Hostname: page-component-78c5997874-8bhkd Total loading time: 0 Render date: 2024-11-10T07:04:45.777Z Has data issue: false hasContentIssue false
  • English
  • Français

Looking beyond depression: a meta-analysis of the effect of behavioral activation on depression, anxiety, and activation

Published online by Cambridge University Press:  06 March 2020

Aliza T. Stein Open the ORCID record for Aliza T. Stein [Opens in a new window] ,
Emily Carl ,
Pim Cuijpers ,
Eirini Karyotaki  and
Jasper A. J. Smits
Aliza T. Stein*
Affiliation:
University of Texas at Austin, Austin, TX, USA
Emily Carl
Affiliation:
University of Texas at Austin, Austin, TX, USA
Pim Cuijpers
Affiliation:
Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
Eirini Karyotaki
Affiliation:
Vrije Universiteit Amsterdam, Amsterdam, The Netherlands Harvard Medical School, Boston, MA, USA
Jasper A. J. Smits
Affiliation:
University of Texas at Austin, Austin, TX, USA
*
Author for correspondence: Aliza T. Stein, E-mail: atstein@utexas.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Depression is a prevalent and impairing condition. Behavioral activation (BA) is a parsimonious, cost-effective, and easily disseminated psychological intervention for depression. The current meta-analysis expands on the existing literature supporting the efficacy of BA for depression by examining the effects of BA on additional relevant outcomes for patients with depression, namely the reduction in anxiety symptoms and increase in activation.

Methods

Randomized controlled trials of BA for depression compared to active and inactive control were identified via a systematic review. Effect sizes using Hedges's g were calculated for each outcome compared to both active and inactive control using random effects models. Subgroup analyses were used to examine the inclusion of a discussion of values as a moderator of depression symptom outcome in BA.

Results

Twenty-eight studies were included. Meta-analyses of symptom change between groups from baseline-to-post intervention indicated that BA outperformed inactive control conditions for improvements in depression (g = 0.83), anxiety (g = 0.37), and activation (g = 0.64). The difference between BA and active control conditions was not significant for improvements in depression (g = 0.15), anxiety (g = 0.03), and activation (g = 0.04). There was no evidence for a discussion of values augmenting BA efficacy. Study quality was generally low, and there was evidence of publication bias.

Conclusions

In addition to improving depression, BA shows efficacy for reducing symptoms of anxiety and increasing activation. BA may not offer better outcomes relative to other active interventions. There is room for improvement in the quality of research in this area.

Keywords

Behavioral activationDepressionMeta-analysis
Type
Original Articles
Information
Psychological Medicine , Volume 51 , Issue 9 , July 2021 , pp. 1491 - 1504
Check for updates
Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Barth, J., Munder, T., Gerger, H., Nüesch, E., Trelle, S., Znoj, H., … Cuijpers, P. (2013). Comparative efficacy of seven psychotherapeutic interventions for patients with depression: A network meta-analysis. PLoS Medicine, 10, e1001454.CrossRefGoogle ScholarPubMed
Borenstein, M., Hedges, L., Higgins, J., & Rothstein, H. (2013). Comprehensive meta-analysis (Version 3). Englewood, NJ: Biostat.Google Scholar
Borenstein, M., Hedges, L. V., Higgins, J. P., & Rothstein, H. R. (2011). Introduction to meta-analysis. Chichester, UK: John Wiley & Sons.Google Scholar
Burns, D. D., & Spangler, D. L. (2000). Does psychotherapy homework lead to improvements in depression in cognitive-behavioral therapy or does improvement lead to increased homework compliance? Journal of Consulting and Clinical Psychology, 68, 46–56.CrossRefGoogle ScholarPubMed
Busch, A. M., Uebelacker, L. A., Kalibatseva, Z., & Miller, I. W. (2010). Measuring homework completion in behavioral activation. Behavior Modification, 34, 310–329.CrossRefGoogle ScholarPubMed
Craske, M. G., Meuret, A. E., Ritz, T., Treanor, M., Dour, H., & Rosenfield, D. (2019). Positive affect treatment for depression and anxiety: A randomized clinical trial for a core feature of anhedonia. Journal of Consulting and Clinical Psychology, 87, 457–471.CrossRefGoogle ScholarPubMed
Cristea, I. A., Huibers, M. J. H., David, D., Hollon, S. D., Andersson, G., & Cuijpers, P. (2015). The effects of cognitive behavior therapy for adult depression on dysfunctional thinking: A meta-analysis. Clinical Psychology Review, 42, 62–71.CrossRefGoogle ScholarPubMed
Cuijpers, P., Karyotaki, E., de Wit, L., & Ebert, D. D. (2019a). The effects of fifteen evidence-supported therapies for adult depression: A meta-analytic review. Psychotherapy Research, 30(3), 1–15.Google Scholar
Cuijpers, P., Reijnders, M., & Huibers, M. J. H. (2019b). The role of common factors in psychotherapy outcomes. Annual Review of Clinical Psychology, 15, 207–231.CrossRefGoogle Scholar
Cuijpers, P., van Straten, A., & Warmerdam, L. (2007). Behavioral activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27, 318–326.CrossRefGoogle ScholarPubMed
Duval, S., & Tweedie, R. (2000). Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics, 56, 455–463.CrossRefGoogle ScholarPubMed
Egger, M., Smith, G. D., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315, 629–634.CrossRefGoogle ScholarPubMed
Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D., & Gilbody, S. (2014). Behavioural activation for depression: An update of meta-analysis of effectiveness and Sub group analysis. PLoS ONE, 9, e100100.CrossRefGoogle ScholarPubMed
Fava, M., Rankin, M. A., Wright, E. C., Alpert, J. E., Nierenberg, A. A., Pava, J., & Rosenbaum, J. F. (2000). Anxiety disorders in major depression. Comprehensive Psychiatry, 41, 97–102.CrossRefGoogle ScholarPubMed
Ferster, C. B. (1973). A functional analysis of depression. American Psychologist, 28, 857.CrossRefGoogle Scholar
Hedges, L. V., & Olkin, I. (1985). Statistical methodsfor meta-analysis. Orlando, FL: Academic Press.Google Scholar
Hedges, L. V., & Olkin, I. (2014). Statistical methods for meta-analysis. Orlando, FL: Academic Press.Google Scholar
Higgins, J. P. T., Altman, D. G., Gotzsche, P. C., Juni, P., Moher, D., Oxman, A. D., … Cochrane Bias Methods Group, Cochrane Statistical Methods Group (2011). The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 343, d5928–d5928.CrossRefGoogle ScholarPubMed
Higgins, J. P., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring inconsistency in meta-analyses. BMJ, 327, 557–560.CrossRefGoogle ScholarPubMed
Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7, 189–202.Google Scholar
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602.CrossRefGoogle ScholarPubMed
Lamers, F., van Oppen, P., Comijs, H. C., Smit, J. H., Spinhoven, P., van Balkom, A. J., … Penninx, B. W. J. H. (2011). Comorbidity patterns of anxiety and depressive disorders in a large cohort study: The Netherlands Study of Depression and Anxiety (NESDA). Journal of Clinical Psychiatry, 72, 341–348.CrossRefGoogle Scholar
Lejuez, C. W., Hopko, D. R., Acierno, R., Daughters, S. B., & Pagoto, S. L. (2011). Ten year revision of the brief behavioral activation treatment for depression: Revised treatment manual. Behavior Modification, 35, 111–161.CrossRefGoogle ScholarPubMed
Lejuez, C. W., Hopko, D. R., & Hopko, S. D. (2001). A brief behavioral activation treatment for depression: Treatment manual. Behavior Modification, 25, 255–286.CrossRefGoogle ScholarPubMed
Lewinsohn, P. M., Sullivan, J. M., & Grosscup, S. J. (1980). Changing reinforcing events: An approach to the treatment of depression. Psychotherapy: Theory, Research & Practice, 17, 322.CrossRefGoogle Scholar
MacPhillamy, D. J., & Lewinsohn, P. M. (1974). Depression as a function of levels of desired and obtained pleasure. Journal of Abnormal Psychology, 83, 651–657.CrossRefGoogle ScholarPubMed
Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2013). Behavioral activation for depression: A clinician's guide. New York, NY: Guilford Press.Google Scholar
Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy and Research, 34, 429–438.CrossRefGoogle ScholarPubMed
Mazzucchelli, T., Kane, R., & Rees, C. (2009). Behavioral activation treatments for depression in adults: A meta-analysis and review. Clinical Psychology: Science and Practice, 16, 383–411.Google Scholar
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Group, T. P. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6, e1000097.CrossRefGoogle ScholarPubMed
Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., … Finning, K. (2016). Cost and outcome of behavioural activation versus cognitive behavioural therapy for depression (COBRA): A randomised, controlled, non-inferiority trial. Lancet (London, England), 388, 871–880.CrossRefGoogle ScholarPubMed
Ryba, M. M., & Hopko, D. R. (2012). Gender differences in depression: Assessing mediational effects of overt behaviors and environmental reward through daily diary monitoring. Depression Research and Treatment, 2012, e865679.CrossRefGoogle ScholarPubMed
Stein, A.T, Shumake, J., Beevers, C. G., & Smits, J. A. J.. (2019, September 27). Therapist guided activity practice for depressive symptoms in university students: A randomized controlled trial. https://doi.org/10.31234/osf.io/4u7qxCrossRefGoogle Scholar
Sturmey, P. (2009). Behavioral activation Is an evidence-based treatment for depression. Behavior Modification, 33, 818–829.CrossRefGoogle ScholarPubMed
Weitz, E., Kleiboer, A., van Straten, A., & Cuijpers, P. (2018). The effects of psychotherapy for depression on anxiety symptoms: A meta-analysis. Psychological Medicine, 48, 2140–2152.CrossRefGoogle ScholarPubMed
Wichers, M. C., Barge-Schaapveld, D. Q. C. M., Nicolson, N. A., Peeters, F., de Vries, M., Mengelers, R., & van Os, J. (2009). Reduced stress-sensitivity or increased reward experience: The psychological mechanism of response to antidepressant medication. Neuropsychopharmacology, 34, 923–931.CrossRefGoogle ScholarPubMed
World Health Organization. (2017). Depression and other common mental disorders: Global health estimates. Geneva: World Health Organization.Google Scholar
Zbozinek, T. D., Rose, R. D., Wolitzky-Taylor, K. B., Sherbourne, C., Sullivan, G., Stein, M. B., … Craske, M. G. (2012). Diagnostic overlap of generalized anxiety disorder and Major depressive disorder in a primary care sample. Depression and Anxiety, 29, 1065–1071.CrossRefGoogle Scholar