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Behavioral Activation vs CBT for Depression
Lancet; 2016 Aug 27; Richards, Ekers, et al
Behavioral activation (BA) can be a more cost-effective treatment option for people with depression than cognitive behavioral therapy (CBT) with no lesser effect, and can be delivered by junior mental health workers with less intensive training, a recent study found. This randomized, controlled noninferiority trial from September 26, 2012, to April 3, 2014, included adults aged ≥18 years who met Diagnostic and Statistical Manual of Mental Disorders IV criteria for major depressive disorder. Primary outcome was depression symptoms according to the Patient Health Questionnaire 9 (PHQ-9) at 12 months. Findings included:
- 221 (50%) participants were randomly allocated to BA and 219 (50%) to CBT.
- 175 (79%) participants were assessable for the primary outcomes in the modified intention to treat (mITT) population in the BA group vs 189 (86%) in the CBT group, whereas 135 (61%) were assessable in the per protocol (PP) population in the BA group vs 151 (69%) in the CBT group.
- BA was noninferior to CBT.
- BA was not different from CBT in anxiety (Generalized Anxiety Disorder 7), depression status, and depression-free days and anxiety diagnoses (SCID at 12 months).
- Between 61% and 70% of mITT and PP participants in both groups met criteria for recovery from depression or response to treatment at 12 months, with no differences in the proportions of patients in each group who recovered or responded.
Richards DA, Ekers D, McMillan D, et al. Cost and outcome of behavioural activation versus cognitive behavioural therapy for depression (COBRA): A randomised, controlled, non-inferiority trial. Lancet. 2016;388:871-80. doi:10.1016/S0140-6736(16)31140-0.
Behavioral activation is an approach to depression that emphasizes graded increases in activity over time as a method of improving depression. Specific activities that lead to positive feedback are chosen and individuals are encouraged to engage in those activities. Behavioral activation is a core part of CBT. Component analysis has shown that BA is the most effective aspect of CBT, and when looked at alone, studies have suggested that it has efficacy for the treatment of depression.1 This randomized trial shows that BA has about equal efficacy to full CBT and can be implemented by individuals who have learned how to do BA, a technique that is far less complicated and easier to learn than CBT. —Neil Skolnik, MD
1. Harris S. Behavioural activation interventions for depressed individuals with a chronic physical illness: a systematic review protocol. Systematic Reviews. 2013;2:105. doi:10.1186/2046-4053-2-105.