Abstract

SummaryBackgroundDepression is a common, debilitating, and costly disorder. Many patients request psychological therapy, but the best-evidenced therapy—cognitive behavioural therapy (CBT)—is complex and costly. A simpler therapy—behavioural activation (BA)—might be as effective and cheaper than is CBT. We aimed to establish the clinical efficacy and cost-effectiveness of BA compared with CBT for adults with depression.MethodsIn this randomised, controlled, non-inferiority trial, we recruited adults aged 18 years or older meeting Diagnostic and Statistical Manual of Mental Disorders IV criteria for major depressive disorder from primary care and psychological therapy services in Devon, Durham, and Leeds (UK). We excluded people who were receiving psychological therapy, were alcohol or drug dependent, were acutely suicidal or had attempted suicide in the previous 2 months, or were cognitively impaired, or who had bipolar disorder or psychosis or psychotic symptoms. We randomly assigned participants (1:1) remotely using computer-generated allocation (minimisation used; stratified by depression severity [Patient Health Questionnaire 9 (PHQ-9) score of <19 vs ≥19], antidepressant use, and recruitment site) to BA from junior mental health workers or CBT from psychological therapists. Randomisation done at the Peninsula Clinical Trials Unit was concealed from investigators. Treatment was given open label, but outcome assessors were masked. The primary outcome was depression symptoms according to the PHQ-9 at 12 months. We analysed all those who were randomly allocated and had complete data (modified intention to treat [mITT]) and also all those who were randomly allocated, had complete data, and received at least eight treatment sessions (per protocol [PP]). We analysed safety in the mITT population. The non-inferiority margin was 1·9 PHQ-9 points. This trial is registered with the ISCRTN registry, number ISRCTN27473954.FindingsBetween Sept 26, 2012, and April 3, 2014, we randomly allocated 221 (50%) participants to BA and 219 (50%) to CBT. 175 (79%) participants were assessable for the primary outcome in the mITT population in the BA group compared with 189 (86%) in the CBT group, whereas 135 (61%) were assessable in the PP population in the BA group compared with 151 (69%) in the CBT group. BA was non-inferior to CBT (mITT: CBT 8·4 PHQ-9 points [SD 7·5], BA 8·4 PHQ-9 points [7·0], mean difference 0·1 PHQ-9 points [95% CI −1·3 to 1·5], p=0·89; PP: CBT 7·9 PHQ-9 points [7·3]; BA 7·8 [6·5], mean difference 0·0 PHQ-9 points [–1·5 to 1·6], p=0·99). Two (1%) non-trial-related deaths (one [1%] multidrug toxicity in the BA group and one [1%] cancer in the CBT group) and 15 depression-related, but not treatment-related, serious adverse events (three in the BA group and 12 in the CBT group) occurred in three [2%] participants in the BA group (two [1%] patients who overdosed and one [1%] who self-harmed) and eight (4%) participants in the CBT group (seven [4%] who overdosed and one [1%] who self-harmed).InterpretationWe found that BA, a simpler psychological treatment than CBT, can be delivered by junior mental health workers with less intensive and costly training, with no lesser effect than CBT. Effective psychological therapy for depression can be delivered without the need for costly and highly trained professionals.FundingNational Institute for Health Research.

Highlights

  • Clinical depression is a common and debilitating mental health disorder, being the second largest cause of global disability.[1]

  • Between Sept 26, 2012, and April 3, 2014, we randomly allocated 221 (50%) participants to behavioural activation (BA) and 219 (50%) to cognitive behavioural therapy (CBT). 175 (79%) participants were assessable for the primary outcome in the modified intention-to-treat (mITT) population in the BA group compared with 189 (86%) in the CBT group, whereas 135 (61%) were assessable in the PP population in the BA group compared with 151 (69%) in the CBT group

  • Patient Health Questionnaire 9 (PHQ-9) score at baseline was negatively skewed, with a high proportion of participants scoring towards the upper end of the distribution, but scores were similar between groups

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Summary

Introduction

Clinical depression is a common and debilitating mental health disorder, being the second largest cause of global disability.[1]. Antidepressant medication and cognitive behavioural therapy (CBT) have the most clinical evidence. Evidence before this study Authors of published systematic reviews, including a Cochrane review, have commented on the limitations of existing evidence for the effectiveness of behavioural activation (BA) for depression compared with cognitive behavioural therapy (CBT) and the scarcity of cost-effectiveness data, with the existing evidence insufficiently robust to establish comparability. Our pretrial evidence took published review findings from the UK National Institute for Health and Care Excellence (NICE), who reported no difference in treatment outcome between BA and CBT immediately after treatment (Hedges’ g 0·139 [95% CI −0·400 to 0·122]; p=0·296) and subsequent follow-up (0·135 [−0·456 to 0·186]; p=0·409). The authors of NICE’s review regarded the existing international evidence as insufficient to recommend BA for first-line treatment in clinical guidelines for depression

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