behavioural activation for depression david ekers phd, msc, enb 650 (cbt), rmn
TRANSCRIPT
What is Behavioural ActivationViews 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
Landmark study-Component Analysis of CT for Depression (Jacobson et al 1996)
2 ye ar
6 m on th
B a se lin e (n= 5 7)
B e ha v iou ra l A c tiva tio n a lo ne
2 ye ar
6 m on th
B a s le line (n = 4 4)
A c tiva tio n a n d th ou gh t m o d if ica tion
2 ye ar
6 m on th
B a se lin e (n= 5 0)
F u ll C T
1 5 0 P a tien ts w ith m a jo r de p ress ion id en tif ie d fo r s tu d y ra n do m a llo ca tion to a rm s
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 : Behavioural Activation for DepressionComparison: 04 Behavioural vs control Outcome: 01 SMD all studies BT vs Waitlist/Placebo Control/TAU
Study Behavioural Wait List SMD (random) SMD (random)or sub-category N Mean (SD) N Mean (SD) 95% CI 95% CI
Wilson 1982 (relax) 6 12.42(9.38) 10 8.50(6.35) 0.49 [-0.54, 1.52] Wilson 1983 8 7.50(4.55) 9 21.44(5.52) -2.60 [-3.98, -1.22] Taylor 1977 7 10.70(5.00) 7 20.10(5.80) -1.63 [-2.89, -0.36] Mclean 1979 42 9.70(8.00) 43 14.95(8.00) -0.65 [-1.09, -0.21] Maldonado Lopez 1982 8 7.38(3.74) 8 17.63(8.33) -1.50 [-2.65, -0.35] Wilson 1982 6 12.42(9.38) 10 14.60(9.73) -0.21 [-1.23, 0.80] Wilson 1982 (PLA) 5 11.89(10.87) 12 14.67(11.12) -0.24 [-1.29, 0.81] Wilson 1982 (PLA/re) 4 11.89(10.87) 10 16.55(10.36) -0.42 [-1.59, 0.76] Cole1983 15 26.40(8.00) 15 31.20(8.00) -0.58 [-1.32, 0.15] Skinner 1984 8 14.62(5.90) 9 18.33(4.92) -0.65 [-1.64, 0.33] Thompson 1987 30 12.40(7.80) 19 22.48(7.82) -1.27 [-1.90, -0.64] Scogin1989 19 9.70(5.70) 21 15.90(6.90) -0.96 [-1.61, -0.30] McKendree Smith 1998 13 12.00(13.15) 14 14.79(9.63) -0.24 [-0.99, 0.52] Cullen 2006 6 3.83(3.31) 8 28.25(16.31) -1.81 [-3.13, -0.49] Dimidjian 2006 22 16.82(8.56) 31 22.50(12.97) -0.49 [-1.05, 0.06] Dimidjian 2006 (ls) 15 15.33(10.03) 19 14.68(7.81) 0.07 [-0.61, 0.75]
Total (95% CI) 214 245 -0.70 [-1.00, -0.39]Test for heterogeneity: Chi² = 31.54, df = 15 (P = 0.007), I² = 52.4%Test for overall effect: Z = 4.50 (P < 0.00001)
-4 -2 0 2 4
Favours Behavioural Favours control
Review : Behavioural Activation for DepressionComparison: 06 SMD BT vs CBT Outcome: 01 BT vs CT Symptom Level
Study Behavioural Therapy Cognitive Therapy SMD (random) SMD (random)or sub-category N Mean (SD) N Mean (SD) 95% CI 95% CI
01 Symptom Level post TreatmentWilson 1983 8 7.50(4.55) 8 9.00(6.82) -0.24 [-1.23, 0.74] Taylor 1977 4 10.70(5.00) 7 10.30(2.60) 0.10 [-1.13, 1.33] Taylor 1977 (CBT) 3 10.70(5.00) 7 5.60(4.70) 0.96 [-0.49, 2.42] Gallaher1982 10 12.62(11.97) 10 9.71(5.74) 0.30 [-0.59, 1.18] Maldonado Lopez 1982 8 7.38(3.74) 8 4.88(3.80) 0.63 [-0.38, 1.64] Maldonado Lopez 1984 8 16.35(5.37) 8 6.37(7.81) 1.41 [0.28, 2.54] Skinner 1984 8 14.62(5.90) 7 15.00(7.40) -0.05 [-1.07, 0.96] McNamara 1986 5 5.50(3.56) 10 6.50(4.17) -0.24 [-1.31, 0.84] MvNamara 1986 (CBT) 5 5.50(3.56) 10 4.80(3.55) 0.19 [-0.89, 1.26] Thompson 1987 30 12.40(7.80) 31 13.60(10.10) -0.13 [-0.63, 0.37] Scogin1989 19 9.70(5.70) 21 7.50(3.60) 0.46 [-0.17, 1.09] Jacobson 1996 28 9.10(7.90) 50 10.10(9.60) -0.11 [-0.57, 0.35] Jacobson1996 (AT) 28 9.10(7.90) 43 10.60(9.30) -0.17 [-0.65, 0.31] McKendree Smith 1998 13 12.00(13.15) 13 5.62(4.33) 0.63 [-0.16, 1.42] Dimidjian 2006 16 8.75(7.96) 18 17.44(15.57) -0.67 [-1.37, 0.02] Dimidjian 2006 (ls) 15 11.00(10.08) 17 9.76(8.15) 0.13 [-0.56, 0.83]
Subtotal (95% CI) 208 268 0.08 [-0.14, 0.30]Test for heterogeneity: Chi² = 19.01, df = 15 (P = 0.21), I² = 21.1%Test for overall effect: Z = 0.75 (P = 0.46)
02 Symptom level Follow upGallaher1982 9 9.89(9.47) 10 9.78(5.67) 0.01 [-0.89, 0.91] Scogin1989 14 9.10(6.30) 15 8.90(6.00) 0.03 [-0.70, 0.76] Jacobson 1996 25 8.50(7.60) 47 10.30(8.60) -0.22 [-0.70, 0.27] Jacobson1996 (AT) 25 8.50(7.60) 39 9.30(8.20) -0.10 [-0.60, 0.40]
Subtotal (95% CI) 73 111 -0.11 [-0.41, 0.19]Test for heterogeneity: Chi² = 0.40, df = 3 (P = 0.94), I² = 0%Test for overall effect: Z = 0.71 (P = 0.47)
-4 -2 0 2 4
Favours BT Favours CT
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 baseNo cost analysis/Small studies/Limited numbers in comparisons beyond BA vs. Control and CBT
All ‘experienced therapists’
So still big questionsDoes 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
Results68 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 ResultsBA superior on all measures with large effect and more recovery BDI-II difference post in favour of BACompleters −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 BACompleters −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=0.001Strong 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
-£1,000
-£500
£0
£500
£1,000
£1,500
£2,000
-0.15 -0.10 -0.05 0.00 0.05 0.10 0.15
Cost Difference
Eff
ec
t D
iffe
ren
ce
Cost more/less effective
Cost less/less effective Cost less/more effective
Cost more/more effective
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 LimitationsSmall sample
2 therapists
No follow up
But helped us in looking at the proof of principle
SummaryBA 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
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 differentOnly 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 BA-
Simple 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
DesignCOBRA 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 cost-effective 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.
InterventionsBA (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 care- recruitment until June 2014
Intervention/follow upCollaborative care, delivered by case manager/own home or over phone
10 sessions Patient engagement & educationCo-ordination of care/Medication managementBrief psychosocial interventions/Behavioural activationEnsure 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
SummaryBA 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.