July 22, 2016

expert reaction to behavioural activation therapy for depression

A comparison between cognitive behavioural therapy (CBT) and behavioural activation (BA) for the treatment of depression is made in a study published in The Lancet journal. The authors report that the two treatments are equally effective at treating depression in adults and that BA can be delivered by junior mental health workers at a lower cost.

Prof. Jan Scott, Professor of Psychological Medicine, Academic Psychiatry Department, Institute of Neuroscience, Newcastle University, said:

“We know that many people with depression would like the option of receiving psychological therapies or counselling in primary care. What we also know is that some people are denied this option because of the lack of availability of trained therapists. Programmes such as ‘increasing access to psychological therapies’ (IAPT) have focused more on the delivery of CBT than other therapies, and reaching a high standard in the practice of CBT can take some therapists longer than others.

“As such, it is encouraging to see that the recent study by Professor Richards and colleagues that suggests that behavioural activation therapy may be another option. Like interpersonal therapy and rumination focused cognitive therapy (for depression), it seems that behavioural activation can be taught to novice therapists in a cost-efficient manner. As such, it would be nice to think that in future there may be additional options available via the IAPT services and similar programmes elsewhere in the world.

“Having said that, I think this study adds just one more piece to the evidence, and there are still several important questions remain to be addressed. I don’t wish to undermine attempts to identify new therapies or to find the ‘active ingredients’ of existing therapies. Also, I am only too aware that undertaking research into psychological therapies is challenging and no study is perfect. However, I think it is fair to say  that there are some weaknesses in the study design and the analysis of the outcomes of this particular therapy trial that mean the results must be treated with cautious enthusiasm rather than getting too carried away.

“The design has only two arms and 80% of cases received an antidepressant, so we don’t know if adding CBT or BA is better than an antidepressant alone. Also we don’t know if equal outcomes across the groups mean patients all did well – or actually if they all did badly.

“The researchers said they looked at cost-effectiveness but they used different levels of therapist at the start – so they are bound to cost differently. For example, they used novice, junior mental-health workers and trained them in BA, but used experienced, employed CBT therapists so CBT was always going to cost more.

“Additional, more sophisticated studies will need to be undertaken before we can come to any conclusions in regard to whether behavioural activation should supersede the established therapy approaches that are currently offered in primary care. I think we should be hopeful that it can be one of a range of options that can be delivered both to the required standard and in a cost-effective manner; but we just need to keep our feed firmly on the ground and be realistic about what this study does and does not tell us.”

Prof. Stephen Lawrie, Head of Psychiatry, University of Edinburgh, said:

“This is a very high quality study from a top research team. As a rigorously conducted randomised clinical trial, the largest such study of Behavioural Activation (BA) thus far, and one of the largest studies ever of any treatment for depression, the results are definitive and should influence clinical practice. The results show clear equivalence of BA and Cognitive Behaviour Therapy (CBT) for mild and moderate depression. They also reinforce the findings from several previous trials showing that BA can be provided with low levels of training in low-resource settings, at lower cost than CBT. This means that BA could become the first line treatment for depression in most countries and settings, freeing up over-stretched services for more difficult cases.”

Prof. Michael Sharpe, Professor of Psychological Medicine, University of Oxford, said:

“This study has found that treatment for moderately severe depression that helps patients change their behaviour, that is to become more active (behavioural activation or BA) is as effective as a more complicated treatment which also involves patients analysing and changing their thinking (cognitive behaviour therapy or CBT). BA helps patients to do things that they believe to be important but that they are avoiding. It has the advantage of being cheaper to deliver because it requires less skilled therapists and (as described in the accompanying commentary) may also be more acceptable to people who do not see depression as a psychological problem.

“There are some caveats to this finding however: BA given over a dozen sessions by trained and supervised therapists- it is not the same as telling someone to ‘pull yourself together’. Most patients in the trial were also taking an antidepressant drug so the findings are really about adding these treatments to antidepressant drugs, not testing them as an alternative to drugs. The study did not compare BA and CBT with well managed active antidepressant drug treatment.

“The finding that BA is no less effective than the gold standard psychological treatment of CBT is useful in allowing effective treatment to be given to more people. However for moderate to severe depression it is often beneficial to take an anti-depressant drug as well as having a psychological therapy. Drugs and psychological treatments often work best together.”

Prof. Shirley Reynolds, Director of the Charlie Waller Institute, University of Reading

“This is a very impressive study. It recruited over 400 people with depression and carefully compared the effects of treating them either with Cognitive Behaviour Therapy (a well-established psychological therapy) or Behavioural Activation.

“The results of this study are likely to be trustworthy. This was a well-designed study and I highlight some of the strengths below. It shows that Behavioural Activation is an effective therapy for depression. This is good for patients as it increases the range of effective treatments.

“Some cautions are also important. Behavioural Activation was a little cheaper than Cognitive Behaviour Therapy. However, it is not a simple, quick or easy therapy to deliver.  Depression can be lethal and all therapists must be able to identify when patients are at risk and know how to help keep them safe. The mental health workers who delivered Behavioural Activation in this study were very carefully supervised and had already had at least one year of clinical training. Services should not offer Behavioural Activation for depression without proper safeguards.

“The quality of the study is good. Patients were randomized to the two treatments, researchers who did not know what treatment they received assessed their mental health, and they were followed up for 18 months. The benefits and any adverse effects of treatment were carefully assessed for all patients throughout the study. The patients included in this study were similar to patients with depression elsewhere in England (middle aged, 90% white, 66% female), 78% were taking anti-depressant medication and they had an average of 6 previous episodes of depression. This means that it is likely that these results can be applied in other settings and to other patients.

“CBT and BA were offered for up to 24 sessions of therapy over 16 weeks. BA was delivered by mental health workers, who were typically psychology graduates with one year of clinical training and CBT was delivered by qualified and accredited CBT therapists. On average patients received 11 sessions of BA and 12 sessions of CBT. In both groups around two thirds of patients recovered from depression after treatment. The results of the study showed that patients who received BA did as well as those who received CBT. This is important because BA was cheaper to deliver than CBT. The difference in cost was mainly because the mental health workers who delivered BA were less expensive to employ than the CBT therapists.”

Dr Michael Bloomfield, Clinical Lecturer in Psychiatry, UCL and MRC Clinical Sciences Centre, London, said:

“This new study published in the Lancet has found that a particular treatment for depression, called behavioural activation, is not inferior to cognitive behavioural therapy for depression. This is good news for the many people who struggle with depression as it provides support for the use of another potential treatment approach for this common, but sometimes devastating illness. However, this does not mean that this treatment is better than other treatments for depression. In particular, I strongly disagree with the authors conclusions that ‘psychological therapy for depression can be delivered without the need for… highly trained professionals’ – given that depression can be complex and life-threatening and this study deliberately excluded patients with a more severe illness.

“Much more research is needed to identify what treatment works for whom, including the different types and combinations of psychotherapies and medicines. When it comes to depression, one size does not fit all.

“Whilst this is a relatively large study by psychotherapy standards, it is important for the public, clinicians and policy-makers to take the findings of a single study with caution.

“Anyone currently engaged in any therapy for depression should not stop this treatment without discussing it with their therapist and/or doctor first.”

‘Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial’ by Richards et al. published in The Lancet on Friday 22^nd July. 

Declared interests

Prof. Jan Scott: “I am an expert in CBT who has undertaken international research into CBT and psycho-education, and have recently been working on adaptations of rumination-focused CBT and behavioural activation adapted for use in  bipolar disorders, especially with young people.” Added 12:35 25/07/2016

Prof. Sharpe: “I have no interests to declare.”

Prof. Reynolds: ““My post at the University of Reading is partly funded by the Charlie Waller Memorial Trust and Berkshire NHS Foundation Trust. I am co-director of the Oxford Academic Health Science Network Anxiety and Depression programme.  I have received grant funding for research from NIHR and MRC.”

Dr Bloomfield:  “I am a member of the Royal College of Psychiatrists, a member of the British Association of Psychopharmacology, a young member of the European College of Neuropsychopharmacology, a young fellow of the Royal Society of Medicine and an international member of the American Psychiatric Association. I conduct research funded by the Medical Research Council, the National Institute of Health Research and the British Medical Association. I work in medical research at the Medical Research Council and University College London. I work clinically in the National Health Service. I have no other interests to declare.”

Others: No interest received