Abstract
Background: Recent recognition highlighted the complex relationship between physical health and mental well-being, particularly in older adults dealing with depression. Pain plays a crucial role in both the development and exacerbation of depression in later life, making it essential to understand its impact for effective intervention. Behavioural Activation (BA), a brief therapy aimed at reducing depression through engagement in rewarding activities, is gaining popularity. However, the extent to which pain affects depression and the effectiveness of BA in treating older adults with low mood remained unclear.Aim: This research explores to what extent does persistent pain impact depression and the treatment of behavioural activation (BA) for older adults?
Methods: This research used a convergent parallel mixed-methods design, combining qualitative and quantitative approaches. The qualitative component explored how persistent pain affected older adults' mood and engagement with BA, while the quantitative component analysed how physical health influenced BA's effectiveness in treating depression. The qualitative study was part of the National Institution Health research (NIHR)-funded Behavioural Activation in Social Isolation (BASIL+) trial by the University of York, conducted across England and Wales. The quantitative analysis was a secondary analysis of the Collaborative Care in Screen Positive Elders with subthreshold depression (CASPER) and Collaborative Care in Screen Positive Elders with major depressive disorder (CASPER+) trials, two major randomised controlled trials of BA for older adults, conducted from March 2011 to July 2013.
Results: The CASPER and CASPER+ trials found that baseline physical health, measured by the Short Form- 12 (SF-12) Physical Component Score (PCS), had minimal and statistically non-significant influence on the effectiveness of Behavioural Activation (BA) treatment in older adults. While there was a slight trend suggesting those with poorer physical health might benefit more, this was not significant. A strong negative correlation was found between pain and physical health (r = -0.784), indicating that greater pain is closely linked to poorer physical functioning. However, this did not significantly affect BA treatment outcomes.
IV
In a qualitative study with thirteen older adults, key themes emerged around the complex relationship between depression and chronic pain, including physical limitations, emotional impact, coping strategies, and feedback on the BA programme. A crosstab analysis identified patterns in how pain severity, gender, treatment response, and socioeconomic status influenced these themes.
Conclusion: The findings reveal a reinforcing cycle between pain and depression in older adults, where pain exacerbated emotional distress and limited mobility, impeding engagement in Behavioural Activation (BA). While BA can be effective, especially for those in poorer physical health, its success is influenced by pain-related fear and avoidance behaviours. The research fills key gaps in understanding the interplay between persistent pain, depression, and treatment response, highlighting the impact of systemic barriers like socioeconomic inequality and fragmented care. It calls for holistic, patient-centred, and multidimensional interventions that address physical, psychological, and social needs. Key recommendations include tailoring care, strengthening coping strategies, addressing inequality, and promoting collaborative care models, offering critical implications for policy, practice, and future research.
| Date of Award | 3 Dec 2025 |
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| Original language | English |
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| Supervisor | Denis Martin (Supervisor), Emma Giles (Supervisor) & David Ekers (Supervisor) |