Pasillo «Despedida»

BACKGROUND

Behavior therapy (BT) for major depression refers to a class of psychotherapy interventions which treat MDD by teaching patients to increase rewarding activities. Patients learn to track their activities and identify the affective and behavioral consequences of those activities. Patients then learn techniques to schedule activities to improve mood. BT emphasizes training patients to monitor their symptoms and behaviors to identify the relationships between them. Primary therapeutic techniques of BT include collaborative empiricism (the therapist and patient working together to increase rewarding behaviors) and functional analysis of obstacles to activities. In addition, treatment incorporates structured practice outside of the session, including scheduled activities, mood tracking and interpersonal skills practice. Behavioral Activation (BA) is a particular version of BT which targets the link between avoidant behavior and depression and expands the treatment component of behavioral activation.

ACTION STATEMENT

Behavior Therapy (BT), including Behavioral Activation (BA), is a recommended treatment option for adults with major depression. It may be considered as a first line treatment for patients with severe depression who do not tolerate pharmacotherapy.

RECOMMENDATIONS

1. Individual Behavior Therapy/Behavioral Activation (BT/BA), is a treatment option for patients with mild to moderate MDD. [A]

2. Sixteen to 24 sessions of individual Behavior Therapy/Behavioral Activation (BT/BA) may be offered to patients with severe MDD, especially if they are not able to tolerate pharmacotherapy (including pregnant, postpartum, or older patients). [B]

3. Individual Behavior Therapy/Behavioral Activation (BT/BA) may be particularly useful in primary care settings, due to the potentially brief nature of the approach and the relative ease in learning how to effectively implement it. [I]

RATIONALE

BT alone, without a cognitive component, shows promise for treating MDD, including severe MDD and MDD in patients who do not want, or cannot tolerate, antidepressive medication.. Although it has a limited body of research, three of the four primary trials were well designed and well-powered, increasing the confidence in these findings. However, the confidence in the overall findings is lower than in CBT, IPT or ADM, as they have a much larger body of literature to date.

EVIDENCE STATEMENTS

There is evidence that BT may be an effective treatment option for mild to severe MDD. The scope of the evidence is limited, however. The literature search revealed no systematic reviews and only four RCT’s that met criteria.

o Dimidjian et al. (2006) found that BA was at least as efficacious as pharmacotherapy, and significantly more efficacious than cognitive therapy and placebo conditions when treating severely depressed patients (24 sessions over 18 weeks, N=241; effect sizes for BA relative to cognitive therapy were 0.87 BDI and 0.59 HRSD).

o McLean & Hakstian (1979) compared psychodynamic therapy, BT, relaxation training, and pharmacotherapy in treating patients with MDD (10 sessions; N=178). BT was superior to other treatments on 9 of 10 outcome measures at the end of treatment, although these benefits were reduced at 3 months post-treatment.

o Jacobson et al. (1996) compared behavioral activation, standard CBT, and a combination of activation with a focus on modifying dysfunctional thoughts in treating patients with MDD (N=150, 12 to 20 sessions). The study found that BA alone was equal in efficacy to more complete versions of cognitive therapy. There were no significant differences between the two at the 6 month follow-up.

o Hopko et al. (2003) compared brief behavioral activation to standard supportive psychotherapy with severely depressed patients on an inpatient psychiatric unit (N=25; effect size 0.73). They found that BA was superior to standard supportive therapy (effect size 0.73).

o There is limited evidence that BT/BA may have a positive effect on retention. In Dimidjian and colleagues’ 2006 study, a greater percentage of patients in the BA group completed treatment as compared to both the CT and pharmacotherapy groups.

o There is limited evidence that there is no difference in relapse rates between BA and CT (Jacobson et al., 1996).

o There is insufficient evidence to determine the effect of BA increasing functioning or decreasing suicidality. The studies rated symptom severity vs. functioning. Follow-up periods were too limited to detect differences in suicide rates.

Behavioral Therapy/Behavioral Activation with pregnant or postpartum patients

o There is insufficient evidence for using BT/BA with pregnant or postpartum patients specifically. However, evidence from general trials should be applicable to this population. There is no evidence that pregnant women would not benefit from BT/BA. Risks of side effects and adverse outcomes are lower than with pharmacotherapy. .

Behavioral Therapy/Behavioral Activation with older patients

o There is insufficient evidence for using BT/BA with older patients specifically. However, as in the general population the risks of side effects and adverse outcomes are lower than with pharmacotherapy.

Behavioral Therapy/Behavioral Activation plus pharmacotherapy

o There is insufficient evidence for combining BT/BA with pharmacotherapy. There is also insufficient evidence on contraindications. There have not been any RCTs studying this particular combination of treatment.

Limitations of the literature

o There has been little replication of the above described results.

o BT has not been manualized, except for BA, and therefore it is not possible to know how similar or dissimilar the behavioral therapy approaches were in the four studies.

EVIDENCE TABLE

Evidence Source QE Overall

Quality

Benefit SR 1 Behavioral therapy/behavioral

activation (BT/BA) is efficacious in the treatment of MDD:

BT/BA is more effective for symptom reduction and remission than no treatment, placebo, or relaxation training, and similarly effective to other evidence-based treatments

Dimidjian et al., 2006 Jacobson et al., 1996 McLean & Hakstian, 1979

I Good Mod A

BA is more efficacious than cognitive

therapy for severely depressed patients Dimidjian et al., 2006 I Fair Mod B BT is more efficacious than

psychodynamic therapy, although these benefits were reduced at 3 months post-treatment

McLean & Hakstian, 1979

I Fair Mod B

BT is more efficacious than relaxation training, although these benefits were reduced at 3 months post-treatment

McLean & Hakstian, 1979

I Fair Mod B

Brief BA is more efficacious than TAU (standard supportive psychotherapy) with severely depressed patients on an inpatient psychiatric unit

Hopko et al., 2003 I Fair Mod B

BT/BA has a positive effect on retention compared to both cognitive therapy and ADM

Dimidjian et al., 2006 I Fair Mod B