Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis

David Ekers, Lisa Webster, Annemieke Van Straten, Pim Cuijpers, David Richards, Simon Gilbody, David Ekers, Lisa Webster, Annemieke Van Straten, Pim Cuijpers, David Richards, Simon Gilbody

Abstract

Background: Depression is a common, disabling condition for which psychological treatments are recommended. Behavioural activation has attracted increased interest in recent years. It has been over 5 years since our meta-analyses summarised the evidence supporting and this systematic review updates those findings and examines moderators of treatment effect.

Method: Randomised trials of behavioural activation for depression versus controls or anti-depressant medication were identified using electronic database searches, previous reviews and reference lists. Data on symptom level and study level moderators were extracted and analysed using meta-analysis, sub-group analysis and meta-regression respectively.

Results: Twenty six randomised controlled trials including 1524 subjects were included in this meta-analysis. A random effects meta-analysis of symptom level post treatment showed behavioural activation to be superior to controls (SMD -0.74 CI -0.91 to -0.56, k = 25, N = 1088) and medication (SMD -0.42 CI -0.83 to-0.00, k = 4, N = 283). Study quality was low in the majority of studies and follow- up time periods short. There was no indication of publication bias and subgroup analysis showed limited association between moderators and effect size.

Conclusions: The results in this meta-analysis support and strengthen the evidence base indicating Behavioural Activation is an effective treatment for depression. Further high quality research with longer term follow-up is needed to strengthen the evidence base.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Flowchart of study inclusion.
Figure 1. Flowchart of study inclusion.
Figure 2. Behavioural Activation vs. control post…
Figure 2. Behavioural Activation vs. control post treatment (ordered by effect size high to low).
Figure 3. Behavioural Activation vs. Antidepressant medication.
Figure 3. Behavioural Activation vs. Antidepressant medication.

References

    1. National Institute of Clinical Excellence (2009) Management of Depression in Primary and Secondary Care. London: NICE.
    1. Mathers CD, Loncar D (2006) Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 3: e442.
    1. Barth J, Munder T, Gerger H, Nüesch E, Trelle S, et al. (2013) Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis. PLoS Med 10: e1001454.
    1. Ekers DM, Dawson MS, Bailey E (2013) Dissemination of behavioural activation for depression to mental health nurses: training evaluation and benchmarked clinical outcomes. J Psychiatr Ment Health Nurs 20: 186–192.
    1. Cuijpers P, van Strate A, Warmerdam L (2007) Behavioural activation treatments of depression: a meta analysis. Clinical Psychology Review 27: 318–326.
    1. Ekers D, Richards D, Gilbody S (2008) A Meta Analysis of Behavioural Therapy for Depression. Psychological Medicine 38: 611–623.
    1. Mazzucchelli T, Kane R, Rees C (2009) Behavioral Activation Treatments for Depression in Adults: A Meta-analysis and Review. Clinical Psychology Science and Practice 16: 383–411.
    1. Cuijpers P, van Straten A, Warmerdam L, Andersson G (2008) Psychological treatment of depression: a meta-analytic database of randomized studies. BMC Psychiatry 8: 36.
    1. Shinohara K, Honyashiki M, Imai H, Hunot V, M CD, et al... (2013) Behavioural therapies versus other psychological therapies for depression. Cochrane Database of Systematic Reviews.
    1. Cuijpers P, Andersson G, Donker T, van Straten A (2011) Psychological treatment of depression: results of a series of meta-analyses. Nord J Psychiatry 65: 354–364.
    1. McManus S, Meltzer H, Brugha T, Bebbington P, Jenkins R (2009) Adult psychiatric morbidity in England 2007: Results of a household survey. Leeds.
    1. Higgins J, Green S (2008) Cochrane handbook for systematic reviews of interventions. Chichester: Wiley.
    1. Furukawa T, Barbui C, Cipriani A, Brambilla P, Watanabe N (2006) Inputing missing standard deviations in meta-analyses can provide accurate results. Journal of Clinical Epidemiology 59: 7–10.
    1. Borenstein M, Hedges L, Higgins J, Rothstein H (2005) Comprehensive Meta-analysis Version 2. Englewood, NJ: Biostat.
    1. Lipsey M, Wilson D (1993) The efficacy of psychological, educational and behavioural treatment. American Psychologist 48: 1181–1209.
    1. Sutton A, Abrams K, Jones D (1998) Systematic reviews of trials and other studies. Health Technology Assessment 2: 19.
    1. Higgins J, Thompson S, Deeks J, Altman D (2003) Measuring inconsistency in meta-analyses. British Medical Journal 327: 557–560.
    1. Kraemer HC, Kupfer DJ (2006) Size of treatment effects and their importance to clinical research and practice. Biol Psychiatry 59: 990–996.
    1. Borenstein M, Hedges L, Higgins J, Rothstein H (2009) Introduction to Meta-Analysis. Chichester: Wiley.
    1. Deeks J, Higgins J, Altman D (2009) Chapter 9: Analysing data and undertaking meta-analyses. In: Higgins J, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 501 (updated 2009): The Cochrane Collaboration.
    1. Egger M, Davey-Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. British Medical Journal 315: 629–634.
    1. Besyner JK (1978) The comparative efficacy of cognitive and behavioral treatments of depression a multi-assessment approach. Dissertation Abstracts International 39: 4568B.
    1. Catanese R, Rosenthal T, Kelley J (1979) Strange bedfellows: Reward, punishment, and impersonal distraction strategies in treating dysphoria. Cognitive Therapy and Research 3: 299–305.
    1. Graf MG (1977) A mood-related activities schedule for the treatment of depression. Dissertation Abstracts International 38: 1400B–1401B.
    1. Gallagher D (1981) Behavioral group therapy with elderly depressives: An experimental study. In D. Upper & S. Ross (Eds.), Behavioral group therapy (pp. 187−224). Champaign: Research Press.
    1. Gallagher D, Thompson L (1982) Treatment of major depressive disorder in older adult outpatients with brief psychotherapies. Psychotherapy 19: 482–490.
    1. Gaston L, Marmar CR, Thompson LW, Gallagher D (1988) Relation of patient pretreatment characteristics to the therapeutic alliance in diverse psychotherapies. Journal of Consulting and Clinical Psychology 56: 483–489.
    1. Hopko DR, Armento MEA, Robertson SMC, Ryba MM, Carvalho JP, et al. (2011) Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: Randomized trial. Journal of Consulting and Clinical Psychology 79: 834–849.
    1. Jacobson N, Dobson K, Truax P, Addis M, Koerner K, et al... (1996) A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology: 295–304.
    1. Kornblith S, Rehm L, O’Hara M, Lamparski D (1983) The contribution of self-reinforcement training and behavioral assignments to the efficacy of self-control therapy for depression. Cognitive Therapy and Research 7: 499–527.
    1. Maldonado Lopez A (1984) Behavioural therapy and depression: an experimental analysis of the interaction between cognitive and behavioural therapies and pharmacological therapy in depressed people. Revista dePsicologia General y Aplicada 39: 517–535.
    1. McNamara K, Horan J (1986) Experimental construct validity in the evaluation of cognitive and behavioral treatments for depression. Journal of Counselling in Psychology 33: 23–30.
    1. Rehm LP, Fuchs CZ, Roth DM, Kornblith SJ, Romano JM (1979) A comparison of self-control and assertion skills treatment of depression. Behavior Therapy 10: 429–442.
    1. Rehm LP, Kaslow NJ, Rabin AS (1987) Cognitive and behavioral targets in a self-control therapy program for depression. Journal of Consulting and Clinical Psychology 55: 60–67.
    1. Turner RW, Ward MF, Turner DJ (1979) Behavioral treatment for depression: an evaluation of therapeutic components. J Clin Psychol 35: 166–175.
    1. Barrera M (1979) An evaluation of a brief group therapy for depression. Journal of Consulting and Clinical Psychology 47: 413–415.
    1. Cole MA (1983) Behavioral treatment of chronic depression. Dissertation Abstracts International 45: 1009B.
    1. Dobson K, Dimidjian S, Kohlenberg R, Rizvi S, Hollon S, et al. (2008) Randomized trial of behavioral activation, cognitive therapy and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of Consulting and Clinical Psychology 76: 468–477.
    1. O’Mahen HA, Woodford J, McGinley J, Warren FC, Richards DA, et al. (2013) Internet-based behavioral activation-Treatment for postnatal depression (Netmums): A randomized controlled trial. J Affect Disord 150: 814–822.
    1. Zeiss A, Lewinsohn P, Munoz R (1979) Nonspecific improvement effects in depression using interpersonal skills training, pleasant activity schedules, or cognitive training. Journal of Consulting and Clinical Psychology 47: 427–439.
    1. Lynch TR, Cheavens JS, Cukrowicz KC, Thorp SR, Bronner L, et al. (2007) Treatment of older adults with co-morbid personality disorder and depression: a dialectical behavior therapy approach. International Journal of Geriatric Psychiatry 22: 131–143.
    1. Wagner AW, Zatzick DF, Ghesquiere A, Jurkovich GJ (2007) Behavioral Activation as an Early Intervention for Posttraumatic Stress Disorder and Depression Among Physically Injured Trauma Survivors. Cognitive and Behavioral Practice 14: 341–349.
    1. Carpenter KM, Smith JL, Aharonovich E, Nunes EV (2008) Developing therapies for depression in drug dependence: results of a stage 1 therapy study. Am J Drug Alcohol Abuse 34: 642–652.
    1. Daughters SB, Braun AR, Sargeant MN, Reynolds EK, Hopko DR, et al. (2008) Effectiveness of a brief behavioral treatment for inner-city illicit drug users with elevated depressive symptoms: the life enhancement treatment for substance use (LETS Act!). J Clin Psychiatry 69: 122–129.
    1. Reynolds EK, Macpherson L, Tull MT, Baruch DE, Lejuez CW (2011) Integration of the brief behavioral activation treatment for depression (BATD) into a college orientation program: depression and alcohol outcomes. J Couns Psychol 58: 555–564.
    1. Teri L, Logsdon RG, Uomoto J, McCurry SM (1997) Behavioral Treatment of Depression in Dementia Patients: A Controlled Clinical Trial. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 52B: P159–P166.
    1. de Jong R, Treiber R, Henrich G (1986) Effectiveness of two psychological treatments for inpatients with severe and chronic depressions. Cognitive Therapy and Research 10: 645–663.
    1. Emanuels-Zuurveen L, Emmelkamp PM (1996) Individual behavioural-cognitive therapy v. marital therapy for depression in maritally distressed couples. Br J Psychiatry 169: 181–188.
    1. Gortner ET, Gollan JK, Dobson KS, Jacobson NS (1998) Cognitive–behavioral treatment for depression: Relapse prevention. Journal of Consulting and Clinical Psychology 66: 377–384.
    1. Hopko D, Lejuez C, Ruggiero K, Eifert G (2003) Contemporary behavioral activation treatments for depression: Procedures, principles, and progress. Clinical Psychology Review 23: 699–717.
    1. McKendree-Smith N (1998) Cognitive and behavioural bibliotherapy for depression: an examination of efficacy and mediators and moderators of change. Dissertation Abstracts International 60: 5783B.
    1. Padfield M (1976) The comparative effects of two counseling approaches on the intensity of depression among rural women of low socioeconomic status Journal of Counselling Psychology. 23: 209–214.
    1. Scogin F, Jamison C, Gochneaur K (1989) Comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults. Journal of Consulting and Clinical Psychology 57: 403–407.
    1. Watkins ER, Baeyens CB, Read R (2009) Concreteness training reduces dysphoria: proof-of-principle for repeated cognitive bias modification in depression. J Abnorm Psychol 118: 55–64.
    1. Gros DF, Haren WB (2011) Open trial of brief behavioral activation psychotherapy for depression in an integrated veterans affairs primary care setting. Prim Care Companion CNS Disord 13.
    1. Hammen CL, Glass DR (1975) Depression, activity, and evaluation of reinforcement. Journal of Abnormal Psychology 84: 718–721.
    1. Snarski M, Scogin F, DiNapoli E, Presnell A, McAlpine J, et al. (2011) The Effects of Behavioral Activation Therapy With Inpatient Geriatric Psychiatry Patients. Behavior Therapy 42: 100–108.
    1. Weinstock LM, Munroe MK, Miller IW (2011) Behavioral activation for the treatment of atypical depression: a pilot open trial. Behav Modif 35: 403–424.
    1. Barlow JP (1986) A Group Treatment for Depression in the Elderly. Dissertation Abstraction International 46: 4389B.
    1. Pace F (1977) Behavioral techniques in the treatment of depression. Dissertation Abstracts International 39: 992B.
    1. Weinberg L (1977) Behaviorally and cognitively oriented approaches to the alleviation of depressive symptoms in college students. 38: 3422–3433.
    1. Kanter JW, Santiago-Rivera AL, Rusch LC, Busch AM, West P (2010) Initial outcomes of a culturally adapted behavioral activation for Latinas diagnosed with depression at a community clinic. Behav Modif 34: 120–144.
    1. Barrera M (1977) An evaluation of a brief group therapy for depression. Dissertation Abstracts International 38: 2842B–2843B.
    1. Cullen JM (2002) Testing the Effectiveness of Behavioral Activation Therapy in the Treatment of Acute Unipolar Depression. Dissertation Abstracts International 64: 412B.
    1. Fuchs CZ, Rehm LP (1977) A self-control behavior therapy program for depression. Journal of Consulting and Clinical Psychology 45: 206–215.
    1. Shaw B (1977) Comparison of cognitive therapy and behavior therapy in the treatment of depression. Journal of Consulting and Clinical Psychology 45: 543–551.
    1. Taylor F, Marshall W (1977) Experimental analysis of a cognitive-behavioral therapy for depression. Cognitive Therapy and Research 1: 59–72.
    1. McLean P, Hakstain R (1979) Clinical depression: comparative efficacy of outpatient treatment. Journal of Consulting and Clinical Psychology 47: 818–836.
    1. Comas-Diaz L (1981) Effects of cognitive and behavioral group treatment on the depressive symptomatology of Puerto Rican women. J Consult Clin Psychol 49: 627–632.
    1. Rehm LP, Kornblith SJ, O’Hara MW, Lamparski DM, Romano JM, et al. (1981) An Evaluation of Major Components in a Self-Control Therapy Program for Depression. Behavior Modification 5: 459–489.
    1. Maldonado Lopez A (1982) Behavioural therapy and depression. Revista dePsicologia General y Aplicada 37: 31–56.
    1. Wilson PH (1982) Combined pharmacological and behavioural treatment of depression. Behaviour Research and Therapy 20: 173–184.
    1. Wilson P, Goldin J, Charbonneau Powis M (1983) Comparative efficacy of behavioral and cognitive treatments of depression. Cognitive Therapy and Research 7: 111–124.
    1. Skinner DA (1984) Self-control of depression: A comparison of behavior therapy and cognitive behavior therapy. Dissertation Abstracts International 45: 1031B.
    1. Thompson LW, Gallagher D (1984) Efficacy of psychotherapy in the treatment of late-life depression. Advances in Behaviour Research and Therapy 6: 127–139.
    1. Thompson L, Gallagher D, Breckenridge J (1987) Comparative effectiveness of psychotherapies for depressed elders. Journal of Consulting and Clinical Psychology 55: 385–390.
    1. Lovett S, Gallagher D (1988) Psychoeducational interventions for family caregivers: Preliminary efficacy data. Behavior Therapy 19: 321–330.
    1. van den Hout JH, Arntz A, Kunkels FH (1995) Efficacy of a self-control therapy program in a psychiatric day-treatment center. Acta Psychiatr Scand 92: 25–29.
    1. Rokke PD, Tomhave JA, Jocic Z (1999) The role of client choice and target selection in self-management therapy for depression in older adults. Psychology and Aging 14: 155–169.
    1. Gallagher-Thompson M, Lovett S, Rose J, McKibbin C, Coon D, et al. (2000) Impact of Psychoeducational Interventions on Distressed Family Caregivers. Journal of Clinical Geropsychology 6: 91–110.
    1. Cullen J, Spates R, Pagoto S, Doran N (2006) Behavioural activation treatment for major depressive disorder: a pilot investigation. Behavior Analyst Today 7: 151–166.
    1. Dimidjian S, Hollon S, Dobson K, Schmaling K, Kohlenberg R, et al. (2006) Randomized trial of behavioural activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology 64: 658–670.
    1. Gawrysiak M, Nicholas C, Hopko D (2009) Behavioural Activation for Moderately Depressed University Students: Randomised Control Trial. Journal of Counselling Psychology 56: 468–475.
    1. Mitchell PH, Veith RC, Becker KJ, Buzaitis A, Cain KC, et al. (2009) Brief psychosocial-behavioral intervention with antidepressant reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomized, controlled trial. Stroke 40: 3073–3078.
    1. Ekers D, Richards D, McMillan D, Bland M, Gilbody S (2011) Behavioural Activation delivered by the non specialist: phase II randomised controlled trial. British journal of psychiatry 198: 66–72.
    1. Armento MEA (2012) Behavioural Activation of Religeous Behaviours (BARB): Randomised Trial With Depressed College Students. Psychology of Religion and Spirituality 4: 206–222.
    1. Carlbring P, Hagglund M, Luthstrom A, Dahlin M, Kadowaki A, et al. (2013) Internet-based behavioral activation and acceptance-based treatment for depression: a randomized controlled trial. J Affect Disord 148: 331–337.
    1. Kanter J, Santiago-Rivera A, Santos MM, Nagy GA, Lopez M, et al... (2013) A Randomized Hybrid Efficacy and Effectiveness Trial of Behavioral Activation for Latinos with Depression. Unpublished Manuscript.
    1. Moradveisi L, Huibers MJ, Renner F, Arasteh M, Arntz A (2013) Behavioural activation v. antidepressant medication for treating depression in Iran: randomised trial. Br J Psychiatry 202: 204–211.
    1. O’Mahen HA, Richards DA, Woodford J, Wilkinson E, McGinley J, et al... (2013) Netmums: a phase II randomized controlled trial of a guided Internet behavioural activation treatment for postpartum depression. Psychol Med: 1–15.
    1. Rhodes S, Richards D, Ekers D, McMillan D, Byford S, et al. (2014) Cost and Outcome of BehaviouRal Activation (COBRA). A Randomised Controlled Trial of Behavioural Activation versus Cognitive Behaviour Therapy for Depression: Study Protocol. Trials 15: 29.

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