For Mild Cognitive Impairment, Behavioral Activation Outperforms Supportive Therapy


Memory decline was worse for patients with MCI receiving supportive therapy over behavioral activation.

Dr Barry Rovner

Barry W. Rovner, MD, from the Sidney Kimmel Medical College of Thomas Jefferson University

Barry W. Rovner, MD

Behavioral activation has shown in a clinical trial to be a better preventer of cognitive decline than supportive therapy in black individuals with mild cognitive impairment (MCI).

The incidence of 2-year memory decline was 1.2% (95% CI, 0.2 to 6.4) for those receiving behavioral activation compared to 9.3% (95% CI, 5.30 to 16.4) for those receiving supportive therapy, for a relative risk of 0.12 (95% CI, 0.02 to 0.74; P = .02).

Led by Barry W. Rovner, MD, from the Sidney Kimmel Medical College of Thomas Jefferson University, the study included 221 patients with amnestic MCI, 80% of which (n = 177) had amnestic-multiple domain MCI. They were randomized to receive either behavioral activation (n = 111), which included goal setting and action plans to reinforce the practice of healthy activities, or supportive therapy (n = 110).

“No effective pharmacotherapy exists to prevent cognitive decline in persons with MCI, and black individuals are twice as likely to decline cognitively, meet criteria for MCI, and develop dementia as white individuals,” Rovner and colleagues wrote. “Black individuals also have less accurate knowledge of dementia and are less likely to be treated for it. These facts highlight the need for culturally competent preventive treatments such as behavioral activation to reduce the burden of dementia and achieve health equity for everyone.”

The Hopkins Verbal Learning Test-Revised (HVLT-R) was used to assess the primary outcome of cognitive decline. After 6 months, the relative risks for a decline at months 12, 18, and 24 were progressively lower for those receiving the behavioral activation intervention. The relative risks were 0.70, 0.37, and 0.12 for months 12, 18, and 24, respectively, with months 18 (P = .05) and 24 (P = .02) showing statistical significance.

When considering HVLT-R scores as a continuous variable in the modified intent-to-treat population, the mean change per year (slope) in HVLT-R total recall scores in behavioral activation participants was 0.74 (95% CI, 0.25 to 1.23; P = .003), which represented an improvement, while supportive therapy participants observed a lack of change (0.04; 95% CI, −0.42 to 0.50; P = .87). The difference in slopes was 0.70 (95% CI, 0.03 to 1.37; P = .04).

When examining patients’ progression to dementia, it was revealed that 4.4% (n = 4) of the behavioral group compared to 8.4% (n = 8) of the supportive group had done so after month 6 (χ2 = 1.45; P = .25). Neuropsychological test outcomes, conducted at months 12 and 24, revealed a significant annual improvement in executive function for the behavioral group (slope, -13.5; 95% CI, -21.4 to -5.52; P <.001), while supportive therapy did not (slope, 3.18, 95% CI, −4.17 to 10.53; P = .40). This resulted in a significant difference in slopes (−16.6; 95% CI, −27.5 to −5.82; P = .003), which was almost identical in the modified intent-to-treat population (difference in slopes, −16.6; 95% CI, −27.6 to −5.67; P = .003).

Behavioral activation was also associated with more stable everyday function, while supportive therapy was associated with a decline (difference in slopes, 2.71; 95% CI, 0.12 to 5.30; P = .04), using the University of California Performance-Based Skills Assessment scores.

“To our knowledge, this is the first RCT to demonstrate that behavioral activation specifically prevents cognitive and functional decline in older black individuals with MCI. We found that 1 behavioral activation participant (1.2%) vs 9 supportive therapy controls (9.3%) declined significantly in memory over 2 years. This was a statistically significant reduction in relative risk (number needed to treat, 12.25), but its clinical significance requires further investigation,” Rovner and colleagues wrote.

For context to their results, they provided evidence suggesting that 12% to 41% of older black individuals decline in memory over 2 years, highlighting behavioral activation’s treatment effect as notable. Supportive therapy’s positive effect suggests, they noted, that social interaction itself may be beneficial, although to a lesser extent.


Rovner BW, Casten RJ, Hegel MT, et al. Preventing cognitive decline in black individuals with mild cognitive impairment: a randomized clinical trial. JAMA Neurol. Published online September 10, 2018. doi:10.1001/jamaneurol.2018.2513.

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