Thursday, August 4, 2016

Behavioral Activation is equally effective to Cognitive Behavioral Therapy

It is needless to say that depression is a dreadful disorder in terms of threatening human life. Therefore, clinicians are eager to develop new treatment strategies for depression. Nowadays, many options are available.


So far, cognitive behavioral therapy (CBT) has been deemed as the most effective psychotherapy for depression. Modifying cognitive distortions seen in patients is a core concept of CBT. The effectiveness of CBT has been proven to be almost equal to antidepressant treatment.

Recently, there are some attempts to enhance the cost-effectiveness of CBT with some modifications. Mindful-based cognitive therapy (MBCT) can be one solution. For example, MBCT has a similar effect as medication regarding the relapse rate. MBCT represents “the third wave of psychotherapy” in the 21st century.

My past entry: Mindfulness-based cognitive therapy, a new way to protect you from depression

On the other hand, the number of therapists who can perform CBT is limited in many countries including the UK, one of the nations in which maximum numbers of the therapist are ready to offer CBT in the world. It suggests that a therapy protocol which is easily learned and offered by relatively less specialized clinicians is needed to be established.

Behavior activation (BA) methods may be a solution. In BA, we think that some specific behaviors exist in depressive people. Such behaviors repeatedly appear, often unconsciously, to work for maintaining the depressive mood in patients. We encourage the patients to change their behaviors to those potentially elevate their mood. Monitoring and scheduling activities are concrete keys for behavior modification in BA.

BA was considered as a part of full series of CBT. Thus, it is easier to conduct in shorter term compared to CBT. If BA has the same effect as CBT, the cost-effectiveness of BA is superior to that of CBT.

Therefore, researchers conducted a randomized trial for comparing BA to CBT regarding the effect of reducing depression. Participants were randomly assigned to either BA or CBT and took each treatment. PHQ-9, a popular self-rating scale of depression was adopted as the primary outcome measure. Therapists were qualified to take each therapy in advance. But, the therapists offering BA had an inferior specialty in psychotherapy.

LANCET: Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomized, controlled, non-inferiority trial

As a result, BA could improve the symptoms of depression in the participants. The effect size seems not inferior to CBT. These facts indicate that we can treat many depressive patients with BA for a lower cost than CBT.


This study is amazing. However, there are some concerns about the interpretation of the result. First, patients with recent suicidal attempts, patients with alcohol abuse, and patients with bipolar disorder were excluded from this study. We are always annoyed in treating such patients. It is uncertain whether seriously ill patients can be treated in BA protocol.

By contrast, patients with mild depression sometimes overcome their difficulty on their own. It is possible that some of the subjects of this study recovered without the effect of psychotherapy. If so, it is not guaranteed that BA is equally effective as CBT.

Even not so qualified as CBT therapists, BA therapists in this study had passed the assessment by Quality of Behavioral Activation Scale. The result of this study never indicates an immature therapist can cure depression.

In my opinion, some patients with depression need cognitive reconstruction session to improve the symptoms. Others do not need it. And it is not easy to distinguish them, or identify the component of the therapy necessary for each patient.

To begin with, only seriously ill patients visit our clinic in Japan. They need both psychotherapy and medication. Considering this fact, primary BA sessions should be offered in non-clinical situations, such as school or industrial setting in Japan. It will lead to improved community mental health, and maybe contributes to reduced prevalence rate of depression.

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