by Joye C. Anestis, M.S.
It seems reasonable that getting individuals with depression involved in activities that increase pleasure and mastery (a therapy task known as behavioral activation) would be beneficial for their treatment. Behavioral activation (BA) is based on behavioral theories of reinforcement (see Jacobson, Martell, & Dimidjian, 2001, for a detailed account of the history of BA) which theorize that depressed individuals are not exposed to stimuli that are positively reinforcing. But what does the empirical literature say about the efficacy & effectiveness of this behavioral activation (BA)?
In 1996, Jacobson and colleagues conducted a dismantling study to determine if specific pieces of cognitive therapy (CT) for depression were more effective than complete CT. Participants (152 adults with major depressive disorder, who met stringent exclusion criteria) were randomly assigned to behavioral activation alone, identification and modification of dysfunctional automatic thoughts alone, and complete CT (which allowed for the use of any CT techniques with the overall aim of modifying the core schema). Results indicated no significant differences between the 3 treatment conditions, both at the end of treatment and at a 6-month follow-up. As you can imagine, these results came as quite a shock to proponents of CT! For practitioners, this indicated that perhaps, for some depressed clients, BA alone could be sufficient (or automatic thought modification alone).
This finding spurred a further interest in examining BA as a stand-alone treatment. Dimidjian and colleagues (2006) randomly assigned participants (241 adults with major depressive disorder, who met stringent exclusion criteria) to BA, CT, antidepressant medication (paroxetine), & placebo medication. The BA component utilized in this study differs somewhat from that used in the Jacobson study. The Jacobson BA closely mirrored the BA conducted in standard CT for depression (i.e., the BA described by Mike). Dimidjian and colleagues used an enhanced BA protocol that is more time-intensive, utilizes functional analysis, focuses more on patterns of avoidance and withdrawal, & offers behavioral strategies to deal with rumination (see Jacobson et al., 2001, for a more comprehensive description). Results indicated that BA was as effective as medication and more effective than CT for the most severely depressed participants only (defined as a Hamilton Rating Scale for Depression scores ≥ 20). Treatment differences were not found in the less depressed subsample. A two-year follow-up study of treatment responders indicated that receiving either of the 2 psychotherapies was as effective as continuing medication in the prevention of relapse and more effective than withdrawing from medication (Dobson et al., 2008). So both of the time-limited therapies were comparable to continuing to take antidepressants throughout the two-year follow-up period. This effect was clearer for CT than for BA, although there were no significant differences between the 2 psychotherapy conditions. This finding adds to a long line of research on the prophylactic effect of specific psychotherapies for depression (see Imel et al., 2008, for a meta-analytic review).
It is interesting to note that the BA literature focuses on 2 distinct forms of BA: BA done as a component of CT and BA done as a stand-alone therapy. And both seem to be efficacious in the treatment of depression in adults (although I have not come across effectiveness studies examining BA alone in less-structured environments).
So what does this all mean? CT & CBT manuals almost always suggest utilizing behavioral strategies initially in the treatment of depression, and the findings discussed above support focusing on BA in the early therapy sessions. Furthermore, it appears that, for some clients, BA alone may be sufficient, although it is not yet clear how to identify such individuals a priori (more severe clients, clients with more complicated interpersonal & life histories have been implicated; Coffman et al., 2007; Dimidjian et al., 2006). Answering this question in a concise manner will further the goal of offering greater specificity of treatment.
Joye Anestis is a doctoral candidate in the clinical psychology program at Florida State University.
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