Simple, Low-Cost Therapy Equal to CBT for Major Depression

Liam Davenport

July 25, 2016

A simple, inexpensive psychological therapy that can be provided by nonspecialist staff with minimal training is as effective as the gold-standard cognitive-behavioral therapy (CBT) in treating depression, new research suggests.

In a randomized controlled trial, investigators at the University of Exeter in the United Kingdom found that behavioral activation (BA) was noninferior to CBT for the treatment of major depressive disorder (MDD), with approximately two thirds of patients in both groups recovering from depression or achieving a response to treatment at 12 months.

Lead author David A Richards, PhD, professor of mental health services research, told Medscape Medical News that this is a "really exciting development."

"I think this offers real hope to people with depression. Currently, about 15% of people with depression are getting psychological therapies in the UK, which is less than some countries, and far less than some other countries.

"If you look at the World Health Organization [WHO] recommendations for increasing the reach of nonpharmacological treatments, we think BA has got an essential role in helping the WHO realize that ambition," he added.

The research was published online July 22 in the Lancet.

Less Expensive

To examine the clinical efficacy and cost-effectiveness of BA relative to CBT, the researchers recruited individuals with MDD from primary care and psychological therapy services in three UK regions.

They excluded patients who were receiving psychological therapy, were alcohol or drug dependent, were acutely suicidal, had recently attempted suicide, were cognitively impaired, or had bipolar disorder or psychotic symptoms.

Between 2012 and 2014, 440 MMD patients were randomly assigned in a 1:1 ratio to receive either BA delivered by 10 junior mental health workers or CBT provided by 12 psychological therapists. Patients underwent a maximum of 20 60-minute sessions over 16 weeks. Patients in the BA group received an average of 11.5 sessions, and those in the CBT group received an average of 12.5 sessions.

The primary outcome was depression symptoms, as assessed using the Patient Health Questionnaire 9 (PHQ-9), at 12 months. Data were available for 175 BA patients and 189 CBT patients for a modified intention-to-treat (mITT) analysis, and for 151 patients and 135 patients, respectively, for a per protocol (PP) analysis.

The researchers found that BA was noninferior to CBT, at a mean difference on the PHQ-9 at 12 months of 0.1 on mITT analysis (P = .89) and 0.0 on PP analysis (P = .99).

On mITT and PP analyses, from 61% to 70% of patients in both groups met criteria for recovery from depression, defined as a PHQ-9 score of ≤9; or response to treatment at 12 months, defined as a 50% reduction in PHQ-9 scores from baseline. There were no differences between the two groups.

There were two non–trial-related deaths, with one in each group. There were 15 depression-related, although not treatment-related, serious adverse events, which occurred in three patients receiving BA and in eight patients receiving CBT.

Data regarding full service use at 18 months' follow-up were available for 159 BA patients and 168 CBT patients. These data revealed that there was a significant difference in mean intervention costs, at £974.81 ($1278.39) for BA vs £1235.13 ($1619.78) for CBT (P < .0001). There were no significant differences in other categories of costs or in total costs.

In all sensitivity analyses, BA was significantly less expensive than CBT. Imputation of missing data increased the difference in overall costs, at £1841.67 ($2415.21) for BA vs £2282.40 ($2993.19) for CBT (P = .13), although this reduced the difference in quality- adjusted life-years, at 1.22 vs 1.19 (P = .55), and an incremental cost-effective ratio of £16,951 ($22,229.95).

Fewer Moving Parts

Dr Richards explained that one advantage of BA in comparison with CBT is that it is a treatment "with less moving parts."

Specifically, it helps people establish a connection between their mood and their behavior. Once that link has been made, "we can help people identify things that they would like to do, such as social activities or individual activities, such as reading, going out, or maybe physical activities.

"We get them to notice how, as they do more things, their mood changes. So we're reducing the amount of avoidance and lack of activity that goes along with depression. In contrast, CBT is a kind of 'inside-out' approach, where therapists work with people's thoughts to try to identify what those thoughts are, how they're perhaps misinterpretations of reality, and then work to try to change the way that people are thinking," he added.

Although the current findings demonstrate that CBT is as effective as BA, "it actually does take a lot of training to get somebody competent in CBT, whereas we can do that more effectively in behavioral activation," said Dr Richards.

"There's probably likely to be more people suitable for training as therapists in BA than in CBT. You don't have to have the same level of professional experience, qualifications, and we're not sacrificing any quality by doing so. We get exactly the same quality of treatment, exactly the same outcomes, by training different people to do it," he added.

Call for Large-Scale Implementation

In an accompanying editorial, Jonathan W. Kanter, PhD, Department of Psychology, University of Washington, Seattle, and Ajeng J. Puspitasari, PhD, Department of Psychological and Brain Sciences, Indiana University, Bloomington, emphasized that the cost-effectiveness of BA "was driven primarily by the low costs of BA providers."

As has been shown in previous studies, the approach is acceptable to culturally diverse patients, including those "for whom a medical model of depression might be incompatible with cultural beliefs.

"Now that we have support for BA as a treatment that is clinically effective and cost-effective, we can shift our efforts to focus on what is necessary to produce sustainable large-scale BA implementation across diverse geographical and cultural settings," the editorialists write.

Speaking to Medscape Medical News, Dr Kanter said that the low cost and cultural acceptability of BA is a "real, important strength of this approach." However, he said that he could not "state with confidence" that it will be used in low-resource settings, "because there are many, many obstacles to doing that work with this treatment.

"We need to get to get more researchers interested in working with these low-resourced, multicultural populations, and we need to get to get researchers more culturally confident in knowing how to collaborate and work in these settings," he added.

"There are lots of obstacles, but I do think the potential is there, and already many researchers are pursuing those directions. In terms of looking at depression as a global health problem, it's extremely important, and I certainly hope this inspires more researchers and policy makers and so forth to get involved in looking at those issues."

In more established healthcare systems in developed nations, Dr Kanter believes that CBT itself could be adapted and streamlined in response to these findings.

"You know, behavioral activation was always hiding, lurking inside mainstream CBT. Even though there's some debate about this, there's a decent amount of research suggesting that the behavioral activation components of CBT are at least partially responsible for its effectiveness.

"If this study and other behavioral activation studies help clarify the active mechanisms of CBT, then that would be a good thing, and if mainstream CBT can be made more efficient and effective through this, then that would be a good thing too," he said.

The report was funded by the UK National Institute for Health Research Health Technology Assessment Programme. A listing of the authors' financial relationships is provided in the published article.

Lancet. Published online July 22, 2016. Full text, Editorial

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