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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

A simpler therapy called behavioural activation can be as effective at treating adults with depression as cognitive behavioural therapy (CBT). Also, it is delivered more cheaply, by trained junior mental health workers.

CBT is commonly provided to adults with depression and it is recommended by NICE as first- line treatment. However, it is complex to deliver and therapists are highly skilled and expensive. Behavioural activation is a simpler type of talking therapy that encourages people to develop more positive behaviour such as planning activities and doing constructive things that they would usually avoid doing.

We did not know if this therapy was as effective as CBT in treating depression. The NIHR funded this trial to answer this question. This is the largest trial on behavioural activation to date.

In this trial, behavioural activation was delivered by relatively inexperienced mental health workers who were trained for five days in intervention delivery. It was as effective for treating symptoms of depression as CBT and less expensive.

Why was this study needed?

Clinical depression is a common mental health disorder affecting approximately 2.6 per 100 people in the UK. First-line treatments include CBT, antidepressants or both.

CBT, as recommended by NICE, is complex to deliver and its effectiveness is dependent on the skills of the therapists delivering it who are expensive to train and employ.

Behavioural activation is a simpler psychological therapy for treating depression, although it is unclear from available research if it is as good as CBT for treating depression. It involves re-engaging participants with their normal activities as well as reducing avoidance of the things that trigger symptoms for them and developing depression management strategies. Specific techniques include identification of depressed behaviours, monitoring of activities, development of alternative goal-orientated behaviours and scheduling of activities. It also identifies triggers and consequences of depressed behaviours, and development of alternative behavioural responses to negative thoughts.

This trial looked at whether behavioural activation therapy delivered by junior mental health workers was as good as CBT for treating adults with depression.

What did this study do?

This reasonably sized UK randomised controlled trial (COBRA) included 440 adults with clinically diagnosed depression from primary care and psychological therapy services. The trial excluded anyone with bipolar disorder, psychotic symptoms or who was acutely suicidal or had attempted suicide in the previous two months.

Half received behavioural activation therapy delivered by a junior mental health worker while the other half received CBT delivered by a psychotherapist or CBT therapist. Mental health workers and therapists received five days training in intervention delivery. Eight to 20 hour-long face-to-face sessions were offered over 16 weeks, though around a third of participants attended less than eight sessions.

The trial was well-designed, groups were comparable at baseline and the outcome assessors were blinded to the treatment received. However, the effect of antidepressant use was not fully taken into account which reduces the reliability in the results. The trial was not designed to see if behavioural activation was better than CBT, but to check it was not worse.

What did it find?

  • At 12 months follow-up, average depression scores on the 0 to 27 point Patient Health Questionnaire (PHQ-9) in both groups reduced from moderately severe to mild. Participants receiving behavioural activation had a mean PHQ-9 score reduction from 17.7 to 8.4 versus 17.4 to 8.4 with CBT (mean difference 0.1, 95% confidence interval [CI] -1.3 to 1.5).
  • At 12 months, there was no difference in anxiety, depression status or depression-free days between participants receiving behavioural activation or CBT.
  • There were 15 episodes of self-harm or overdose, three by three people in the behavioural activation group and 12 by eight people in the CBT group.
  • In the trial savings were generated by the use of behavioural activation instead of CBT. At 18 months, average intervention cost per participant with behavioural activation was (£974.81) compared to CBT (£1,235.23) (mean difference -£262.29, 95% CI -£381.40 to -£143.19). There was no difference in hospital, community or medication costs or total treatment costs. It is unclear if these savings could be realised in practice.

What does current guidance say on this issue?

NICE 2009 guidance on depression for adults recommends CBT for persistent depressive symptoms or mild to moderate depression. It does not currently recommend behavioural activation as first line treatment for depression due to insufficient evidence. This trial goes some way in addressing this evidence gap.

The guidance states that for people with persistent subthreshold depressive symptoms or mild to moderate depression, individually guided self-help programmes including behavioural activation should include written materials and be supported by a trained practitioner. They should also consist of up to six to eight face-to-face or telephone sessions over nine to 12 weeks.

What are the implications?

This trial provides evidence that psychological therapy for depression can be delivered without the need for costly and highly trained professionals.

Junior mental health workers who receive basic training can deliver behavioural activation therapy to treat adults with depression that is as effective as CBT at reducing depression symptoms, and at estimated 21% less cost.

These findings are likely to change practice, suggesting that behavioural activation is a viable first-line treatment for depression. Implications will include the training of mental health workers in delivery of behavioural activation.

Citation and Funding

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. [Epub ahead of print].

This project was funded by the National Institute for Health Research (HTA programme) (project number 10/50/14).


Mind UK. Mental health facts and statistics. London: Mind UK; 2009.

NICE. Depression in adults: recognition and management. CG90. London: National Institute for Health and Care Excellence; 2009.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

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Depression was diagnosed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID). Patient Health Questionnaire (PHQ-9): This is a multipurpose tool that can be used to screen for and monitor the severity of depression. A score of 0 to 4 indicates no depression, 5 to 9 mild, 10 to 14 moderate, 15 to 19 moderately severe and 20 to 27 severe depression.  
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