title: Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial.
abstract: BACKGROUND
  Depression is a common, debilitating, and costly disorder. Many patients request psychological therapy, but the best-evidenced therapy-cognitive behavioural therapy (CBT)-is complex and costly. A simpler therapy-behavioural activation (BA)-might be as effective and cheaper than is CBT. We aimed to establish the clinical efficacy and cost-effectiveness of BA compared with CBT for adults with depression.
  
  
  METHODS
  In this randomised, controlled, non-inferiority trial, we recruited adults aged 18 years or older meeting Diagnostic and Statistical Manual of Mental Disorders IV criteria for major depressive disorder from primary care and psychological therapy services in Devon, Durham, and Leeds (UK). We excluded people who were receiving psychological therapy, were alcohol or drug dependent, were acutely suicidal or had attempted suicide in the previous 2 months, or were cognitively impaired, or who had bipolar disorder or psychosis or psychotic symptoms. We randomly assigned participants (1:1) remotely using computer-generated allocation (minimisation used; stratified by depression severity [Patient Health Questionnaire 9 (PHQ-9) score of <19 vs ≥19], antidepressant use, and recruitment site) to BA from junior mental health workers or CBT from psychological therapists. Randomisation done at the Peninsula Clinical Trials Unit was concealed from investigators. Treatment was given open label, but outcome assessors were masked. The primary outcome was depression symptoms according to the PHQ-9 at 12 months. We analysed all those who were randomly allocated and had complete data (modified intention to treat [mITT]) and also all those who were randomly allocated, had complete data, and received at least eight treatment sessions (per protocol [PP]). We analysed safety in the mITT population. The non-inferiority margin was 1·9 PHQ-9 points. This trial is registered with the ISCRTN registry, number ISRCTN27473954.
  
  
  RESULTS
  Between Sept 26, 2012, and April 3, 2014, we randomly allocated 221 (50%) participants to BA and 219 (50%) to CBT. 175 (79%) participants were assessable for the primary outcome in the mITT population in the BA group compared with 189 (86%) in the CBT group, whereas 135 (61%) were assessable in the PP population in the BA group compared with 151 (69%) in the CBT group. BA was non-inferior to CBT (mITT: CBT 8·4 PHQ-9 points [SD 7·5], BA 8·4 PHQ-9 points [7·0], mean difference 0·1 PHQ-9 points [95% CI -1·3 to 1·5], p=0·89; PP: CBT 7·9 PHQ-9 points [7·3]; BA 7·8 [6·5], mean difference 0·0 PHQ-9 points [-1·5 to 1·6], p=0·99). Two (1%) non-trial-related deaths (one [1%] multidrug toxicity in the BA group and one [1%] cancer in the CBT group) and 15 depression-related, but not treatment-related, serious adverse events (three in the BA group and 12 in the CBT group) occurred in three [2%] participants in the BA group (two [1%] patients who overdosed and one [1%] who self-harmed) and eight (4%) participants in the CBT group (seven [4%] who overdosed and one [1%] who self-harmed).
  
  
  CONCLUSIONS
  We 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.
  
  
  BACKGROUND
  National Institute for Health Research.
authors.affiliation: Medical School, University of Exeter, Exeter, UK. Electronic address: d.a.richards@exeter.ac.uk.
authors.forename: David A
authors.initials: DA
authors.lastname: Richards
authors.affiliation: Psychological Therapy Department, Tees, Esk and Wear Valleys NHS Foundation Trust, Chester-le-Street, County Durham, UK.
authors.forename: David
authors.initials: D
authors.lastname: Ekers
authors.affiliation: Department of Health Sciences, University of York, Heslington, York, UK.
authors.forename: Dean
authors.initials: D
authors.lastname: McMillan
authors.affiliation: Medical School, University of Exeter, Exeter, UK.
authors.forename: Rod S
authors.initials: RS
authors.lastname: Taylor
authors.affiliation: Institute of Psychiatry, Kings College London, London, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Byford
authors.affiliation: Medical School, University of Exeter, Exeter, UK.
authors.forename: Fiona C
authors.initials: FC
authors.lastname: Warren
authors.affiliation: Institute of Psychiatry, Kings College London, London, UK.
authors.forename: Barbara
authors.initials: B
authors.lastname: Barrett
authors.affiliation: School of Psychology, University of Exeter, Exeter, UK.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Farrand
authors.affiliation: Department of Health Sciences, University of York, Heslington, York, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Gilbody
authors.affiliation: Department of Psychiatry, University of Oxford, The Prince of Wales International Centre, Warneford Hospital, Oxford, UK.
authors.forename: Willem
authors.initials: W
authors.lastname: Kuyken
authors.affiliation: School of Psychology, University of Exeter, Exeter, UK.
authors.forename: Heather
authors.initials: H
authors.lastname: O'Mahen
authors.affiliation: School of Psychology, University of Exeter, Exeter, UK.
authors.forename: Ed R
authors.initials: ER
authors.lastname: Watkins
authors.affiliation: School of Psychology, University of Exeter, Exeter, UK.
authors.forename: Kim A
authors.initials: KA
authors.lastname: Wright
authors.affiliation: Department of Psychology, Vanderbilt University, Nashville, TN, USA.
authors.forename: Steven D
authors.initials: SD
authors.lastname: Hollon
authors.affiliation: Lived Experience Group, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK.
authors.forename: Nigel
authors.initials: N
authors.lastname: Reed
authors.affiliation: Medical School, University of Exeter, Exeter, UK.
authors.forename: Shelley
authors.initials: S
authors.lastname: Rhodes
authors.affiliation: Medical School, University of Exeter, Exeter, UK.
authors.forename: Emily
authors.initials: E
authors.lastname: Fletcher
authors.affiliation: Medical School, University of Exeter, Exeter, UK.
authors.forename: Katie
authors.initials: K
authors.lastname: Finning
mesh_terms: D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000627:therapeutic use; D015928:Cognitive Behavioral Therapy / Q000191:economics* / Q000379:methods*; D015897:Comorbidity; D003362:Cost-Benefit Analysis; D003863:Depression / Q000175:diagnosis / Q000191:economics / Q000523:psychology / Q000628:therapy*; D003865:Major Depressive Disorder / Q000175:diagnosis / Q000191:economics / Q000523:psychology / Q000628:therapy*; D039721:Diagnostic and Statistical Manual of Mental Disorders; D004180:Direct Service Costs; D037001:Directive Counseling / Q000191:economics*; D004522:Educational Status; D004739:England; D005260:Female; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D016896:Treatment Outcome
chemical_list: D000928:Antidepressive Agents