From the Guidelines
Behavioral activation is as effective as full cognitive behavioral therapy (CBT) for treating depression, and it should be considered a first-line treatment option due to its simplicity and potential for widespread accessibility. This finding is supported by a recent network meta-analysis of almost 200 randomized trials, which indicated no major differences between seven major types of psychotherapy, including CBT, interpersonal psychotherapy (IPT), behavioral activation, problem-solving therapy, psychodynamic therapy, nondirective counseling, and social skills training 1. A more recent study published in 2016 also supports the use of behavioral activation as a nonpharmacologic treatment for adult patients with major depressive disorder, recommending that clinicians select between either cognitive behavioral therapy or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient 1.
Some key points to consider when implementing behavioral activation include:
- Patients typically begin by monitoring their daily activities and mood, then gradually increase pleasant or meaningful activities while decreasing avoidance behaviors
- A standard behavioral activation protocol might involve 12-16 weekly sessions, starting with activity monitoring for 1-2 weeks, followed by scheduled activity planning that progressively increases in difficulty
- Patients are taught to recognize patterns between their behaviors and mood, and to engage in valued activities even when they don't feel motivated
- This approach works by directly addressing behavioral withdrawal and avoidance that maintain depression, while naturally providing opportunities for positive reinforcement
The effectiveness of behavioral activation is particularly significant because it may be easier to implement than full CBT, potentially making effective depression treatment more accessible to a wider population through less extensively trained providers. Additionally, the treatment of depression can be characterized by three phases: acute, continuation, and maintenance, and relapse is defined as the return of depressive symptoms during the acute or continuation phases, whereas recurrence is defined as the return of depressive symptoms during the maintenance phase 1.
Overall, behavioral activation is a viable and effective treatment option for depression, and it should be considered as a first-line treatment due to its simplicity, accessibility, and potential for positive outcomes.
From the Research
Effectiveness of Behavioral Activation
- Behavioral activation is an evidence-based treatment for depression, with studies showing it to be as effective as cognitive behavior therapy (CBT) and cognitive therapy 2.
- A systematic review of behavioral activation treatment for depression found that it was consistently superior to wait list and treatment as usual control groups, with effect sizes not different from CBT or cognitive therapy 2.
- Behavioral activation may be more effective than cognitive therapy and CBT in terms of lower dropout rates, and it may also be useful for individuals with severe, lifelong depression, substance abuse, and dementia with severe depression 2.
Components of Behavioral Activation
- Behavioral activation treatment packages typically include components such as activity monitoring, assessment of life goals and values, activity scheduling, skills training, relaxation training, contingency management, and procedures targeting verbal behavior and avoidance 3.
- Activity scheduling and relaxation training have received empirical support as standalone components, while other procedures have shown effectiveness as part of larger treatment packages 3.
Application to Children and Adolescents
- Research on the application of behavioral activation to children and adolescents is emerging, with some studies suggesting it may be effective in treating depression and anxiety in young people 4, 5.
- A systematic review of behavioral activation for children and adolescents found that it may be effective in reducing depression symptoms, but more research is needed to fully establish its effectiveness 4.
- Behavioral activation has been delivered by trained therapists, doctoral trainee psychologists, social workers, or psychology graduates, and adaptations have included flexibility in content delivery, youth-friendly materials, and parental involvement 4.
Comparison to Other Treatments
- A study comparing the combination of selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) to SSRI monotherapy found that the combination treatment produced greater improvement in symptoms of depression and anxiety in youth 6.
- The study found that the additive benefit of CBT over SSRI monotherapy was not statistically significant until week 12 of treatment, and that the fastest response to combination treatment was for patients who were younger, with milder baseline symptoms, and depressive disorders 6.