An approach to therapy that may make depression treatment more accessible

James Cartreine, PhD
James Cartreine, PhD, Contributing Editor

It makes no difference that effective depression treatments exist if you don’t have access to them. Increasing the availability of behavioral treatments is a key challenge for the field of mental health care. A recent study has just suggested a way to do this. The research was published in The Lancet.

Cognitive behavioral therapy (CBT) and behavioral activation (BA)

Cognitive behavioral therapy (CBT) is the most researched non-medication treatment for depression. It’s been shown to be effective, yet access to CBT is limited. One reason is that there are not enough well-trained clinicians (usually psychologists, social workers, and psychiatrists) to meet demand. And, training clinicians well is expensive. The upshot is that if you do have access to CBT, it is costly — either to you or your insurance company. Is there an alternative to CBT that could be more available and less costly to the system and individuals?

Researchers at the University of Exeter in Great Britain examined the effectiveness and cost of just such an alternative. It’s called behavioral activation (BA) and its focus is on actions — getting back to doing enjoyable activities as well as those that offer the opportunity to achieve a goal or improve a skill. BA also addresses the avoidance of certain activities (read: procrastination) that, when a person can actually do them, have an upside — for example, meeting new people or trying new activities. CBT involves changing behaviors, too (the “B” part). But, part of the process includes evaluating our thoughts, or cognitions (the “C” part), to see if we’re viewing ourselves, other people, our future, and the world around us accurately. Patients learn to challenge negative thinking — not to fool themselves into thinking everything’s okay, but to look at things more objectively.

A big difference between CBT and BA is that it’s easier to provide BA. Paraprofessionals can offer BA, whereas you need clinicians with more — and therefore more expensive — training to provide CBT.

Comparing behavioral activation and cognitive behavioral therapy

In this study, BA worked equally well as CBT (it was “non-inferior” to CBT), and was 21% less expensive because the providers were less expensive. The good news is that this form of depression treatment works as well as CBT, and is more affordable; therefore it should become available more broadly.

Here’s how the study worked. In just five days, the research team trained junior mental health workers to deliver BA. These workers had no prior training in mental health interventions. They also recruited therapists with extensive training in CBT and gave them a five-day workshop to ensure they would all follow the same CBT approach to depression treatment. (In this study, the CBT approach emphasized the “C” — cognitive therapy.) Investigators went on to ensure that all the providers (BA and CBT) were delivering the therapies correctly.

Study participants included 440 patients with major depressive disorder (that’s a large sample). Half received BA and half received CBT — 67% of the BA and 72% of the CBT patients completed at least eight sessions (a good completion rate). Twelve months after they started treatment, approximately 80% of patients in both groups no longer met the criteria for having major depressive disorder. That’s an encouraging success rate for both forms of therapy.

One caveat about this study was that there wasn’t a “no treatment” comparison group, so we don’t know how many patients would have improved on their own. But what’s especially interesting is that 78% of the participants were taking antidepressant medications and were still depressed before the study. These volunteers also averaged six to seven prior episodes of depression. That suggests that they probably would not have improved much without the BA or CBT.

Overall, this study is exciting because it suggests ways to treat depression that can reach the many people who need treatment but are having trouble getting it.

Related Information: Understanding Depression

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  9. carol

    Hi!i’ve been living with this sickness since 2014,my head freeze when i take tablets,i become weak sumtym strong i dream scary dreams that make me realize that mybe someone want to kill me&i can’t remember lots of things.i attend psychiatry last year but the dr did not have time for his patient he just give you pills,then i ask him to quit tablets,i do not want to see myself like this cause it affect my mirriage,can you please tell me what to drink to clear my head,now i’m take bruofen because antidepressant make it worse it freeze my head.

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  11. Delarno

    This article is very informative. Considering how many people around the world commit suicide due to severe depression symptoms we need more awareness like this in order to stop or reduce the fatal trend of this disorder.

    A medscape statistics (medscape.com/viewarticle/813896 ) reveal that major depressive disorder (MDD) is the second leading cause of disability worldwide and a major contributor to suicide and ischemic heart disease. That is, by educating people about the disease we are saving life. The problem, some people would like to help but don’t the right steps to take.

    On article published on Booboone.com, a psychologist indicates 7 simple ways to help a depressed friend or a family member. In one of these methods, he indicates how important it is for us to listen carefully and patiently to the depressed individual to be able to determine the right approach to take. Most importantly, we need to be comprehensive; a simple gesture of indifference can increase the suicidal thoughts and lead to disaster.

  12. amit kumar

    It should be better for anyone to decrease his/her stress by any mode many type of problems are solved by less stress .
    And this is a great blog to provide reliable information as well as healthy topic that are covered in it .

  13. Sharon Deaver

    I am in the throes of my first episode of depression and hope it is the last one!! I am a Senior Citizen. I have a daughter who is on “mood elevators” and is a chronic procrastinator. She became depressed after her husband left her, and then went home to die shortly of various reasons due to other health problems unrelated to her. She discovered he had died when she searched for an address to send divorce papers to and discovered his death report. I have become overwhelmed with financial worries, health concerns, and other concerns too. Now what do I do? Sharon

    • Safina

      I am really sorry to know that you and your daughter are going through so much but hope is a light,which shines bright but we just have to feel it and search for it.I strongly suggest that you both should make time for meditation and mindfulness,which are interlinked.
      Start by doing deep breathing exercises preferably in front of an open window or outside,inhale I. e take derry breath through nose,hold for few seconds than exhale through mouth slowly,do it 5 to 20 times and increase to 15,it helps in keeping your focus on your breaths and is one of the treatments for anxiety too,with practise it will help you to remain in the present not in the past,which is what mindfulness means,to be fully aware and present in the present moment.
      Next whenever you go for a walk,smell the flowers,observe the plants, trees,birds,sky and people around you,listen to the sounds and with practise you will get rid of procrastination and will feel relaxed and contented with the present.
      Lastly find a moment of quiet and sit relaxly and close your eyes and meditate that is offer prayers in silence,repeat something on your fingers which you find comforting,like asking God for help and mercy,giving yourself positive affirmations like I am brave and blessed in many ways and above all pay gratitude for having all the blessings that you czn count because we should never forget that in life at any moment there are still many people who are brave and inspiring as they are fighting harder battles of their lives,May God enable everyone to understand and love their lives,Amen

  14. Pat

    Ditto, Michael Jones and Elise. I will add, however, I have seen many mental health “professional’s”. I include psychiatrist’s, one psychologist from U of M in ’80 who actually took offense to me suggesting he was trying to emulate Freud and wrote me a prescription for the medication Elavil. I had no idea at that time psychologist’s were not allowed to write prescriptions. Perhaps it was allowed because as many hospital’s say they are a “teaching” hospital. When I was in high school my English teacher exposed her students to things like the play about the Frenchman, Merat Sade; who was said to be a psychiatrist who had gone insane after being in charge of an insane asylum. That being said, at the age of 66, I have found that to be true at every level as a client/patient of too many inpatient psychiatric hospital units and outpatient clinics. I have found it interesting they are now known as “behavioral health units” and have been one of the many who were forced to receive injections of in particular antipsychotic medication, Haldol, at a now closed state psychiatric hospital which was still being used as a “warehouse” for the “criminally insane” known as Northville State Regional Psychiatric Hospital in Northville, MI. The hospital is slowly decaying on it’s own as Northville does not want the land and nearby Livonia at one time wanted to purchase it to develop it into more useful and current revenue ideas. For example, possible apartment’s, shops, park. However, as with so many things seems to be a “political issue”.

  15. TERESITA ARNAIZ JOHNSON

    Yo hice DBT .
    Podrían publicar sobre ese tipo de terapia.
    Para mi ha sido lo mejor. EFECTIVIDAD TOTAL.
    Aprendí a vivir la vida que quiero vivir!!!!!

  16. Avi Newman

    I am not convinced by these studies: they do not follow patients over time. Then too, the studies may play to the funding sources for depression by telling them that this or that method works rapidly and cheaply: so give us money. These studies are devoid of the applicability of being helpful by being genuine, warm, and supporting. These studies are also devoid of the power of leadership. Leadership is not synonymous with managing. Leadership is the sharing of experience.
    Finding “therapists” with good life experience on the cheap is a non-sequitur. I do not want to be lead from behind. I want my Marine Corps DI to have had combat experience, and I want my mentor in business to have the credibility of having made a lot of money. Avi Newman

  17. Paawan Singh

    I am currently a student of the MPH (Master of Public Health) at the University of Michigan, Ann Arbor, and have a keen interest in the area of mental health and other ailments pertaining to the neuro-psychiatry segment.

    This article served as a great learning in the upcoming approaches to manage depression. Having previously worked in the pharmaceutical industry and getting a first hand account of the provider-patient dynamics in India, I couldn’t agree more on the fact that the 4 A’s- awareness, affordability, accessibility and availability of healthcare services play a crucial role in the delivery of healthcare. Thus, reading about such advances that are bridging the gap of availability and affordability is encouraging.

  18. Bob Jarmusz

    I am a retired Clinical Social Worker . I am pleased to see that
    some research is being done on an alternate method of reaching
    the un-served with Major Depression with a favorable outcome
    using BA.
    In the 70’s Paraprofessionals were very helpful reaching out
    to patients in their communities that were intimidated by using
    office based help. Of course money was available to pay them
    a reasonable amount of money and when the money dried up
    so did the use of Paraprofessionals.

    • Deborah

      This new approach claims to be in the interest of the unserved population of people who need clinical or psych. services but it seems to me just another measure to cut trained clinical therapists. I am left always wondering if anything is done for the patients interest or is it just another measure to slash health care workers?

  19. Michael Jones

    I have experienced dysthymia for decades…..moment-to-moment , day to-day, year-to-year, unrelenting depression. I have tried all the pills, decades of psychotherapy, electro convulsive therapy and transcranial magnetic stimulation.
    At the risk of being irresponsible, I’ll sit this one out.

  20. Gayle

    I’d like to know where you get these paraprofessionals? What degrees or credentials would they need? Who would be willing to employ them instead of more credentialed clinicians? I suspect many states, such as California, would make it difficult.

    • Pat

      Gayle, I was treated by a psychiatrist in Palatine, IL, who used hypnotism and taught me somewhat about self-hypnosis. I now use visualization, very similar and find it helpful. He also treated me when in patient with only vitamins and I did well. I consider him the best of many I have seen. His name is Adrian Finkelstein. He let me know he was writing a book on reincarnation and I thought that was interesting. Years later, I found his book online. Later still, I had a feeling had probably left IL and searched for him online in Los Angeles, CA and phoned him because I had hoped to pay him the $150. I still owed him before my now ex-husband insisted we return to MI. Unfortunately, I was in aI horrific auto accident following him in a U-Haul. The accident was not my fault and I was badly injured. A couple of weeks ago, I had a feeling he was still in CA, and again found him. However, I did not call him.

  21. Dr Edmond O`Flaherty

    There is an American treatment available for treating depression often referred to as the Pfeiffer/Walsh method. It is based on the biochemistry of the patient which is usually abnormal when the patient has a mental health problem. I am a primary care physician in Dublin and I have found this method successful in most cases. I take blood and urine samples, many of which I send to an American lab,DHA in Illinois. There are courses for physicians arranged by walshinstitute.org. Several psychiatrists who have attended have very positive results since and a UK psychiatrist told me recently that she plans to use this method later this year.

  22. lia

    Talking about procrastination, I’ve been struggling with mine for the last 10 years and read countless books and self help methods. Here is what I’m having best results with. First of all, procrastination bulldozer method has worked wonders for me. I highly recommend you apply it. Secondly, whenever you have a task that takes less than 5 minutes to do, do it right away. No delays. I’m really starting to take control of my life now.