Behavioural Activation for Depression: a systematic review and controlled clinical trial

Background Depression is a common, disabling condition for which psychological treatments, in particular cognitive behavioural therapies are recommended. Promising results from randomised trials has renewed interest in behavioural therapy, which may be suitable for delivery by non-specialist therapists. Aims To deliver a phased research programme to examine the clinical and cost effectiveness of behavioural therapy for depressed adults, and in particular the suitability of the intervention for delivery by non specialists. Research design A systematic review and meta-analysis examined randomised trials of behavioural treatments for depression compared to controls or other psychotherapies. Data on symptom level, recovery/dropout rate and study level moderators (study quality, number of sessions, severity and level of training) were extracted and analysed. Based upon results of the meta-analysis a randomised controlled trial of clinical and cost effectiveness comparing BA delivered by non-specialist with treatment as usual in a primary care setting was conducted. Results Meta-Analysis: Seventeen randomised controlled trials including 1109 subjects were included. A meta-analysis of symptom level post-treatment showed behavioural therapies were superior to controls (SMD -0.70 CI -1.00 to -0.39, k=12, N= 459), brief psychotherapy (SMD -0.56 -1.0 to-0.12, k=3, N=166), supportive therapy (SMD -0.75 CI –1.37 to -0.14, k=2, N=45) and equal to cognitive behavioural therapy (SMD 0.08 CI -0.14 to 0.30, k=12, N=476). Randomised controlled trial: Intention to treat analyses indicated a difference in favour of BA of −15.79 (95% CI −24.55 to −7.02) on the Beck Depression Inventory-II, −11.12; (95% CI = −17.53 to −4.70), on the Work and Social Adjustment Scale and a 0.20 (95% CI 0.01 to 0.39) improvement in quality adjusted life year. An incremental cost effectiveness ratio of £5756 per QALY indicates with a 97% probability that BA delivered by non-specialists is more cost effective than usual primary care at a threshold value of £20,000. Conclusion Behavioural Activation is an effective psychological treatment for depression that appears suitable for delivery by non-specialists. Further research with larger sample sizes and longer follow up is required to expand on the findings reported in this thesis.