Global dissemination and implementation of behavioural activation
Authors: Jonathan W Kanter, Ajeng J Puspitasari
Journal: The Lancet (2016)

In The Lancet, David Richards and colleagues1Richards DA Ekers D McMillan D et al.Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, open-label, non-inferiority trial.Lancet. 2016; (published online July 22.)http://dx.doi.org/10.1016/S0140-6736(16)31140-0Google Scholar present the Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA) trial—one of the largest randomised controlled trials so far of psychotherapy for depression—comparing junior, low-cost mental health workers delivering a simple treatment (behavioural activation [BA]) to experienced psychological therapists delivering the gold-standard treatment (cognitive behavioural therapy [CBT]). Results identified BA as non-inferior to (mean difference 0·1 Patient Health Questionnaire 9 points [95% CI −1·3 to 1·5], p=0·89) and more cost-effective than (incremental cost-effectiveness ratio –£6865) CBT. Both treatments performed well, with responses consistent with those from a previous meta-analysis of treatment efficacy.2Amick HR Gartlehner G Gaynes BN et al.Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis.BMJ. 2015; 351: h6019Crossref PubMed Scopus (133) Google Scholar Therapists in three different routine UK care settings provided treatment, and exclusion criteria were minimal and representative of practice. The study is generalisable to many mental health-care settings in the UK. Countries like the UK, where government-funded health care and clear evidence-based practice guidelines exist, as well as large health-care organisations internationally, should take note. Stakeholders should understand that the COBRA trial results are not surprising. The promise of BA—that it can produce equivalent if not superior outcomes to more complex treatments and can do so more efficiently and cost-effectively—has been in place since BA's inception, and results consistent with this promise have been accruing for decades.3Dimidjian S Barrera Jr, M Martell C Muñoz RF Lewinsohn PM The origins and current status of behavioral activation treatments for depression.Annu Rev Clin Psychol. 2011; 7: 1-38Crossref PubMed Scopus (402) Google Scholar Findings from several trials show that BA can be applied effectively by providers with low levels of training in low-resource settings, including in India,4Chowdhary N Anand A Dimidjian S et al.The Healthy Activity Program lay counsellor delivered treatment for severe depression in India: systematic development and randomised evaluation.Br J Psychiatry. 2016; 208: 381-388Crossref PubMed Scopus (84) Google Scholar Iran,5Moradveisi L Huibers MJ Renner F Arasteh M Arntz A Behavioural activation v. Antidepressant medication for treating depression in Iran: randomised trial.Br J Psychiatry. 2013; 202: 204-211Crossref PubMed Scopus (47) Google Scholar and Iraq,6Bolton P Bass JK Zangana GA et al.A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq.BMC Psychiatry. 2014; 14: 360Crossref PubMed Scopus (73) Google Scholar with low-income Latinos in the USA,7Kanter JW Santiago-Rivera AL Santos MM et al.A randomized hybrid efficacy and effectiveness trial of behavioral activation for Latinos with depression.Behav Ther. 2015; 46: 177-192Crossref PubMed Scopus (48) Google Scholar and with old veterans via telemedicine.8Egede LE Acierno R Knapp RG et al.Psychotherapy for depression in older veterans via telemedicine: a randomised, open-label, non-inferiority trial.Lancet Psychiatry. 2015; 2: 693-701Summary Full Text Full Text PDF PubMed Scopus (110) Google Scholar WHO has identified BA as a recommended treatment for depression in low-resource settings.9WHOWHO mhGAP Guideline Update. World Health Organization, Geneva2015Google Scholar Scientific caution is advised, however, when considering large-scale global dissemination of BA. Substantial obstacles to successful international dissemination and implementation of any evidence-based practice exist at multiple provider, patient, organisational, and sociopolitical levels beyond the scope of the COBRA trial.10Damschroder LJ Aron DC Keith RE Kirsh SR Alexander JA Lowery JC Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.Implement Sci. 2009; 4: 50Crossref PubMed Scopus (5918) Google Scholar Common obstacles include lack of training and support for providers, patients' low acceptability of and stigma towards treatment, organisational climates and cultures that are incompatible with evidence-based practices, and an absence of governmental policies and support for mental health service delivery. BA is a promising treatment to consider in international research efforts to overcome these obstacles. BA's face validity is crucial and might help it address some implementation obstacles. For example, BA's cross-cultural fit and adaptability, an issue not addressed in the COBRA trial (the study's 91% white British sample is representative of the UK, but not the rest of the world), might be strong. The fundamental rationale behind BA—the importance of engagement in value-driven and meaningful activities as a response to adversity and despair—is recognised globally and has been for a long time. We have found BA's rationale to be easy for culturally diverse patients to accept, including patients for whom a medical model of depression might be incompatible with cultural beliefs.11Mir G Meer S Cottrell D McMillan D House A Kanter J Adapted behavioural activation for the treatment of depression in Muslims.J Affect Disord. 2015; 180: 190-199Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar Although rooted in medical science, BA does not need to be explained in such terms to patients. The message from the provider to the patient, simply put, could be: "Life will inevitably throw obstacles at you, and you will feel down. When you do, stay active. Do not quit. I will help you get active again." When defining activation targets, a patient's cultural, spiritual, and other personal values could be incorporated into treatment by the provider without compromising BA's core strategies or mechanism of action. Thus, when the goal is wide dissemination and implementation across cultures and settings, BA might be considered acceptable and appropriate by multilevel stakeholders (eg, patients, providers, and organisational leaders).12Proctor E Silmere H Raghavan R et al.Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda.Adm Policy Ment Health. 2011; 38: 65-76Crossref PubMed Scopus (2683) Google Scholar The cost-effectiveness of BA in the COBRA trial was driven primarily by the low costs of BA providers. Because BA's rationale, techniques, and core mechanism are straightforward and face valid, an additional benefit of BA is that costs of training these providers might be low as well. Considering the few financial and human resources available to mental health services in many parts of the world, research into scalable and cost-effective training strategies, such as brief online training,13Puspitasari A Kanter JW Murphy J Crowe A Koerner K Developing an online, modular, active learning training program for behavioral activation.Psychotherapy. 2013; 50: 256Crossref PubMed Scopus (22) Google Scholar is important. Research into these and other potential strengths of BA in the context of implementation science is necessary for the hope and promise offered by the COBRA trial to be fulfilled. Now that we have support for BA as a treatment that is clinically effective and cost-effective, we can shift our efforts to focus on what is necessary to produce sustainable large-scale BA implementation across diverse geographical and cultural settings.14Powell BJ Waltz TJ Chinman MJ et al.A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project.Implement Sci. 2015; 10: 21Crossref PubMed Scopus (1389) Google Scholar We declare no competing interests. Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trialWe found that BA, a simpler psychological treatment than CBT, can be delivered by junior mental health workers with less intensive and costly training, with no lesser effect than CBT. Effective psychological therapy for depression can be delivered without the need for costly and highly trained professionals. 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