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Behavioural Activation for Depression

EKERS, D., WEBSTER, L., VAN STRATEN, A., CUIJPERS, P., RICHARDS, D. & GILBODY, S. 2014. Behavioural Activation for Depression; An Update of Meta-Analysis of Effectiveness and Sub Group Analysis. PLoS ONE, 9, e100100.

This paper is a meta-analysis of Behavioural Activation (BA) as a treatment for depression. In total, 25 randomised controlled trials were included in the study. Interestingly the medium for delivering the therapy included individual, group and self-help. In addition, although 22 papers included trained therapists, the remaining three used non-specialists to deliver BA. The severity of depression reported in study participants ranged from mild to severe. Finally, the session numbers median was eight (range from 1-16).

Examining the quality of this systematic review, a transparent and systematic process for reviewing the literature was clearly outlined. More specifically, whilst it is clear that there was a rigorous process for reaching consensus about the data extracted from the included articles and quality appraisal. It seemed less clear how consensus was reached as to whether or not to include or exclude a primary research papers. This is important because it increases the potential for bias within the process of identifying relevant papers. On balance, this was a well-conducted review that is clearly described within the paper.

The findings from the meta-analysis was for a large effect size post treatment and medium effect size at follow up when compared to control groups and for a moderate effect size for BA when compared to antidepressant medication. The researchers reported that when poorer quality studies were excluded from the comparison with antidepressant medications the results were no longer statistically significant. Of note, the researchers reported that neither the therapy medium nor the therapist’s training seemed to make a difference to the outcome.

In my view, this paper makes a case for BA as an intervention for people with depression by clinicians with specialist knowledge of psychological therapies but also by non-specialists following specific training. Importantly, it seems possible to offer this therapy using self-help literature, individual or group sessions. The reviewers questioned the quality of some of the included studies and there were a lot fewer studies utilising group therapy or non-specialists. For these reasons, I think that BA should be considered a first line treatment for depression but that it may be important to evaluate any non standard implementation to ensure that it is helpful to depressed patients.

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