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Behavioural activation delivered by the non-specialist: phase II randomised controlled trial

  • David Ekers (a1), David Richards (a2), Dean McMillan (a3), J. Martin Bland (a4) and Simon Gilbody (a5)...
Abstract
Background

Behavioural activation appears as effective as cognitive– behaviour therapy (CBT) in the treatment of depression. If equally effective, then behavioural activation may be the preferred treatment option because it may be suitable for delivery by therapists with less training. This is the first randomised controlled trial to look at this possibility.

Aims

To examine whether generic mental health workers can deliver effective behavioural activation as a step-three high-intensity intervention.

Method

A randomised controlled trial (ISRCTN27045243) comparing behavioural activation (n = 24) with treatment as usual (n = 23) in primary care.

Results

Intention-to-treat analyses indicated a difference in favour of behavioural activation of –15.79 (95% CI –24.55 to –7.02) on the Beck Depression Inventory–II and Work and Social Adjustment Scale (mean difference –11.12, 95% CI –17.53 to –4.70).

Conclusions

Effective behavioural activation appears suitable for delivery by generic mental health professionals without previous experience as therapists. Large-scale trial comparisons with an active comparator (CBT) are needed.

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Copyright
Corresponding author
David Ekers, Mental Health Research Centre, Durham University, Health Centre, Chester Le Street, Co Durham, DH3 3UR, UK. Email: david.ekers@tewv.nhs.uk
Footnotes
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Declaration of interest

None.

Footnotes
References
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Behavioural activation delivered by the non-specialist: phase II randomised controlled trial

  • David Ekers (a1), David Richards (a2), Dean McMillan (a3), J. Martin Bland (a4) and Simon Gilbody (a5)...
Submit a response

eLetters

Does behavioural activation really work in depression?

MOHINDER KAPOOR, Specialty Registrar(ST5) in Old Age Psychiatry
26 January 2011

Ekers et al 1 present interesting findings in their randomised controlled trial study of behavioural activation delivered to people with depression by generic mental health workers with limited training. If these findings can be replicated and translated into daily practice, then the clinical and cost implications would be substantial for this disablingcondition.

However, I have a few reservations in relation to the study design and analysis of outcomes in this study. We all know the strength of a double blind design in eliminating the potential for observation (information) bias.2 Authors have acknowledged, that given the nature of therapy/treatment, participants were aware of their treatment allocations.Not only this, self-report measures for depression symptom level, functioning and satisfaction were used in the study. This knowledge of theintervention to which participant has been assigned raises the potential of information bias. Given that the double blind design was not possible in this study, it was imperative that special precautions should have beentaken to reduce the potential for information bias. For measurement of endpoints, especially in the case of depression symptom level, objective criteria should have been used. Although authors have mentioned these shortcomings under the limitations section of the study, it is imperative that we all understand not only the importance of these shortcomings but also the impact these can have on the main findings of this study.

There is another issue relating to lack of follow-up in this study. This can raise serious doubts about the improvement shown in Beck depression inventory – II and work and social adjustment scales. It is possible that participants might have shown improvement simply in responseto the fact that they were being studied, not in response to any particular intervention. In other words “The Hawthorne effect” might have played its part. The Hawthorne effect is a form of reactivity whereby subjects improve or modify an aspect of their behavior being experimentally measured simply in response to the fact that they are beingstudied and made to feel important, not in response to any particular experimental manipulation.3,4,5 Considering this as an alternative explanation to authors conclusions it is possible that any improvement in depression symptom level, functioning and satisfaction could have been short-lived.

Declaration of interest: None

References:

1.Ekers D, Richards D, et al. Behavioural activation delivered by the non-specialist: phase II randomised controlled trial. Br J Psychiatry 2011; 198: 66-72.

2.Hennekens CH, Burning JE et al. Epidemiology in Medicine. Little, Brown and Company Boston/Toronto, 1987.

3.McCarney R, Warner J, et al. "The Hawthorne Effect: a randomised,controlled trial". BMC Med Res Methodol 2007; 7: 30. doi:10.1186/1471-2288-7-30. PMID 17608932. PMC 1936999. http://www.biomedcentral.com/1471-2288/7/30.

4.Fox NS, Brennan JS, Chasen ST "Clinical estimation of fetal weight and the Hawthorne effect". Eur. J. Obstet. Gynecol. Reprod. Biol. 2008; 141 (2): 111–4. doi:10.1016/j.ejogrb.2008.07.023. PMID 18771841. http://linkinghub.elsevier.com/retrieve/pii/S0301-2115(08)00300-X.

5.Franke RH, Kaul JD: The Hawthorne experiments: First statistical interpretation. Am Sociol Rev 1978, 43:623-643.
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Conflict of interest: None Declared

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