mood who self-scored 27 or more on the long-form (child-
rated) version of the MFQ (Wood, Kroll, Moore, & Harrington,
1995).
Ethical approval for phase one was granted by the National
Research Ethics Service Committee North West, in March 2015
(REC reference: 15/NW/0155).
Ethical approval for phase two was from the same committee
in February 2019 (REC reference: 19/NW/0042). Written con-
sent was obtained from young people and parents.
Phase two: Mixed method feasibility study
The second phase was a feasibility study over 10 months (July
2019 to April 2020). This study was initially planned to take
place in two sites in east Manchester (Oldham and Tameside),
although due to loss of staff and service differences, recruitment
largely took place in Oldham. Inclusion and exclusion criteria
were the same as for phase one. We developed the training pro-
gramme further to include a fidelity measure, video training
materials, digital versions of the eight workbooks and a website
delivery platform for staff and young people. When COVID-19
restrictions started towards the end of this study, we adapted
the website further for clinicians to use with young people over
the phone or via video calls. Our training videos were developed
at the request of trainees and provide a standardised introduc-
tion about how to start conversations about key BA ingredients.
We complemented these videos with worked vignettes within
the training manual.
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doi:10.1111/camh.12474 Behavioural activation for depressed mood 133

Session no Session name Session content

Session 1 Geng to know you and Socialisaon to the model and goal seng
geng started
Session 2 Acvity Rang Introducing enjoyment and achievement,
values and life areas
Session 3 What is important to you? Understanding how acvity is linked to values
and life areas
Session 4 Further acvity planning Values-based acvity scheduling
Session 5 Geng stuck Geng support and rewards
Session 6 Avoidance Addressing avoidance in the context of the
behavioural formulaon
Session 7 Problem solving Problem solving worked example
Session 8 Geng well and staying well Review of the programme and goals, next
steps and relapse prevenon

Figure 1. Workbook content

in the supporting information (Appendix S1). Six (6) of

Outcome measures
For phase one, the main outcomes were feasibility (recruitment
and retention) and acceptability of the BA programme for young
people and clinicians. Acceptability of the workbooks and the
programme was assessed using specific questionnaires after
every session, with Likert style questions (rated 1 to 5, 5 being
high acceptability) and free text questions from both young peo-
ple and clinicians. Ratings for the overall programme were col-
lected at the end of treatment in a similar format.
For phase two, our outcome measures were changes in
depressed mood using the self-rated long-form version (MFQ;
Costello & Angold, 1988) and impairment (CGAS; Shaffer et al.,
1983), as well as recruitment and retention. The MFQ was com-
pleted by the young person and the CGAS by the clinician deliv-
ering BA.
Training and supervision
We delivered training for clinicians and supervisors in the phase
two feasibility study over one and a half days and then offered
half-day follow-up training sessions to the clinicians every
3 months. These half-day sessions included specific case dis-
cussion and general clinical dilemma discussions, particularly
dealing with risk, complexity and comorbidity. Usual clinical
supervision for the therapy and case management were offered
fortnightly by local clinical supervisors.
Results: Phase one
Over one year (2015), 15 young people took part, mean
age 14.6 (range 13–16). The two males and 13 females
had a range of comorbidities; nine had anxiety, two had
social communication problems, two had gender dys-
phoria, one had learning problems and one had auditory
hallucinations. Six (6) were receiving selective serotonin
re-uptake Inhibitor (SSRI) medication. The young peo-
ple’s mean MFQ at baseline was 41.5 (SD 8.8) indicating
moderate to severe depression, and their CGAS was 57.1
(SD 11.6), indicating noticeable problems of impairment.
The MFQ is scored from 0 to 66 and a score greater or
equal to 27 is likely to indicate a depressive disorder.
CGAS is scored from 1 to 100 ranging from ‘extremely
impaired’ (1–10) to ‘doing very well’ (91–100).
The acceptability of the workbooks was good or very
good (4 or 5 on the 5-point Likert scale) from both the
young people and clinicians. Acceptability for the BA
programme overall was also either 3 or 4 (‘OK’ or ‘good’).
Free text comments gave suggestions about areas for
improvement, and we adjusted the workbooks, as well
as the clinicians guide. Full detail of feedback is available
the 15 young people completed all eight sessions with 10
completing at least four sessions. Perceived mood from
young people improved for nine of the 15 young people.
We did not collect post-BA MFQ or CGAS outcome data
in this phase.
Results: Phase two
Figure 2 shows the flow of young people and the number
of sessions and questionnaires completed. We used con-
venience sampling and depended on the referral teams
and initial assessment teams to refer young people to the
study. We did not have research resources to screen all
young people with low mood, nor was this a routine pro-
cess in the clinical services. 36 consented to the study, of
which 33 started BA therapy and 27 completed four or
more sessions. Three CGAS ratings were not completed
by referring clinicians on the three YP who dropped out
before starting therapy.
The mean number of sessions completed was 6.6, with
a median of 8.
Table 1 shows the characteristics of young people,
their MFQ and CGAS scores at baseline and after BA
therapy. Paired t-tests were calculated and showed sig-
nificant change on MFQ and CGAS between baseline
and after therapy.
From the young peoples’ case note narratives, 20 pre-
sented with low or minimal risk (using the CAMHS clini-
cal risk assessment procedure of harm, suicidal
thoughts or self-harm), nine with moderate or high risk,
and in this group, risk decreased in six and continued in
the other three throughout BA therapy.
16 young people were discharged from the service.
Three were discharged as they did not engage with any
part of the service (they did not commence BA, despite
consenting to do so). One was discharged after dropping
out after two sessions of BA, outcome was unknown
despite numerous attempts to contact. The remaining
12 were discharged with improvement in functioning
and mood. For the other 20, most were referred to other
parts of CAMHS, though two were referred to external
services (adult attention deficit hyperactive disorder
(ADHD) service and early intervention service for psy-
chosis (EIS). Internal referrals included 2 for autism
spectrum disorder (ASD) assessment, 2 for anxiety work,
1 to the eating disorder service, 3 for attachment/

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134 Bernadka Dubicka et al. Child Adolesc Ment Health 2022; 27(2): 131–7

Screened prior to eligibility

Screened assessment (Convenience)

Decided by clinical team who was

eligible for referral to trial.

Assessed for eligibility (n=51)

Enrolment

Excluded (n=15)
Not meeting inclusion criteria (n=0)
Declined to participate (n=15)
Other reasons (n=0)

Allocation

Allocated to intervention (n=36)

Received allocated intervention (n=33)
Did not receive allocated intervention (n=3) as
dropped out after consent

Sessions /ratings

Completed all eight session (n=22)

Completed more than 4 sessions but less than

8 (n=5)

Completed less than 4 sessions (n =6)

MFQ completed pre (n=36) post (n=28)

CGAS completed pre (n=33) post (n=29)

Figure 2. Phase two, feasibility study flow diagram

psychotherapy work, 1 for trauma-focused work, 4 for
medication review, 1 for family therapy and the other 4
for general review.
Clinical outcomes by clinician rating indicated that 25
improved (CGAS improved by 10 or more points with a
case note narrative confirming improvement). 16 showed
a 10 or more points improvement on the MFQ; 4, more
than 5 MFQ points; and one, an improvement of 3 MFQ
points. Four showed worsening of MFQ scores, which
were not in line with clinical assessment or the young
person’s narrative. Two of these were discharged as
there was agreed improvement, one improved and was
awaiting an ASD assessment, and the other showed no
change clinically and was awaiting a psychotherapy
assessment. Of those that had not improved using the
CGAS indicator, 2 were discharged due to nonengage-
ment; the other 9 continued to be assessed or offered
further treatment.
Fidelity measure
The fidelity measure was developed by A.M., S.B., J.H.,
L.K. and B.D., and adapted (with permission) from a
measure used in another BA trial (Jahoda et al., 2017).
Our measure covers similar areas of process and con-
tent. Process sections (e.g. a collaborative stance, scaf-
folding sessions, showing warmth and empathy)
consisted of 9 items overall: 6 focused on structure and
flow of therapy, 2 sections on communication and 1 on
empathy. Each section is rated on a four-point scale with
anchored descriptions.
The content sections contain items specific for each
workbook with binary ratings for each question. There is
also a general content section that pertains to all ses-
sions.
Of a total of 219 sessions over the course of the study,
we rated 16 sessions (7%) from 5 therapists to assess
adherence to the BA manual and ensure parity and con-
sistency across therapists. We only collected tapes dur-
ing the student MSc study (July to October 2019) and
collected a total of 16 recordings. All these recordings
were rated. Of these 16 sessions, 8 were from session
one, 2 from session two, 1 from session three, 2 from ses-
sion four and 3 from session six. S.B. and A.M. rated
each session independently to assess inter-rater reliabil-
ity. The internal consistency of the process section, mea-
sured by Cronbach’s alpha, was 0.86. Agreement
between raters for the process sections was high overall,
except for one item ‘asking for feedback within current
session’. With this item removed, agreement between
raters was 93%.
Clinician adherence on both process and content
measures was high and consistent across the different
sessions rated. Out of a total score of 36 for the 9 process
measures, the mean score was 32.3 (SD 3.3). For

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doi:10.1111/camh.12474 Behavioural activation for depressed mood 135

Table 1. Characteristics and outcomes phase two feasibility study found similar results (Gudmundsen et al., 2016;
Age Kitchen, Tiffin, Lewis, Gega, & Ekers, 2020; Pass,
Mean 14.5, range 12–17 (SD 1.2) Lejuez, & Reynolds, 2018).
Gender Our retention rate in both phase one and two studies
Male 11 (33%) was in line with other studies such as the IMPACT trial
Female 22 (67%) (an RCT of CBT vs. short-term psychoanalytical psy-
Ethnicity Mixed (White and Asian) (2), Asian chotherapy vs. a brief psychosocial intervention in ado-
(2), Black (African) (1), White lescents with unipolar major depressive disorder
British (28) Goodyer et al., 2017) where 37% did not complete all ses-
Comorbidities (one or 19/33 (58%) had at least one
sions (O’Keeffe, Martin, Goodyer, et al., 2019).
more) anxiety (12), social
Our training programme requires further develop-
communication difficulties (3),
gender dysphoria (1), adhd (1), ment including a competency assessment (Puspitasari
eating problems (1) and auditory et al., 2017), though the findings from the fidelity mea-
hallucinations (1), medical sure development suggest that competency was
problems (4), trauma (3), OCD (1) achieved in the second phase. The fidelity scale helped
Medication clinicians focus on key essential ingredients of BA, as
Antidepressants 4/33 well as open a discussion of the need to be flexible and
Other psychotropic None attentive to therapeutic process.
medication Behavioural activation is being integrated into UK ser-
Questionnaire scores, pre and post
vices such as the Improving Access to Psychological
MFQ baselinea Mean 43.2 (SD 9.3) n = 36
Therapies services (a national programme to deliver psy-
MFQ post-treatment Mean 27.6 (SD 14.7) n = 28
Difference with 95% 14.6 (8.7 to 20.2) n = 28 chological therapies to adults and young people), and
confidence intervals The National Institute for Health and Care Excellence
(paired t) (NICE) (2019) has recommended further research in BA
CGAS baselineb Mean 52.3 (SD 17.8) n = 33 for young people with mild depression. Interpersonal
CGAS post-treatment Mean 69.8 (SD 13.7) n = 29 psychotherapy for adolescents (IPT-A) incorporates
Difference with 95% 18.0 (11.9 to 24.2) n = 29 some aspects of BA, and briefer adapted versions of IPT-
confidence intervals A show promise for mild to moderate depression deliv-
(paired t) ered by youth workers (Wilkinson, Cestaro, & Pinchen,
2018). We believe BA has a place for young people with
a
MFQ is scored from 0–66 and a score ≥27 indicates a likelihood of
a depression disorder. more severe depression, and for young people with
b
CGAS is scored from 1–100 indicating ‘extremely impaired’ (1– comorbidity and risk issues. Findings from adult studies
10) to ‘doing very well’ (91–100). suggest this (Lorenzo-Luaces & Dobson, 2019), and if
this was true for young people, then BA could be offered
as a first-line treatment in specialist services. This might
help free up resources for those young people who are
content, the adherence was 96% for session one, 100% waiting for more specialised therapy.
for session two, three and four, and 83% for session six. Our BA programme, designed for clinical and research
More detail about the fidelity measure is available in the use in a specialist CAMHS context, adds to the two other
supporting information (Appendix S2). manualised BA programmes (McCauley et al., 2016;
Reynolds et al., 2020). We believe our package offers
COVID-19 experience and adjustments some potential advantages, particularly the use of work-
During the latter part of the study, we adapted BA deliv- books to deliver BA. The workbooks provide a clear
ery because of the COVID-19 pandemic. We improved structure for less specialised clinicians, and our training
our website so that staff and young people could view programme was also designed specifically for working
and download the workbooks and complete them digi- within specialist CAMHS and with young people with
tally if they chose to do so. Five young people completed more severe and complex problems. We were keen to
BA during the COVID-19 pandemic using this approach, train professionals to be flexible in the use of workbooks
using video, text or phone communication. and the order in which they were used, particularly if
there were considerable barriers to activation. We feel
flexibility is essential to BA and needs further considera-
Discussion tion. For example, in research with adults, using BA may
Our BA programme and workbooks were coproduced have more impact for adults with depression, whereas
with young people and clinicians over a 6-year period. other strategies may have more utility for anxiety symp-
The two studies suggest that this BA programme may toms (Webb, Beard, Kertz, Hsu, & Bj€ orgvinsson, 2016).
have utility, with good retention rates and satisfaction For supervisors of BA and CBT therapy, there is often
with the programme, as well as feasibility of recruitment. tension about where to focus; cognitions, behaviour or
We have demonstrated that the programme can be used both. Researchers too vary in their focus (Hetrick et al.,
by relatively less specialised staff. 2014) and within BA itself, there is ongoing discussion
The young people who took part had moderate to about the relative importance of a focus on values versus
severe depression, many with comorbid conditions, goals (Stein et al., 2020), with a recommendation for
risk and complexity. Outcomes after therapy from the more research in this area. Interviews with BA therapists
second study are in line with published RCTs of psy- (Cassar et al., 2016) highlight areas that therapists
chological therapies (Goodyer et al., 2008, 2017). regard as important, namely a focus on values, barriers
Other researchers using BA in specialist CAMHS have and activity in producing change. Qualitative research

© 2021 Association for Child and Adolescent Mental Health


136 Bernadka Dubicka et al.
with young people shows that therapeutic process is also
important in therapeutic change and retention within
therapy (O’Keeffe, Martin, & Midgley, 2020; O’Keeffe
et al., 2020; O’Keeffe, Martin, Target, Martin, Target, &
Midgley, 2019).
The COVID-19 pandemic pushed our research study
into adapting our BA website to facilitate clinical work.
Clinician reports (RCPsych digital survey 2020, in sub-
mission) suggest that some initial face-to-face meetings
are needed with young people and their families to
develop a working relationship and assess risk. This can
then be followed by choices of approaches facilitated by
digital platforms.
Limitations
The small sample size, and uncontrolled design of both
phase one and two studies, together with limited out-
come measures limit the findings of our work. In addi-
tion, one site was more successful in recruiting young
people to the study and having staff available to deliver
BA therapy. This was due in part to high staff turnover
and resource pressures on other parts of the service. We
did not follow up the young people over a longer time per-
iod, and larger funded randomised controlled trials are
needed including long-term follow-up and economic
analysis. Although our phase two study suggests effec-
tiveness of BA for young people with more severe depres-
sion, we need better evidence than this study provides. It
may be that BA is no better than general support (Weisz
et al., 2017), however, evidenced-based approaches
probably have additional impact (Deighton et al., 2016).
Conclusion
Behavioural activation has the potential to offer an
evidenced-based personalised first-line treatment for
young people who have all levels of depression severity
and complexity. BA may be deliverable at a more afford-
able cost in terms of training time and clinician experi-
ence level, so freeing up resources for more specialist
intensive therapies within specialist CAMHS.
Acknowledgements
This research did not receive any specific grant from funding
agencies in the public, commercial or not-for-profit sectors. All
authors listed meet the authorship criteria according to the
latest guidelines of the International Committee of Medical
Journal Editors, and all authors are in agreement with the
manuscript. The auhors would like to thank the young people
who took part in this study; colleagues who conducted the
qualitative studies, Kate Whittenbury (who helped develop the
videos), Zarah Eve, Naomi Shenton, Tomos Redmond, Geor-
gina Hurdsfield, Eleanor Bull and Sarah Parry; Lauren Aber-
nethy who filmed and produced videos; Ian Duncan and Lizzie
Lagan who helped with data collection during the study. B.D.
was chief investigator for the projects and coproduced the
manual, fidelity measure and paper. S.M. coproduced the
workbooks and led the phase 1 study. S.B. codeveloped the
fidelity measure. A.M. codeveloped the fidelity measure, the
professional’s manual and video materials. T.T. codeveloped
the professional’s manual. J.H. provided academic support on
the methodology and supervision for S.B. and cowrote the
paper. L.K. was principal investigator for the second project,
codeveloped the professional’s manual, website, videos and
fidelity measure. He led on analysis and writing the paper.
B.D. receives funding from the National Institute of Heath
Research HTA programme and is Editor in Chief of CAMH.
14753588, 2022, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/camh.12474 by University Of Toronto Librarie, Wiley Online Library on [26/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Child Adolesc Ment Health 2022; 27(2): 131–7
The remaining authors have declared that they have no com-
peting or potential conflicts of interest.
Ethical information
Ethical approval for phase one was granted by the
National Research Ethics Service Committee North
West, in March 2015 (REC reference: 15/NW/0155).
Ethical approval for phase two was from the same com-
mittee in February 2020 (REC reference: 19/NW/0042).
Correspondence
Bernadka Dubicka, Young People’s Mental Health
Research Unit, Pennine Care NHS Foundation Trust
Headquarters, 225 Old Street, Ashton-under-Lyne, Lan-
cashire, UK; Email: bernadka.dubicka@manchester.ac.
uk
Supporting information
Additional Supporting Information may be found in the online
version of this article:
Appendix S1. Phase one acceptability data.
Appendix S2. Fidelity development and inter-rater reliability.
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Accepted for publication: 29 March 2021