In 2015 I attended a talk at the BABCP conference given by Dave Richards telling us all about COBRA, a very large scale research project aimed at determining whether stand-alone Behavioural Activation (BA) could be recommended as strongly as CBT for depression. The current NICE guidelines for Depression recommend CBT over BA - which, whilst understandable given the sheer quantity of evidence for CBT - seemed to me a recommendation waiting to be revised. Having used both BA and standard CBT for depression, I have found BA components to be very powerful.
Of course NICE can't recommend treatments on such clinical impressions. They need hard evidence.
Enter COBRA - a massive 4 year, 440 participant study to test out whether depressed patients fared better with standard CBT or BA. By 2015 many of the preliminary results were in, but Richards was not allowed to tell us anything about them at the BABCP conference.
Now the wait is over and the result is that
BA was found to be not inferior to CBT for depression
The wording is important - to encourage NICE to make BA an equal treatment of choice to CBT next time it updates its guidance for depression, the focus was on BA being as good as standard CBT. The authors of the study hope that this finding will make treatment for depression more affordable, since BA can be provided by practitioners with less experience and for less money than fully qualified CBT practitioners. The question I want to consider here is a different one. How can COBRA help us CBT practitioners o become more effective in treating depression. You might like to read the full report here and come up with your own thoughts ...
Here are three things I take from the report ....
1) Learn more about Behavioural Activation
The BA protocol used in COBRA was described as follows :-
[BA Practitioners] delivered an individually tailored programme re-engaging participants with positive environmental stimuli and developing depression management strategies. Participants were encouraged to increase their contact with individually specified positive situations and reduce their avoidance of other situations. Specific BA techniques included identification of depressed behaviours, analysis of the triggers and consequences of depressed behaviours, monitoring of activities, development of alternative goal-orientated behaviours, scheduling of activities, and development of alternative behavioural responses to rumination
So BA is much more than just scheduling positive activities. It involves quite sophisticated functional analysis of depression and teaching of goal-orientated behaviours and anti-rumination techniques.
A good brief introduction on the web can be found here
2) Incorporate BA techniques into your standard CBT treatment
The "standard CBT" protocol excluded some of behavioural techniques that might easily be included into your CBT treatment for depression.
[CBT Practitioners] delivered a personalised treatment programme based on an assessment of how participants’ beliefs lead to emotional distress and ineffectual coping. Participants used cognitive and behavioural exercises to specifically test the accuracy of those beliefs by identifying and modifying negative thoughts and beliefs that give rise to them. Specific techniques included participants monitoring moods and activities, planning of exercises to test negative beliefs, and thought records to identify and examine the accuracy of negative automatic thoughts and underlying beliefs
The CBT delivered appears to have been very cognitive, with the main behavioural compoment being behavioral experiments to test out beliefs.
There appears to be plenty of scope for incorporating more behavioural strategies into your CBT treatment - especially activity scheduling and anti-rumination techniques. Personally I have found that focussing on rumination has greatly benefitted many sufferers of depression.
3) Develop an individualised formulation to decide whether to focus more on behavioural or cognitive methods
Good CBT is driven by an individualised formulation. Is your client depressed mainly because they are thinking negatively or because they have lost contact with enjoyment and a sense of achievement? Are they ruminating a lot? Have they lost a sense of purpose? Is a negative view of themselves, the world and the future at the heart of their depression? Do they know how to problem solve and set SMART goals? Are they falling prey to a lot of thinking traps? These and other questions (asked in assessment) can give you a good sense of where to focus your treatment. Your formulation can help you summarise this understanding of their depression and help you make the quickest wins
Of course, cognitive change can bring about behavioural change and vice-versa, so you probably dont have to go through every behavioural ("outside-in") and cognitive ("inside-out") strategy to achieve improvement. The idea here is to work out which element is causing the biggest problems and target that first.
The COBRA study does not directly provide evidence that such an approach would be superior to either BA or CBT as per the protocols followed. However, it would appear to make a lot of sense.
What do you think?