Behavioural Activation for
Depression
David Ekers PhD, MSc, ENB 650 (CBT),
RMN
What is Behavioural Activation
Views depression as based in
interaction with environment-Loss of
positive reinforcement
Uses behavioural theory
Largely forgotten in favor of CBT over
past 3 decades
Potentially simple to deliver possibly
suited to wider dissemination ‘less
moving parts’
This may then be of particular use if it
remains as effective
OUR RESEARCH STORY SO FAR
Landmark study-Component Analysis
of CT for Depression (Jacobson et al
1996)
150 Patients with major depression identified for study random allocation to arms
Behavioural Activation alone
Activation and thought modification
Full CT
Baseline (n=57)
Basleline (n=44)
Baseline (n=50)
6 month
6 month
6 month
2year
2 year
2 year
Systematic review and Meta-analysis of
behavioural treatment for depression
Psychological Medicine 2008; 38(5): 611-623.
What a meta analysis tells us
The combined effect over a number of studies
Is there importance variance across findings of studies
Is there evidence of important studies missing
Generally reports ‘effect size’ as standardised mean
difference
0.33-0.55 moderate
0.55 and above large effects
Findings
BA vs. Control/Usual Care
 12 studies (459 participants)
 Effect size -0.70 in favour of BA (large) (95% CI −0.39 to −1, p=0.001),
recovery rate favours BA OR= 4.18 CI 1.14 to 15.28 (p=0.03)
BA vs. CT/CBT
 Twelve studies (476 patients)
 No difference effect size at post treatment and follow up (SMD 0.08 95%
CI −0.14 to 0.30, SMD of 0.25, 95% CI −0.21 to 0.70, p=0.28) or recovery
rate (OR 0.92, 95% CI 0.59 to1.44, p=0.72)
Review :
Comparison:
Outcome:
Behavioural A ctivation f or Depression
04 Behavioural vs control
01 SMD all studies BT vs Waitlist/Placebo Control/TAU
Study
or sub-category
N
6
8
7
42
8
6
5
4
15
8
30
19
13
6
22
15
Wilson 1982 (relax)
Wilson 1983
Taylor 1977
Mclean 1979
Maldonado Lopez 1982
Wilson 1982
Wilson 1982 (PLA)
Wilson 1982 (PLA/re)
Cole1983
Skinner 1984
Thompson 1987
Scogin1989
McKendree Smith 1998
Cullen 2006
Dimidjian 2006
Dimidjian 2006 (ls)
Behavioural
Mean (SD)
Wait List
Mean (SD)
N
12.42(9.38)
7.50(4.55)
10.70(5.00)
9.70(8.00)
7.38(3.74)
12.42(9.38)
11.89(10.87)
11.89(10.87)
26.40(8.00)
14.62(5.90)
12.40(7.80)
9.70(5.70)
12.00(13.15)
3.83(3.31)
16.82(8.56)
15.33(10.03)
10
9
7
43
8
10
12
10
15
9
19
21
14
8
31
19
214
Total (95% CI)
Test f or heterogeneity: Chi² = 31.54, df = 15 (P = 0.007), I² = 52.4%
Test f or overall ef f ect: Z = 4.50 (P < 0.00001)
SMD (random)
95% CI
8.50(6.35)
21.44(5.52)
20.10(5.80)
14.95(8.00)
17.63(8.33)
14.60(9.73)
14.67(11.12)
16.55(10.36)
31.20(8.00)
18.33(4.92)
22.48(7.82)
15.90(6.90)
14.79(9.63)
28.25(16.31)
22.50(12.97)
14.68(7.81)
245
-4
-2
0
Favours Behavioural
Review :
Comparison:
Outcome:
Study
or sub-category
SMD (random)
95% CI
2
0.49
-2.60
-1.63
-0.65
-1.50
-0.21
-0.24
-0.42
-0.58
-0.65
-1.27
-0.96
-0.24
-1.81
-0.49
0.07
[-0.54,
[-3.98,
[-2.89,
[-1.09,
[-2.65,
[-1.23,
[-1.29,
[-1.59,
[-1.32,
[-1.64,
[-1.90,
[-1.61,
[-0.99,
[-3.13,
[-1.05,
[-0.61,
1.52]
-1.22]
-0.36]
-0.21]
-0.35]
0.80]
0.81]
0.76]
0.15]
0.33]
-0.64]
-0.30]
0.52]
-0.49]
0.06]
0.75]
-0.70
[-1.00,
-0.39]
4
Favours control
Behavioural Activation f or Depression
06 SMD BT vs CBT
01 BT vs CT Symptom Level
N
Behavioural Therapy
Mean (SD)
01 Symptom Level post Treatment
8
7.50(4.55)
Wilson 1983
4
10.70(5.00)
Taylor 1977
3
10.70(5.00)
Taylor 1977 (CBT)
10
12.62(11.97)
Gallaher1982
8
7.38(3.74)
Maldonado Lopez 1982
8
16.35(5.37)
Maldonado Lopez 1984
8
14.62(5.90)
Skinner 1984
5
5.50(3.56)
McNamara 1986
5
5.50(3.56)
MvNamara 1986 (CBT)
30
12.40(7.80)
Thompson 1987
19
9.70(5.70)
Scogin1989
28
9.10(7.90)
Jacobson 1996
28
9.10(7.90)
Jacobson1996 (AT)
13
12.00(13.15)
McKendree Smith 1998
16
8.75(7.96)
Dimidjian 2006
15
11.00(10.08)
Dimidjian 2006 (ls)
208
Subtotal (95% CI)
Test f or heterogeneity: Chi² = 19.01, df = 15 (P = 0.21), I² = 21.1%
Test f or overall ef f ect: Z = 0.75 (P = 0.46)
02 Symptom level Follow up
9
9.89(9.47)
Gallaher1982
14
9.10(6.30)
Scogin1989
25
8.50(7.60)
Jacobson 1996
25
8.50(7.60)
Jacobson1996 (AT)
73
Subtotal (95% CI)
Test f or heterogeneity: Chi² = 0.40, df = 3 (P = 0.94), I² = 0%
Test f or overall ef f ect: Z = 0.71 (P = 0.47)
N
Cognitive Therapy
Mean (SD)
SMD (random)
95% CI
SMD (random)
95% CI
8
7
7
10
8
8
7
10
10
31
21
50
43
13
18
17
268
9.00(6.82)
10.30(2.60)
5.60(4.70)
9.71(5.74)
4.88(3.80)
6.37(7.81)
15.00(7.40)
6.50(4.17)
4.80(3.55)
13.60(10.10)
7.50(3.60)
10.10(9.60)
10.60(9.30)
5.62(4.33)
17.44(15.57)
9.76(8.15)
-0.24
0.10
0.96
0.30
0.63
1.41
-0.05
-0.24
0.19
-0.13
0.46
-0.11
-0.17
0.63
-0.67
0.13
0.08
[-1.23, 0.74]
[-1.13, 1.33]
[-0.49, 2.42]
[-0.59, 1.18]
[-0.38, 1.64]
[0.28, 2.54]
[-1.07, 0.96]
[-1.31, 0.84]
[-0.89, 1.26]
[-0.63, 0.37]
[-0.17, 1.09]
[-0.57, 0.35]
[-0.65, 0.31]
[-0.16, 1.42]
[-1.37, 0.02]
[-0.56, 0.83]
[-0.14, 0.30]
10
15
47
39
111
9.78(5.67)
8.90(6.00)
10.30(8.60)
9.30(8.20)
0.01
0.03
-0.22
-0.10
-0.11
[-0.89,
[-0.70,
[-0.70,
[-0.60,
[-0.41,
-4
-2
Favours BT
0
2
Favours CT
4
0.91]
0.76]
0.27]
0.40]
0.19]
Possible implications of findings
BA works compared to control
No apparent added benefit of cognitive components
BA appears strong in relation to other therapies
Limitations of evidence base
No cost analysis/Small studies/Limited numbers in comparisons
beyond BA vs. Control and CBT
All ‘experienced therapists’
So still big questions
Does BA’s equivalence maintain with less ‘qualified’ therapists? (as
per Jacobson 1996)
Parsimony- but if a simple intervention is delivered by ‘expert
therapists’ what is active ingredient?
No help to improving access to evidenced based therapies if reliant
on ‘experts’
Do we need more therapies for delivery
by the same therapists?? (or more meta analysis
from the same studies)
Behavioural activation delivered by the
non specialist: Phase II randomised
controlled trial
D Ekers, D. Richards, S Gilbody, D McMillan &
M Bland
British Journal of Psychiatry 2011
Results
 68 referrals (41 GP, 27 PCMH)
 Excluded: diagnosis 17, refused 2, risk 2
 Recruited 47
 23 BA-24 usual care
 7 dropout BA, 2 usual care
 Final clinical measures 16 BA, 22 usual care
 High level of baseline severity BDI-II-35.32 (SD 9.50)
 Long duration 3.67 years (SD 7.2 years)
 Randomisation produced equal groups
Clinical Results
 BA superior on all measures with large effect and more recovery
 BDI-II difference post in favour of BA
 Completers −15.65 (95% CI −6.90 to −24.41) SMD −1.15 (−1.85
to −0.45)
 ITT−15.78 in favour of BA (95% CI −24.55 to −7.02, p= 0.001)
 WASA in favour of BA
 Completers −11.56 (−4.79 to−18.33) p=0.001 SMD −1.14 (−1.84
to −0.45)
 ITT−11.12 in favour of BA (95% CI −17.53 to −4.70, p= 0.001)
 Satisfaction BA: 29 on 32 point scale, Better than usual care
p=0.001
 Strong adherence on checklist
Comparison to studies with ‘expert’
therapists
Ekers, Dawson and Bailey Journal of Psychiatric
and Mental Health Nursing 2013, 20, 186–192
Economic Analysis
Ekers D, Godfrey C, Gilbody S, Parrott S,
Richards D, Hammond D and Hayes A. (In
Press BJ Psych)
£2,000
£1,500
Cost more/more effective
Cost more/less effective
£1,000
Effect Difference
£500
-0.15
-0.10
-0.05
£0
0.00
0.05
0.10
-£500
-£1,000
-£1,500
Cost less/less effective
Cost less/more effective
-£2,000
Cost Difference
0.15
ICER based upon 1000 bootstrapped replications = £5,006 £5,756
97% likelihood that the additional cost of BA over usual care per QALY
gained is less than £20,000,
Small Study - Big Limitations
Small sample
2 therapists
No follow up
But helped us in looking at the proof of principle
Summary
 BA for some time has been viewed as an effective
intervention (as effective as CBT)
 Results appear to maintain when delivered by non
specialists with appt training (parsimony-dissemination
as per Jacobson 1996?)
 Cost effectiveness appears very promising with BA
offering well below NICE threshold cost per QALY even
using conservative estimate
 Large scale replication needed to examine results with
more therapists and participants
CURRENT RESEARCH
Behavioural Therapy for depression. A
meta-analysis update Ekers, Webster, Cuijpers, Von
Straten, Richards, Gilbody
29 studies-36 comparisons BA vs. controls (1387
participants)
Effect size maintains at the large level vs. control
−0.72 (95% CI −0.88 to −0.55 p<0.001 NNT 2.5)
Vs. medication results 4 studies, 5 comparisons 288
participants
−0.37 (95% CI −0.74 to −0.05 p 0.05 NNT 4.9)
Did any subgroups of studies look any
different
Only control group type had any strong
association/placebo controls=reduced effect size
Level of therapist
Non specialist BA 6 studies SMD −0.66 −0.90 to −0.43
p< 0.001 I2 25.60%
Specialist BA 23 studies SMD −0.74 −0.95 to −0.54 p<
0.001 I2 47.27%
Complexity of BASimple BA 19 studies (SMD −0.72 −0.92 to −0.51 p<
0.001 I2 58.01%)
Complex BA in 10 studies (SMD −0.73 −1.01 to −0.44 p<
0.001 I2 36.49%)
What we see
BA is an effective treatment for depression
Effect sizes appear consistent as the number of studies
slowly grow
Subgroup analysis do not show strong association
supporting increasing complexity or higher trained
therapists
We do however need larger studies to provide more
definitive examination of this
COBRA
(Cost and Outcome of BehaviouRal
Activation)
A Randomised Controlled Trial of Behavioural
Activation versus Cognitive Therapy for Depression
Multi-site Research Team
 MDC and PCMD, Exeter

Richards (CI), Farrand, Kuyken, O’Mahen,
Taylor, Watkins, Wright
 York

Gilbody, McMillan
 Durham

Ekers
 Depression Alliance

O’Neill
 IOP
–
Byford
 TSC

Tylee
 DMeC

Cape, Lovell
 CBT Assessors

OCTC
 BA Assessor

Martell
 Advisors

Hollon, Martell, Dimidjian
Design
COBRA is a two-arm Phase III, non-inferiority randomised controlled trial of
a psychological intervention: Behavioural Activation (BA).
The COBRA programme of research seeks to answer two interlinked
questions:
 What is the clinical effectiveness of BA compared to CBT for
depressed adults in terms of depression treatment response
measured by the PHQ9 at six, 12 and 18 months?
 What is the cost-effectiveness of BA compared to CBT at 12 and 18
months?
We hypothesize that BA is non-inferior compared to CBT in reducing
depression severity but that BA will be less costly and thus more costeffective than CBT.
In addition, we will undertake a secondary process evaluation to investigate
the moderating, mediating and procedural factors in BA and CBT which
influence outcome.
Interventions
BA (Non specialist Band 5)
CBT (specialist band 7 therapist)
Both active psychological treatments which have previously
demonstrated positive effects for people with depression, and are
recommended by NICE guidelines for the treatment of depression
In both arms of the study, 220 (440 total) participants will receive a
maximum of 20 sessions over 16 weeks with the option of four
additional booster sessions
Sessions will be face to face, of one-hour duration maximum
CASPER & CASPER Plus
Chief Investigator Prof Simon Gilbody University of York
Local Principal Investigator-Site lead Dr David Ekers
Funded by NIHR HTA programme
What is the effectiveness and cost-effectiveness of brief
interventions to prevent the progression of sub-clinical
depression in older people?’
CASPER- Sub Threshold Depression- recruitment
completed-705 people randomised into Collaborative
Care/usual care-recruitment complete
CASPER plus- Older adults with depression 450
people to be randomised collaborative care/usual carerecruitment until June 2014
Intervention/follow up
Collaborative care, delivered by case manager/own home or over phone
10 sessions
 Patient engagement & education
 Co-ordination of care/Medication management
 Brief psychosocial interventions/Behavioural activation
 Ensure follow up/Monitor outcomes
 ‘Stepping-up’ as needed
Manual guided intervention – adapted from previous research
12 month follow up of clinical and cost outcomes
One of largest RCTs of psychological support for older adults
internationally
Example how BA may lend itself to collaborative care structures across
health settings
Summary
BA looks to be an effective and simple intervention for
depression
Its simplicity may make it suitable for wide and efficient
dissemination but more research is ongoing
Whilst psychotherapies for depression have the same
effectiveness the search for improved reach may
result in greater clinical/population benefit-this is where
BA may have greatest advantage.
Behavioural Activation for
Depression
David Ekers PhD, MSc, ENB 650 (CBT),
RMN
David.ekers@durham.ac.uk