Behavioral Activation Cheaper, Non-Inferior Compared with CBT for Depression

two seated people having thoughtful discussion
two seated people having thoughtful discussion
These findings challenge the dominance of CBT as the leading evidence-based psychological therapy for depression.

Behavioral activation, a simple and inexpensive type of psychotherapy, may be as effective at treating depression in adults as cognitive behavioral therapy (CBT), according to a study published in The Lancet.

Unlike CBT, behavioral activation can be administered by non-specialists with minimal training and at a much lower cost.

“Our findings challenge the dominance of CBT as the leading evidence-based psychological therapy for depression,” David Richards, PhD, lead author and Professor of Mental Health Services Research at the University of Exeter in the United Kingdom, said. “Behavioral activation should be a front-line treatment for depression in the UK and has enormous potential to improve reach and access to psychological therapy worldwide.”

This is largest trial of behavioral activation to date, and the results suggest that behavioral activation therapy could be conducted by junior mental health workers. This could lead to an estimated 21% in cost savings to clinical providers compared with the cost of CBT and may allow the many people on waiting lists for CBT to receive treatment for depression.

“Behavioral activation is an ‘outside in’ treatment that focuses on helping people with depression to change the way they act. The treatment helps people make the link between their behavior and their mood. Therapists help people to seek out and experience more positive situations in their lives. The treatment also helps people deal with difficult situations and helps them find alternatives to unhelpful habitual behaviors,” said Dr Richards.

Until now, there was insufficient evidence to recommend behavioral activation as a first-line treatment for depression. The U.K. National Institute for Health and Clinical Excellence (NICE) called for a large non-inferiority study to determine whether behavioral activation could be an effective alternative treatment to CBT for those with depression.

In the Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA) trial, researchers recruited 440 adults with depression from primary care and psychological therapy services from 3 areas of England. Out of 440 participants, 221 were randomly assigned to a maximum of 20 sessions of behavioral activation with junior mental health workers, and 219 were assigned to CBT with experienced psychological therapists. Between 20% and 30% in each group did not attend more than 8 therapy sessions or dropped out and were not included in the final analysis.

One year after starting treatment, behavioral activation was found non-inferior to CBT. Around two-thirds of participants in each group had at least a 50% reduction in symptoms, similar numbers of anxiety diagnoses and depression-free days, and equal likelihoods of experiencing remission. While 3 participants being treated with behavioral activation and 8 being treated with CBT had serious adverse events (self harm and overdose), these were depression related and not treatment related.

Due to the low cost of non-specialist mental health providers, behavioral activation was more cost-effective and affordable compared with CBT. The researchers found that the cost per person of behavioral activation was significantly lower than for CBT (£974.81 vs £1235.23 per person). This would amount to a 21% savings for health care systems.

“Our findings indicate that health services worldwide, both rich and poor, could reduce the need for costly professional training and infrastructure, reduce waiting times, and increase the availability of psychological therapies. However, more work still needs to be done to find ways to effectively treat up to a third of people with depression who do not respond to CBT or behavioural activation,” concluded Dr Richards.


Richards DA, Ekers D, McMillan D, et al. Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. Lancet. 2016; doi: 10.1016/S0140-6736(16)31140-0.

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