Theories of emotion see affective processes as important in guiding behaviour, and social/cognitive theories have implicated cognitive appraisals in a motivational context. The control-value theory combines these approaches, predicting that high levels of expectancy and control lead to associated levels of anticipatory affect in those approaching a goal. This theory, combined with literature on approach motivation in depression, led to the proposed model of the effect of depression on behavioural striving, and subsequent levels of depression. The current study aimed to test this model. Sixty participants completed measures of depression, approach-related affect, cognitive appraisals and striving behaviour in relation to their own personal goals, with follow-up measures of depression and striving behaviour completed two weeks later. They also participated in an experimental manipulation of approach-related cognitive appraisals. The model received mixed support, with strongest evidence for the proposed pathway from depression to anticipatory affect via cognitive appraisals, especially for those who were at least mildly depressed. However contrary to the model, depression was not found to be associated to striving, and no variables other than depression predicted future depression. The study was conducted with a non-clinical population, there was reduced power at follow-up, and the experimental manipulation may have been unsuccessful. This study provided preliminary support for the new model, and although findings were mixed, future research may be more conclusive. Findings suggest that therapy specifically tapping into approach-related cognitive appraisals, as well as approach-related affect, may be therapeutically beneficial in working with depression.

Purpose: Postnatal depression (PND) has significant negative outcomes for both mother and baby. The literature indicates that cognitive behavioural interventions can be effective and efficacious treatments, less is known about what mechanisms underpin change in such interventions. The present study aimed to explore severity of depression as a moderator and Behavioural Activation (BA) as a possible mediator of treatment outcome in an online BA intervention for PND. Methods: Follow-up of postnatal women participating in a feasibility Randomised Controlled Trial (RCT) of Netmums, an online BA treatment with telephone support. Results: There was no evidence to support the hypothesis that severity of depression acted as a moderator for treatment outcome. No mediation effects for BA were found. Rumination and avoidance did predict treatment outcome, but this did not differ between the treatment and control group. Post Hoc sudden gains analysis revealed that 48.90% of the treatment group sample experienced a sudden gain. Those who experienced a sudden gain had better post intervention outcomes. Conclusions: The findings have important implications for both theory and the design of future interventions. Future research should consider collecting weekly measures from both treatment and control groups.

Background: There is increasing evidence supporting the potential use of physical activity as an intervention for depression. However, effective behavioural interventions which focus on encouraging physical activity in people with depression are needed. Aim: This thesis reports on the development and pilot evaluation of a web-based intervention based on behavioural activation (BA) and physical activity promotion for people with depression (eMotion). There is also a specific focus on intervention fidelity. Method: A systematic review was conducted to identify how fidelity is assessed in behavioural interventions promoting physical activity in adults. Findings from the systematic review and the Centre for eHealth and Disease Management (CeHReS) Roadmap informed the development of eMotion. A novel “design fidelity” methodology was devised, which involved using an independent coder to systematically verify the presence or absence of intended and non-intended behaviour change techniques (BCTs). A pilot RCT of eMotion was conducted to provide evidence on the feasibility and acceptability of eMotion, and exploratory data on outcomes. A mixed methods process evaluation of the understanding, feasibility and enactment of the main BCTs used in eMotion, and participant’s perceptions of eMotion was conducted. Results: The systematic review presents a critical appraisal of the wide range of methods and measures used to assess intervention fidelity. The eMotion intervention consisted of weekly modules designed to re-engage people in routine, pleasurable, necessary or physical activities. Design fidelity of the intervention was excellent with discrepancies between intervention materials and the intended design for 12 out of 221 (AC1 =0.91) and 14 out of 221 (AC1 = 0.88) BCTs relating to BA and physical activity respectively. In the pilot trial, 62 people (≥10 on the PHQ-8) were randomised, and the two-month attrition rate was 19% (95% CI: 11 to 30%). Study completers in the eMotion group (n=25) had a significantly larger reduction in depressive symptoms than the waiting list control group (n=25) (Adj Mean Diff -3.6, 95% CI: -6.1 to -1.1). Participants using eMotion also reported significantly higher levels of understanding, ability and enactment of most BCTs compared with controls. Interviews with participants revealed a number of possible mechanisms by which eMotion may have changed behaviour (e.g. increased awareness of the link between mood and activity) and reduced depression (e.g. through distraction). Conclusion: This thesis has reported on the development and pilot evaluation of a behavioural intervention promoting physical activity for depression while focussing on fidelity. Further insight into a number of methodological and clinical implications for the conduct of future RCTs in this area has also been provided.

Yes / Printed participant information about randomised controlled trials is often long, technical and difficult to navigate. Improving information materials is possible through optimisation and user-testing, and may impact on participant understanding and rates of recruitment. Methods: A study within a trial (SWAT) was undertaken within the CASPER trial. Potential CASPER participants were randomised to receive either the standard trial information or revised information that had been optimised through information design and user testing. Results: A total of 11,531 patients were randomised in the SWAT. Rates of recruitment to the CASPER trial were 2.0% in the optimised information group and 1.9% in the standard information group (odds ratio 1.027; 95% CI 0.79 to 1.33; p=0.202). Conclusions: Participant information that had been optimised through information design and user testing did not result in any change to rate of recruitment to the host trial. Registration: ISRCTN ID ISRCTN02202951; registered on 3 June 2009. / UK National Institute of Health Research Health Technology Assessment Programme (project number 08/19/04) / This article is included in the Studies Within A Trial (SWAT) collection (https://f1000research.com/collections/swat)

Purpose: Postnatal depression has significant negative outcomes for both mother and baby. Cognitive-behavioural interventions have proven promising in its treatment, but there are a number of barriers, specific to the postnatal period, which lead to low take-up of treatment. Online interventions may circumvent some of these barriers. However, evidence of long-term follow-up is sparse, in spite of the importance of knowing how such treatments work over the longer-term. Methods: Long-term follow-up of postnatal women participating in a feasibility randomised controlled trial of NetmumsHWD, an online behavioural activation treatment with telephone support. Results: Retention rates of over 70 percent were obtained. There were small but non-significant effects of treatment on depressive symptomology and behavioural activation scores at 16 months post-randomisation. Baseline depression and behavioural activation scores predicted attrition prior to the implementation of outreach strategies for data collection; these systematic differences in attrition disappeared post-implementation. Measures of treatment adherence were not related to outcome. Conclusions: Collection of long-term follow-up data from postnatal women appears feasible. The findings demonstrate the importance of outreach in maximising retention, especially in relation to the generalizability of results. Future research should consider ways to assess treatment engagement and its relationship with outcome.

Background: Despite their potential as low-threshold, low-cost and high-flexibility treatments of depression, behavioural activation and physical exercise have not yet been directly compared. This study will examine the effects of these interventions, administered via the Internet. The added effect of providing a treatment rationale will also be studied, as well as a relapse prevention program featuring cognitive behavioural therapy components. Methods/Design: This randomised controlled trial will include 500 participants meeting the diagnostic criteria for major depression, recruited in multiple cycles and randomised to either a waiting list control group with delayed treatment, or one of the four treatment groups: (1) physical exercise without a clear treatment rationale; (2) physical exercise with treatment rationale; (3) behavioural activation with treatment rationale; or (4) behavioural activation without a clear treatment rationale. Post treatment, half of the participants will be offered a relapse prevention program. Primary outcome measure will be the Patient Health Questionnaire 9-item. Secondary measures include diagnostic criteria for depression, as well as self-reported anxiety, physical activity and quality of life. Measurements done via telephone and the Internet -will be collected pre-treatment, weekly during treatment period, immediately post treatment and then monthly during a 24-month follow-up period. Discussion: The results of this study will constitute an important contribution to the body of knowledge of the respective interventions. Limitations are discussed.

Background: Research into the benefits of exercise for individuals with Bipolar Disorder (BD) is limited and no current guidelines exist around recommending exercise during a hypomanic/manic state. The Behavioural Activation System (BAS) dysregulation theory is a popular model that attempts to explain the link between approach motivation (AM) and the difficulties that individuals with BD experience. It may offer an explanation for the ‘upward spiral’ reported by individuals with a diagnosis of BD in response to certain types and intensities of exercise. This study looked to investigate the impact of different intensities of exercise on the maintenance of AM levels. The presence of hypomanic traits and how these interacted between AM and exercise was also of interest. Method: Participants filled out an online pre-screening questionnaire identifying hypomanic traits. 61 then completed a computer task designed to induce higher levels of AM before taking part in one of three 15 minute activities (sedentary, moderate exercise or vigorous exercise). Various measures linked to hypomanic symptoms were taken during testing. Results The main findings indicated that vigorous exercise significantly increased individuals AM levels in comparison to moderate or no exercise. This relationship was not however found to be moderated by the presence of hypomanic traits. Conclusions: Vigorous exercise seems to have a greater impact on AM levels regardless of an individual’s levels of hypomanic traits. This has implications in terms of the type of exercise should engage in when experiencing hypomania. Any recommendations however within this study should be taken in light of the limitations identified. Further research replicating these results with a larger sample or using a BD population are recommended.

Psychiatric inpatient services provide important care for individuals with serious mental health problems. Studies show that passivity and social disengagement prevail in inpatient settings, and the transition to outpatient care is associated with increased suicide risk. Behavioural Activation is an intervention that targets depression by increasing personally meaningful activities. Preliminary research shows that Behavioural Activation can be used in inpatient settings. The overall aim of this thesis was to evaluate the feasibility and effectiveness of Behavioural Activation for individuals in psychiatric inpatient settings, and in the transition between inpatient and outpatient care. Study I investigated inpatient activities and associated experiences. Study II was a pilot single-case experimental study of the feasibility and effectiveness of inpatient Behavioural Activation. Study III, was an interrupted time series evaluation of nursing-adapted Behavioural Activation across three wards. In Study IV Behavioural Activation in the transition from inpatient to outpatient care was compared to Supportive Therapy in a randomised controlled trial with 64 participants. The primary outcome was that of self-reported depressive symptoms and participants were followed up 12 months after treatment completion. Doing nothing was the most common inpatient activity, along with meal related activities. Passive and solitary activities were associated with negative distress and reward profiles. The preliminary evaluation of Behavioural Activation found high patient and staff satisfaction, and four of six participants showed improvement in depressive symptoms and functioning. After nursing-adapted Behavioural Activation was implemented on three wards, engagement increased. Avoidance decreased but later returned to baseline levels. Depressive symptoms and global clinical severity did not improve after nursing-adapted Behavioural Activations was introduced. The randomised controlled trial found that adding Behavioural Activation in the transition to outpatient care had a small, short-term, advantage over Supportive Therapy for self-reported depression. In conclusion, inpatient disengagement is associated with distress, and Behavioural Activation is a feasible intervention in inpatient settings that can be used by both trained therapists and nursing staff to increase patients’ treatment engagement. Behavioural Activation seems useful in targeting depressive symptoms in the transition from inpatient to outpatient care, a period associated with increased risk of suicide and clinical deterioration.

It is well established that methadone maintenance (MM) reduces but does not eliminate the self-administration of other illicit drugs. For those on MM, there is considerable variation in consumption patterns, route of heroin administration, additional non-opioid substances routinely administered and the clinical disorders associated with these patterns of use. While there is a large literature base documenting these phenomena, studies have been almost exclusively descriptive in nature, with little attempt to develop a theoretical model in which to understand such use. In the following thesis, a model proposed by Gray was tested, the Reinforcement Sensitivity Theory (RST). This biopsychosocial model broadly describes two action tendencies; approach (Behavioural Activation System) and avoidance or withdrawal (Flight Fight Freeze System and the Behavioural Inhibition System). The model proposes that a heightened sensitivity to punishment underlies anxiety disorders. Conversely, a heightened sensitivity to rewarding stimuli may predispose some individuals to engage in highly rewarding behaviour and is associated with conduct disorder and antisocial personality disorder. According to the Joint Subsystems Hypothesis, these personality styles are mutually dependent, whereby BIS and BAS interact to influence reward mediated and punishment mediated behaviours. Based on Gray's model, this thesis tests whether opiate dependent individuals with heightened sensitivity to punishment are more likely to use anxiolytic drugs (such as benzodiazepines), and individuals with heightened reward sensitivity will show a preference for substances that have high reward potential (such as stimulants). At time one, the participant sample (N= 120) comprised 71 males (59%) and 49 females who were opioid dependent and recruitment took place over an eight-month period in two city opioid replacement clinics. A range of measures was administered to assess substance use, mood, anxiety and the personality dimensions of reward sensitivity and punishment sensitivity, with substance use again measured at three months. Results of the first study suggested that a large proportion of the variance was accounted for by personality within the models. A total of 98 participants (81%) participated in the 12-week follow-up study. Sensitivity to punishment and reward significantly predicted drug preference. Although psychopathology symptoms were not able to moderate the relationship between personality and drug use, anxiety symptoms negatively mediated the relationship between punishment sensitivity and anxiolytic use, whereby the relationship became non-significant. In contrast, sensitivity to reward remained the strongest predictor of amphetamine use over antisocial characteristics. Individual differences were not able to predict treatment retention nor susceptibility to relapse during a 12-week initiation to a MM programme.