Changing Behavior, Easing Depression


Studies have shown that two very different approaches to treating depression-antidepressant medications and psychotherapy-are both effective. But both can be problematic for patients, as well.

Medications often have unwanted side effects, such as drowsiness, diarrhea, or loss of libido. Psychotherapy, which requires time and commitment, also has some side effects, such as overstimulation-stirring up the emotions too much in certain situations. And since the leading form of psychotherapy for depression, cognitive behavioral therapy (CBT), is complex and requires multiple sessions with a highly trained psychotherapist, treatment is often expensive.

New evidence now suggests that another option, called behavioral activation (BA), may be helpful for some patients.

How BA therapy works

Although there is no single “approved” approach to BA, according to Behavioral Activation for Depression: A Clinician’s Guide, this streamlined method for treating depression is typically guided by several key ideas:

  • Changing what you do can change the way you feel.
  • Some behaviors may make your depression worse-deciding not to go out with friends, for example, or bingeing on food.
  • Doing what you enjoy-including activities you’ve avoided because you’re depressed-can make you feel better.
  • If you suffer from depression, it’s important to schedule activities according to a plan, not the mood you’re in.
  • Small behavioral changes are easier to accomplish than big, sweeping changes.
  • The overall goal is to avoid behaviors that trigger depression and replace them with activities and behaviors that make you feel good.

Re-emerging therapy

BA itself isn’t new-the principles behind it have been around for decades. But until recently, there hasn’t been persuasive evidence that the approach-a kind of “CBT lite”-works as well as formal CBT.

In an influential study published in The Lancet in August 2016, researchers offered solid data showing BA to be as effective as CBT in treating depression. What’s more, the study suggested that the approach could be taught by counselors with only the most basic training, making it potentially less expensive than CBT-at least in Great Britain, where the study was conducted. Experts say that the BA approach could allow for effective treatment to be given to more people because of the reduced cost.

A pragmatic approach

As the name suggests, cognitive behavioral therapy focuses on two things: cognition (thinking) and behavior. With CBT, people who suffer from depression learn to identify thoughts and beliefs that lead them into depression and to adopt alternative and more positive patterns of thinking that help them avoid the downward spiral. In addition, they learn to change behaviors that may trigger depression, such as staying at home and becoming isolated.

BA therapy focuses solely on behavior. The notion behind the approach is that behaviors, thoughts, and physical symptoms are all interconnected. Each one influences and is influenced by the other two. If you change one, you might change them all. For many people, the thinking goes, changing behaviors is more practical and achievable than changing thoughts and beliefs. The latest evidence seems to support that philosophy.

What the study says

In The Lancet study, known as Cost and Outcome of Behavioural Activation (COBRA), researchers at the University of Exeter in England recruited 221 patients with major depressive disorder. The researchers excluded people who were already receiving psychological therapy, were dependent on drugs or alcohol, were cognitively impaired or acutely suicidal, or had bipolar disorder or psychotic symptoms. Included were people on antidepressant medication and people who were not.

Half of the participants received CBT and the other half BA. Over the course of a year, the researchers found no difference between the groups: In both, roughly two thirds of the volunteers had at least a 50 percent improvement in symptoms of depression.

The results seem encouraging and support the findings of other clinical trials showing BA to be an effective treatment for depression in some people. However, it’s important to note that relapses occur often with depression, and the follow-up in the COBRA study was only 18 months. Another limitation was that 35 percent of the subjects chose not to attend even the minimum number of sessions, generally a common problem for psychological studies.

Also, the study didn’t account for the effect antidepressant medication may have had on the outcomes, although the researchers noted that participants who were taking medication had been doing so for a considerable amount of time before entering the trial.

The COBRA study did find that BA is potentially much less costly to deliver to patients than CBT, with estimated savings of about 20 percent. The reason: BA can be conducted by what the researchers described as mental health workers with very basic training, rather than psychotherapists with advanced training. The researchers theorized that BA therapy might also be a way to offer treatment in places where there is very little in the way of mental health or psychological services. However, besides receiving five days of clinical training, the mental health workers in this study were supervised by psychological therapists clinically experienced in BA or CBT and overseen by trial team experts.

The right fit?

The COBRA study included adults 18 and older with major depressive disorder. The results suggest that BA can be effective for a wide range of people with depression. Other smaller, short-term studies looking at specific patient populations-older adults and adolescents, for example-have also found BA to be an effective treatment for depression.

What’s involved? In a behavioral activation program offered by the University of Exeter, for example, participants begin by making a list of things that they do differently, or stop doing entirely, when they begin to become depressed. Then they make a list of things they aren’t doing currently but would like to do if only they felt better.

They are encouraged to record their daily activities over a week, identifying what makes them feel good and what makes them feel depressed. Finally, they find specific opportunities during the week for activities that make them feel better. Throughout the program, mental health workers are available to answer questions or offer encouragement. A typical program might last about three months.

But there are many variations in the way BA is offered-there are even apps designed to help guide people through BA. In a report published in the journal PLOS ONE in May 2016, researchers identified 117 smartphone apps designed to help people with depression. Twelve of the apps were based around the principles of either CBT or BA, but only loosely. Rating the BA apps, the researchers found that the programs followed the core principles only about 18 percent of the time. That doesn’t mean that some of the apps might not be helpful, of course, but it is a good reason to be skeptical. Also important to keep in mind is the fact that personal information shared on a smartphone isn’t necessarily secure.

Bottom line

For now, BA therapy on its own isn’t widely available in the United States. However, CBT therapists include behavior change as part of their practice. Also, some of the principles of BA are being incorporated into other medical specialties, such as geriatric medicine and wellness programs, as a way to treat depression. As always, it’s important to check a provider’s credentials-less expensive care may not result in the best treatment for your condition, especially if your depression is severe.