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Behavioral activation may be effective, cost-efficient alternative to CBT

Recent findings indicated that behavioral activation, a psychological treatment that can be delivered by junior mental health workers, had comparable efficacy to cognitive behavioral therapy for depression in adults.

“CBT is as effective as are antidepressants and provides long-term protection against relapse, but it is complex and its effectiveness is dependent on the skills of psychological therapists, who are expensive to train and employ,” David A. Richards, PhD, of the University of Exeter, United Kingdom, and colleagues wrote. “One potential alternative, behavioral activation, is a simple psychological treatment for depression. It might be easy and quick to train junior mental health workers in [behavioral activation] who have no professional training in psychological therapies. However, this method is only appropriate if [behavioral activation] delivered in this way is as effective as and more cost-effective than is CBT.”

To determine clinical efficacy and cost-effectiveness of behavioral activation compared with CBT for adults with depression, researchers conducted a randomized, controlled, noninferiority trial among adults who met DSM-IV criteria for major depressive disorder. Study participants were randomly assigned to receive behavioral activation from junior mental health workers (n = 221) or CBT from psychological therapists (n = 219).

The modified intention-to-treat population included study participants who were randomly assigned and had complete data, while the per-protocol population included those who were randomly assigned, had complete data, and received at least eight treatment sessions.

Behavioral activation was noninferior to CBT in both the modified intention-to-treat population (mean difference in PHQ-9 scores = 0.1; 95% CI, –1.3 to 1.5; P = .89) and the per-protocol population (mean difference = 0; 95% CI, –1.5 to 1.6; P = .99).

Fifteen depression-related serious adverse events occurred in 2% of the behavioral activation group and 4% of the CBT group. These events were not related to treatment, according to researchers.

Two non-trial-related deaths occurred.

“The cost-effectiveness of [behavioral activation] in the [Cost and Outcome of Behavioral Activation vs. Cognitive Behavioral Therapy for Depression (COBRA)] trial was driven primarily by the low costs of [behavioral activation] providers. Because [behavioral activation’s] rationale, techniques, and core mechanism are straightforward and face valid, an additional benefit of [behavioral activation] is that costs of training these providers might be low as well. Considering the few financial and human resources available to mental health services in many parts of the world, research into scalable and cost-effective training strategies, such as brief online training, is important,” Jonathan W Kanter, PhD, of University of Washington, Seattle, and Ajeng J Puspitasari, PhD, of Indiana University, Bloomington, Indiana, wrote in an accompanying editorial. “Research into these and other potential strengths of [behavioral activation] in the context of implementation science is necessary for the hope and promise offered by the COBRA trial to be fulfilled.” – by Amanda Oldt

Disclosure: The study was supported by the National Institute for Health Research. Richards reports grants from the European Science Foundation, funding support from NIHR Collaborations for Leadership in Applied Health Research and Care and NIHR panel memberships. Kanter and Puspitasari reports no relevant financial disclosures. Please see the full study for a list of all authors’ relevant financial disclosures.