In October 2023, the World Health Organization (WHO) stated that approximately 14% of older adults live with mental health disorders like depression – by 2030, 1 in 6 people will be aged 60 years old or over (WHO, 2023).

Depression among older adults is linked to decreased quality of life, increased morbidity (Obuobi-Donkor et al., 2021), and higher healthcare utilization (Lamoureux-Lamarche et al., 2021). Despite the effectiveness of psychological therapies,they face barriers to accessing treatment, and antidepressants remain the dominant intervention, despite biological risks (Hetlevik et al., 2019).

Behavioural Activation (BA) is a structured psychological intervention, that focuses on increasing engagement in rewarding activities while reducing avoidance behaviors that contribute to depression. BA is an evidence-based therapy for depression that focuses on increasing engagement in rewarding activities (Richards et al, 2016; Orgeta et al., 2017); it has also been suggested as a viable alternative to medication (Moradveisi et al., 2013).

A new study by Janssen et al. (2024) addresses a gap in research: is BA is a cost-effective alternative to treatment as usual (TAU) for older adults with depression, in primary care?

Methods

This study conducted a cost-effectiveness analysis alongside a cluster randomised controlled trial (RCT) comparing Behavioural Activation (BA) delivered by mental health nurses (MHNs) with Treatment as Usual (TAU) in primary care settings in the Netherlands.

A total of 161 older adults (≥65 years) with moderate to severe depressive symptoms (PHQ-9 ≥ 10) participated in the study. Randomization was at the primary care centre (PCC) level. In the BA group, participants received an 8-session BA treatment over 8 weeks (first session 45 mins, the rest 30 mis), delivered by trained MHNs. In the TAU group participants received usual General Practitioner (GP) care, which could include antidepressants, psychotherapy, or other primary care-based interventions.

To test the comparative cost-effectiveness of BA, the following outcomes were measured:

• depressive symptoms measured via the Quick Inventory of Depressive Symptomatology (QIDS-SR).
• the costs and health benefits of BA versus TAU in terms of costs per quality-adjusted life year (QALY) assessed using the EQ-5D-5L.
• societal costs including healthcare, informal care, and productivity losses.

Bivariate linear regression models were used to estimate cost and effect differences. Bootstrapping was applied to assess statistical uncertainty. Cost-effectiveness acceptability curves were used to determine the probability that BA is cost-effective at different willingness-to-pay thresholds.

Results

In terms of clinical effectiveness, the study found that:

• BA was more effective than TAU in reducing depressive symptoms at the 12-month follow-up (mean difference: -2.4 points, 95% CI: -4.0 to -0.8), suggesting that BA led to clinically significant improvements in depression symptoms, though with substantial uncertainty and variability.
• There was a non-significant difference in quality of life improvement (mean difference in QALYs: 0.03, 95% CI: -0.01 to 0.07), meaning that any advantages of BA could be random.

In terms of cost effectiveness, the study found that:

• BA was slightly less expensive than TAU, with total societal costs being €485 lower per participant in the BA group (mean difference: -€485, 95% CI: -€3,861 to €2,792). However, the confidence interval is wide, and this uncertainty means that the intervention may reduce costs, but could also increase them.
• Societally, BA had a 60% probability of being cost-effective at a willingness-to-pay threshold of €0 per QALY gained, increasing to 72% at a threshold of €50,000 per QALY gained. This means that, even at a relatively high threshold, the probability of BA being cost-effective is still not close to 100%.
• From a healthcare perspective, BA was more likely to be cost-effective, reaching 85% at a willingness-to-pay threshold of €50,000 per QALY gained.

Conclusions

This study suggests that behavioural activation (BA) is, at least, clinically effective in reducing depressive symptoms in older adults.

However, its impact on quality of life and costs remains uncertain. BA may be cost-effective, but the probability varies depending on how much society or a healthcare system is willing to pay for each additional quality-adjusted life year (QALY).

Strengths and limitations

The authors identified several strengths of the study. One key strength is its pragmatic design, as the trial was conducted in real-world primary care settings, making the findings more applicable to everyday clinical practice. Another strength is the comprehensive cost analysis, which included both healthcare costs (such as consultations and medications) and societal costs (such as informal care and lost productivity), offering policymakers valuable insights into its potential cost-effectiveness.

Beyond what the authors highlighted, the decision to include older adults with comorbidities increases the external validity of the study, as in real-world primary care settings, comorbidities are common. Another important strength is that the intervention was delivered by mental health nurses (MHNs), rather than specialist therapists. This is crucial for the feasibility and scalability of BA, as MHNs are more widely available in primary care than clinical psychologists.

One key limitation that the authors acknowledged is the uncertainty in cost-effectiveness estimates, especially given that the observed cost differences were not statistically significant, limiting any conclusions on the financial benefits of BA. The authors also noted the high rate of missing data; although they used state-of-the art techniques to account for missing values, the validity of these estimates depends on the assumption that the missing data were random. Finally, cost-effectiveness was evaluated over a 12-month period, but cost-effectiveness in mental health can take longer to materialise, especially with chronic conditions like depression.

Some further observations are, that the generalisability of these findings is restricted by real-life variability in BA protocols and intervention delivery. While BA was structured as an eight-session program, real-world differences in how mental health nurses delivered the intervention may have influenced outcomes; it is unknown whether a different BA protocol would lead to similar clinical or cost-efficacy. The variability of what constitutes TAU — anything from medication to psychotherapy referrals—makes it difficult to determine whether BA was cost-effective compared to a specific or consistent alternative.

Baseline cohort differences, such as the BA group having a higher average education level and a shorter mean duration of depression, could influence differences in treatment response and engagement, and willingness to pay for services.

Lastly, country-level differences should be considered: the study assessed cost-effectiveness through BA delivery by MHNs, but in many countries, implementing BA may require hiring or training new providers, which was not factored into the cost analysis. Conversely, if TAU in other countries is less intensive than in the Netherlands, BA might appear more cost-effective elsewhere.

Implications for practice

The authors suggest key implications for practice and research based on their findings:

• Primary care providers should consider BA as a low-cost, scalable intervention that can be delivered by mental health nurses (MHNs) and does not require highly trained specialists, as e.g., in CBT.
• Further research is needed to provide evidence for BA’s cost-effectiveness in older adults, across healthcare systems and over a longer timeframe. This would help determine whether BA provides sustained benefits over time, for this cohort.

Beyond the authors’ recommendations, there are important implications that researchers, policymakers and healthcare providers should consider:

• Quality-adjusted life years (QALYs) were not designed to capture fluctuating changes in mood, cognitive functioning, or social engagement. Future studies should explore alternative outcome measures that are more sensitive to improvements in depression, such as well-being-adjusted life years (WELLBYs).
• Future studies must explore the additional barriers to real-world implementation of BA not included in the research conditions, such as limited staff availability, competing clinical priorities, and varying levels of provider engagement.
• Given the increasing use of telehealth, future research should explore whether BA can be effectively delivered via telemedicine, which could improve accessibility for individuals who may face mobility barriers or limited access to in-person care. Previous studies have shown promising results for telephone-delivered BA in older adults (Pellas et al., 2023).
• In the UK, NHS Talking Therapies (formerly IAPT) provides psychological treatments for depression. BA could be integrated as a first-line intervention, particularly as it can be delivered by Psychological Wellbeing Practitioners, who already work within NHS primary care settings.

Statement of interests

I have no competing interests to declare.

Links

Primary paper

Janssen, N.P., Hendriks, G.J., Sens, R., Lucassen, P., Oude Voshaar, R.C., Ekers, D., van Marwijk, H., Spijker, J., & Bosmans, J.E. (2024). Cost-effectiveness of behavioral activation compared to treatment as usual for depressed older adults in primary care: A cluster randomized controlled trial. Journal of Affective Disorders, 350, 665–672. https://doi.org/10.1016/j.jad.2024.01.109

Other references

Hetlevik, Ø., Garre-Fivelsdal, G., Bjorvatn, B., Hjørleifsson, S., & Ruths, S. (2019). Patient-reported depression treatment and future treatment preferences: An observational study in general practice. Family Practice, 36(6), 771–777.

Lamoureux-Lamarche, C., Berbiche, D., & Vasiliadis, H. M. (2022). Health care system and patient costs associated with receipt of minimally adequate treatment for depression and anxiety disorders in older adults. BMC psychiatry, 22(1), 175.

Moradveisi, L., Huibers, M. J., Renner, F., Arasteh, M., & Arntz, A. (2013). Behavioural activation v. antidepressant medication for treating depression in Iran: randomised trial. The British Journal of Psychiatry, 202(3), 204-211.

Obuobi-Donkor, G., Nkire, N., & Agyapong, V. I. (2021). Prevalence of major depressive disorder and correlates of thoughts of death, suicidal behaviour, and death by suicide in the geriatric population—A general review of literature. Behavioral Sciences, 11(11), 142.

Orgeta, V., Brede, J., & Livingston, G. (2017). Behavioural activation for depression in older people: systematic review and meta-analysis. The British Journal of Psychiatry, 211(5), 274-279.

Pellas, J., Renner, F., Ji, J. L., & Damberg, M. (2023). Telephone-based behavioral activation with mental imagery for depression in older adults in isolation during the COVID-19 pandemic: long-term results from a pilot trial. Clinical Gerontologist, 46(5), 801-807.

Richards DA, Ekers D, McMillan D, Taylor RS, Byford S, Warren FC, Barrett B, Farrand PA, Gilbody S, Kuyken W, O’Mahen H, Watkins ER, Wright KA, Hollon SD, Reed N, Rhodes S, Fletcher E, Finning K. (2016) Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. Published Online: 22 July 2016 http://dx.doi.org/10.1016/S0140-6736(16)31140-0

World Health Organization (WHO). (October, 20, 2023). Mental health of older adults. Retrieved February 28, 2025.

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