By Michael O. Schroeder | Staff Writer
Nov. 24, 2016, at 9:00 a.m.
The laundry is piling up. Calls from friends and family are going unreturned. You haven’t been active for quite some time, and in general you’ve stopped doing many things you used to love to do. It’s not that you’re busy: You’re depressed.
Cognitive behavioral therapy, the gold standard in psychotherapy for addressing depression, helps individuals change the negative thought patterns that may contribute to the mood disorder. A changed mind can help a person get back in the swing of things. It’s “an ‘inside out’ treatment which asks people to review and change the way they think to alter mood,” David Richards, a professor of mental health services research at the University of Exeter Medical School in England, explains in an email.
Now, emerging evidence finds that a simple therapy called behavioral activation – which overlaps with CBT’s behavioral component, but doesn’t share its thought-pattern focus – may be equally effective in treating depression. “BA is ‘outside in’ – it is a treatment that teaches people that what they do and their mood are linked, and so by changing your behavior, mood can also change,” Richards says. He led research published in July in The Lancet that found patients who underwent so-called behavioral activation therapy fared as well as those who received CBT. Because of its simplicity, BA was delivered by junior mental health workers at a lower cost than CBT, a more complex psychotherapy that requires more training to provide.
BA involves teaching clients to notice when they’re starting to get depressed, and when that depression leads them to isolate themselves and become passive and inactive, explains Jonathan Kanter, a research associate professor of psychology and director of the Center for the Science of Social Connection at the University of Washington in Seattle. And then – when they notice that – they learn to engage in activities specific to their wants and needs, he says. Those activities could range from spending more time with friends or family to simply taking up a to-do list, getting to the gym (exercise, on its own, has also been shown to reduce depressive symptoms) or even reengaging in a job search if unemployed. “To keep moving, to keep going, to not give up, to not quit, that’s the key,” says Kanter, who wrote a commentary on the study also published in The Lancet. “At the heart of the treatment, it’s about tailoring the activity that is done as part of the therapy to the patient’s values, to the patient’s local world.”
The July study – funded by the U.K.’s National Institute for Health Research – is the largest to date on behavioral activation and reflects findings from previous smaller studies also supportive of using BA to treat depression. But behavioral activation has been paid relatively little mind in practice and research given contemporary focus on cognitive therapies.
“BA is an older treatment that fell out of favor as the ‘cognitive revolution’ took hold, driven by psychologists who preferred this approach,” Richards says. “It is mainly a lack of attention and research that has led BA to be neglected.” The research on BA published in July randomly allocated about half of 440 study participants with major depressive disorder to be treated with BA and the others to be treated with CBT. “We now have enough evidence to be able to recommend BA or CBT to people with depression,” Richards says. “People now have a choice.” Researchers spoke about the international implications of their findings – particularly for extending depression treatment to more people, especially underserved, low-income individuals – amid increasing efforts to control health care costs by countries around the world, including the U.S..
“We could potentially help more people if we have therapies that are easier to implement and just as effective,” Kanter says. At present, BA isn’t widely used internationally or in the U.S., compared with standard therapies for depression – from medication to CBT. But more therapists are being trained in behavioral activation, so it’s becoming more available, Kanter says.
He adds that BA may be an option for patients who find traditional forms of psychotherapy, like CBT, too “touchy feely,” and who are looking for a less involved approach. “It’s very pragmatic; it’s very focused on what are your goals – how can we help you achieve your goals,” says Kanter, who isn’t taking client referrals, but incorporates BA in his own clinical psychological research.
[See: Coping With Depression at Work.]
Combined with its low cost, the malleability of the approach is another reason some experts think it could be used to reach people who might not otherwise receive treatment for depression. “There are big disparities in access to mental health care for minorities in the United States, [and] there’s growing research suggesting behavioral activation is a good fit for minority patients as well,” Kanter says.
However, he’s quick to emphasize BA is but one treatment option, and that its important patients find a proven therapy that suits them best. He stresses that therapy is as effective as medication.
For individuals seeking a local therapist who provides BA, or behavioral therapy focused on changing behavior to treat depression, Andrew Elmore, a psychologist in private practice in New York City and assistant clinical professor of psychiatry at Icahn School of Medicine at Mount Sinai, recommends checking with the American Psychological Association, including state and regional chapters. The APA offers a search tool that can be used to find psychologists who specialize in particular issues, including depression, in a given geographic area.
“You can help people a lot by getting them to control their negative thinking,” he says. “But if depression has a functional impact, which it usually does – that is, to reduce the amount of activity that a patient engages in that will result in them having a fuller, happier or more rewarding life – in the end, you’ve got to get them to change that behavior, to return to more fruitful activity.”
Above all, when seeking treatment for depression, experts stress seeing a health provider or mental health professional who offers evidence-based treatment and has patients’ best interests at heart. “Whether it’s compliance with taking prescription medication or being the beneficiary of cognitive behavioral therapy or behavioral activation therapy,” Elmore says, “in the end the patients are obviously more motivated to comply with a treatment regimen if they believe that the person who’s administering it is someone that really cares about them and wants to help them.”