Cognitive behavioral therapy (CBT), sometimes known as talk therapy, is often considered the “gold standard” for treating depression—but it can be expensive and difficult to get appointments with therapists who are trained in the procedure. Now, a new study suggests that a simpler technique—known as behavioral activation (BA)—may work just as well for some patients.
The research, published online Friday by The Lancet, could make treatment for depression more affordable and available in many different countries, say the study authors. This is important, since clinical depression is the second leading cause of disability worldwide.
CBT does help many people with depression; it’s shown to be more effective, long-term, than antidepressant drugs. But access is limited: In the United States, only about one-fourth of people with depression have received any type of psychological therapy in the last 12 months, according to a University of Exeter press release about the study. In the United Kingdom, 10 percent of people are on waiting lists for more than a year to receive talk therapy.
So a team of British researchers decided to compare CBT with BA, a type of counseling that can be conducted by junior mental-health workers without professional CBT training. They recruited 440 patients with depression and followed them for 18 months while half received CBT and half got BA.
Both groups showed similar improvements at several checkpoints throughout the study. After one year, about two-thirds of participants in each group experienced at least a 50 percent reduction in depressive symptoms, and both groups reported a similar number of depression-free days. (About 20 to 23 percent of patients were not helped by either treatment.)
“Our most striking finding is that BA leads to similar clinical outcomes for patients with depression,” the study authors wrote, “but at a financial saving to clinical providers of 21 percent compared with the costs of provision of CBT.”
BA, explains lead author and University of Exeter professor David Richards, PhD, is an “outside in” treatment that focuses on helping people change the way they act. Therapists help people seek out positive situations, and find alternatives to unhealthy habits.
“They would ask a person to record their daily activities—we call this self-monitoring—in a diary that includes a space for activities and a space for their mood,” he explains. “Then the therapist begins to help the patient unravel the pattern of behaviors and moods, by helping them identify the triggers that lead to depressed mood, the activities that the patient does or doesn’t do in response to triggers, and the consequences of this behavior.”
Once this connection is made, therapists help patients schedule new activities into their days to see how they might change their mood. “Other techniques might come later and include helping the patient problem solve difficulties, deal with rumination, or manage additional anxiety symptoms,” Richards says.
In contrast, CBT is an “inside out” treatment that focuses on how a person thinks, rather than how they act. “In CBT, the therapist is mainly concerned with helping patients identify ‘thinking errors,’” says Richards. Patients are encouraged to challenge the negative thoughts that enter their mind, and are often given “homework” exercises to help them do so.
But Richards says it is not yet known who, specifically, might benefit most from a therapy like BA. “It is just as likely that people who don’t do so well with CBT might do better with BA, as it is that people who receive BA and don’t benefit might do better with CBT,” he says.
What the study does show, however, is that BA should be considered a front-line treatment for depression—and that people who don’t have access to CBT shouldn’t rule out mental-health counseling altogether.
Another finding of the study, says Richards, is that there is a clear link between behavior and mood. “The key message is that activity—social, physical, individual, anything that fits the values of the person themselves—is beneficial for people with depression,” he says. “The less we do, the more likely we will be blue.”