While CBT has been viewed as the “gold standard” psychological intervention for depression, the new study finds that Behavioral Activation (BA) is an approach that is equally effective and less expensive.
Behavioral Activation is relatively simple, meaning it can be delivered by more junior staff with less training — making it a cost-effective option. It is estimated to be approximately 20 percent less expensive than CBT, meaning it could help ease current difficulties in accessing timely and affordable treatment.
BA encourages people to focus on meaningful activities driven by their own personal values as a way of overcoming depression.
Led by researchers from the University of Exeter, the multi-center Cost and Outcome of Behavioral Activation versus Cognitive Behavioral Therapy for Depression (COBRA) trial is one of the largest in the world to assess psychological treatments of depression. Importantly, researchers used a randomized controlled trial method to compare different treatments between groups.
A collaborative team of researchers from the Universities of Exeter, York, Kings College London and Tees Esk and Wear Valleys NHS Foundation Trust worked with clinical services, to investigate the effectiveness and cost effectiveness of BA. The treatments were delivered by NHS mental health workers and therapists.
Professor David Richards, NIHR Senior Investigator at the University of Exeter Medical School, led the study. He said, “Effectively treating depression at low cost is a global priority. Our finding is the most robust evidence yet that Behavioral Activation is just as effective as CBT, meaning an effective workforce could be trained much more easily and cheaply without any compromise on the high level of quality.
This is an exciting prospect for reducing waiting times and improving access to high-quality depression therapy worldwide, and offers hope for countries who are currently struggling with the impact of depression on the health of their peoples and economies.”
Clinical depression is the second largest cause of disability globally, affecting around 350 million people worldwide. The impact on economic output across the world is projected to be US$5.36 trillion between 2011 and 2030.
Although CBT is known to be effective, access is often restricted, with long waiting lists. In England, one in 10 people have been waiting over a year to receive talking therapy, whilst in the USA, only about a quarter of people with depression have received any type of psychological therapy in the last 12 months.
Yet, until now, the UK’s National Institute for Health and Clinical Excellence (NICE) has said there is insufficient evidence to recommend behavioral activation as a first-line treatment in clinical guidelines, and has called for more robust research to investigate the benefits. The COBRA trial, one of the largest of its kind in the world, was designed to meet this need.
The trial recruited participants from primary care and psychological services in three sites in Devon, Durham, and Leeds. The 440 participants were split into two groups — 219 were given CBT and 221 received BA. The groups were followed up and assessed at six, 12, and 18 months. The researchers found no difference between the groups at follow-up, providing the strongest evidence to date that BA is just as effective as CBT.
Behavioral activation is an “outside in” treatment that focuses on helping people with depression to change the way they act. BA helps people make the link between their behavior and their mood. Therapists help people to seek out and experience more positive situations in their lives. The treatment also helps people reduce the amount of times they avoid difficult situations and helps them find alternatives to unhelpful habitual behaviors.
In contrast, CBT is an “inside out” treatment where therapists focus on the way a person thinks. Therapists help people to identify and challenge their thoughts and beliefs about themselves, the world and their future. CBT helps people to identify and modify negative thoughts and the beliefs that give rise to them.
A year after the start of treatment, BA was found to be non-inferior (not worse than) than CBT, with around two-thirds of participants in both groups reporting at least a 50 percent reduction in depressive symptoms.
Participants in both groups also reported similar numbers of depression free days and anxiety diagnoses, and were equally likely to experience remission. Cost of delivery for BA therapy was found to be around 20 percent cheaper than CBT.
In line with other trials of a similar nature, drop-out rates were around 20 percent and around a third of participants in both groups did not attend the minimum number of therapy sessions.
Dr David Ekers, a nurse consultant from who led the Durham study site explains that the practical nature of BA and the relative simplicity of delivery makes it an attractive option. “This intervention will offer a cost effective option to provide evidence based psychological interventions for depression across a range of clinical teams.”
The study was funded by the National Institute for Health Research (NIHR) Health Technology Assessment Programme and published in The Lancet.
Source: University of Exeter