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Behavioral Activation Is an Evidence-Based Treatment for
Depression
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Behavior Modification
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Behavioral Activation
Is an Evidence-
Based Treatment for
Depression
Peter Sturmey1
Abstract
Recent reviews of evidence-based treatment for depression did not identify
behavioral activation as an evidence-based practice. Therefore, this article
conducted a systematic review of behavioral activation treatment of
depression, which identified three meta-analyses, one recent randomized
controlled trial and one recent follow-up of an earlier randomized control
trial. Behavioral activation was consistently superior to wait list and
treatment as usual control groups. Effect sizes were not different from
cognitive behavior therapy or cognitive therapy, both post-treatment and
at follow-up. Indeed, behavioral activation may be more effective than
cognitive therapy and cognitive behavior therapy in terms of lower drop-
out. Behavioral activation, like cognitive behavior therapy, may be superior
to paroxitine because it results in less relapse and recurrence, may be
substantially cheaper, and does not have risks of pharmacotherapy. There
is some evidence that behavioral activation may also be useful with some
people for whom cognitive and cognitive-behavior therapy is less effective,
such as those with severe, lifelong depression, people with substance abuse
and people with dementia and severe depression. There is now sufficient
evidence to conclude that behavioral activation is an evidence-based therapy.
Corresponding Author:
Peter Sturmey, PhD, Department of Psychology, Queens College, City University of New York,
65-25, Kissena Boulevard, Flushing, NY 11367
Email: psturmey@gmail.com
Keywords
behavioral activation, depression, cognitive therapy, cognitive behavior
therapy, evidence-based practice
Skinner (1953, 1971) provided speculative behavioral accounts of depression and subsequently, Ferster (1973) and Lewinsohn, Biglan, and Zeiss (1976) provided a more detailed behavioral account of depression and its behavioral treatment. Following observations that mood is significantly correlated with activities (Hopko, Armento, Chamber, Cantu, & Lejuez, 2003), several authors developed behavioral activation (Addis & Martell, 2004; Hopko & Lejuez, 2008; Hopko, Lejuez, LePage, Hopko, & McNeil, 2003; Lewinsohn & Graf, 1973, Lewinsohn & Libet, 1972), which involves identifying activi-ties associated with positive mood, client self-recording of engagement in pleasant activities and setting weekly, small goals and longer term goals to gradually increasing the frequency and duration of pleasant activities. Recent variants have included values clarification at the beginning of therapy to identify pleasant activities that are consonant with client core values (Hopko & Lejuez, 2008; Hopko, Lejuez et al., 2003, Lejuez, Hopko, & Hopko, 2003). Behavioral activation treatment manuals are now available (Hopko & Lejuez, 2008; Lejuez et al., 2003), which may facilitate dissemination in applied set-tings and treatment integrity in research. Thus, there has been a continuing interest in behavioral activation for more than 50 years and recently there has been increased interest in this approach to treating depression.
Despite early promise of behavioral activation¸ cognitive therapy (CT) and cognitive behavior therapy (CBT) have dominated psychological treatment of depression (British Psychological Society, 2004; National Institute for Clinical Excellence [NICE], 2007), even though early accounts of CBT emphasized behavioral activation as an important element of CBT (Beck, Rush, Shaw, & Emery, 1979). Gortner, Gollan, Dobson, and Jacobson (1998) and Jacobson et al. (1996) challenged the centrality of cognitive aspects of CBT in a disman-tling study. Jacobson et al. (1996) randomly assigned 150 outpatients with major depression to three groups: (a) behavioral activation without CT, (b) behavioral activation with CT for automatic thoughts only, and (c) the full CBT package. They found that, despite therapist allegiance and competent delivery of CT, behavioral activation produced outcomes equivalent to CBT both post-treatment, 6 months follow-up on cognitive and other outcome mea-sures. There were also no differences in treatment outcomes between behavioral activation and the two other treatments at 2 year follow-up (Gortner et al., 1998). Subsequent comparisons of behavioral activation and CBT have replicated this finding in more than 10 randomized controlled trials (RCTs; Cuijpers, van Straten, Andersson, & van Open, 2008; Ekers, Richards, & Gilbody, 2007). Indeed, some studies have found behavioral activation to be superior to CBT in terms of drop-out (Cuijpers et al., 2008) or treatment of extreme nonresponders to CT (Coffman, Martell, Dimidjian, Gallop, & Hollon, 2007). These recent findings support the notion that behavioral activation is an evidence-based practice for depression. Furthermore, they challenge earlier conclusions that CBT is the preferred evidence-based treatment for depression (British Psychological Society, 2004; NICE, 2004, 2007), and that mechanisms of change in CBT for depression is because of changes in cognitive structures that precede and cause changes in depressed behavior.
Despite accumulating evidence of the effectiveness of behavioral activa- tion, recent guidelines did not explicitly identify behavioral activation as an evidence-based treatment. For example, NICE’s (2007) amended practice guideline did not mention behavioral activation, but only “behavior therapy” for depression. When it cited “behavior therapy” it noted recommended that future studies should conduct adequately powered RCTs. Its sections on psychological treatments mentioned CBT, interpersonal psychotherapy, couple-focused therapy and psychodynamic psychotherapy, but did not men-tion behavioral activation or behavior therapy (pp. 29-33). The full guidance (British Psychological Society, 2004) does mention behavioral activation, including Jacobson et al. (1996) dismantling study, but identified only two RCTs that met inclusion criteria. Since recent practice guidelines did not rec-ommend behavioral activation as an evidence-based treatment for depression and because these has been increased activity in this area over the past 10 years, this article systematically reviewed the evidence to ascertain if behav-ioral activation is an evidence-based treatment (Chambless & Hollon, 1998).
Method
Literature Search
An online literature search for meta-analyses of behavioral activation was first conducted beginning. A search of PubMed using the search terms “((behavioral OR behavioural) AND activation AND depression AND meta-analysis)).” A subsequent search of PubMed was conducted on August 2, 2009 to identify RCTs of behavioral activation published from 2007 onward that were not included in these two meta-analyses using the search terms “((behavioral OR behavioural) AND (activation) AND (depression) AND ((RCT) OR (randomized controlled trial)).” Results
Search Results
The first search identified two were meta-analyses of behavioral activation
and depression. The five excluded articles were studies of psychotropic med-
ications or psychometric assessment of depression. These two meta-analyses
were based on searches from 1966 to March 2005 (Cuijpers, Van Staten, &
Warmerdam, 2007) and from 1966 to May 2007 (Cuijpers et al., 2008). The
search for more recent RCTs of behavioral activation identified one new
RCT (Daughters et al., 2008) and a follow-up of an earlier RCT of behavioral
activation (Dobson et al., 2008), which were not included in the two meta-
analyses (Cuijpers et al., 2007, 2008). Reviewers of an earlier draft of this
article identified a third meta-analysis of behavioral treatments of depression
(Ekers et al., 2007). Thus, this review includes three meta-analyses and two
other recent articles.
Meta-AnalysesCuijpers et al. (2007) conducted a systematic search of a database of 777 articles on psychological treatment of depression which they had assembled through comprehensive search of four databases from 1966 to March 2005. They also reviewed articles identified in 22 meta-analyses of psychological treatment of depression and the NICE (2004) review of depression and reviewed reference lists of candidate articles. They included studies that compared behavioral activation in adults with clinical depression or elevated depression symptoms compared to a control condition or other treatment in an RCT.
There were 16 RCTs with 241 participants who participated in behavioral activation and 367 who participated in other treatments and 172 in control conditions. Ten studies recruited participants from community settings, four from clinical settings, and two used varied recruitment strategies or did not report their recruitment strategies. In 10 studies that compared behavioral activation with a control condition the mean Cohen’s d was 0.87 (large). In 18 comparisons of behavioral activation with other psychological treatments the mean d was 0.12, indicating little difference between behavioral activa-tion and other psychological therapies. In 10 comparisons of behavioral activation to CT alone d was 0.02, in three studies comparing behavioral activation to combined behavioral activation and CT mean d was –0.16 and in one study comparing behavioral activation to antidepressant medication d was 0.26 in favor of behavioral activation, indicating no difference in effect sizes between the behavioral activation and other psychological treatments. Comparisons of behavioral activation with control conditions and other treat-ments revealed that treatment effects of behavioral activation maintained or perhaps improved further up to 6 and 12 month months follow-up.
The authors noted several limitations in this meta-analysis. The quality of the studies was “not optimal” (p. 323) in that an independent party did not allocate participants to group, there was no concealment of random alloca-tion; 10 of 16 studies did report blinding of assessors; drop-out ranged from 2% to 39%; and no studies conducted intention-to-treat analysis. There also were relatively few studies with small group sizes in comparisons between behavioral activation and some other psychological treatments and a prepon-derance of comparisons to waiting list control, rather than TAU, perhaps resulting in inflated effect sizes.
In a second article, Cuijpers et al. (2008) conducted a meta-analysis of a CBT, nondirective supportative therapy, behavioral activation, psychody-namic psychotherapy, problem solving, interpersonal psychotherapy and social skills training for depression. They used multiple search strategies which identified nearly 7,000 abstracts of articles published between 1966 and May 2007. They identified 91 articles that assessed effectiveness of psy-chotherapy for adults with clinical depression or elevated depression symptoms and compared the treatment with another treatment in a RCT. They screened these 91 articles to identify specific treatments with five or more studies and to develop operational definitions of these treatments. The final pool of articles consisted of 53 RCTs comparing two or more psycho-logical treatments. They classified RCTs as high quality, if participants met diagnostic criteria for depression, assessors were blind to group, authors ana-lyzed data using intent to treat analysis, authors used a treatment manual, authors trained therapists to implement the specific therapy and authors checked treatment integrity.
The 53 articles included 2,757 participants with depression and involved 56 treatment comparisons. Thirty-eight articles involved CBT, 21 nondirec-tive supportive therapies, 15 behavioral activation, 10 psychodynamic psychotherapy, 7 problem solving, 6 interpersonal psychotherapy, and 15 studies evaluated other psychological treatments. Thirty-one studies recruited participants from the community, in 31 studies participants met diagnostic criteria for depression, and 22 studies included other operationalized inclu-sion criteria, such as cut off scores on depression checklists.
Values of d were almost uniformly low and ranged from –0.26 to 0.40, indi- cating little differences between the seven types of psychotherapy, although there modest effect sizes suggesting nondirective supportive therapies were less effective than other therapies (d = –0.13) and that interpersonal therapies were superior to other therapies (d = 0.19), but the magnitude of these differ-ences was modest. The mean effect size for comparisons of activation therapy with CBT based on 18 studies was 0.15 (95% CI = –0.08 to 0.18) indicating no difference. Comparison of drop out rate substantially favored behavioral acti-vation: The relative risk of drop out for behavioral activation was only 0.84 (95% CI = 0.55 to 1.28) but for CBT was 1.17 (95% CI = 1.02 to 1.35). The authors concluded there was little difference between behavioral activa-tion and CBT.
This meta-analysis has several limitations. Only approximately one third of RCTs were high quality, although there was no association between RCT quality and effect size. In addition, many studies reported outcome data on completers only, rather than intent-to-treat analyses. Finally, the number of studies in some comparisons between treatments was relatively small.
Ekers et al. (2007) conducted a third meta-analysis in which they com- pared behavioral activation to TAU or other psychotherapies, including CT/CBT, brief psychotherapy, and supportive counseling. They searched seven databases from their inception until January 2006 for studies with partici-pants aged more than 16 years, treated in out- or in-patient settings, with a primary diagnosis of depression and excluded studies with participants with other diagnoses, such as substance abuse. Their primary outcome measures were self-rated depression, clinician-rated depression at post-treatment, and 6 month follow-up (or the nearest available data point). They rated study quality an 8-point scale measuring selection, measurement, performance, and attrition bias.
Of 3,353 studies, only 20 met inclusion criterion, and they excluded three of these due to insufficient data. These remaining 17 studies had 1,109 par-ticipants. Twelve compared behavior therapy (BT) to waitlist or placebo. There was a large effect size (standardized mean difference [SMD] = –0.70, 95% CI = –1.00 to –0.39), no difference in drop-out between BT and control groups in three studies, and there was a greater rate of recovery in BT (52%) versus controls (21%) (95% CI = –3.39 to 1.29, p = .03). Twelve studies compared BT to CT/CBT. There was no difference between BT and CT/CBT on post-treatment depression symptoms, depression symptom level at follow-up (based on eight studies), and drop-out (also based on eight stud-ies). BT was distinctly superior to brief psychotherapy in three studies with positive effects on depression symptoms at post-treatment (SMD = –0.56; 95% CI = –1.0 to –0.12, p = .01), at follow-up (based on two studies) (SMD = –0.50, 95% CI = –0.90 to –0.09, p = .02), and no difference in drop-out (based on three studies). Two studies with 45 participants compared BT to supportive, Rogerian therapy. BT was superior to supportive, Rogerian therapy on measures of depressive symptoms at end of treatment (SMD = –0.75, 95% CI = –1.37 to –0.14, p = .02). This meta-analysis did not report data on any other outcomes of this comparison.
The authors concluded that there was “clear evidence that B[ehavior] T[herapy] was an effective treatment for depression” (p. 620). They also noted several limitations in their analysis. These included the variable quality of the trials and the small number of participants and studies comparing BT with brief psychotherapy and supportive counseling.
Recent StudiesDaughters et al. (2008) conducted a RCT comparing behavioral activation and TAU in 44 adult illicit drug users with DSM-IV diagnoses of substance dependence and scores on the Beck Depression Inventory of 10 and above. Most participants were middle-aged African American men and just over half also met DSM-IV criteria for a mood or anxiety disorder. The treatment was Lejuez et al. (2003) brief behavioral activation protocol modified for this population and context and delivered in groups of 3 to 5 patients. Behavioral activation was superior to TAU on the Hamilton and a measure of enjoyment. Using pooled baseline standard deviations, the values of d were 0.39 for the Hamilton and 0.67 for the measure of enjoyment. There were no effects of treatment on the Beck Depression Inventory or the Beck Anxiety Inventory. There was a nonsignificant trend for clients who received behavioral activa-tion to drop out less frequently, which was not quite statistically significant (p = .068), but the difference between the groups was large (4.5% vs. 22.7% drop out in behavioral activation and TAU respectively, odds ratio = 6.18). This study demonstrated that behavioral activation can be successful with clients with multiple clinical problems, that therapists can deliver it in a small group format, and that behavioral activation may have lower drop out rates than TAU.
Finally, Dobson et al. (2008) reported 2 year follow-up data of a RCT Dimidjian et al.’s (2006) RCT in which participants received either parox-etine (N = 100), CT (N = 45) or behavioral activation (N = 43). There were more participants in the paroxetine group, so half of them later took placebo at 1 year. Dobson et al. found that at 2 years participants who participated in either CT or behavioral activation were significantly less likely to relapse or experience reoccurrence of depression than those who took paroxetine and who had been withdrawn to placebo. In addition, although the initial costs of psychological therapy were approximately twice that of paroxetine, after approximately 9 months of treatment the costs of continued medication resulted in the costs of pharmacotherapy exceeding the costs of psychologi-cal therapy.
Discussion
The three meta-analyses and two other studies reviewed here suggest that
behavioral activation is an evidence based practice for depression. One might
dismiss Cuijpers et al. (2007) meta-analysis because of the poor quality of
the studies reviewed. The same criticism, however, cannot be made of Cui-
jpers et al. (2008) meta-analysis in which at least 10 RCTs were rated as
“high quality.” Like Cuijpers et al. (2007), Ekers et al. (2007) noted that qual-
ity of the studies in their meta-analysis was varied and that the results of
some low-quality studies did deviate from other studies’ results (p. 620);
however, their use of multivariate analyses which showed no effects of study
quality on effect size, may mitigate this potential problem. Thus, although
some studies included in these meta-analyses were of low quality, not all
were; therefore, one may conclude that, since there were some high quality
studies, that there is adequate evidence that behavioral activation is an evi-
dence-based treatment for depression (Chambless & Hollon, 1998). The
difference between this review’s conclusion and the earlier reviews (British
Psychological Society, 2004; NICE, 2004, 2007) may reflect the publication
of a number of studies over the past few years and perhaps the use of broader
inclusion criteria in Ekers et al.’s meta-analysis.
Number of comparisons between behavioral activation and CT/CBT was relatively large, leading to confidence in conclusions relating to these com-parisons; however, failure to detect differences between behavioral activation and CT/CBT must be treated with caution. Whereas it may be tempting to conclude that these therapies are equivalent, the failure to detect differences may merely reflect the lack of experimental power to detect true differences between two relatively effective treatments (Chambless & Hollon, 1998). Future comparisons might detect such differences, if they exist, by maximiz-ing the reliability and sensitivity of dependent variables, ensuring treatment integrity and using power calculations to determine the sample sizes neces-sary to detect such differences. These differences might appear relatively unimportant, because the effects sizes are likely to be of moderate magni-tude; however, they may be highly socially significant. Since depression is a very common disability with large societal costs due to lost workdays, addi-tional burden of care to family members and cost of continued treatment. Relatively modest improvements in treatment effectiveness might result in large economic benefits to society.
Number of RCTs comparing behavioral activation with psychological therapies other than CT/CBT was relatively small. This may have lead to contradictory findings. For example, Cuijpers et al. (2008) found that inter-personal psychotherapy was somewhat more effective than behavior activation (d = 0.20), whereas Ekers et al. (2007) found that behavioral acti-vation was moderately superior to brief psychotherapy (SMD = –0.56). Since these studies have produced contradictory results, future studies should address this issue.
Economic analysis of behavioral activation also suggested that the costs of behavioral activation, like CT, are less than paroxitine (Dobson et al., 2008), although this analysis was incomplete, as it did not consider the reduced costs of other forms of public services and costs to families and the added gains from people with depression returning to work.
Behavioral activation has at least four potentially significant advantages over CT. First, it may be suitable for a number of populations and specific individuals who do not respond to CBT, such as people with poor verbal skills, those who are not “psychologically minded” and those who do not respond to cognitive or other therapies. In this regard it is notable that studies of behavioral activation have included several populations that might be dif-ficult to treat for depression, such as people with dementia and depression (Teri, Logsdon, Uomoto, & McCurry, 1997), people with substance depen-dence and depression (Daughter et al., 2008), depressed cancer patients (Hopko et al., 2008) and psychiatric in-patients (Hopko, Lejuez, et al., 2003). To date, no studies have directly compared CT/CBT with behavioral activa-tion in these populations and future research should do so. Second, the skills required to deliver behavioral activation are relatively straightforward and highly structured. Availability of several treatment manuals and courses may mean that this treatment is easy to disseminate by a range of relatively cheap therapists or perhaps even nonprofessionals, although this has not yet been demonstrated empirically. Third, behavioral activation may be relatively effi-cient, since it produced outcomes that are equivalent or sometimes superior to CBT without the additional costs of delivering CT, and can be delivered effectively in group formats. Finally, behavioral activation, like some other psychological treatments, may provide greater protection against relapse than antidepressant medication after treatment is completed without the addi-tional costs and medical risks of psychotropic medication.
Results of this literature review demonstrate that behavioral activation is an evidence-based psychotherapy which is not different from and perhaps in some ways superior to other forms of psychotherapy for depression. It may be easy to disseminate, applicable to a range of populations commonly experienced in clinical practice and have positive economic impact. These findings challenge the conclusions of earlier reviews of psychological treat-ment of depression that did not identify behavioral activation as an evidence-based practice for depression.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interests with respect to the authorship
and/or publication of this article.
Funding
The authors received no financial support for the research and/or authorship of this
article.
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Bio
Peter Sturmey teaches psychology at Queens College and The Graduate Center, City
University of New York and is a member of the learning Processes and Behavior
Analysis and Neuropsychology Doctoral Programs. His research interests include
applied behavior analysis related to developmental disabilities and clinical
psychology.

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