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Dr Tarun Gupta, Chief Medical Officer, UK Protection, Legal & General Retail, interviews Professor Simon Gilbody, to learn about his findings following a major clinical trial to address loneliness and depression. Also, to discuss potential implications for return to work support.
Tarun: First things first, to what extent is loneliness a problem amongst the working-age population in the UK?
Simon: Loneliness is now part of the national conversation and has become so only in the last 5-10 years. Awareness was raised hugely a few years ago when the US Surgeon General Dr Vivek Murthy famously described loneliness as an epidemic on par with tobacco use and obesity.
I was privileged to supervise a super-bright PhD student around 10 years ago called Dr Nicole Valtorta. She did some really excellent epidemiology and created systematic reviews that charted, irrefutably, the link between loneliness and an increased risk of developing coronary heart disease and stroke. This link was still there even when you tried to iron out all the alternative explanations.
The link between loneliness and poor physical health, as well as mental health, set me on a personal journey. I was interested in the wider impact of that too, such as the ability to work, hold down a job and be productive.
We know, through Office for National Statistics research, that a fairly consistent 6-8% of the UK population – around 4 million people – is impacted by chronic loneliness; that’s the unremitting type of loneliness, that’s going to impact both physical and mental health.
So, it’s a significant issue; one that further came to the fore during the Covid-19 pandemic. Lots of people, at all ages, became much more socially isolated. The pandemic helped raise public awareness of the issue of loneliness.
And, during that time, we started thinking about how we could respond to the problem as a research community.
Tarun: Please tell me about you research here; in particular, the Behavioural Activation in Social Isolation clinical trial, or BASIL+ for short. How did that come about?
Simon: We secured a substantial grant pre-pandemic, funded by the National Institute for Health and Care Research (NIHR) to carry out a major clinical trial. We were to design and deliver a brief, scalable intervention, for people with multiple long-term conditions who are at particular risk for depression and, to a lesser extent, anxiety.
For the last 20 years, we’ve come up with scalable, slightly simplified interventions, that tend to focus on the core effective ingredients of psychological therapies.
This has involved finding parsimonious psychological interventions that work and that we can take out of clinical psychology out-patient clinics. Ultimately, we’re looking at how interventions might be more readily delivered in primary care, or via a workforce that hasn’t been through six to eight years of specialist clinical training.
For the purposes of this latest trial, we wanted to focus specifically on the B of CBT (Cognitive Behavioural Therapy). Our theory was that if we simplify things, by focusing on improving the behavioural aspect on its own, then the cognitive aspect will naturally improve too. This would effectively remove the complexity of full CBT in terms of things like logging emotions and getting people to think about the difference between thought and emotion. This is the essence of behavioural activation, which has a long tradition in psychological research but is not as widely used as CBT.
So, we were all ready to go with our clinical trial, then the pandemic hit and NIHR and the comprehensive research networks [their delivery arm in the NHS], said all trials are cancelled so please send your workforce home.
We were just about to put everyone on furlough, then we thought what else can we do here.
Now, I’m a part of the sandwich generation, caring at the time for younger and older dependents; the latter in terms of my dad, who had COPD (Chronic Obstructive Pulmonary Disease) and peripheral vascular disease (reduced circulation of blood to parts of the body).
He liked to go down the pub to hang out with his mates three or four times a week. All of a sudden, as a result of lockdowns, he was told he couldn’t interact with anyone else, and I could see his mental and physical health slipping away.
Many of the team were in the same situation and we wanted to help address this, but there was nothing around. Together with brilliant colleagues [Professors David Ekers and Dean McMillan], we took what we had on the shelf, which was a very brief behavioural activation intervention and, together with our team, we sat down – socially distanced! – with various older people with long-term conditions, who effectively told what we were hearing from our parents; that they were socially isolated and [as Dr Nicola Valtorta predicted] this was impacting on their mental and physical health.
Never ones to let a crisis go to waste, we designed what turned out to be the largest ever trial of a brief psychological intervention to tackle loneliness. The NHS went on a war footing and delivered some the best research in its history.
Tarun: So, a clinical trial at a time when loneliness was probably at an all-time high. What did the trial involve? And what did the results show?
Simon: Focusing on the B rather than the C of CBT, as mentioned, we designed a ‘behavioural activation’ intervention to address low mood and social isolation. This centred on helping people maximise their social networks and interactions, even when they couldn’t physically meet others face to face.
We recruited between over 500 participants who’d been told to shield during the pandemic. These were people with multiple long-term conditions, who were at a high risk of depression. As you can imagine, levels of social isolation for this population had just gone through the roof.
The trial involved the delivery of weekly phone calls, over an eight week period, to each member of this population. The calls were delivered by specially trained coaches who helped participants maintain their social connections and remain active.
We also got this trial, now known as BASIL+, adopted on an important trials’ portfolio called the ‘NIHR Covid Urgent Public Health Programme’. This was the programme that delivered all the great vaccine trials and the RECOVERY trials programme. Ours was the only trial focused on mitigating some of the psychological impacts of the pandemic.
We demonstrated that in this ‘at risk’ population we were able to achieve two things: prevent the onset of loneliness; and reduce and prevent the incidence of depression.
This evidence, combined with the results of various other clinical trials over recent years, gave us irrefutable evidence that if you can adapt cognitive and behavioural interventions and target them at social interactions, you get a benefit in terms of mental health but also in reducing levels of loneliness. We see that as a ‘double benefit’.
So, we emerged from the pandemic with a greater sense that loneliness is important. And, also, a better sense of how we might help with that.
Tarun: Can you please explain what you mean by ‘behavioural activation’ – the core element in this clinical trial? And how does it work?
Simon: In simple terms, doing stuff is good for your physical health and your mental health. One of the first things you do when you feel depressed is you stop doing stuff. In psychological terms, there is a loss of positive reinforcement and the emergence of avoidant behaviours and negative reinforcement.
So, the basic thesis for behavioural activation is that you get people to do stuff and recognise avoidance because that improves their mental health.
The first thing you do is get people to plan what they’re going to do on a daily basis. So, instead of just waking up to foreboding and dread about the day ahead, you wake up with a plan about what you’re going to do.
When you’ve got a plan to introduce positive reinforcement and address avoidance, it’s easier to stick to it. So, this is about spending some time helping people put that plan in place.
It takes a few sessions to get that right, but you notice early gains with behavioural activation. When people are getting back on track, we gradually challenge them to do more difficult things and to think more creatively, positively reinforcing purposeful activity.
Tarun: Thinking about that in a workplace sense, the way we, as an insurer and provider of Vocational Rehabilitation (VR) support, design and deliver return to work programmes could arguably be considered to have a behavioural activation element. A successful return to work is as much about small behaviours on the road to a return – such as logging in to keep up to date with what’s happening at work – as it is about personalised treatment. Would you agree there’s a role for this in a return to work context?
Simon: Yes, it probably lends itself to that structured nature of having an action plan – in your case a return-to-work plan and a recognition of the key role of avoidance and negative reinforcement.
Having a plan is integral to behavioural activation; activity scheduling is one of the core ingredients.
Tarun: So, with that in mind, could the behavioural activation model be applied and delivered by professionals in the field of employee health and wellbeing?
Simon: Yes, absolutely. One of the things that we learnt from the BASIL+ trial was that if we’re going to have a workforce to deliver this, it’s really important that we find people who are readily accessible and can deliver this at scale.
The main criterion for it was: good interpersonal skills – the ability to engage people; and willingness to complete a two day training programme.
We ended up with a range of individuals, from skilled healthcare professionals – nurses in particular were keen to be involved – to receptionists in healthcare practices who often have great interpersonal skills.
So, thinking about the transferability of this model of care to Vocational Rehabilitation, it’s well within the gift of the range of professionals who deliver this with skill and expertise.
It’s also something that could arguably – and easily – be integrated into Employee Assistance Programmes (EAPs).
Tarun: It’s clearly something that’s transferable and scalable, so how can we take that forward in a practical way?
Simon: It could be easily and readily integrated into existing rehabilitation programmes.
Also, it’s readily adaptable for a range of different severities and durations of sickness; from those with lower severity disorders who might not, yet, have taken sickness absence, through to people long-term absent and struggling to get into the right mindset and routine to consider a return to work.
Tarun: And, finally, this is obviously an individual-focused intervention, but do you think there’s a role for organisations to also consider loneliness as part of their wider work in creating environments that prevent issues like loneliness?
Simon: So, thinking about loneliness as a ‘thing’, what we have here is an intervention targeted at the individual who’s either got a disorder or is at risk.
But I wouldn’t view this in isolation. Some of the things that are really important for employers to consider are the work and the environment – or culture. Adversity in the workplace can be a triggering event for workplace absence, and behavioural activation can help get people back to work. However, the role of culture and environment cannot be ignored.
Some of the organisational or vocational aspect of the job might be driving loneliness or depression. It’s crucial, therefore, for employers – as part of wider wellbeing strategy – to identify and attend to those organisational factors; be they systems, structures, policies, practices or behaviours. In our group [the Behavioural Therapeutics Lab] we have borrowed the phrase that ‘an ounce of prevention is worth a pound of cure’ and we like to think about prevention from both the individual and organisational level.
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