problem solving therapy e behavioural activation

Behavioral Activation Therapy: 14+ Techniques & Worksheets

Behavioral activation stems from a behavioral model of depression that conceptualizes depression as a consequence of a lack of positive reinforcement . BA is highly customizable and is a very personal treatment plan.

This article will cover what BA is, the behavioral model it is based on, and how to implement BA as a treatment plan, including some of the techniques used in Behavioral Activation.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into Positive CBT and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is behavioral activation (ba) and how is it used to treat depression, behaviorism: the behaviorist theory behind ba, applied behavior analysis: can aba help your client, the use of a behavioral model for behavioral activation, 10+ techniques for behavioral activation, 4+ behavioral activation worksheets & activities, a take-home message.

Behavioral activation (BA) is “a structured, brief psychotherapeutic approach that aims to (a) increase engagement in adaptive activities (which often are those associated with the experience of pleasure or mastery), (b) decrease engagement in activities that maintain depression or increase risk for depression, and (c) solve problems that limit access to reward or that maintain or increase aversive control” (Dimidjian et al., 2011).

The main idea behind BA as a treatment for depression is “to allow patients with depressive symptoms to learn to cope with their negativity” and to “increase positive awareness through the re-development of personal goals in the form of short, medium and long-term life goals ” (Chan et al., 2017).

In other words, BA is a type of therapeutic intervention (most often used to treat depression) that focuses on behavioral changes in a client’s daily life. BA interventions might involve helping the client plan more activities they actually enjoy doing, helping the client develop their social skills, or just generally having the client track their own emotions and activities.

Behavioral Activation is a highly-personalized intervention that targets one’s depression by targeting the behaviors that feed into that depression.

Behavioral activation is informed by a behavioral model of depression, such as the one outlined by Lewinsohn & Shaffer (1971).

These researchers believed that depression was a behavioral issue (as opposed to a cognitive issue) that arose from a lack of positive reinforcement, particularly in social relationships.

Since they subscribed to a behavioral model of depression, the authors believed that the best way to treat depression was to “restore an adequate schedule of positive reinforcement for the individual by changing the patient’s behavior and/or the environment”.

While some psychologists still subscribe to radical behaviorism, most modern behavioral models are not exclusively behaviorist and do include cognitive components.

Most modern psychological models, in general, include both cognitive and behavioral aspects, exemplified by cognitive-behavioral therapy (CBT), perhaps the most common therapeutic treatment today. In fact, behavioral activation has begun to be explored as a component of CBT for disorders beyond depression, such as anxiety (Boswell et al., 2017).

Interestingly, behavioral activation may even be the driving force behind the efficacy of CBT. A study by Jacobson et al. (1996) which found that to be the case is one of the main reasons people are interested in Behavioral Activation today. Specifically, those researchers found that people with depression who completed BA saw as many benefits as people with depression who completed both BA and some cognitive components of CBT .

While behaviorists no longer deny the importance of cognition, they still advocate for behavioral treatments over cognitive treatments, since behaviors are easy to target than thoughts.

The paper cited above (Jacobson et al., 1996) indicates that behavioral activation may even be the reason CBT is so effective.

Download 3 Free Positive CBT Exercises (PDF)

These detailed, science-based exercises will equip you or your clients with tools to find new pathways to reduce suffering and more effectively cope with life stressors.

Download 3 Free Positive CBT Tools Pack (PDF)

By filling out your name and email address below.

Behavioral activation is a type of applied behavior analysis, which is a field of research based on the principles of B.F. Skinner’s work, and particularly his findings that “ in a given environmental context, behaviors that produce favorable outcomes will continue to occur through the process of reinforcement and those behaviors that do not produce favorable consequences will decrease over time, or extinguish ” (Roane et al., 2016).

One of the strengths of behavioral activation is that it can be customized according to a person’s “values and abilities”, and can also be customized for specific types of MDD, such as comorbid MDD and a personality disorder (Cannity & Hopko, 2017; Kanter et al., 2010). In other words, in almost all cases of depression, some sort of BA intervention is appropriate.

One thing to keep in mind about BA interventions is that the therapist must be mindful of their own reinforcement of the client’s behaviors (Pass et al, 2016). That is, the therapist should make sure to reinforce healthy behavior from their client during their sessions.

What is behavioural activation (BA)? – Psychological therapy for depression explainer – Cochrane Mental Health

In order to develop a behavioral activation intervention for a client, one must first conceptualize a behavioral model of that client’s depression.

Take the case study of a 16-year-old girl named Amy with depression (Pass et al., 2016). In order to begin treating her depression, her therapist interviewed both Amy and her mother in order to figure out what her depression looked like.

From their input, the therapist determined that Amy’s depressive symptoms likely stemmed from her father’s recent death, her mother’s recent illness, her symptoms of fatigue, and her increased academic workload. Her fatigue was of particular interest, as it kept her from positive reinforcement, particularly in her social life.

That is, since she felt tired, she would not go hang out with her friends. Since she was not hanging out with her friends, she would feel bad, and this bad feeling would lead her to have low energy levels. This “vicious” cycle is presented here (reprinted from the article), along with an alternative cycle which Behavioral Activation interventions aim to put in place:

BA was ultimately able to help Amy get over her feelings of depression, in part by helping her find more positive reinforcement in her social life. The personalized behavioral model of Amy’s depression conceptualized by Amy, her mom, and her therapist was a crucial aspect of this improvement.

The benefits of a behavioral approach (as opposed to a cognitive approach) like this are illustrated by a comment from Amy, as the paper notes that “Amy had stated in her assessment that she wanted something more ‘practical’ than the bereavement counseling she had received previously. She felt that she had already had an opportunity to explore her feelings toward her father’s death, and this was not her aim for the current work”.

World’s Largest Positive Psychology Resource

The Positive Psychology Toolkit© is a groundbreaking practitioner resource containing over 500 science-based exercises , activities, interventions, questionnaires, and assessments created by experts using the latest positive psychology research.

Updated monthly. 100% Science-based.

“The best positive psychology resource out there!” — Emiliya Zhivotovskaya , Flourishing Center CEO

Some of the techniques used in behavioral activation include (Dimidjian et al., 2011; Lejuez et al., 2001a):

• Self-monitoring of activities and mood
• Activity scheduling
• Activity structuring
• Problem-solving
• Social skill training
• Hierarchy construction (ranking how easy certain activities are to accomplish)
• Shaping (training healthy behaviors)
• Behavior contract (signing a contract with friends and family so that they will only reinforce healthy behaviors)
• Life area assessment (determining in which areas of life one desire success)

More information on some of these techniques can be seen in A Brief Behavioral Activation Treatment for Depression Treatment Manual (Lejuez et al., 2001a), listed at the end of the following section.

Positive Activities for Behavioral Activation

This worksheet will help someone figure out some of the activities that they find rewarding, and how rewarding they find those activities. The worksheet simply asks for a list of activities, then asks how rewarding each of those activities is. This worksheet is a good way for someone to figure out which activities they actually find rewarding in life.

Behavioral Activation Worksheet Fun & Achievement

This is a basic activity scheduling worksheet. Activity scheduling helps people follow through on their responsibilities, but also helps people plan more positively-reinforcing activities (such as spending time with friends). As the worksheet states, the best effects are achieved by scheduling a balance of responsibilities and fun activities.

Behavioral Strategies for Managing Depression

The above worksheet is part of a larger packet, and this is that larger packet . Aside from the activity scheduling worksheet, it also includes a more rigid activity schedule that can help someone plan out their days, rather than just plan a few activities for the near future.

Besides those two worksheets, this packet also includes information on how behavioral techniques can help depression, and how one can use these behavioral techniques to their advantage. This is a deep resource that can help someone both understand why BA is helpful and start practicing it in their lives.

A Brief Behavioral Activation Treatment for Depression Treatment Manual

Finally, this is an entire treatment manual for a brief behavioral activation treatment for depression (BATD), as outlined by Lejuez et al. (2001b).

It can “be used as a complete treatment, or as a component of therapy that may include other therapeutic techniques and possibly medications”. It includes a discussion of BA and BATD as well as justifications for these treatments and also includes worksheets and other resources to help someone follow a BA program.

This manual is deep and will take a while to work through but is likely the most complete resource available for someone interested in Behavioral Activation.

17 Science-Based Ways To Apply Positive CBT

These 17 Positive CBT & Cognitive Therapy Exercises [PDF] include our top-rated, ready-made templates for helping others develop more helpful thoughts and behaviors in response to challenges, while broadening the scope of traditional CBT.

Created by Experts. 100% Science-based.

Ever since Jacobson et al. (1996) claimed that behavioral activation was the most effective component of CBT, Behavioral Activation has been a treatment of interest for depression. Several papers have since found that BA is indeed an effective way to treat depression, even when that depression is comorbid with another disorder.

There is no doubt that BA is an effective way to treat depression, but BA carries with it a unique implication.

A key aspect of Behavioral Activation is positive reinforcement, particularly in social situations. This means that how we respond to the people with depression around us can have major impacts on their mood in the short-term and their health in the long-term.

While we all have plenty of things on our mind at all times, we should also keep in mind how we are responding to the healthy and unhealthy behaviors of the ones we love. Reinforcing the healthy behaviors of a friend may just be the key to their recovery from disorders like depression.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Boswell, J.F., Iles, B.R., Gallagher, M.W., Farchione, T.J. (2017). Behavioral Activation Strategies in Cognitive-Behavioral Therapy for Anxiety Disorders. Psychotherapy, 54(3) , 231-236.
• Cannity, K.M., Hopko, D.R. (2017). Behavioral Activation for a Breast Cancer Patient with Major Depression and Coexistent Personality Disorder. Journal of Contemporary Psychotherapy, 47(4) , 201-210.
• Chan, A.T.Y., Sun, G.Y.Y., Tam, W.W.S., Tsoi, K.K.F., Wong, S.Y.S. (2017). The effectiveness of group-based behavioral activation in the treatment of depression: An updated meta-analysis of randomized controlled trial. Journal of Affective Disorders, 208(1) , 345-354.
• Cuijpers, P., van Straten, A., Warmerdam, L. (2007). Behavioral activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27(3) , 318-326.
• Dimidjian, S., Barrera, M., Martell, C., Muñoz, R.F., Lewinsohn, P.M. (2011). The Origins and Current Status of Behavioral Activation Treatments for Depression. Annual Review of Clinical Psychology, 7(1) , 1-38.
• Jacobson, N.S., Dobson, K.S., Truax, P.A., Addis, M.E., Koerner, K., Gollan, J.K., Gortner, E., Prince, S.E. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64(2) , 295-304.
• Kanter, J.W., Manos, R.C., Bowe, W.M., Baruch, D.E., Busch, A.M., Rusch, L.C. (2010). What is behavioral activation?: A review of the empirical literature. Clinical Psychology Review, 30(6) , 608-620.
• Lejuez, C.W., Hopko, D.R., Hopko, S.D. (2001a). A Brief Behavioral Activation Treatment for Depression. Behavior Modification, 25(2) , 255-286.
• Lejuez, C.W., Hopko, D.R., LePage, J.P., Hopko, S.D., McNeil, D.W. (2001b). A brief behavioral activation treatment for depression. Cognitive and Behavioral Practice, 8(1) , 164-175.
• Lewinsohn, P.M., Shaffer, M. (1971). Use of home observations as integral part of treatment of depression – preliminary report and case studies. Journal of Consulting and Clinical Psychology, 37(1) , 87-94.
• Pass, L., Whitney, H., Reynolds, S. (2016). Brief Behavioral Activation for Adolescent Depression: Working With Complexity and Risk. Clinical Case Studies, 15(5) , 360-375.
• Roane, H.S., Fisher, W.W., Carr, J.E. (2016). Applied Behavior Analysis as Treatment for Autism Spectrum Disorder. Journal of Pediatrics, 175(1) , 27-32.

Share this article:

Article feedback

What our readers think.

The ideas presented here have metaphorically helped my eyes to focus on the shape of the next stepping stone I need to progress out of my depression; essentially encouraging me to “activate” through decisive scheduling, the knowledge I have gained from the study of CBT ( but wasn’t sure how to connect the dots.) This publication of Joaquin Selva Bc.S.’s research has served as a tutor to explain to me in practical terms, ways that I can bennefit from CBT through the practice of BADT: as if I am now sitting at a game table with those I love and Joaquin has helped deal me in and given me enough information that I can partipate. I am already using some of the suggestions and revisiting the artical to reinforce my practice. It struck me as unique to this set of information – how the patient is encouraged to interact with their significant others in a supportive team effort. For some reason I had percieved CBT to be a bit more isolating, like “You’ve got to think through your depression, and only you can think your issues through for yourself. Becaause you have no control over others, you and your therapist can only work on you.” (I dont mean to reflect poorly on CBT – which has been groundbreaking work for me; only to reflect my personal understanding of my CBT experience which felt like hard work I was meant to do on my own. Perhaps why the concepts of BA ring so truly in me is due to the work I have already completed in CBT. )

what are the limitations and strengths to this approach

I can see one significant limitation to this: in severe long-term depression there may in fact be nothing that a person finds pleasurable and/or knows they enjoy, which would make the mentioned activities harder to complete. There may also be no social network for them to lean on, meaning they will have to rely on strangers for positive reinforcement, and as we all know that’s very difficult to get in this world.

Thank you for taking the time to share your thoughts on the article! Your observations regarding the challenges faced by individuals with severe long-term depression are important considerations.

We understand that for some people, identifying pleasurable activities or having a supportive social network may not be feasible, and this could pose difficulties in implementing behavioral activation therapy as described in the article. It’s crucial to acknowledge these limitations and explore alternative approaches that may be more suitable for individuals in these circumstances.

We will consider creating additional resources that delve into alternative therapeutic approaches for individuals with severe long-term depression who may require more specialized interventions.

Thank you again for your valuable feedback, and please don’t hesitate to reach out if you have any further suggestions or concerns.

Kind regards, Julia | Community Manager

Studying Counselling psychology, this article was helpful to me to understand the subject

Hi, I found this article very helpfull as a therapist using CBT treatment. However, 2 of the links for the worksheets did not work, and I was forwarded to a 404 error page? I hope, I can get a chance to download, and implement, your exercises. Fingers crossed. Best Regards, Inge

I had the same issue accessing the worksheets – if you go to the same web page and search ‘behavioural activation worksheets’ they come up 🙂

Hi Anna and Inge, Thanks for spotting these broken links. We’ll get these corrected very soon. But in the meantime, you can find the third worksheet here , and the fourth larger activity packet here. – Nicole | Community Manager

Thank you very much!

Thanks for your information.

Thia was a very useful read !!

Very impacting,Iam using it for my thesis,thanks.

Let us know your thoughts Cancel reply

Your email address will not be published.

Save my name, email, and website in this browser for the next time I comment.

Related articles

How to Integrate Milieu Therapy & Positive Psychology

Milieu therapy and positive psychology offer a unique synergy that has the potential to transform mental health care and create environments that nurture and uplift [...]

Humanistic Therapy: Unlocking Your Clients’ True Potential

Humanism recognizes the need of the individual to achieve meaning, purpose, and actualization in their lives (Rowan, 2016; Block, 2011). Humanistic therapy was born out [...]

Trauma-Informed Therapy Explained (& 9 Techniques)

Trauma varies significantly in its effect on individuals. While some people may quickly recover from an adverse event, others might find their coping abilities profoundly [...]

Read other articles by their category

• Body & Brain (52)
• Coaching & Application (39)
• Compassion (23)
• Counseling (40)
• Emotional Intelligence (21)
• Gratitude (18)
• Grief & Bereavement (18)
• Happiness & SWB (40)
• Meaning & Values (26)
• Meditation (16)
• Mindfulness (40)
• Motivation & Goals (41)
• Optimism & Mindset (29)
• Positive CBT (28)
• Positive Communication (23)
• Positive Education (36)
• Positive Emotions (32)
• Positive Leadership (16)
• Positive Parenting (14)
• Positive Psychology (21)
• Positive Workplace (35)
• Productivity (16)
• Relationships (46)
• Resilience & Coping (38)
• Self Awareness (20)
• Self Esteem (37)
• Strengths & Virtues (29)
• Stress & Burnout Prevention (33)
• Theory & Books (42)
• Therapy Exercises (37)
• Types of Therapy (54)

3 Positive CBT Exercises (PDF)

How To Use Behavioral Activation (BA) To Overcome Depression

When we are depressed  we become less active. The less active we are the fewer opportunities there are for positive and rewarding things to happen to us. And the fewer rewarding things that happen to us the lower our mood becomes. Behavioral Activation (BA) is one way out of this vicious cycle. It is a practical and evidence-based treatment for depression.

The relationship between what we do and how we feel

Psychologists have found that there is a close relationship between our activity and our mood. When we are feeling good we spend time with people whose company we enjoy, do activities that make us feel good, and take on new tasks and adventures that challenge us as individuals. All of this activity has positive feedback effects:

• Doing things we enjoy gives us feelings of pleasure
• Challenging ourselves means that we have a chance to grow and develop, and gives us a sense of mastery
• Having positive relationships with other people makes us feel connected and valued

The reverse is true too. People who are depressed tend to do less overall and so they have fewer opportunities to feel pleasure, mastery, and connection – the things we need to feel good [1, 2, 3]. It is easy to fall into a trap:

What is Behavioral Activation?

One way out of this trap is to wait until something external improves our mood – if it does then we might feel more like getting back to our old levels of activity. This approach is passive though, and it can leave you feeling helpless. One big problem with the passive approach is that you are likely to be waiting for a long time – left to themselves episodes of depression can last for months at a time!

A more proactive way of breaking the vicious cycle of depression is to increase our level of activity even if we don’t feel like it to begin with . This approach is called Behavioral Activation (BA) and it is a psychological treatment for depression with one of the biggest evidence bases to demonstrate how effective it is [4, 5, 6].  Behavioral activation for depression is about making your life meaningful and pleasurable again, it involves these steps:

• Learning about the vicious cycle of inactivity > depression > inactivity  and understanding that we need to activate ourselves to feel better again
• Monitoring our daily activities to understand the relationships between our activity and our mood
• Identifying our values and goals (working out what really matters to us)
• Simple activation ( scheduling and carrying out meaningful activities to boost our experiences of pleasure and mastery)
• Problem-solving any barriers to activation

This guide will walk you through all of the essential steps to get you started with behavioral activation.

Activity monitoring: recording what you do and how you feel

The first step in behavioral activation therapy is to monitor your activity and mood to understand more about how your depression works. This is called Activity Monitoring .

You can use an activity monitoring worksheet to record what you do each waking hour every day for a week. Make sure to record everything on this behavioral activation worksheet – even activities that don’t seem very important. We need to find out how your mood changes as you do different activities, so rate your mood for each time slot on a scale of 0 to 10, with 0 representing feeling very depressed and 10 representing feeling very good.

If you don’t have an activity monitoring worksheet an even simpler approach is to make a note of what you do for every hour of the day. You can do this on a bit of paper, or a note-taking app on your phone.

Reviewing your activity monitoring: learning about the association between activity and your mood

Once you have monitored your activity for a week you can use your activity monitoring record to look for patterns between your activity and your mood. Look at your completed behavioral activation worksheet and ask yourself these questions:

• What activities were associated with your highest mood? What were you doing when your mood was highest?
• What activities were associated with your lowest mood? What were you doing when your mood was lowest?
• What do you notice about the relationship between your mood and how active you were?
• Were there any days when you didn’t leave the house? What was your mood like on those days?
• What was your mood like on the days when you were most active?

Now make a list of activities which helped you to feel good, and which made you feel bad. You will use this list in one of the later steps.

Values: thinking about what matters to you deep down

Our values reflect what we find meaningful in life. They are what you care about, deep down, and what you consider to be important. Everybody’s values are different, and they can change over time. They reflect how we want to engage with the world, with the people around us, and with ourselves. Psychologists think that a happy life is one where we are in touch with our values: where we are doing at least some of the things that we think are important.

Values are different from goals. Put crudely, goals can be achieved whereas values are more like directions that we want to head in. For example we might have the value of being a good parent which may require a lifetime’s effort, and the specific achievable goal of getting my children to school on time . Or we might have the goal of going for a jog  while placing value upon our physical health .

The domains below are valued by some people. There might be values you think are important, and others that don’t matter so much to you. There are no ‘right’ answers. Read the descriptions and think about what makes for a meaningful life that you could value.

Spend some time thinking about your values. Which values are important to you? How successfully you are living your life in accordance with your values at the moment? Use the table below to guide your thought process.

Simple activation: planning and engaging in valued activity

The next step of behavioral activation is to get active. You know by now that it is important to increase your level of activity even if you don’t feel like it to begin with . With behavioral activation for depression we can kick-start your activity by planning it and sticking to the plan. Get a piece of paper and write down a selection of possible activities.

Good places to get some activation targets for your activity plan are:

• Get activation targets from your activity monitoring worksheet:  Which activities were best at improving your mood?
• Get activation targets from your values assessment worksheet:  Which values matter to you the most? What activities could you do that would be in line with your values? For example, if family is something you value perhaps you could plan to spend time with them doing something specific.
• Make sure that you are doing the basics:  Be sure to include targets like washing and brushing your teeth every day, doing laundry every week, cooking meals, shopping for food, and to include some activities that are social and which mean you will have contact with other people.
• Use an activity menu : Use a list of activities that have helped other people to pick some that you think might lift your mood.

Once you have written down a selection of possible activities it is time to create an activity hierarchy. This will help you to choose the best activities to get started with. To create your activity hierarchy write a list of activities and rank them according to how difficult you think they will be to accomplish (0 = not at all difficult, 10 = very difficult).

Now it is time to schedule some activities for the next week. Start by choosing some activities with low difficulty ratings. Write down the activities that you will do on an activity monitoring record form. It is important to be specific about:

• What  the activity is
• When  you plan to do it
• Where  you will do it
• Who  you might do the activity with

Once you have planned activities for a week in advance the next step is to put the plan into action. Good luck!

Tips for getting the most out of behavioral activation

• Don’t start too hard:  Life is a marathon, not a sprint. The new level of activity has to be more than your ‘depression level’ but it also has to be realistically achievable.
• Break activities down into smaller steps:  Let’s say you had identified a value of becoming independent, but were living with your parents and weren’t qualified to drive. Some helpful steps towards your value of living independently might be making an online application for a driving license, or doing some budgeting to work out how soon you might be able to move into your own place.
• Reward yourself:  Make the effort to acknowledge when you have completed something, and don’t just rush on to the next target. Some people find it helpful to make a ‘check off’ activities that have completed as an acknowledgement that they have done it. Can you think of a way of treating yourself if you complete half of your planned activities? What would a fair reward be if you completed all of them?
• Remind yourself why you’re doing this:  Thoughts like “I’ll do it when I feel better”  are insidious and can creep back in. Remind yourself often that it’s important to get active even if you don’t feel like it  and that behavioral activation is one of the most effective treatments for depression.

[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®) . American Psychiatric Pub.

[2] Elfrey, M. K., & Ziegelstein, R. C. (2009). The “inactivity trap”. General Hospital Psychiatry , 31(4), 303.

[3] Roshanaei-Moghaddam, B., Katon, W. J., & Russo, J. (2009). The longitudinal effects of depression on physical activity. General Hospital Psychiatry , 31(4), 306-315.

[4] 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(6), e100100.

[5] Kanter, J. W., Manos, R. C., Bowe, W. M., Baruch, D. E., Busch, A. M., & Rusch, L. C. (2010). What is behavioral activation?: A review of the empirical literature. Clinical Psychology Review , 30(6), 608-620.

[6] Dimidjian, S., Barrera Jr, M., Martell, C., Munoz, R. F., & Lewinsohn, P. M. (2011). The origins and current status of behavioral activation treatments for depression. Annual Review of Clinical Psychology , 7, 1-38.

Related self-help

• For clinicians
• For students
• Resources at your fingertips
• Designed for effectiveness
• Resources by problem
• Translation Project
• Help center
• Try us for free
• Terms & conditions
• Privacy Policy
• Cookies Policy

Behavioral Activation

Reviewed by Psychology Today Staff

Behavioral Activation (BA) is a form of short-term outpatient therapy that engages individuals in rewarding activities of their own choosing as a way to counter the negative feelings and withdrawal that are typical of depression . Increasingly, BA is being applied in the treatment of anxiety as well. Behavioral Activation is a basic component of Cognitive Behavioral Therapy, but, applied intensively, it is also used as a treatment in its own right and can be incorporated into many other types of therapy.

BA is a way of changing from the outside in—jump-starting individuals back to the kind of life they once enjoyed. Evidence suggests that even in small doses, engaging in a constructive activity is positively reinforcing, not only rekindling interest in and energy for the activity but providing a sense of achievement—enough to disrupt the negative feelings, avoidant behavior, and disturbed mood that keep people trapped in depression, and the avoidant behavior that is the hallmark of anxiety.

Under the active guidance of a therapist, individuals are assigned to activities they themselves select—whether meeting a friend for coffee, listening to a podcast, or going for a walk in the park—and learn to formulate and accomplish behavioral goals .

The changes in overt behavior are accompanied by changes in thoughts and mood. A number of studies suggest that Behavioral Activation is the component of CBT most responsible for its effectiveness and that it is at least as effective as antidepressant medication , even among the severely depressed.

• When Is It Used?
• What to Expect
• How It Works
• What to Look for in a Behavioral Activation Therapist

BA is suitable for people with depression who are not at immediate risk of self-harm . Studies indicate that it may be especially useful for those who are chronically depressed. It is also suitable for those with depression or anxiety who do not want to take medication , or who can’t tolerate medication or its side effects, or for whom medication has failed to relieve symptoms.

Studies show that BA is at least as effective as antidepressant medication, even for people with severe depression. Moreover, because it is action-oriented, it can be used to help people who are reluctant to talk about their feelings or do not have the language to do so

BA usually takes place in weekly sessions for anywhere from eight to 24 weeks, depending on depression severity and response to treatment. One of the essential ingredients of BA is understanding that depression works in vicious cycles. A stressful or negative event—such as ending a relationship or losing a job—triggers negative thoughts and feelings and behavioral shutdown. People withdraw from pleasurable social and other activities; the isolation amplifies negative feelings and provides no relief from them, intensifying depression.

The first step in BA is activity monitoring. Individuals are provided with worksheets on which they note daily activities and rate the moods each is associated with. Next, individuals identify their life values and goals —whether related to work, learning, health and fitness, family, friendship , intimacy , entertainment, or more—as a guide to choosing concrete activities they will focus on adding to their days. They select a mix of those they find meaningful and those that build a sense of mastery, as well as those that bring pleasure.

Then, usually one week at a time, individuals create daily schedules in which they build in both meaningful activities and enjoyable ones. The activities deemed pleasant and those delivering mastery will be different for each person, as will the balance of the two kinds of activities.

In sessions, individuals discuss how to problem-solve, especially how to motivate themselves when they feel stuck. Between sessions, individuals can expect assignments that focus on workarounds for any specific obstacles they encounter in getting things done. And while no one activity will alleviate depression, the effects of building routines of activities and accomplishing goals will build over time.

BA is based on the knowledge that inactivity leads to depression, which leads to more inactivity and deeper depression. BA provides a way of feeling better quickly, directly stimulating improvement in mood through action.

In depression, people generally disengage from their routines and withdraw from their environment; as a result, there is no source of pleasant or rewarding experiences to draw on to motivate continued engagement. With BA, the activity itself generates changes in body physiology and chemistry that are mood-enhancing.

BA works in more sustaining ways as well—participating in valued activities provides a sense of achievement that counters the negative thinking that keeps depressed people stuck. Over time, individuals build a sense of mastery that helps make them emotionally resilient .

Two regimens of BA are in general use—standard BA, presented in 20 to 24 sessions, and a brief form, lasting eight to 12 weeks, called Behavioral Activation Treatment for Depression (BATD). Both focus on activity monitoring and scheduling in accordance with what people value, and both address obstacles to activity and problem-solving.

A BA therapist can be a licensed mental health professional who has additional training and experience in BA or a community health worker who has also undergone training in BA. The training in BA may be stand-alone or embedded in classic training for Cognitive Behavior Therapy , as BA is one of the component skills of CBT. All CBT therapists have had some training in BA.

While BA therapists follow standardized treatment protocols, experience counts. It is advisable to seek a therapist who has not just training but experience using BA to treat people presenting with concerns such as yours.

As with all forms of therapy, it is important to find a BA therapist with whom you feel comfortable. Look for someone with whom you can establish clarity of communication and a sense of good fit.

You might ask a prospective therapist such questions as:

• How often have you dealt with problems such as mine before?
• How do you know whether my situation is a good candidate for BA?
• How does BA work?
• What is a typical plan of treatment, and how long is a typical course of therapy?
• How do you measure progress?
• Find a Therapist
• Find a Treatment Center
• Find a Psychiatrist
• Find a Support Group
• Find Online Therapy
• United States
• Brooklyn, NY
• Chicago, IL
• Houston, TX
• Los Angeles, CA
• New York, NY
• Portland, OR
• San Diego, CA
• San Francisco, CA
• Seattle, WA
• Washington, DC
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Relationships
• Child Development
• Self Tests NEW
• Therapy Center
• Diagnosis Dictionary
• Types of Therapy

Sticking up for yourself is no easy task. But there are concrete skills you can use to hone your assertiveness and advocate for yourself.

• Emotional Intelligence
• Gaslighting
• Affective Forecasting
• Neuroscience

• Presidential Message
• Nominations/Elections
• Past Presidents
• Member Spotlight
• Fellow List
• Fellowship Nominations
• Current Awardees
• Award Nominations
• SCP Mentoring Program
• SCP Book Club
• Pub Fee & Certificate Purchases
• LEAD Program
• Introduction
• Find a Treatment
• Submit Proposal
• Dissemination and Implementation
• Diversity Resources
• Graduate School Applicants
• Student Resources
• Early Career Resources
• Principles for Training in Evidence-Based Psychology
• Advances in Psychotherapy
• Announcements
• Submit Blog
• Student Blog
• The Clinical Psychologist
• CP:SP Journal
• APA Convention
• SCP Conference

DIAGNOSIS: Depression TREATMENT: Behavioral Activation for Depression

2015 est status : treatment pending re-evaluation very strong: high-quality evidence that treatment improves symptoms and functional outcomes at post-treatment and follow-up; little risk of harm; requires reasonable amount of resources; effective in non-research settings strong: moderate- to high-quality evidence that treatment improves symptoms or functional outcomes; not a high risk of harm; reasonable use of resources weak: low or very low-quality evidence that treatment produces clinically meaningful effects on symptoms or functional outcomes; gains from the treatment may not warrant resources involved insufficient evidence: no meta-analytic study could be identified insufficient evidence: existing meta-analyses are not of sufficient quality treatment pending re-evaluation, 1998 est status : strong research support strong: support from two well-designed studies conducted by independent investigators. modest: support from one well-designed study or several adequately designed studies. controversial: conflicting results, or claims regarding mechanisms are unsupported., strength of research support.

Find a Therapist specializing in Behavioral Activation for Depression List your practice

Brief Summary

• Basic premise : When people get depressed, they may increasingly disengage from their routines and withdraw from their environment. Over time, this avoidance exacerbates depressed mood, as individuals lose opportunities to be positively reinforced through pleasant experiences, social activity, or experiences of mastery.
• Essence of therapy : Behavioral Activation (BA) seeks to increase the patient's contact with sources of reward by helping them get more active and, in so doing, improve one's life context. One version of BA (BATD) is briefer, focusing specifically on identifying values that will guide the selection of activities. In addition to a focus on increasing activities, the second version of BA also works on identifying processes that inhibit activation/encourage avoidance and teaching problem solving skills.
• Length : Full BA: 20-24 sessions; BATD: 8-15 sessions

Treatment Resources

Editors: Rachel Hershenberg, PhD; Stephanie Goldstein, BS

Note: The resources provided below are intended to supplement not replace foundational training in mental health treatment and evidence-based practice

Treatment Manuals / Outlines

Treatment manuals.

• Brief Behavioral Activation Treatment for Depression  (BATD; Lejuez, Hopko, & Hopko, 2000)
• Brief Behavioral Activation Treatment for Depression: 10 Year Revision  (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011)
• Brief Behavioral Activation Treatment for Depression – Revised  (Lejuez & Hopko, 2013)
• Behavioral Activation for Latinos  (Kanter, Santiago-Rivera, Santons, Hurtado, West, Nagy, et al., 2014)
• Client Manual
• Therapist Manual

Books Available for Purchase Through External Sites

• Depression in Context: Strategies for Guided Action (Addis, Jacobson, & Martell, 2001)
• Behavioral Activation for Depression: A Clinician’s Guide (Martell, Dimidjian, Herman-Dunn, & Lewinsohn, 2013)
• Behavioral Activation with Adolescents: A Clinician’s Guide (McCauley et al., 2016)

Training Materials and Workshops

• Sign up here for a  free  training program for providers specifically working with firefighters
• To access free BA training designed for employment counselors, click here
• Initial development of an online training program  (Puspitasari, Kanter, Murphy, Crowe, & Koerner, 2013)

Measures, Handouts and Worksheets

• Review of Measures  (Manos, Kanter, & Busch, 2010)
• Behavioral Activation for Depression Scale – Short Form  and  Instructions
• Environmental Reward Observation Scale
• Reward Probability Index
• The Coalition for the Advancement and Application of Psychological Science provides dozens of free patient handouts for adults, adolescents, and children as well as guidance about how to flexibly adapt handouts to meet different client needs

Self-help Books

• Overcoming Depression One Step at a Time: The New Behavioral Activation Approach to Getting Your Life Back (Addis & Martell, 2004)
• Activating Happiness: A Jump-Start Guide to Overcoming Low Motivation, Depression, or Just Feeling Stuck (Hershenberg, 2017)
• For information about the project and an overview, click  here
• To preview the program for  free , sign up  here  

Smartphone Apps

• Read about the development of Moodivate .
• ¡Aptívate! (Dahne, Lejuez, & Kustanowitz), a Spanish-language self-help Brief Behavioral Activation mobile app.
• Read about the development and preliminary feasibility of Behavioral Apptivation .

Important Note: The apps listed above are based on empirically-supported in-person treatments. They have not all been evaluated empirically either by themselves or in conjunction with in-person treatment. We list them as a resource for clinicians who assign them as an adjunct to conducting in-person treatment.

Video Demonstrations

• Derek Hopko role plays how to discuss the treatment rationale with a patient ; to purchase the whole video, click  here

Videos from the Coalition for the Advancement and Application of Psychological Science featuring Dr. Chris Martell

Brief videos (~15 min) outline components:

• Developing and assigning homework

• Troubleshooting barriers

Longer videos that show more of the full sessions:

• Developing and assigning homework – long version

• Troubleshooting barriers – long version

Clinical Trials

• Behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of major depression  (Dimidjian et al., 2006)
• Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression  (Dobson et al., 2008)
• Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: Randomized trial  (Hopko et al., 2011)
• Behavioural activation versus mindfulness-based guided self-help treatment administered through a smartphone application: A randomised controlled trial  (Ly et al., 2014)
• A Randomized Hybrid Efficacy and Effectiveness Trial of Behavioral Activation for Latinos with Depression  (Kanter et al., in press)

Meta-analyses and Systematic Reviews

• Behavioral activation treatments of depression: A meta-analysis  (Cuijpers et al., 2007)
• A meta-analysis of randomized trials of behavioural treatment of depression  (Ekers et al., 2008)
• Behavioral activation treatment for depression in adults: A meta-analysis and review  (Mazzucchelli et al., 2009)
• Behavioral activation interventions for well-being: A meta-analysis  (Mazzucchelli, Kane, & Rees, 2010)

Other Treatment Resources

• Contemporary behavioral activation treatments for depression: Procedures, principles, and progress  (Hopko et al., 2003)
• Behavioral activation is an evidence-based treatment for depression  (Sturmey, 2009)
• What is behavioral activation?: A review of the empirical literature  (Kanter et al., 2010)
• The origins and current status of behavioral activation treatments for depression  (Dimidjian et al., 2011)
• Behavioral Activation . In A.M. Nezu, and C.M., Nezu (Eds.)  The Oxford Handbook of Cognitive and Behavioral Therapies.  (Hopko et al., in press)
• Behavioral Activation: Distinctive Features (CBT Distinctive Features), available for purchase.
• Developmental considerations in conducting behavioral activation with youth (Coalition for the Advancement and Application of Psychological Science)

Thank you for supporting the Society of Clinical Psychology. To enhance our membership benefits, we are requesting that members fill out their profile in full. This will help the Division to gather appropriate data to provide you with the best benefits. You will be able to access all other areas of the website, once your profile is submitted. Thank you and please feel free to email the Central Office at  [email protected] if you have any questions

• Alcohol & food
• Autogenic training, session 1
• Autogenic training, session 2
• Autogenic training, session 3
• Autogenic training, session 4
• Autogenic training, session 5
• Autogenic training, session 6
• Autogenic training, session 7
• Autogenic training, session 8
• Compassion & criticism
• Depression assessment
• Depression information
• Depression, CBASP & neuroscience
• Emotions, feelings & personality
• Exercise & light
• GAD and health anxiety
• How to live well, A: questionnaires
• How to live well, B: session 1
• How to live well, C: session 2
• How to live well, D: session 3
• How to live well, E: session 4
• How to live well, F: session 5
• How to live well, G: session 6
• How to live well, H: session 7
• How to live well, I: session 8
• How to live well, J: session 9
• How to live well, K: session 10
• Increasing access psychological therapies
• Opening up group, session 1
• Opening up group, session 2
• Opening up group, session 3
• Opening up group, session 4
• Opening up group, session 5
• Opening up group, session 6
• Opening up group, session 7
• Opening up group, session 8
• Introduction & monitoring
• Life review, traumatic memories & therapeutic writing
• A: Life skills for stress, health & wellbeing, session 1
• B: Life skills for stress, health & wellbeing, session 2
• C: Life skills for stress, health & wellbeing, session 3
• D: Life skills for stress, health & wellbeing, session 4
• E: Life skills for stress, health & wellbeing, session 5
• F: Life skills for stress, health & wellbeing, session 6
• G: Life skills for stress, health & wellbeing, session 7
• H: Life skills for stress, health & wellbeing, session 8
• I: Life skills for stress, health & wellbeing, session 9
• J: Life skills for stress, health & wellbeing, session 10 (part 1 - goodwill practice)
• K: Life skills for stress, health & wellbeing, session 10 (part 2 - therapeutic writing)
• L: Life skills for stress, health & wellbeing, session 11
• M: Life skills for stress, health & wellbeing, session 12
• Pain assessment & information
• Panic, OCD & depersonalization information & assessment
• Problem solving & behavioural activation
• Recent psychedelic research: an introduction
• Recent psychedelic research: their use in psychotherapy (1st post)
• Recent psychedelic research: their use in psychotherapy (2nd post)
• Recent psychedelic research: how do they work?
• Recent psychedelic research: what are the risks?
• Psychedelics and end of life distress
• Recent psychedelic research: their use in the general population
• Psychedelics: lessons from current personal experience - introduction
• Psychedelics: lessons from current personal experience - description
• Psychedelics: lessons from current personal experience - suggestions
• Psychedelics: again the pilgrimage - current experience, preparing
• Psychedelics: again the pilgrimage - current experience, high dose
• Psychedelics: again the pilgrimage - current experience, low/moderate dose
• Psychedelics: again the pilgrimage - current experience, lessons
• Psychedelics: a group retreat - initial thoughts
• Psychedelics: a group retreat - meeting up, orientation & the ceremony.
• Psychedelics: a group retreat - the ceremony, integration & follow-up.
• Psychedelics: a group retreat - lessons: ceremonies, duration & organisation
• Psychedelics: a group retreat - lessons: playlists, nature & integration
• Sam Harris/Roland Griffiths conversation
• Trip-sitting for a dear friend: before
• Trip-sitting for a dear friend: during
• Trip-sitting for a dear friend: after
• Psychedelics: university memories
• Psychedelics: re-mining personal experience
• 5th international 'breaking convention' psychedelic conference: 1st morning - microdosing and group retreats & ceremonies
• Recent psychedelic research: where from here?
• Psychedelics, meditation & wellbeing retreat
• Pastoral Foundation Workshop - August '23
• PTSD assessment, images, memories & information
• Relationships in general
• Relationships, families, couples & psychosexual
• Sleep, ADHD & fatigue
• Social anxiety information & assessment
• Wellbeing, calming & mindfulness skills
• Wellbeing, time management, self-control & self-determination

“ No man is an island entire of itself; every man is a piece of the continent, a part of the main. ” - John Donne

Here are a series of forms, questionnaires and handouts that I use regularly in my work.  The problem solving diagram is a recurring theme - both at the start of therapy and as a sheet to return to when reviewing and considering additional therapeutic options.  Other sheets are classic variants on the tools used by many cognitive behavioural therapists - with occasional alternatives and additions, that I've come up with over the years, thrown in as well.

Problem solving diagrams - here are half a dozen Powerpoint slides providing different options for the Problem solving diagram I use with nearly all clients who come to see me.  My typical routine at a first session is to gather information.  If the case is relatively straightforward, towards the end of this first session (when I've gathered most of the information I need) I will give them some initial screening and assessment questionnaires to fill in.  While they are doing this, I transfer information that I have been jotting down as they told me their story, onto a problem solving diagram.  I usually use the diagram making up the fifth of the six slides you can download here, but sometimes (with anxiety problems) I will use the sixth slide diagram.  Slides one to four are simpler versions of the same approach.  If I'm pushed for time, I may only fill in the top two thirds of the problem solving diagram at this stage - detailing "problems & wellbeing" and their "evolving wishes & worst symptoms".  If I get the chance though, I will also brainstorm the best supported therapeutic options that they have.  With more complex cases, all this may have to wait until the second session.  I then show them the diagram, make changes if they have further comments, and then photocopy it for them to take away and revise/add to if they want before our next session.  Typically - although I am simply organizing and feeding back the information they have given me - clients usually seem very grateful for this "making sense of" their symptoms and "giving hope" that there are options that can help them.

Rumination assessment - a simple four question way of assessing initial severity and monitoring progress in reducing rumination. 

Rumination, from TRAP to TRAC - classic behavioural activation model of the shift from ruminative Trigger-Response-Avoidance-Pattern TRAP to getting back onto the problem solving Trigger-Response-Alternative-Coping TRAC.  This handout also contains plenty of research back-up for the notion that rumination is largely bad news.

Checklist of potential problem areas - this is a list of a dozen potential problem areas that it can be helpful to show clients to jog their memories for any important issues that they have failed to mention in the initial interview.

Hassles scale - this is the classic 117 items hassles assessment scale.  More minor hassles of everyday living can be as important as major problems in wearing people down.

Psychological & physical difficulties are so common that they're normal - the facts & figures on this sheet are now somewhat dated.  The intention however is clear - to try to reduce a sense of stigma/shame about having difficulties by highlighting how common it is to sometimes struggle with psychological and physical symptoms. 

Problem solving therapy - a three page handout I put together describing an approach to effective problem solving.

Initial person-centred outcome measures - assessment measures adapted from the MYMOPS - Measure Yourself Medical Outcome Profile - inititiative. 

Follow-up person-centred outcome measures - adapted MYMOPS follow-up assessment measure.

Disability assessment, 3 areas - this is the classic Sheehan three item disability questionnaire using 0 - 10 scales to assess difficulties with work (including housework), family relationships, and recreational & social functioning.  This type of simple scale can be very helpful for assessment, clarifying appropriate activity challenges, and monitoring progress.  

Disability assessment, 4 areas - this is the Sheehan scale (see above) slightly extended to separate out couple/marriage issues from other family difficulties. 

Disability assessment, 5 areas - the NHS Increasing Access to Psychological Therapies (IAPT) initiative has extended this disability measurement still further, using 0 - 8 scales to assess work, home management, social/leisure activities with others, social/leisure activities on one's own, and family & other relationship activities.  This "Work & social adjustment scale (W&SAS)" is downloadable as a Word doc and as a PDF file  - see too the associated scoring advice . 

Disability assessment, 8 areas - and the last of these disability scale options is an eight item questionnaire, where the items are typically more narrowly focused and are chosen by client & therapist to focus on issues that are specifically relevant for the client involved. 

Pittsburgh enjoyable activities test (PEAT)  - (also available as a PDF file ) this useful 10 item questionnaire looks broadly at both individual and social forms of enjoyable activity.  It has been shown to correlate with a whole series of both physical and psychological positive measures.  Good both for broadening one's mind about the variety of enjoyable activities to consider and for producing a score showing how the frequency of one's involvement with such activities compares with a general population.  Writing more about this questionnaire, I've posted Assessing and encouraging enjoyable activities .

Behavioural activation strategies - a handout detailing the kinds of activation strategies to be used in a Jacobson style approach to depression treatment. 

Nourishment, adversity & suffering - a handout giving a simple fairly behavioural view of the development & treatment of depression.

Activity schedule 1 & instructions - slightly adapted classic CBT one page weekly activities record sheet with a second page giving instructions on its use.

Activity schedule 2A and schedule 2B  & instructions - here are a couple of slightly more adapted activities record sheets with instructions.  These record sheets are designed to take into account more recent research suggesting that increasing pleasant emotional experiences of various kinds and decreasing unpleasant experiences of various kinds may provide additive benefits for depression and other disorders.

Post new comment

• Web page addresses and e-mail addresses turn into links automatically.
• Use [fn]...[/fn] (or <fn>...</fn>) to insert automatically numbered footnotes.
• Allowed HTML tags: <a> <em> <strong> <cite> <code> <ul> <ol> <li> <dl> <dt> <dd>
• Lines and paragraphs break automatically.

More information about formatting options

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Cochrane Database Syst Rev

Behavioural activation therapy for anxiety disorders in adults

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

• To study the effects of BA in comparison with other psychological therapies (e.g. mindfulness therapy, CBT, dialectical behavioural therapy) for anxiety disorders in adults
• To study the effects of BA compared with pharmacotherapy for anxiety disorders in adults
• To study the effects of BA compared with treatment as usual, waiting list, placebo, and no treatment for anxiety disorders in adults

Description of the condition

Anxiety disorders are a group of disorders that share features of excessive fear and anxiety and related behavioral disturbances. These disorders include separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder (social phobia), panic disorder, agoraphobia, generalized anxiety disorder, substance/medication‐induced anxiety disorder, and anxiety disorder due to another medical condition as classified by the American Psychiatric Association ( APA 2013 ; Robichaud 2019 ; WHO 2021 ). Anxiety disorders are the most common mental health problem globally and if severe, they can significantly interfere with daily activities ( Baxter 2014 ).  In 2019, 300 million individuals suffered from anxiety disorders. In addition, anxiety disorders contributed to 24.6 million   years lived with disability (YLD) in 2015 ( GBD 2018 ; Xiong 2022 ). 

Despite rising prevalence rates, only one‐third of people with GAD receive treatment ( Waldock 2015 ). To address this treatment gap, the Lancet Commission on global mental health and sustainable development identified scaling‐up of psychotherapeutic interventions as a potential approach, pointing to the use of community‐based support from non‐specialists in mental health as a means of increasing access to care ( Patel 2018 ). 

Description of the intervention

The UK National Institute for Health and Care Excellence (NICE) guidelines for anxiety disorder treatment recommend a stepped‐care approach, first offering low‐intensity psychological interventions, and secondly offering a choice of a high‐intensity psychological intervention or a drug treatment for patients in whom the first intervention fails to achieve the desired response ( Kendall 2011 ,  NICE 2014 ).

Behavioural activation (BA) is a time‐efficient, evidence‐based psychotherapy for common mental health disorders ( Kanter 2012 ). The primary therapeutic techniques of BA are activity monitoring and scheduling, through which the patient increases active and goal‐oriented behaviours ( Quigley 2017 ). The original model of BA, developed by Jacobson, was defined primarily by the elimination of cognitive intervention elements ( Dimidjian 2011 ; Jacobson 2001 ).  On the basis of its original design, components of the BA model commonly include developing a shared treatment rationale; promoting access to meaningful events, activities, and consequences; activity scheduling; developing social skills; and self‐monitoring links between behaviour and mood. In some cases, the use of problem‐solving or functional analysis are added to understand, consider and overcome any potential barriers to the scheduling of activities. In contrast to cognitive behavioural therapy (CBT), no attempt is made to directly change cognitions. However, BA commonly involves an exploration of how cognitive processes, such as rumination, can limit access to behaviours and events which give positive reinforcement; for example, in stopping people with anxiety from meeting up with friends or participating in physical exercise ( Chen 2013 ).

How the intervention might work

BA can be defined as a brief psychotherapeutic approach that seeks to change the way a person interacts with their environment, aiming to:

• increase access to positive reinforcers of healthy behaviours;
• reduce avoidance behaviours that limit access to positive reinforcement;
• understand and address barriers to activation.

Treatments are collaborative between the patient and the therapist and are focused on the present time, rather than the past or future. Many schedule‐planning techniques are incorporated into treatment; however, all use self‐monitoring of a mood‐environment link and scheduling of new or adaptive behaviours to meet targets ( Martell 2011 ). In doing so, BA therapy helps people to make contact with potentially reinforcing experiences ( Jacobson 2001 ). BA interventions have been commonly used in treating depression ( Hopko 2006 ) and have been shown to be effective in improving depression symptoms and recovery ( Cuijpers 2007 ;  Quigley 2017 ;  Richards 2016 ). There is an overlap between some symptoms of anxiety and depression, and there is evidence that therapies for a given anxiety or depressive disorder may attenuate symptoms associated with not only the target condition, but also improve the 'non‐targeted' disorder ( Schulberg 1996 ;  Standley 2003 ). Nevertheless, there are considerable differences in presentation, course and prognosis of these disorders, and therapies may have differential effectiveness in these conditions ( Sheard 1999 ). Evidence for the effectiveness of BA for depression cannot, therefore, be generalised to anxiety disorders.   

Using BA to treat anxiety disorder is a relatively new concept ( Boswell 2017 ). Proposed mechanisms for improving anxiety symptoms include reinforcing healthy behaviour and self‐monitoring, which have been shown to enhance the person’s sense of control and predictability over the environment, and decrease self‐focused attention (e.g. ruminative behaviour) ( Hopko 2006 ).

Two studies suggest that BA may be effective in reducing and managing anxiety symptoms ( Hopko 2006 ;  Quigley 2017 ). A Cochrane Review found low‐certainty evidence that BA improves anxiety symptoms in people with depression, compared to the outcomes of  waiting‐list controls, however found no  ( Uphoff 2020 ). Several studies have addressed the feasibility and acceptability of BA for GAD and other anxiety disorders ( Hopko 2016 ;  Soleimani 2015 ;  Turner 2009 ). However, it is still unclear whether BA is effective as a treatment for anxiety disorders in any setting ( Hopko 2016 ).

Why it is important to do this review

There has not yet been a Cochrane Review or other systematic review and meta‐analysis examining the effectiveness of BA for treatment of anxiety disorder. According to NICE clinical guidelines, behavioural therapies are one of the recommended treatment options for anxiety disorders ( Kendall 2011 ). However, the evidence for BA in anxiety disorders is currently less clear than for the other recommended therapies.

Evidence indicates that BA therapy is a skill that can be effectively transferred to primary care providers in five‐day courses ( Moore 2013 ). Combined with its time‐limited nature, this makes BA a potential option to meet the treatment gap for anxiety disorders. To this end, it is important to conduct a synthesis of evidence to know whether BA could be an effective and acceptable treatment to offer to people with anxiety.

BA has increasingly received attention as a potentially cost‐effective intervention for anxiety disorders, which may be delivered and implemented in settings with low resources or where the demand is greater than the availability of mental health practitioners to deliver more complex treatments. Given this resurgence of interest, a comprehensive review of the comparative effectiveness and acceptability of BA interventions for anxiety disorders is timely, to inform and update clinical practice and future clinical guideline development.

Criteria for considering studies for this review

Types of studies.

All randomised controlled trials (RCTs), irrespective of their reported outcomes, will be eligible for inclusion in this review. Cross‐over trials (using data from the first active treatment phase), cluster‐RCTs, and quasi‐experimental RCTs will also be eligible for inclusion. 

Quasi‐experimental RCTs, in which treatment assignment is decided through methods such as alternating days of the week, will not be eligible for inclusion. We will include trials that replace dropouts without randomisation only when the proportion of replaced participants is less than 20%.

Types of participants

Participants characteristics.

Adults aged 18 years and older and of either sex will be eligible for inclusion. Trials that involve only participants under 18 years of age will be excluded. Trials involving some participants younger and older than 18 years will be eligible for inclusion if the majority of participants are aged 18 or over or if results for those aged 18 and over are reported separately. 

Trials conducted in primary, secondary, tertiary, clinic  or community settings will be included. Trials that involve inpatients and those which focus on specific populations, e.g. nurses, caregivers, or participants at a specific workplace, will be eligible.Trials conducted in any country will be eligible. 

Diagnosis of target condition

• We will include trials where the diagnosis of anxiety disorder has been made using a validated assessment instrument or diagnosed using the standardized diagnostic criteria in the International Classification of Disease (ICD) version 10 (ICD 10) ( WHO 1992 ), ICD version 11 (ICD 11) ( WHO 2021 ), or in the Diagnostic and Statistical Manual of Mental Disorders (DSM) third edition (DSM‐III), fourth edition (DSM‐IV) or fifth edition (DSM‐5) ( APA 2013 ) .
• Trials will be included where the diagnosis is either made by a clinician through validated diagnostic interview or using a validated questionnaire, e.g. the Symptom Checklist‐90 ( Franke 2014 ), the general health questionnaire (GHQ) ( Jackson 2007 ), the medical outcomes study short form 36 ( Ware 1992 ), the Spielberger state trait anxiety inventory (STAI) ( Spielberger 1983 ), the Beck anxiety inventory (BAI) ( Beck 1988 ) and the hospital anxiety and depression scale‐anxiety (HADS) ( Stern 2014 ).

Comorbidity

Studies in adults with physical or psychiatric comorbidities will be also be included in the review, as long as the comorbidity was not the focus of the trial. For example, we will exclude trials that focus on anxiety among individuals with Parkinson's disease or acute myocardial infarction, but will accept trials that may have included some participants with Parkinson's disease or with acute myocardial infarction. We made this decision to be consistent with the methods of a similar Cochrane Review that evaluated BA for depression in adults ( Uphoff 2020 ).

Types of interventions

Experimental intervention (ba).

We will include trials that use treatment approaches for anxiety that are either explicitly called 'behavioural activation', or are treatments that are described using the main elements of BA. These main elements include pleasant events and activities scheduling, positive reinforcement from the environment, and positive interaction or re‐engagement with the environment. Therapies with only some components of BA, but not its main elements, will not be included.

Comparators

All comparators will be accepted, as long as they are not a type of BA. Comparators may include the following. 

• Psychological and psychosocial therapies: we will include any psychological intervention including (e.g. counselling, cognitive behaviour therapies, exposure therapies or relaxation therapies and mindfulness based therapies, social skills training, assertiveness training).
• Pharmacotherapy: benzodiazepines; buspirone; calcium modulators e.g. pregabalin; antidepressants e.g. selective serotonin reuptake inhibitors (SSRIs), serotonin‐norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs); and beta blockers.
• Any other comparator: e.g. treatment as usual (TAU), attention or psychological placebo, waiting list.

Format of psychological therapies

Therapies delivered by therapists of all levels will be eligible for inclusion. These therapists include the following.

• Psychologists or psychotherapists accredited by a professional body for psychology or psychotherapy, who completed formal training to deliver psychological therapies.
• Those who received substantial training (more than a year) but are not yet qualified.
• Lay counsellors and non‐specialist therapists who have been specifically trained to deliver treatment according to a BA protocol. 

We will include computerised and self‐help interventions, if they were facilitated. This means at least some element of interaction with a therapist was required. Psychological therapies conducted on an individual or group basis will be eligible for inclusion.

The number of sessions will not be limited, and we will accept psychological therapies delivered in only one session.

Behavioural therapy

We will not include any behavioural therapies that contain the main elements of BA as comparator. 

Social skills training

Social skills training/assertiveness training (SST) subsumes assertion and conversational skills, together with more specialised sub‐skills such as dating and job interview skills. Different social contexts may be targeted; for example, interaction with friends, family members, people at school, or at work, and interventions such as instruction, modelling, rehearsal, feedback and reinforcement are used to enable the development of new responses ( Jackson 1985 ). As assertiveness training represents a key component of SST, we will include it in the SST category.

Relaxation therapy

Relaxation training is a behavioural stress management technique that induces a relaxation response, helping to switch to the rest/digest response and causing levels of stress hormones in the bloodstream to fall. A variety of techniques may be used to induce relaxation, the most common of which is Jacobson's progressive muscle relaxation training ( Bernstein 1973 ).

Cognitive behavioural therapies (CBTs)

In CBT, therapists aim to work together with people receiving treatment to understand the link between thoughts, feelings and behaviours, and to identify and modify unhelpful thinking patterns and underlying assumptions about the self, others and the world ( Beck 1979 ). Cognitive change methods for depression are targeted at the automatic thought level in the first instance and include thought catching, reality testing and task assigning, as well as generating alternative strategies ( Williams 1997 ). Behavioural experiments are then used to re‐evaluate underlying beliefs and assumptions .

'Third‐wave' CBTs

Third‐wave CBT approaches have been developed more recently and now exist alongside established therapies such as CBT. Rather than focusing on the contents of thoughts, these therapies tend to focus on the process and functions of thoughts and an individual's relationship with thoughts and emotions. This may include suppressing or avoidance of emotions, thoughts, and bodily sensations ( Hofmann 2008 ). Third‐wave approaches use strategies relating to mindfulness, emotions, acceptance, relationships, values, goals, and understanding the thinking process, to bring about changes in thinking ( Hayes 2017 ). Drawing from psychodynamic and humanistic principles, third‐wave CBT approaches place great emphasis on use of the therapeutic relationship. We can  categorise these therapies into subcategories: acceptance and commitment therapy, compassionate mind training, functional analytic psychotherapy, metacognitive therapy, mindfulness‐based cognitive therapy, dialectical behaviour therapy and other third‐wave CBTs.

Psychodynamic therapies (PDs)

Grounded in psychoanalytic theory ( Freud 1989 ). PDs use the therapeutic relationship to explore and resolve unconscious conflict through transference and interpretation, with development of insight and character change (within certain boundaries) as therapeutic goals, and relief of symptoms as an indirect outcome. Brief therapy models have been devised ( Malan 1963 ;  Mann 2009 ;  Strupp 1984 ).

Humanistic therapies

Contemporary models of humanistic therapies differ from one another somewhat in clinical approach, but all focus attention on the therapeutic relationship ( Cain 2002 ), within which therapist ‘core conditions’ of empathy, genuineness, and unconditional acceptance and support (positive regard) ( Rogers 1951 ) are regarded as cornerstones for facilitating insight and change.

Interpersonal, cognitive analytic and other integrative therapies

Integrative therapies are approaches that combine components of different psychological therapy models. Integrative therapy models include interpersonal therapy (IPT) ( Klerman 1987 ), and cognitive analytic therapy (CAT) ( Ryle 1990 ). With its focus on the interpersonal context, IPT was developed to specify what was thought to be a set of helpful procedures commonly used in psychotherapy for depressed outpatients ( Weissman 2008 ), drawing in part from attachment theory ( Albert 1982 ), and cognitive‐behavioural therapy within a set timeframe (time‐limited). CAT, also devised as a time‐limited psychotherapy, integrates components from cognitive and psychodynamic approaches. The conversational model integrates psychodynamic, interpersonal and person‐centred model components.

Counselling interventions traditionally draw from a wide range of psychological therapy models, including person‐centred, psychodynamic and cognitive‐behavioural approaches, applied in combination, according to the theoretical orientation of practitioners. Therefore, we will include trials of counselling with integrative therapies. However, if the counselling intervention consists of a single discrete psychological therapy approach, we will categorise it as such, even if the intervention is referred to as 'counselling'. If the intervention was manualised, this would inform our classification. Motivational interviewing and other forms of integrative therapy approaches are also included in this category.

Waiting list

Participants are randomly assigned to the active intervention group or control group, and they will either receive the intervention first or be assigned to a waiting list until all participants in the intervention group have received the intervention. During the course of the trial, people on the waiting list can receive any appropriate medical care.

Attention placebo

We will define this as a control condition that is regarded as inactive by both researchers and participants in a trial. 

Psychological placebo 

We define this as a control condition in a trial that is regarded by researchers as inactive but is regarded by participants as active (also called placebo therapy or sham treatment).

All medication prescribed with the goal to treat anxiety, most commonly anti‐anxiety medications; any dose, route of administration, duration and frequency.

No treatment

Trial participants not receiving any treatment for anxiety during the course of the trial.

Treatment as usual

Treatment as usual, standard care, or usual care would be any appropriate medical care during the course of the study. This may  for example involve monitoring of the person receiving treatment, regular check‐ups, no treatment, or any type of treatment. What constitutes treatment as usual will depend on the setting and healthcare system in which the study was conducted. If a study arm fitted clearly in any of the above categories, for example 'no treatment' or a type of psychological therapy, we will categorise it as such.

Excluded interventions

We will exclude trials of long‐term, continuation, or maintenance therapy interventions designed to prevent relapse of anxiety, or to treat chronic anxiety disorders. Similarly, we will exclude trials of interventions designed to prevent a future episode of anxiety.

We will exclude psychological therapy models based on social constructionist principles (that focus on the ways in which individuals and groups participate in the construction of their perceived social reality), including couples therapy, family therapy, solution‐focused therapy, narrative therapy, personal construct therapy, neuro‐linguistic programming and brief problem‐solving. These therapies work with patterns and dynamics of relating within and between family, social and cultural systems to create a socially constructed framework of ideas ( O’Connell 2007 ), rather than focusing on an individual's reality. 

Types of outcome measures

Primary outcomes.

• Reduction in anxiety mean score, measured using any valid scale (continuous outcome); and remission, defined as having anxiety or not having anxiety at the end of the trial (dichotomous outcome)
• Treatment acceptability, measured as the number of participants who dropped out of the study for any reason after being randomised and allocated to a study arm

Secondary outcomes

• Quality of life, as assessed with the use of any validated measure.
• Social adjustment and social functioning, including Global Assessment of Function (GAF) scores ( Luborsky 1962 ).
• Proportion of participants experiencing any adverse events including but not limited to worsening of symptoms or relapses.
• Improvement in depression symptoms, based on a continuous outcome of group mean scores at the end of treatment using the Beck depression inventory (BDI) ( Beck 1996 ) , the Hamilton depression rating scale (HAM‐D) ( Hamilton 2012 ), the Montgomery and Asberg depression rating scale (MADRS) ( Montgomery 2012 ) or any other validated depression scale.

Time points for primary and secondary outcomes

We will summarise and categorise post‐treatment outcomes and outcomes at each reported follow‐up point as follows: short term (up to six months post‐treatment), medium term (seven to 12 months post‐treatment) and long term (longer than 12 months post‐treatment). If data at multiple time points are available within one of our categories, we will use the latest time point.

Search methods for identification of studies

Electronic searches.

The Cochrane Common Mental Disorders' Information Specialist will conduct searches on the following bibliographic databases, using relevant subject headings (controlled vocabularies) and search syntax, appropriate to each resource:

• Cochrane Common Mental Disorders Controlled Trials Register (CCMD‐CTR) (all available years);
• Cochrane Central Register of Controlled Trials (CENTRAL; current issue) in The Cochrane Library;
• Ovid MEDLINE (from 1946 onwards);
• Ovid Embase (from 1974 onwards);
• Ovid PsycINFO (all available years) ( Appendix 1 ).

There will be no restrictions on date, language or publication status applied to the searches. 

We will search for unpublished or ongoing trials via the World Health Organization's International Clinical Trials Registry Platform (ICTRP) (trialsearch.who.int) and the trials registry at the US National Institutes of Health (ClinicalTrials.gov)

Searching other resources

We will search for grey literature (primarily for dissertations and theses) via the following sources:

• Open Grey (opengrey.eu);
• ProQuest Dissertations & Theses Global (search.proquest.com/pqdtglobal/dissertations);
• DART‐Europe E‐theses Portal (dart-europe.eu/basic-search.php);
• Networked Digital Library of Theses and Dissertations (NDLTD) (search.ndltd.org);
• EThOS ‐ the British Libraries e‐theses online service;
• Open Access Theses and Dissertations (OATD) (oatd.org).

To help identify further published, unpublished or ongoing research we will scan the reference lists of included studies and any relevant systematic reviews. 

We may contact original authors to obtain any missing data or information, as required.

Data collection and analysis

Selection of studies.

Two review authors will independently examine each title and abstract obtained through the search strategy for relevance. We will then obtain full texts for all of these articles and two independent review authors will assess the full texts according to the criteria relating to characteristics of the studies, participants, and interventions. Disagreements will be discussed and a decision will be made by a third review author if agreement cannot be reached. We will record reasons for excluding studies at this stage. For all included studies, we will link multiple reports from the same study. 

Data extraction and management

Two review authors will independently extract data from each selected study. The data extracted by the review authors will be compared and any discrepancies will be resolved through consensus. A third review author may be requested as needed to resolve discrepancies. 

We will extract and enter information for the following categories into Covidence data extraction forms ( Covidence ): trial design, source of funding, study population, country,  interventions and comparators, outcomes, attrition rates, adverse effects, missing data, main findings, missing outcomes (compared with the protocol) and sample size.

Assessment of risk of bias in included studies

We will assess risk of bias for each included trial using Cochrane's 'Risk of bias 2 ' tool (RoB2) ( Cumpston 2019 ), which considers the following domains.

• Risk of bias arising from the randomisation process, including allocation and randomisation
• Risk of bias due to deviations from the intended interventions, including blinding of participants and people delivering the interventions
• Incomplete outcome data
• Risk of bias in measurement of the outcome, including blinding of outcome assessors
• Selective outcome reporting

The overall risk of bias will be defined as the worst risk of bias in any of the domains. However, if we judge a study to have some concerns about risk of bias for more than three domains, we will judge it to be at high risk of bias overall ( Sterne 2019 ).  

Measures of treatment effect

Continuous outcomes.

Where trials have used the same outcome measure for comparison, we will pool data by calculating the mean difference (MD) and 95% confidence intervals (CIs). Where trials have used different measures to assess the same outcome, we will pool data calculating the standardised mean difference (SMD) and 95% CIs.

Dichotomous outcomes

We will analyse dichotomous outcomes by calculating risk ratios (RRs) and 95% CIs for each comparison in RevMan Web ( RevMan Web 2020 ).

Unit of analysis issues

We will identify the number of included RCTs in which the unit of analysis error occurs and conduct reanalysis where possible for these studies. To assess for unit of analysis error, we will look for whether the study population is truly randomly selected, whether the provider effect and patient‐provider interaction effect are accounted for in the analysis, and whether the unit of randomisation and the unit of analysis are the same.

Cluster‐randomised trials

We will include cluster‐randomised trials as long as proper adjustment for the intracluster correlation can be conducted, in accordance with the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2021 ).

Cross‐over trials

We will include trials employing a cross‐over design in the review, but we will only use data from the first active treatment phase. 

Trials with multiple treatment groups

Multiple‐arm trials (those with more than two intervention arms) can pose analytical problems in pairwise meta‐analysis. For trials with more than two eligible arms, we will manage data as follows:

Multiple experimental intervention groups versus a single control group

If studies compare multiple eligible experimental interventions with a single control group, we will split the control group to enable pairwise comparisons.

One or more experimental intervention groups versus multiple control groups

• If studies use multiple 'active' comparator interventions, we will combine these comparator groups to compare to the BA intervention group (objective 1/2).
• If studies use multiple control groups including treatment as usual, waiting list, attention placebo, or psychological placebo, we will combine the control groups to compare to the BA intervention group (objective 3).

Dealing with missing data

We will contact the authors of the original studies to fill in gaps in our data. We will take a pragmatic approach to contacting authors. We will make contact via email or research sharing platforms only and will make two attempts (one week apart) to contact them. If missing information about study design or methods prevents us from assessing the eligibility of a study, we will include it in the review as a study awaiting assessment. Where missing outcomes data cannot be obtained from authors, we will impute the missing data and use statistical methods to account for the uncertainty in our imputed data. We will conduct a sensitivity analysis to assess the impact of data imputation on our study analysis. We will also address the types of missing data and its implications in our 'Discussion' section. 

We will manage missing dichotomous data through intention‐to treat (ITT) analysis, in which we will assume that participants who dropped out after randomisation had a negative outcome. We will also conduct best case/worst case scenarios for the clinical response outcome. In these scenarios, we will assume that dropouts in the active treatment group had positive outcomes and that those in the control group had negative outcomes (best case scenario). We will assume that dropouts in the active treatment group had negative outcomes and that those in the control group had positive outcomes (worst case scenario). These assumptions provide boundaries for the observed treatment effect. Where there is a large amount of missing data, we will give these best case/worst case scenarios greater emphasis in the presentation of results.

We will analyse missing continuous data on an endpoint basis, including only participants with a final assessment; or if trial authors reported these data, by using the last observation carried forward (LOCF) to the final assessment. Where standard deviations (SDs) are missing, we will attempt to obtain these data by contacting trial authors. Where SDs are not available from trial authors, we will calculate them from P values, t values, CIs or standard errors (SEs), if these are reported in the articles ( Deeks 2021 ). If the great majority of SDs are available and only a minority of SDs are unavailable or unobtainable, we will use the method devised by Furukawa and colleagues to impute SDs and calculate percentage responders ( Costa 2012 ;  Furukawa 2005 ). We plan to interpret these data with caution and take into account the degree of observed heterogeneity.

Assessment of heterogeneity

We will assess our included studies for clinical, statistical and methodological heterogeneity. We will calculate the I 2 statistic to calculate the percentage of heterogeneity that is not due to chance alone. In our 'Discussion' section, we will address potential causes for heterogeneity in our included studies. Where I 2 values in pooled data suggest substantial or considerable heterogeneity, we will use a random‐effects meta‐analytic model ( Higgins 2021 ).

We will use the heterogeneity thresholds suggested by the Cochrane handbook (Chapter 10) ( Higgins 2021 ); 

• 0% to 40%: might not be important;
• 30% to 60%: may represent moderate heterogeneity;
• 50% to 90%: may represent substantial heterogeneity;
• 75% to 100%: considerable heterogeneity.

Assessment of reporting biases

We will minimise the impact of reporting biases as much as possible by undertaking comprehensive searches of multiple sources (including trials registries) to identify unpublished material. We will include reports published in any language. We will also try to identify outcome reporting bias in trials by recording all trial outcomes, planned and reported, and noting where outcomes were missing. If a study protocol is available, we will compare outcomes in the protocol and the published report. If a study protocol is not available, we will compare outcomes listed in the article's 'methods' section with those actually reported in the article's 'results'. If we find evidence of missing outcomes, we will contact trial authors to try to obtain any available data directly, although it is important to note that such information may be unreliable ( Chan 2004 ).

Data synthesis

In a narrative synthesis of the results, we will report treatment efficacy (number of participants responding to treatment), treatment acceptability (number of participants who dropped out), improvement in anxiety outcomes as a continuous score, and where available, quality of life. We will present standardized effect size estimates and 95% CIs. We will also present these data in tabular form.

If possible, we will also conduct a meta‐analysis of included trials for each primary and secondary outcome. Given the potential heterogeneity of BA approaches for inclusion, together with the likelihood of differing secondary comorbid mental disorders in the population of interest, we will use a random‐effects model in all analyses.

Subgroup analysis and investigation of heterogeneity

We will conduct the following subgroup analyses, based on the availability of sufficient data on outcomes and comparators: 

• Mild versus moderate versus severe GAD groups, based on the psychometric tools used, or clinical assessment using a diagnostic criterion.
• People with or without severe mental illness (bipolar disorder, major depressive disorder, and schizophrenia).
• Length of treatment (brief versus long‐term interventions) and its effect on recovery/improvement.
• BA alone versus BA plus other components (e.g. pharmacotherapy, mindfulness‐based interventions).

Sensitivity analysis

• Low risk of bias studies: we will exclude studies categorised as some concerns and high risk of bias.
• Sub‐threshold anxiety: we will exclude trials of sub‐threshold anxiety to determine whether the decision to include the trials of anxiety not meeting clinical thresholds has a substantial impact on the results.
• Mode of delivery: we will exclude therapies delivered through computer–based electronic guidance without a face‐to‐face component.
• Group therapy: we will exclude trials of group therapy for BA as the mode of delivery of psychotherapy can influence its effectiveness. 

Summary of findings and assessment of the certainty of the evidence

We will construct a 'Summary of findings' table to present the findings for the primary and secondary outcomes using GRADE Pro Software ( GRADEpro GDT ), with the GRADE assesment of the quality of the body of evidence as described in the Cochrane Handbook ( Schünemann  2021 ).

For each of our main comparators we will include the following outcomes, measured at six, 12 and up to 24 months.

• Treatment efficacy (number of participants responding to treatment).
• Treatment acceptability (number of participants who dropped out).
• Improvement in anxiety outcomes as a continuous score.
• Quality of life.
• Social adjustment/ functioning score.
• Improvement in depression symptoms as a continuous score.

Acknowledgements

Cochrane Common Mental Disorders (CCMD) supported the authors in the development of this protocol.

The following people conducted the editorial process for this article:

• Sign‐off Editor (final editorial decision): Nick Meader, Centre for Reviews and Dissemination, University of York
• Managing Editor (selected peer reviewers, collated peer‐reviewer comments, provided editorial guidance to authors, edited the article): Jessica Hendon, Centre for Reviews and Dissemination, University of York
• Peer‐reviewers (provided comments and recommended an editorial decision): Christopher R. Martell, University of Massachusetts (clinical/content review), Karen Morley, Cochrane Consumer Network (consumer review), Lindsay Robertson, Centre for Reviews and Dissemination, University of York (methods review).

The authors and the CCMD Editorial Team are grateful to the peer reviewers for their time and comments. They would also like to thank Cochrane Copy Edit Support for the team's help.

Cochrane Group funding acknowledgement: The UK National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Common Mental Disorders Group.

Disclaimer: The views and opinions expressed herein are those of the review authors and do not necessarily reflect those of the NIHR, National Health Service (NHS), or the Department of Health and Social Care.

Appendix 1. PsycINFO Search

APA PsycInfo (Ovid) <1806 to October Week 1 2021>

1 behavioral activation system/ 529 2 ((behavio* adj1 activ*) or BATD).ti,ab,id. 7183 3 (behavio* adj3 (reinforce* or re‐inforce*)).ti,ab,id. 5675 4 reinforc*.ti,id. or (((contingent or positive) adj1 reinforc*) or (reinforc* adj3 (environment* or experience*))).ti,ab,id. 30993 5 exp reinforcement/ 53062 6 (reinforce or reinforcer or reinforcement or reinforcements or re‐inforcement or re‐inforcements).ab. /freq=2 16714 7 (behavio* adj2 (contracting or modification or modify*)).ti,ab,id. 8345 8 behavior contracting/ or behavior modification/ 10864 9 ((activit* or event?) adj2 schedul*).ti,ab,id. 882 10 planned behavior/ 2758 11 ((pleas* or enjoyable or rewarding) adj (activit* or event?)).ti,ab,id. 1073 12 (operant conditioning or instrumental learning).ti,ab,id. 4989 13 exp operant conditioning/ 36365 14 (positive interaction* or avoidant coping or environmental contingenc* or contigency management).ti,ab,id. 3177 15 exp contingency management/ 3176 16 ((gain? or reapprais*) adj2 focus*).ti,ab,id. 149 17 functional analysis.ti,ab,id,sh. 4427 18 (behavio* and (self adj (care or efficacy or evaluat* or monitor*))).ti,id,hw. 11068 19 ((psychoeducat* or psycho‐educat*) and (coping behavi* or coping skills or self manag* or (behavi* adj2 chang*))).ti,ab,id,hw. 1050 20 self management/ and behavior change/ 131 21 or/1‐20 140597 22 *behavior therapy/ and anxi*.ti,hw,tm. 1016 23 anxiety/ 67191 24 anxiety disorders/ or generalized anxiety disorder/ or panic attack/ or panic disorder/ or exp phobias/ or separation anxiety disorder/ 39313 25 (anxiety disorder* or agoraphobi* or generalized anxiety or generalised anxiety or GAD or (separation adj2 anxiety) or (social adj2 anxi*) or panic or phobi*).ti,ab,id. 70914 26 anxi*.ti,id. or (worry or worries).ti,ab,id. 111614 27 (mood? or mental health or ((emotion* or psychological) adj (distress or trauma*))).ti,id,hw. 205074 28 or/23‐27 347029 29 (21 and 28) 7119 30 clinical trials.sh. 11982 31 (randomi#ed or randomi#ation or randomi#ing).ti,ab,id. 96092 32 (RCT or at random or (random* adj3 (administ* or allocat* or assign* or class* or control* or crossover or cross‐over or determine* or divide* or division or distribut* or expose* or fashion or number* or place* or recruit* or split or subsitut* or treat*))).ti,ab,id. 112701 33 ((single or double or triple or treble) adj2 (blind* or mask* or dummy)).ti,ab,id. 27591 34 trial.ti. 33752 35 placebo.ti,ab,id,hw. 42017 36 (control* and (trial or study or group?) and (no‐treatment or waitlist* or wait* list* or ((treatment or care) adj2 usual))).ti,ab,id,hw. 14126 37 (((allocat* or assign* or receive*) adj5 ("no‐treatment" or waitlist* or wait* list* or ((treatment or care) adj2 usual))) and (control or group?)).ab. 2712 38 empirical study.md. and (("no‐treatment" or waitlist* or wait* list* or ((treatment or care) adj2 usual)) adj5 (control or group? or compared or comparison)).ab. 10000 39 (treatment adj5 control).ab. 13494 40 treatment outcome.md. 21904 41 treatment effectiveness evaluation.sh. 26099 42 mental health program evaluation.sh. 2216 43 or/30‐42 220940 44 (22 and 43) 297 45 (29 and 43) 829 46 (44 or 45) 1098  

Contributions of authors

Drafting of protocol: GZ, EU, SA, SD, ALB, JVEB, KC, AHE, MI, AJ, KNK, NSM, FNR, SR, RR, TR, NS

Search strategy and search methodology: SD, GZ

Sources of support

Internal sources.

• University of York, UK

External sources

EU time on protocol funded via Cochrane Infrastructure funding to the Common Mental Disorders Cochrane Review Group.

Research funding (NIHR) 17/63/130 (using UK aid from the UK Government to support global health research) supported the training of authors included on this protocol.

Declarations of interest

SA: no conflicts of interest EU: is a current member of the editorial staff of the Cochrane Common Mental Disorders Review Group. EU was not involved in the editorial process for this protocol. ALB: no conflicts of interest JVEB: no conflicts of interest KC: no conflicts of interest SD: no conflicts of interest AHE: no conflicts of interest MI: no conflicts of interest AJ: no conflicts of interest KNK: no conflicts of interest NSM: no conflicts of interest FNR: no conflicts of interest SR: no conflicts of interest RR: no conflicts of interest TR: no conflicts of interest NS: no conflicts of interest GZ: no conflicts of interest

Additional references

Albert 1982.

• Albert S, Bowly J. Attachment and loss: sadness and depression . Journal of Marriage and the Family 1982; 44 ( 1 ):248. [ Google Scholar ]
• American Psychiatric Association. Diagnostic and statistical manual of mental disorders . 5th edition. American Psychiatric Association, 2013. [ Google Scholar ]

Baxter 2014

• Baxter AJ, Vos T, Scott KM, Ferrari AJ, Whiteford HA. The global burden of anxiety disorders in 2010 . Psychological Medicine 2014; 44 ( 11 ):2363-374. [ PubMed ] [ Google Scholar ]
• Beck AT. Cognitive therapy of depression . Guilford Press, 1979. [ Google Scholar ]
• Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties . Journal of Consulting and Clinical Psychology 1988; 56 ( 6 ):893-97. [ PubMed ] [ Google Scholar ]
• Beck, AT, Steer, RA and Brown, GK. Beck depression inventory (BDI-II)  . Pearson, 1996. [ Google Scholar ]

Bernstein 1973

• Bernstein DA, Borkovec TD. Progressive relaxation training: a manual for the helping professions . Research Press, 1973. [ Google Scholar ]

Boswell 2017

• Boswell JF, Iles Brittany R, Gallagher MW, Farchione TJ. Behavioral activation strategies in cognitive-behavioral therapy for anxiety disorders . Psychotherapy 2017; 54 ( 3 ):231-36. [ PubMed ] [ Google Scholar ]
• Cain DJ. Humanistic psychotherapies: handbook of research and practice . American Psychological Association, 2002. [ Google Scholar ]
• Chan AW, Hróbjartsson A, Haahr MT, Gøtzsche PC, Altman DG. Empirical evidence for selective reporting of outcomes in randomized trials: comparison of protocols to published articles . JAMA 2004; 291 ( 20 ):2457-65. [ PubMed ] [ Google Scholar ]
• Chen J, Liu X, Rapee RM, Pillay P. Behavioural activation: a pilot trial of transdiagnostic treatment for excessive worry . Behavioural Research and Therapy 2013; 51 ( 9 ):533-9. [ PubMed ] [ Google Scholar ]
• da Costa BR, Rutjes AWS, Johnston BC, Reichenbach S, Nüesch E, Tonia T, et al. Methods to convert continuous outcomes into odds ratios of treatment response and numbers needed to treat: meta-epidemiological study . International Journal of Epidemiology 2012; 41 ( 5 ):1445-59. [ PubMed ]

Covidence [Computer program]

• Veritas Health Innovation Covidence . Version accessed 10 November 2021. Melbourne, Australia: Veritas Health Innovation. Available at covidence.org.

Cuijpers 2007

• Cuijpers P, Straten A, Warmerdam L. Behavioral activation treatments of depression: a meta-analysis . Clinical Psychology Review 2007; 27 ( 3 ):318-26. [ PubMed ] [ Google Scholar ]

Cumpston 2019

• Cumpston M, Li T, Page MJ, Chandler J, Welch VA, Higgins JP, et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions [Editorial] . Cochrane Database of Systematic Reviews 2019, Issue 10 . [DOI: 10.1002/14651858.ED000142] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Deeks JJ, Higgins JPT, Altman DG (editors). Chapter 10: Analysing data and undertaking meta‐analyses . Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.2 (updated February 2021) .

Dimidjian 2011

• Dimidjian S, Barrera MJ, Martell C, Muñoz RF, Lewinsohn PM. The origins and current status of behavioral activation treatments for depression . Annual Review of Clinical Psychology 2011; 7 :1-38. [ PubMed ] [ Google Scholar ]

Franke 2014

• Franke GH. Diagnostische Verfahren in der Psychotherapie . 1st edition. Oxford, England: Hogrefe Ltd, 2014. [ Google Scholar ]
• Freud S. An outline of psycho-analysis . WW Norton, 1989. [ Google Scholar ]

Furukawa 2005

• Furukawa TA, Cipriani A, Barbui C, Brambilla P, Watanabe N. Imputing response rates from means and standard deviations in meta-analyses . International Journal of Clinical Psychopharmacology 2005; 20 ( 1 ):49-52. [ PubMed ] [ Google Scholar ]
• GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017 . Lancet 2018; 392 ( 10159 ):1789-858. [ PMC free article ] [ PubMed ] [ Google Scholar ]

GRADEpro GDT [Computer program]

• McMaster University (developed by Evidence Prime) GRADEpro GDT . Version accessed 10 November 2021. Hamilton (ON): McMaster University (developed by Evidence Prime). Available at gradepro.org.

Hamilton 2012

• Hamilton M. Hamilton rating scale for depression . PsycTESTS Dataset 2012.
• Hayes SC, Hofmann SG. The third wave of cognitive behavioral therapy and the rise of process‐based care . World Psychiatry 2017; 16 ( 3 ):245-46. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Higgins 2021

• Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 6.2 (updated February 2021). Cochrane, 2021 . Available from training.cochrane.org/handbook . [ PMC free article ] [ PubMed ]

Hofmann 2008

• Hofmann SG, Asmundson GJG. Acceptance and mindfulness-based therapy: new wave or old hat? Clinical Psychology Review 2008; 28 ( 1 ):1-16. [ PubMed ] [ Google Scholar ]
• Hopko DR, Robertson S, Lejuez CW. Behavioral activation for anxiety disorders . The Behavior Analyst Today 2006; 7 ( 2 ):212. [ Google Scholar ]
• Hopko DR, Lejuez CW, Ryba MM, Shorter RL, Bell JL. Support for the efficacy of behavioural activation in treating anxiety in breast cancer patients . Clinical Psychology 2016; 20 ( 1 ):17-26. [ Google Scholar ]

Jackson 1985

• Jackson HJ, Moss JD, Solinski S. Social skills training: an effective treatment for unipolar non-psychotic depression? Australian & New Zealand Journal of Psychiatry 1985; 19 ( 4 ):342-53. [ PubMed ]

Jackson 2007

• Jackson C. The General Health Questionnaire . Occupational Medicine 2007; 57 ( 1 ):79. [DOI: 10.1093/occmed/kql169] [ CrossRef ] [ Google Scholar ]

Jacobson 2001

• Jacobson NS, Martell CR, Dimidjian S. Behavioral activation treatment for depression: returning to contextual roots . Clinical Psychology: science and practice 2001; 8 ( 3 ):255-70. [ Google Scholar ]

Kanter 2012

• Kanter JW, Puspitasari AJ, Santos MM, Nagy GA. Behavioural activation: history, evidence and promise . British Journal of Psychiatry 2012; 200 ( 5 ):361-63. [ PubMed ] [ Google Scholar ]

Kendall 2011

• Kendall T, Cape J, Chan M, Taylor C, Guideline Development Group. Management of generalised anxiety disorder in adults: summary of NICE guidance . BMJ 2011; 342 :c7460. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Klerman 1987

• Klerman GL, Weissmann MM. Interpersonal psychotherapy (IPT) and drugs in the treatment of depression . Pharmacopsychiatry 1987; 20 ( 1 ):3-7. [ PubMed ] [ Google Scholar ]

Luborsky 1962

• Luborsky L. Clinicians' judgments of mental health . Archives of General Psychiatry 1962; 7 ( 6 ):407. [ PubMed ]
• Malan DH. A study of brief psychotherapy . Springer, 1963. [ Google Scholar ]
• Mann J. Time-limited psychotherapy . Harvard University Press, 2009. [ Google Scholar ]

Martell 2011

• Martell CR, Kanter JW. Behavioral activation in the context of “third wave” therapies. In: Acceptance and mindfulness in cognitive behavior therapy: Understanding and applying the new therapies . John Wiley & Sons, 2011:193-209. [ Google Scholar ]

Montgomery 2012

• Montgomery SA, Asberg M. Montgomery-Asberg Depression Rating Scale . PsycTESTS Dataset 2012.
• Moore RC, Chattillion EA, Ceglowski J, Ho J, Känel R, Mills PJ, et al. A randomized clinical trial of Behavioral Activation (BA) therapy for improving psychological and physical health in dementia caregivers: results of the Pleasant Events Program (PEP) . Behaviour Research and Therapy 51; 10 :623-32. [DOI: 10.1016/j.brat.2013.07.005] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• National Institute for Health and Care Excellence (NICE). Anxiety disorders Quality standard (QS53) . Available from www.nice.org.uk/guidance/qs53 (accessed 25 October 2021).

O’Connell 2007

• O’Connell B. Dryden’s Handbook of Individual Therapy . Sage, 2007. [ Google Scholar ]
• Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development . Lancet 2018; 392 ( 10157 ):1553-98. [ PubMed ] [ Google Scholar ]

Quigley 2017

• Quigley L, Dobson KS. Behavioral activation treatments for depression. In: SG Hofmann, GJG Asmundson, editors(s). The Science of Cognitive Behavioral Therapy . Elsevier Academic Press, 2017:291-318. [ Google Scholar ]

RevMan Web 2020 [Computer program]

• The Cochrane Collaboration Review Manager Web (RevMan Web) . Version 1.22.0. The Cochrane Collaboration, 2020. Available at revman.cochrane.org.

Richards 2016

• Richards DA, Ekers D, McMillan D, Taylor RS, Byford S, Warren FC, et al. Cost and Outcome of Behavioural Activation versus cognitive behavioural therapy for depression (COBRA): a randomised, controlled, non-inferiority trial . Lancet 2016; 388 ( 10047 ):871-80. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Robichaud 2019

• Robichaud M, Koerner N, Dugas MJ. Description of generalized anxiety disorder. In: Cognitive Behavioral Treatment for generalized anxiety disorder . Routledge, 2019:1-17. [ Google Scholar ]

Rogers 1951

• Rogers CR. Client-centered therapy, its current practice, implications, and theory . Houghton Mifflin, 1951. [ Google Scholar ]
• Ryle A, Poynton AM, Brockman BJ. Cognitive-analytic therapy: Active participation in change: A new integration in brief psychotherapy . Vol. 267 . John Wiley & Sons, 1990. [ Google Scholar ]

Schulberg 1996

• Schulberg HC, Block MR, Madonia MJ, Scott CP, Rodriguez E, Imber SD, et al. Treating major depression in primary care practice. Eight-month clinical outcomes . Archives of General Psychiatry 1996; 53 ( 10 ):913-9. [DOI: 10.1001/archpsyc.1996.01830100061008] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Schünemann  2021

• Schünemann HJ, Higgins JPT, Vist GE, Glasziou P, Akl EA, Skoetz N, et al . Chapter 14: Completing ‘Summary of findings’ tables and grading the certainty of the evidence. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 6.2 (updated February 2021). Cochrane, 2021 . Available from training.cochrane.org/handbook .

Sheard 1999

• Sheard T, Maguire P. The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses . British Journal of Cancer 1999; 80 ( 11 ):1770-80. [DOI: 10.1038/sj.bjc.6690596] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Soleimani 2015

• Soleimani M, Mohammadkhani P, Dolatshahi B, Alizadeh H, Overmann KA, Coolidge FL. A comparative study of group behavioral activation and cognitive therapy in reducing subsyndromal anxiety and depressive symptoms . Iranian Journal of Psychiatry 2015; 10 ( 2 ):71-8. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Spielberger 1983

• Spielberger CD. Manual for the State-trait anxiety inventory (form Y self-evaluation questionnaire) . Palo Alto: Consulting Psychologists Press, 1983. [ Google Scholar ]

Standley 2003

• Stanley MA, Beck JG, Novy DM, Averill PM, Swann AC, Diefenbach GJ, et al. Cognitive-behavioral treatment of late-life generalized anxiety disorder . Journal of Consulting and Clinical Psychology 2003; 71 ( 2 ):309-19. [DOI: 10.1037/0022-006x.71.2.309] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stern AF. The hospital anxiety and depression scale . Occupational Medicine 2014; 64 ( 5 ):393-4. [DOI: 10.1093/occmed/kqu024] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Sterne 2019

• Sterne, JA, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al . RoB 2: a revised tool for assessing risk of bias in randomised trials . BMJ 2019; 28 :366. [ PubMed ] [ Google Scholar ]

Strupp 1984

• Strupp HH, Binder JL. Psychotherapy in a new key: a guide to time-limited dynamic psychotherapy . Basic Books, 1984. [ Google Scholar ]

Turner 2009

• Turner JS, Leach DJ. Brief behavioural activation treatment of chronic anxiety in an older adult . Behaviour Change 2009; 26 ( 3 ):214-22. [ Google Scholar ]

Uphoff 2020

• Uphoff E, Ekers D, Robertson L, Dawson S, Sanger E, South E, et al. Behavioural activation therapy for depression in adults . Cochrane Database of Systematic Reviews 2020, Issue 7 . Art. No: CD013305. [DOI: 10.1002/14651858.CD013305.pub2] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Waldock 2015

• Waldock H, Callaghan P. Common mental disorders. In: Oxford Handbook of Mental Health Nursing . Oxford University Press, 2015:177-222. [ Google Scholar ]
• Ware JE Jr, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36): I. Conceptual Framework and Item Selection . Medical Care 1992; 30 ( 6 ):473-83. [ PubMed ] [ Google Scholar ]

Weissman 2008

• Weissman MM, Markowitz JC, Klerman G. Comprehensive guide to interpersonal psychotherapy . Basic Books, 2008. [ Google Scholar ]
• World Health Organization. The ICD-10 classification of mental and behavioural disorders . Geneva: World Health Organization, 1992. [ Google Scholar ]
• World Health Organization. International Classification of Diseases 11th Revision . Geneva: World Health Organization, 2021. [ Google Scholar ]

Williams 1997

• Williams JMG. Specific problems and disorders: depression. In: Clark DM, Fairburn CG, editors(s). Science and Practice of Cognitive Behaviour Therapy . Oxford University Press, 1997:259-84. [ Google Scholar ]
• Xiong P, Liu M, Liu B, Hall BJ. Trends in the incidence and DALYs of anxiety disorders at the global, regional, and national levels: estimates from the Global Burden of Disease Study 2019 . Journal of Affective Disorders 2022; 297 :83-93. [DOI: 10.1016/j.jad.2021.10.022] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Jump to navigation

• Bahasa Malaysia

Behavioural activation therapy for depression in adults with long-term physical conditions

Depression is common in adults with long-term physical conditions. Long-term physical illnesses, such as cardiovascular disease, diabetes, cancer, or chronic respiratory conditions, can impact on mental health. Mental health problems can also affect how people cope with a physical condition. Behavioural activation is a type of talking therapy used to treat depression in adults and it could be an alternative to other psychological therapies or medication. This review assesses the effects of behavioural activation on depression for people with long-term physical conditions.

We included randomised controlled trials (RCTs) of behavioural activation with adults who were diagnosed with depression and cardiovascular disease, diabetes, cancer, or a chronic respiratory condition. An RCT is a study with a control group, in which participants are allocated to the treatment and control groups at random. We searched a variety of online databases, including regional databases and trial registries. The search, conducted on 4 October 2019, identified 6066 records. After screening records, we included two studies in this review and 181 participants contributed data to the analyses.

Both studies recruited participants from US hospitals. One study included participants recovering from a stroke and the other included women with breast cancer. In both studies, participants received behavioural activation delivered in eight weekly, face-to-face sessions. One study compared behavioural activation with poststroke treatment as usual, while the other compared behavioural activation with problem-solving therapy, a talking therapy.

Low to moderate-certainty evidence suggested that behavioural activation may be more effective in the treatment of depression than included comparators, but these estimates were imprecise and effects were reduced in the longer term. There was no evidence of any differences between groups in the number of people who dropped out of the studies, depression symptoms, quality of life, physical functioning, or anxiety symptoms. The studies did not report on side effects during the study period.

There were several limitations to the included studies. In both studies, participants were aware of the treatment they received. Also, researchers were involved in the design of the intervention in both studies, and may, therefore, have had an interest in a favourable outcome for behavioural activation. In one study, missing data caused by participants dropping out of the study may have influenced results.

We did not find enough evidence in this review to know whether behavioural activation should be used to treat depression in adults with long-term physical conditions.

Evidence from this review was not sufficient to draw conclusions on the efficacy and acceptability of behavioural activation for the treatment of depression in adults with NCDs. A future review may wish to include, or focus on, studies of people with subthreshold depression or depression symptoms without a formal diagnosis, as this may inform whether behavioural activation could be used to treat mild or undiagnosed (or both) depressive symptoms in people with NCDs. Evidence from low-resource settings including low- and middle-income countries, for which behavioural activation may offer a feasible alternative to other treatments for depression, would be of interest.

Depression is common in people with non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. The co-existence of depression and NCDs may affect health behaviours, compliance with treatment, physiological factors, and quality of life. This in turn is associated with worse outcomes for both conditions. Behavioural activation is not currently indicated for the treatment of depression in this population in the UK, but is increasingly being used to treat depression in adults.

To examine the effects of behavioural activation compared with any control group for the treatment of depression in adults with NCDs.

To examine the effects of behavioural activation compared with each control group separately (no treatment, waiting list, other psychological therapy, pharmacological treatment, or any other type of treatment as usual) for the treatment of depression in adults with NCDs.

We searched CCMD-CTR, CENTRAL, Ovid MEDLINE, Embase, four other databases, and two trial registers on 4 October 2019 to identify randomised controlled trials (RCTs) of behavioural activation for depression in participants with NCDs, together with grey literature and reference checking. We applied no restrictions on date, language, or publication status to the searches.

We included RCTs of behavioural activation for the treatment of depression in adults with one of four NCDs: cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. Only participants with a formal diagnosis of both depression and an NCD were eligible. Studies were included if behavioural activation was the main component of the intervention. We included studies with any comparator that was not behavioural activation, and regardless of reported outcomes.

We used standard methodological procedures expected by Cochrane, including independent screening of titles/abstracts and full-text manuscripts, data extraction, and risk of bias assessments in duplicate. Where necessary, we contacted study authors for more information.

We included two studies, contributing data from 181 participants to the analyses.

Both studies recruited participants from US hospital clinics; one included people who were recovering from a stroke and the other women with breast cancer. For both studies, the intervention consisted of eight weeks of face-to-face behavioural therapy, with one study comparing to poststroke treatment as usual and the other comparing to problem-solving therapy.

Both studies were at risk of performance bias and potential conflict of interest arising from author involvement in the development of the intervention. For one study, risks of selection bias and reporting bias were unclear and the study was judged at high risk of attrition bias.

Treatment efficacy (remission) was greater for behavioural activation than for comparators in the short term (risk ratio (RR) 1.53, 95% confidence interval (CI) 0.98 to 2.38; low-certainty evidence) and medium term (RR 1.76, 95% CI 1.01 to 3.08; moderate-certainty evidence), but these estimates lacked precision and effects were reduced in the long term (RR 1.42, 95% CI 0.91 to 2.23; moderate-certainty evidence). We found no evidence of a difference in treatment acceptability in the short term (RR 1.81, 95% CI 0.68 to 4.82) and medium term (RR 0.88, 95% CI 0.25 to 3.10) (low-certainty evidence).

There was no evidence of a difference in depression symptoms between behavioural activation and comparators (short term: MD –1.15, 95% CI –2.71 to 0.41; low-certainty evidence). One study found no difference for quality of life (short term: MD 0.40, 95% CI –0.16 to 0.96; low-certainty evidence), functioning (short term: MD 2.70, 95% CI –6.99 to 12.39; low-certainty evidence), and anxiety symptoms (short term: MD –1.70, 95% CI –4.50 to 1.10; low-certainty evidence).

Neither study reported data on adverse effects.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Behavioral activation and problem-solving therapy for depressed breast cancer patients: preliminary support for decreased suicidal ideation

Affiliation.

• 1 The University of Tennessee-Knoxville, TN, USA.
• PMID: 23990646
• DOI: 10.1177/0145445513501512

Major depressive disorder (MDD) is the most common psychiatric disorder in breast cancer patients. The prevalence of suicidal ideation in breast cancer patients is considerable, and relative to the general population, the prevalence of completed suicide is elevated, particularly in cancer patients with MDD. A major component of suicide prevention is effective treatment of MDD. Although some research has explored the utility of psychotherapy with breast cancer patients, only three trials have explored the benefits of behavior therapy in patients with well-diagnosed MDD and there has been no systematic investigation of the potential benefits of psychotherapy toward reducing suicidal ideation in breast cancer patients. As a follow-up to a recently completed randomized trial, this study examined the efficacy of 8 weeks of behavioral activation treatment for depression (BATD) and problem-solving therapy (PST) in reducing depression and suicidal ideation, as well as increasing hopefulness in breast cancer patients with MDD (n = 80). Across both treatments, GEE analyses revealed decreased depression and suicidal ideation and increased hopefulness at posttreatment, results that were maintained at 12-month follow-up. Moreover, follow-up patient contact at approximately 2 years posttreatment yielded no indication of completed suicide. Although these data are preliminary, BATD and PST may represent practical approaches to decrease suicidal ideation in depressed breast cancer patients.

Keywords: behavioral activation; breast cancer; depression; problem-solving therapy; suicide.

PubMed Disclaimer

Similar articles

• Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: randomized trial. Hopko DR, Armento ME, Robertson SM, Ryba MM, Carvalho JP, Colman LK, Mullane C, Gawrysiak M, Bell JL, McNulty JK, Lejuez CW. Hopko DR, et al. J Consult Clin Psychol. 2011 Dec;79(6):834-49. doi: 10.1037/a0025450. Epub 2011 Oct 10. J Consult Clin Psychol. 2011. PMID: 21988544 Clinical Trial.
• Problem-Solving Therapy Reduces Suicidal Ideation In Depressed Older Adults with Executive Dysfunction. Gustavson KA, Alexopoulos GS, Niu GC, McCulloch C, Meade T, Areán PA. Gustavson KA, et al. Am J Geriatr Psychiatry. 2016 Jan;24(1):11-17. doi: 10.1016/j.jagp.2015.07.010. Epub 2015 Jul 30. Am J Geriatr Psychiatry. 2016. PMID: 26743100 Free PMC article. Clinical Trial.
• Effect of Problem-Solving Therapy on Depressed Low-Income Homebound Older Adults' Death/Suicidal Ideation and Hopelessness. Choi NG, Marti CN, Conwell Y. Choi NG, et al. Suicide Life Threat Behav. 2016 Jun;46(3):323-36. doi: 10.1111/sltb.12195. Epub 2015 Oct 12. Suicide Life Threat Behav. 2016. PMID: 26456016 Free PMC article.
• A Southeast Asian expert consensus on the management of major depressive disorder with suicidal behavior in adults under 65 years of age. Chee KY, Muhdi N, Ali NH, Amir N, Bernardo C, Chan LF, Ho R, Ittasakul P, Kwansanit P, Mariano MP, Mok YM, Tran DT, Trinh TBH. Chee KY, et al. BMC Psychiatry. 2022 Jul 21;22(1):489. doi: 10.1186/s12888-022-04140-6. BMC Psychiatry. 2022. PMID: 35864465 Free PMC article. Review.
• Suicidal crises in unipolar depression: How do non-drug interventions impact their management? IQWiG Reports – Commission No. HT17-03 [Internet]. [No authors listed] [No authors listed] Cologne (Germany): Institute for Quality and Efficiency in Health Care (IQWiG); 2020 Oct 8. Cologne (Germany): Institute for Quality and Efficiency in Health Care (IQWiG); 2020 Oct 8. PMID: 33175482 Free Books & Documents. Review.
• Efficacy of behavioural activation in the treatment of negative symptoms in people with schizophrenia spectrum disorders: A systematic review. Muyambi K, Walsh S, Dan Bressington, Gray R, Dennis S, Brown E, Grimshaw M, Drummond J, Jones M. Muyambi K, et al. Int J Nurs Stud Adv. 2023 May 15;5:100132. doi: 10.1016/j.ijnsa.2023.100132. eCollection 2023 Dec. Int J Nurs Stud Adv. 2023. PMID: 38746587 Free PMC article. Review.
• Suicidal ideation in Chinese patients with advanced breast cancer: a multi-center mediation model study. Zhang Y, He Y, Pang Y, Su Z, Wang Y, Zhou Y, Lu Y, Jiang Y, Han X, Song L, Wang L, Li Z, Lv X, Wang Y, Yao J, Liu X, Zhou X, He S, Song L, Li J, Wang B, Tang L. Zhang Y, et al. BMC Psychol. 2024 Mar 12;12(1):139. doi: 10.1186/s40359-024-01607-x. BMC Psychol. 2024. PMID: 38475847 Free PMC article.
• A Narrative Review of Empirical Literature of Behavioral Activation Treatment for Depression. Wang X, Feng Z. Wang X, et al. Front Psychiatry. 2022 Apr 25;13:845138. doi: 10.3389/fpsyt.2022.845138. eCollection 2022. Front Psychiatry. 2022. PMID: 35546948 Free PMC article. Review.
• Cognitive Behavioral Therapy plus Coping Management for Depression and Anxiety on Improving Sleep Quality and Health for Patients with Breast Cancer. Lai HL, Chen CI, Lu CY, Huang CY. Lai HL, et al. Brain Sci. 2021 Dec 8;11(12):1614. doi: 10.3390/brainsci11121614. Brain Sci. 2021. PMID: 34942916 Free PMC article.
• Interventions for Reducing Suicide Risk in Cancer Patients: A Literature Review. Bulotiene G, Pociute K. Bulotiene G, et al. Eur J Psychol. 2019 Sep 27;15(3):637-649. doi: 10.5964/ejop.v15i3.1741. eCollection 2019 Sep. Eur J Psychol. 2019. PMID: 33680150 Free PMC article.

Publication types

• Search in MeSH

Related information

Linkout - more resources, full text sources.

• Ovid Technologies, Inc.

Other Literature Sources

• scite Smart Citations
• Genetic Alliance
• MedlinePlus Health Information

Research Materials

• NCI CPTC Antibody Characterization Program

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.