CoChat
Sign Up
Cited by 595Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychotherapy Techniques and ApplicationsDigital Mental Health Interventions

Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial

Open access
Richards, David A, Ekers, David, McMillan, Dean, Taylor, Rod S, Byford, Sarah, Warren, Fiona C, Barrett, Barbara, Farrand, Paul A +10 more·2016·The Lancet
DOI 10.1016/s0140-6736(16)31140-0PMC PMC5007415
Open this paper in CoChat — free accountOpen PDF

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. FINDINGS: 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). INTERPRETATION: 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. FUNDING: National Institute for Health Research.

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1016/s0140-6736(16)31140-0

Cites

30 of 30 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Psychology graduates can be readily employed in assistant psychologist roles at lower cost than more specialist therapists.

    “they can be readily employed in assistant psychologist (AP) roles at lower cost than more specialist therapists”

    From Increasing access to CBT for psychosis patients: A feasibility, randomised controlled trial evaluating brief, targeted CBT for distressing voices delivered by assistant psychologists (GiVE2) (2020) · cites this paper as [20]

    The Methods (Procedures; Statistical analysis, page not provided) describe graduate junior mental health workers delivering behavioural activation and assign them a lower salary band than specialist CBT therapists. The Discussion also says their lower costs drove savings and that this workforce could be trained more easily. The paper does not identify the graduates as psychology graduates or describe them as assistant psychologists, nor does it establish that they can readily be employed in those roles. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • Psychology graduates are well-positioned to undertake the role of delivering CBTp.

    “Psychology graduates, however, are well-positioned to undertake such a role [18, 20]”

    From Increasing access to CBT for psychosis patients: A feasibility, randomised controlled trial evaluating brief, targeted CBT for distressing voices delivered by assistant psychologists (GiVE2) (2020) · cites this paper as [20]

    The Methods (Procedures; page unavailable) say that graduates delivered behavioural activation, but do not identify them as psychology graduates. CBT was delivered by accredited psychotherapists, and the Methods (Abstract; page unavailable) say that people with psychosis or psychotic symptoms were excluded. The paper therefore does not establish that psychology graduates are well-positioned to deliver CBT for psychosis (CBTp). (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Psychology graduates' degree provides them with training in psychological models of emotion and behaviour.

    “their degree provides them with training in psychological models of emotion and behaviour”

    From Increasing access to CBT for psychosis patients: A feasibility, randomised controlled trial evaluating brief, targeted CBT for distressing voices delivered by assistant psychologists (GiVE2) (2020) · cites this paper as [20]

    The Methods > Procedures passage describes graduates who received training to deliver guided self-help interventions, but it does not identify them as psychology graduates or describe what their degrees taught. Searches for psychology graduates and degree-level training in models of emotion and behaviour found no passage addressing the claim. The paper’s statement that these workers lacked formal training in psychological therapies does not establish what their degrees covered. (LLM, conf=0.75)

    Experimental — accuracy not yet measured

  • There is a large number of psychology graduates in the UK, the USA and elsewhere.

    “there is a large number of psychology graduates in the UK, the USA and elsewhere”

    From Increasing access to CBT for psychosis patients: A feasibility, randomised controlled trial evaluating brief, targeted CBT for distressing voices delivered by assistant psychologists (GiVE2) (2020) · cites this paper as [20]

    The Methods > Procedures passage describes the trial's junior mental health workers as graduates, and the Discussion discusses the potential availability of a BA workforce. Neither passage says they were psychology graduates or addresses how many psychology graduates there are in the UK, USA, or elsewhere (searched: psychology graduates, graduate workforce). No page numbers are available in our copy. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

3 of the 33 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. [8]National Institute for Health and Care Excellence Depression in adults: recognition and management 2009 National Institute for Health and Care Excellence London 31990491
  2. [9]First MB Spitzer RL Gibbon M Williams JB Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition. (SCID-I/P) 2002 New York State Psychiatric Institute New York
  3. [24]National Institute for Health and Care Excellence Guide to the methods of technology appraisal 2013 2013 National Institute for Health and Care Excellence London 27905712

Cited by

Sorted by citations

Related

Authors
Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., Barrett, B., Farrand, P. A., Gilbody, S., Kuyken, W., O'Mahen, H., Watkins, E. R., Wright, K. A., Hollon, S. D., Reed, N., Rhodes, S., Fletcher, E., & Finning, K.
Affiliations
  • University of Exeter (GB)
  • Tees, Esk and Wear Valleys NHS Foundation Trust (GB)
  • University of York (GB)
  • King's College London (GB)
  • Warneford Hospital (GB)
  • Vanderbilt University (US)
Corresponding author
Richards, David A
ORCID
Venue
The Lancet
Publisher
Elsevier BV
Published
2016-08
Volume
388
Issue
10047
Pages
871-880
ISSN
  • 0099-5355 (ISSN-L)
  • 0140-6736
DOI
10.1016/s0140-6736(16)31140-0
PMC
PMC5007415
OpenAlex
W2502560620
Cited by
595
References
33
Citations by year
2026: 41 · 2025: 44 · 2024: 59 · 2023: 53 · 2022: 51 · 2021: 92 · 2020: 64 · 2019: 60 · 2018: 69 · 2017: 48 · 2016: 13 · 2012: 1
FWCI
90.14
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion)
  • Durham Research Online (Durham University) (acceptedVersion, other-oa)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (submittedVersion)
  • Research Portal (King's College London) (submittedVersion, cc-by)
  • Open Research Exeter (University of Exeter) (submittedVersion, cc-by)
Funders
  • National Institute for Health and Care Research (NF-SI-0514-10037, NF-SI-0611-10203, NF-SI-0514-10155, 10/50/14)
  • European Science Foundation
  • Collaboration for Leadership in Applied Health Research and Care - Greater Manchester
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
Keywords
behavioral activation, cognitive behavioral therapy, depression, major depressive disorder, cost-effectiveness, non-inferiority, PHQ-9, psychotherapy, primary care, treatment safety, depression severity, antidepressant use, remote treatment delivery, hopelessness
MeSH terms
Adult, Aged, Antidepressive Agents, Cost-Benefit Analysis, Depression, Depressive Disorder, Major, Major Depressive Disorder, Direct Service Costs, Educational Status, England, Female, Humans, Male, Middle Aged, Quality of Life, Comorbidity, Cognitive Behavioral Therapy, Linear Models, Treatment Outcome, Quality-Adjusted Life Years, Directive Counseling, Diagnostic and Statistical Manual of Mental Disorders

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review