One of the elements of collaborative care in the studies described in this Highlight was a simple form of psychosocial therapy called behavioural activation.
In fact, when researchers in one study analysed which elements of collaborative care seemed to have most effect on patients’ depression symptoms, they found that it was behavioural activation that had the biggest impact, even though in this trial it was delivered in a simple, low-intensity form.
Behavioural activation (BA) is a therapy that encourages patients with depression to approach activities they may have been avoiding. With a therapist, patients define goals and ‘activity schedules’. The rationale is that depression is a consequence of avoiding particular activities or situations. It is similar to cognitive behavioural therapy (CBT), but does not focus on analysing thought patterns, but rather on encouraging an increase in activity. At the moment, NICE recommends behavioural activation for mild to moderate depression, with the caveat that the evidence base is less strong than for CBT.
BA is of interest because it can be delivered by more junior mental health workers than CBT. If it is as effective as CBT, then it could be a cost-effective way of increasing access to therapies for people with depression – but up until now, there has not been sufficient evidence to show this.
The NIHR has supported new research which may help fill some of this evidence gap. This large trial found that behavioural activation was no less effective than the more commonly used CBT in treating depression. The study recruited over 400 adults, all of whom were suffering from depression, and randomly allocated them to receive either CBT or BA. In both cases, participants received up to 20 sessions over a period of 16 weeks. The CBT was delivered by qualified psychotherapists with additional qualifications in CBT. The BA was delivered by junior mental health workers, who had received previous training in delivering self-help interventions together with five additional days of specific BA training. They had no professional mental health qualifications. However, BA in this study was a more intensive therapy than that delivered in the collaborative care trials discussed elsewhere in this Highlight.
After 12 months, both groups of patients reported that their depression symptoms had reduced, by a similar amount. Patients who had received BA also showed no difference in recovery from symptoms of anxiety compared to those who had received CBT. Around two thirds of patients in both groups demonstrated recovery from depression or response to treatment.
This is the largest trial of BA to date, was well-designed and implemented, and offers promising results. There may be some limitations – for example, many patients in both groups were also using anti-depressants, which could affect their response to the therapies. The study also excluded patients who had primary alcohol or drug problems, so we don’t know if BA would work for these groups.
Behavioural activation can be delivered by more junior mental health workers, who have been trained in the therapy but don’t necessarily have formal mental health qualifications. The study found that BA is likely to be cost-effective compared to CBT, according to the standard measures used by decision-makers such as NICE. This underlines the potential of BA for increasing access to therapy in a cost-effective way.
“Patient choice and collaboration are highly associated with recovery so you can help people better if you can provide them with a choice of treatments that are evidence based.” Jamie Short, Psychological Wellbeing Practitioner.