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Targeting behavioural activation better both for decreasing depression and increasing wellbeing (first post)

There are a series of meta-analyses showing that "behavioural activation" (BA) is a good treatment for depression and that it is as effective as best-established approaches like full cognitive behavioural therapy - see, for example, last year's paper by Trevor and colleagues "Behavioral activation treatments for depression in adults: a meta-analysis and review".  BA involves encouraging increased engagement in enjoyable activities.  Subjects may be asked to keep a record of their daily activities and associated feelings - for example, feelings of achievement and enjoyment.  The downloadable charts and handouts further down this website's "Problem solving and behavioural activation" page illustrate this well-known approach.

Fascinatingly Mazzuchelli et al have recently looked at the benefits of behavioural activation for encouraging wellbeing rather than just reducing depression.  In their open access paper "Behavioral activation interventions for well-being: a meta-analysis"  they write "One of the most promising ways to increase well-being is to engage in valued and enjoyable activities.  Behavioral activation (BA), an intervention approach most commonly associated with the treatment of depression, is consistent with this recommendation and can easily be adapted for non-clinical populations. This study reports on a meta-analysis of randomized controlled studies to examine the effect of BA on well-being. Twenty studies with a total of 1353 participants were included. The pooled effect size (Hedges's g) indicated that the difference in well-being between BA and control conditions at posttest was 0.52. This significant effect, which is comparable to the pooled effect achieved by positive psychology interventions, was found for non-clinical participants and participants with elevated symptoms of depression. Behavioral activation would seem to provide a ready and attractive intervention for promoting the well-being of a range of populations in both clinical and non-clinical settings."

This is very interesting and it leads me to wonder again about the possible value of going beyond a basic behavioural activation approach of simply encouraging a general increase in pleasant activities to making the encouraged activities a bit more targeted.  Three overlapping ways of making the activity encouragement more targeted are 1.)  To problem solve - so where there has been a worsening of mood or functioning, to review what has contributed to this worsening (for example, relationship or job or health factors) and use behavioural activation to target these contributing factors (for example, to resolve conflict, move beyond loss, build alternative resources/interests, and so on).  It seems likely that this type of targeting might make BA more "logical" and personalised - thus encouraging engagement and reducing drop out.  Cuijpers et al's 2008 meta-analysis "Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies" reported that "The authors conducted 7 meta-analyses (with a total of 53 studies) in which 7 major types of psychological treatment for mild to moderate adult depression (cognitive-behavior therapy, nondirective supportive treatment, behavioral activation treatment, psychodynamic treatment, problem-solving therapy, interpersonal psychotherapy, and social skills training) were directly compared with other psychological treatments."  They found that "The drop-out rate was significantly higher in cognitive-behavior therapy than in the other therapies, whereas it was significantly lower in problem-solving therapy." So one way of targeting BA better - and potentially increasing engagement - is to link it with a more personalised problem-solving approach.

As an aside, I would also point out that it may be particularly helpful to target possible interpersonal/relationship contributing factors.  So the Cuipers study (above) found that "... There was no indication that 1 of the treatments was more or less efficacious, with the exception of interpersonal psychotherapy (which was somewhat more efficacious; d = 0.20)."  Interpersonal psychotherapy focuses on factors like loss, role change, conflict and lack of social support.  The second slide in this website's handout "Life events, genetics & depression onset" highlights that of 10 key life events that can dramatically increase the chance of becoming depressed, 6 are interpersonal/relationship focused.  So one way that has a reasonable chance of making a behavioural activation approach more effective and less likely to lead to drop-out is to target BA towards factors - especially interpersonal ones - that were associated with a worsening of mood.  

In tomorrow's post "Targeting behavioural activation better both for decreasing depression and increasing wellbeing (second post)", I'll look at a couple of further ways of making behavioural activation both more targeted and also more focused on wellbeing.


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