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People living with multiple long-term conditions may be facing additional mental health difficulties during the pandemic. Calls to our member charities’ helplines strongly suggest that is the case. In our latest blog, GP Carolyn Chew-Graham, a member of the External Advisory Group for the Taskforce on Multiple Conditions, explores how behavioural activation techniques can be delivered by clinicians, practice nurses, voluntary sector practitioners and pharmacy staff via telephone and video consultations during the lockdown and beyond.

Guest blog by Carolyn Chew Graham, Professor of General Practice Research, Keele University, General Practitioner, Manchester and member of the Taskforce on Multiple Conditions Expert Advisory Group*

COVID-19 and long-term conditions

People with long term conditions (LTCs) have an increased risk of anxiety and depression, which can impact on both physical and mental health outcomes (1).  It is likely that people living with multiple long-term conditions (MLTCs) may be facing additional difficulties during the COVID-19 outbreak and beyond. Some may have been advised to ‘shield; due to vulnerability (2). whilst others may be self-isolating due to their own, or a household member’s, symptoms. If not, they will be physically distancing. It is likely that people will move between these situations. Anxiety about COVID-19 and having to change behaviour may contribute to low mood.

Access to services

For people with LTCs, contacts with health care professionals may be reduced in the COVID-19 lockdown. Certainly routine face-to-face consultations in primary care are not occurring: chronic disease and medication reviews have been suspended. Any contacts (whether for an acute or a non-urgent problem) are likely to be by telephone or video – much more transactional in nature – dealing with one problem, with a solution proffered by the healthcare professional – little room for exploration and discussion of concerns, and little opportunity for ongoing support and advice.

A way forward?

The ‘making every contact count’ (MECC) initiative (3) is an approach to behaviour change that utilises the millions of day to day interactions that care organisations and people have, with a focus on encouraging changes in behaviour that have a positive effect on the health and wellbeing of individuals, communities and populations.

Behavioural Activation (BA) is an intervention that encourages patients with depression to resume activities they may have been avoiding, or take up new activities, with the purpose of engaging and supporting participation. The rationale is that encouragement to reengage in activities may be helpful to those with depression and or anxiety. BA helps people to think about what an activity that is no longer possible provided for them, and how to identify new activities that may provide the same thing – even if that new behaviour looks different. With support, patients define their own goals and ‘activity schedules’, using diaries to support this.

There is a good evidence base for BA for people with depression (4). and the intervention can be delivered by practice nurses (5), third sector practitioners (6), and pharmacy staff (7). Researchers at the University of York and Keele University have developed an intervention for people with multiple LTCs (8), and a group at Keele University are working on an intervention for people with persistent pain and depression (9).

Using BA during COVID-19 virtual consultations

So, could clinicians use the principles of BA in their telephone and video consultations during the lockdown? Yes. The technique can be learned (10), BA can be discussed in any consultation where social isolation or low mood are identified, and there are plenty of resources that clinicians can use to support their advice (11). And for people with LTCs, BA can be supported by useful information that is out there (12,13).


1. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. The Lancet 2007;370:851-8.
2. (accessed 22/04/2020).
4. Ekers D, Webster l, Van Starten A et al. Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis. Plos One. 2014 Jun 17;9(6):e100100.
5. Webster LAD, Chew-Graham CA, Ekers D. Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions. BMC Nursing. (2016) 15:71 DOI 10.1186/s12912-016-0190-2.
6. Kingstone T, Bartlam B, Burroughs H, Bullock P, Lovell K, Ray M, Bower P, Waheed W, Gilbody S, Nicholls E, Chew-Graham CA. Can support workers from AgeUK deliver an intervention to support older people with anxiety and depression? A qualitative evaluation.
7. Littlewood E, Ali S, Badenhorst J, Bailey D, Bhambra C, Chew-Graham CA…..Ekers D. Community Pharmacies Mood Intervention Study (CHEMIST): feasibility and external pilot randomised controlled trial protocol. Pilot and Feasibility Studies (2019) 5:71
13. mood

*The following authors are co-contributors to this piece:

David Ekers

Honorary Visiting Professor, University of York

Dean McMillan

Professor of Clinical Psychology, University of York

Simon Gilbody

Professor of Psychological Medicine and Health Services Research, University of York

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