What is behavioral activation (BA) treatment and how does it differ from cognitive behavioral therapy (CBT)?
BA and CBT are quite fundamentally different. BA is what we call an outside-in treatment, which means it focuses on helping people with depression change the way in which they behave.
In BA, we help people establish that there is a link between their behavior, what they do and their mood. That's two-fold really, because when you're depressed, you tend to close in on yourself and become less interested in the outside world.
Sometimes that's quite adaptive. If things are a bit aversive out there, you might say "Well, I'm not feeling up to it, I'm going to not interact with it." The problem with that is that it then gives you less opportunity to interact with things that keep us human, if you like, and less opportunity to interact with the world.
It's a two-fold process. People close in on themselves, which can be adaptive temporarily, but in the long run it stops you experiencing many of the things that keep us engaged in the world such as human contact, social contact or even just individual things. If a person is creative and likes to do things with their hands or read, they may also stop doing those things.
People often come to us and say "Oh, I just feel depressed all the time," but if you monitor that closely you'll find that people can recognize that their mood changes and goes up and down in response to doing certain things.
BA helps people establish that there is a link between behavior and mood because, often, people tell themselves that they will only do things when they feel more like it. The problem is with that is that it can take a very long time.
What CBT does is try to change the internal world of the person more, in order to prepare them for doing these things, whereas BA is the other way around. CBT is an inside-out treatment and BA is an outside-in treatment.
Why can BA, but not CBT, be delivered by non-specialist staff?
Our trial didn't show that that was the case. It may be possible, but BA has got less moving parts than CBT and it's inherently simple to understand and implement.
We've also got qualitative work, which we've not yet published, where we've interviewed patients and staff who are doing this. The overwhelming message they give us is that it's a pretty straight forward thing to understand.
In most advanced health systems, it tends to be the case that people with extensive experience and long training periods get taught how to do CBT. Our central hypothesis, which was advanced by Neil Jacobson in the States over twenty years ago, was that BA was just inherently so much more simple, that more people could learn it. Also as a patient, it would be easier for you to implement it.
I don’t know whether CBT could be delivered by less well qualified staff. Our trial didn't test that, but I think whenever you go to conferences these days, CBT seems to be getting more and more complex and to have more and more bells and whistles.
It tends to be restricted to people with clinical psychology qualifications or some other form of psychotherapy qualification. None of our workers had those qualifications and were able to do psychological therapy very well. Basically, it's just designed to be simpler.
How much evidence is there for BA as a psychological therapy for depression and why is CBT currently the gold-standard in treating depression?
We cited a reasonable amount of evidence, but before we undertook our COBRA trial, the evidence was from small clinical trials and some of them are not of very good quality.
In the UK, in 2010 the National Institute for Health and Care Excellence (NICE) only regarded three behavioral activation trials, all of which were quite small, as meeting its quality criteria. On that basis, they weren't able to recommend BA as a frontline treatment.
There are actually more trials than that and in our reviews, I think we've got up to nearly twenty, but they all tend to be small. The essential reason why the English National Institute for Health Research funded our trial was to try to redress the gap in the evidence.
We believe that we have done the job that they suggested needed to be done and that the evidence for BA is now be compelling. It's not for me to speak for NICE. The NICE guidelines for depression are currently being rewritten and not to paraphrase Paddy Ashdown, but I'd publicly eat my hat if they thought that we now didn't have sufficient evidence to recommend it as a first line treatment!
Our trial is the largest in the area by a long way. It's also one of the largest trials of CBT and depression. The way you have to do this kind of research is what we call powering a trial to be sufficiently large to answer the question to the avoidance of doubt. There is no doubt in our trial that BA is not at all inferior to CBT.
There are two reasons why CBT is currently the gold standard. Firstly, it works and our trial certainly didn't refute that. The majority of our patients receiving CBT in the trial recovered and our outcomes were at least as good, if not better, than those in other kinds of trials.
Secondly, CBT became very fashionable from the '80s onwards and a lot of research effort and attention was put into it, I think to the wrongful exclusion of other approaches. Other approaches have been forgotten about.
We like to think of BA in what we've just done as the ‘shock of the old’, which is the title of a book by the historian David Edgerton. BA has been around for quite a while, but had been essentially somewhat ignored in terms of research effort. I think there's nothing wrong with CBT, it does work fine and probably the reason it's the gold standard is just the amount of research.
Can you please outline your recent study on behavioral activation?
We were asking whether BA is in any way inferior to CBT and whether it can be delivered in a more cost effective way. To do that, we randomized 440 people with depression to one of the two treatments, either BA or CBT. Those two groups of people were treated by National Health Service (NHS) therapists who were working half of their week for us and half of the week for the NHS.
Both treatments took up a maximum of twenty sessions with a therapist or a mental health worker, so the BA was delivered by mental health workers. Typically, they were workers who had been trained to be coaches just to support patients using self-directed treatments like guided self-help. The CBT was delivered by bonafide trained therapists, often professionals such as nurses, psychologists and occupational therapists, who, in the UK system, can then do a post graduate diploma or a master’s degree in CBT.
Usually, therapists are paid a couple of grades higher in the NHS than the mental health workers, so the deliverers were quite different, but in terms of duration, both actual treatments were delivered over one hour appointments for twenty sessions, plus some boosters if necessary.
Most treatment happened within a period of six months, although there’s a little bit of leeway there. We then followed patients up. Our primary outcome was at 12 months.
We assessed the mental health and physical health of patients 12 months after they entered the trial. We also conducted an economic evaluation at 18 months and measured people’s health at 6 and 18 months.
What were your main findings?
The main finding was that BA is not inferior to CBT in terms of any outcome, with depression being our primary outcome, and that it is more likely to be cost effective than CBT.
What impact do you think the results will have on depression treatment?
If we have a treatment that is not inferior to another, then there's no reason that people shouldn't be offered a choice between those two treatments.
Firstly, I think that, as a first line treatment for depression, people should be offered BA as one of the choices.
Secondly, and I think more importantly, where there are not extensive professional infrastructures or where there is severe pressure in terms of treatment costs, there's no reason why BA shouldn't become the first offering. We ought to be able to offer more of it, because if it's cheaper, that could hopefully lead to reduced waiting lists and greater access, with no loss of quality or effect. I think that's really important to stress.
For me, I think one of the things that high income countries often do is to export their good ideas without thinking too carefully about them. There are many countries that don't have the level of professional infrastructure - training, supervision and so on - that perhaps we are lucky to have here in the UK. It's those countries to which I think we're turning and saying "Well, you know what, BA really could be a good option for you," because it's certainly possible that we might be able to train people to be just as effective without those long professional trainings being needed.
What will be the main challenges for large-scale BA implementation and how can these be overcome?
I think there are many. Jonathan Kanter, quite rightly pointed out that there's more to it than just having an effective treatment. Scalability is important.
For instance, if you go to a country that doesn't have the infrastructure that many high-income countries do, you'd be asking who's going to do it and who the mental health workers are - junior mental health workers or junior health workers? You would ask “are they nurses, are they field workers, who are they?” It would depend on the culture and the context in the original country.
In terms of large scale implementation, the first thing we would have to ask is "Who?" Once you've discovered who, then you've got to think about who's going to do the training, the supervision and how you would embed those treatments so that they continue to be effective.
One of the things that our therapists have told us is that their supervision was essential to their continuing competence. That's actually true in CBT as well. With any psychological therapy, you need to supervise people and, typically, that's done by people getting together with a supervisor in a group every fortnight and talking about cases.
Often, they might tape record cases and bring those to supervision as a way of reviewing their practice and so we just keep keeping people on track. You can't do this without any infrastructure. What we're saying is you can do it without the extensive infrastructure, but there still needs to be something.
That's another question you would ask: how you would embed it in practice once it's there.
If you read Jonathan Kanter's article, which is only a page long, he talks about the considerable evidence for the cultural portability of BA. It's not dependent on a high-income country medical model because it's a contextual therapy.
Lots of people can very easily understand life's going to throw obstacles at you. People may feel down, but need to make sure they stay active and not quit. That is a message that many cultures can incorporate within their beliefs, rather than the medical model, which is to say there's something wrong with you and you need to get a drug for it and so on.
I think there are challenges, but there's also hope, principally because BA isn't wedded to that particular medical model. However, we of course have to think about the culture, who is going to do it and what infrastructure is needed to implement it at scale.
Why don’t some people respond to CBT or BA? What further research is needed to find additional treatments for these people?
I wish we knew. The problem with trials is that some people drop out. Often, not only do they drop out of treatment, but they drop out of interviews with researchers, so it's really hard to find the answer to that question.
We do know something about it. What we find is that people tend to drop out early. In our paper, on average, people had about 12 or 13 sessions of both treatments. There wasn’t much difference, but there was a group of people who didn't make what we call the minimal dose, which we set at eight sessions.
On average, those people only had a couple of sessions, and if you took those out of the equation everybody else had about 16. The message there is you either engage and stick to it, or you don't.
There is a host of reasons why people don’t stick to it, but sometimes it's really just for practical reasons. Therapy requires you to give up an hour of your day plus traveling time and sometimes people find that very difficult to do. Their employer may be less than sympathetic or they may have childcare or other caring responsibilities.
For some people, it can feel a bit alien to come and do that. There's a whole bunch of practical reasons why people don't do so well and don't respond and I think it's often because of a lack of engagement rather than the treatments not being good for them.
A smaller number of people try it out and find it still doesn't work for them and if we knew the reason why, we'd be in a lot better position to point them in the direction of something that might work. However, I don't think we know that yet.
Research is only just starting to figure out what the predictors are for why people do get better and some people don't. The main issue is lack of engagement: people not getting there and not sticking with it. If you can overcome that, then most people respond.
What do you think the future holds for BA and treatment for depression?
I think BA is now, and I hope rightly, going to take its place as one of the principle evidence-based psychological treatments for depression. I don't think we need very much in the way of additional evidence to show its effect.
Any work now for BA should be looking at ways of making it available to more people. I think what a lot of people are now saying is that there probably isn't a fantastic new psychotherapy that is going to beat everything else. I think most psychological treatments achieve the same kind of outcomes.
We need the question that you asked previously to be answered, which is how we can direct people to treatments that are most likely to benefit them? That tends to be called personalized medicine or precision medicine. I think we need to be going down a precision medicine route for the treatment of depression. Whether we can do that via genetic markers or phenotype markers, I don't know, but certainly we would wish to improve the effects of these treatments by personalizing them more.
We are really excited about the developments we have made. These trials take a very long time and sometimes they don't really come up with earth shattering results, but the attention given to this trial once we published it has been absolutely astonishing. The media ratings and metrics have been enormous and I think that really does reinforce just how exciting it is that after all these years, we now have a psychotherapy that's straightforward, simple and just as effective as something quite a lot more complicated.
Psychotherapy is often seen as a complex endeavor, but it needn’t be and we're really excited about getting that message out.
Where can readers find more information?
At this stage, I think the paper and the commentary:
We will be submitting a report to our funder in mid-October. I would hope by Christmas there would be a full report on the National Institute for Health Research website, but it's not there yet. The full report will be hundreds of pages long and contain much more information about what we're doing, including our clinical protocols and so on.
About Professor David Richards
David is Professor of Mental Health Services Research at the University of Exeter. He runs the University's Complex Interventions Research Group, and is also President of the European Academy of Nursing Science (EANS).
Dave has been a mental health nurse for over 30 years. For the last 17 years he has been working as a researcher in academic settings, currently at the University of Exeter’s Medical School. Much of his work is funded by the National Institute for Health Research (NIHR). David’s work was recognized by the NIHR when it awarded him the status of ‘Senior Investigator’ as one of the top 200 researchers in England.
David’s research has focused on improving access to healthcare for people with common mental health disorders such as anxiety and depression. David has undertaken clinical trials of simple psychological therapies applied to depression and systems of organizing depression treatment. He has also investigated nursing roles in primary care telephone triage, a research program he first initiated over 16 years ago. His emphasis in all his work is that people should receive rapid access to healthcare that is efficient, effective and equitable.
His most significant contribution to healthcare reform in the UK was as part of the team that established the Improving Access to Psychological Therapies (IAPT) program at the Department of Health, regarded as second only in importance to the shutting down of the Victorian asylums in terms of significant mental health reforms. David pushed for ‘low-intensity’ simple interventions to be included in IAPT as a fundamental part of the operating principles and established the base for a completely new ‘Psychological Wellbeing Practitioner’ workforce – now numbering over 3,000 in England alone – including the role definitions, curricula and training courses throughout the NHS.
As the editor of the world’s first textbook on research methods for ‘complex interventions’ – which describes essentially pretty much all that health care professionals do – he is at the forefront of both clinical and methodological developments in health services research.
Whilst there is much still to be done, David never forgets that research activity and its findings should always provide clinicians on the ground with information about how they can work to deliver the best possible clinical care to their patients. It is this key principle that drives him.
David’s profile: http://medicine.exeter.ac.uk/about/profiles/index.php?web_id=david_richards
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