In this Cochrane review, we wanted to find out how well behavioural activation therapy works for depression in adults.
Why this is important
Depression is a common mental health problem that can cause a persistent feeling of sadness and loss of interest in people, activities, and things that were once enjoyable. A person with depression may feel tearful, irritable, or tired most of the time, and may have problems with sleep, concentration, and memory. These and other symptoms can make daily life more difficult than usual.
Treatments for depression include medications (antidepressants) and psychological therapies (talking therapies). Behavioural activation is a type of psychological therapy that encourages a person to develop or get back into activities which are meaningful to them. The therapy involved scheduling activities and monitoring behaviours and looking at specific situations where changing these behaviours and activities may be helpful. A therapist may support people in person, over the phone, or online, usually over multiple sessions.
It is important to know whether behavioural activation could be an effective and acceptable treatment to offer to people with depression.
What we did
In January 2020, we searched for studies of behavioural activation therapy for depression in adults (aged over 18 years). We looked for randomised controlled trials, in which treatments were given to study participants at random; these studies give the most reliable evidence.
We included 53 studies involving 5495 participants. The studies compared behavioural activation with no treatment, standard or usual care, a dummy treatment (placebo), taking medications, being on a waiting list for treatment, or other psychotherapies (cognitive behavioural therapy (CBT), third-wave CBT, humanistic therapy, psychodynamic therapy, and integrative therapy).
The studies were conducted in 14 countries; most were conducted in the USA (27 studies). Most studies lasted from four to 16 weeks.
The outcomes we focussed on were how well the treatments worked and whether they were acceptable to participants. How well treatments worked (efficacy) was measured by the number of people who responded well to treatment or no longer met criteria for depression at the end of treatment. Acceptability was measured by counting how many people dropped out during the study.
What did we find?
Behavioural activation may treat depression better than receiving usual care. We were uncertain whether behavioural activation worked better than medication or being on a waiting list, and we found no evidence for this outcome comparing behavioural activation to no treatment or placebo treatment.
We found no differences between behavioural activation and CBT in treating depression. Although we did not find enough evidence to compare behavioural activation reliably with other psychotherapies, it may work better than humanistic therapy, and we found no differences between behavioural activation and third-wave CBT or psychodynamic therapy. No evidence was available comparing behavioural activation to integrative therapies.
Behavioural activation is probably less acceptable to people than usual care. We found no differences in acceptability of behavioural activation compared with being on a waiting list, no treatment, taking antidepressants, or receiving a placebo treatment. We also found no differences in acceptability between behavioural activation and other psychotherapies studied (CBT, third-wave CBT, humanistic therapy, integrative therapies). For behavioural activation compared with psychodynamic therapy, we found no evidence on treatment acceptability.
Behavioural activation may be an effective and acceptable treatment for depression in adults. Offering this therapy in practice would give people with depression greater treatment choice, and different formats and types of delivery could be explored to meet the demand for mental health support. Our confidence in these findings is limited due to concerns about the certainty of the evidence.
Most findings were short-term, meaning that we cannot be sure behavioural activation would be helpful to people with depression in the longer term.
Certainty of the evidence
Our certainty (confidence) in the evidence is mostly low to moderate. Some findings are based on only a few studies, with poorly reported results, in which the participants knew which treatment they received. Therefore, we are not sure how reliable the results are. Our conclusions may change if more studies are conducted.
This systematic review suggests that behavioural activation may be more effective than humanistic therapy, medication, and treatment as usual, and that it may be no less effective than CBT, psychodynamic therapy, or being placed on a waiting list. However, our confidence in these findings is limited due to concerns about the certainty of the evidence.
We found no evidence of a difference in short-term treatment acceptability (based on dropouts) between behavioural activation and most comparison groups (CBT, humanistic therapy, waiting list, placebo, medication, no treatment or treatment as usual). Again, our confidence in all these findings is limited due to concerns about the certainty of the evidence.
No data were available about the efficacy of behavioural activation compared with placebo, or about treatment acceptability comparing behavioural activation and psychodynamic therapy, interpersonal, cognitive analytic and integrative therapies.
The evidence could be strengthened by better reporting and better quality RCTs of behavioural activation and by assessing working mechanisms of behavioural activation.
Behavioural activation is a brief psychotherapeutic approach that seeks to change the way a person interacts with their environment. Behavioural activation is increasingly receiving attention as a potentially cost-effective intervention for depression, which may require less resources and may be easier to deliver and implement than other types of psychotherapy.
To examine the effects of behavioural activation compared with other psychological therapies for depression in adults.
To examine the effects of behavioural activation compared with medication for depression in adults.
To examine the effects of behavioural activation compared with treatment as usual/waiting list/placebo no treatment for depression in adults.
We searched CCMD-CTR (all available years), CENTRAL (current issue), Ovid MEDLINE (1946 onwards), Ovid EMBASE (1980 onwards), and Ovid PsycINFO (1806 onwards) on the 17 January 2020 to identify randomised controlled trials (RCTs) of 'behavioural activation', or the main elements of behavioural activation for depression in participants with clinically diagnosed depression or subthreshold depression. We did not apply any restrictions on date, language or publication status to the searches. We searched international trials registries via the World Health Organization's trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished or ongoing trials.
We included randomised controlled trials (RCTs) of behavioural activation for the treatment of depression or symptoms of depression in adults aged 18 or over. We excluded RCTs conducted in inpatient settings and with trial participants selected because of a physical comorbidity. Studies were included regardless of reported outcomes.
Two review authors independently screened all titles/abstracts and full-text manuscripts for inclusion. Data extraction and 'Risk of bias' assessments were also performed by two review authors in duplicate. Where necessary, we contacted study authors for more information.
Fifty-three studies with 5495 participants were included; 51 parallel group RCTs and two cluster-RCTs.
We found moderate-certainty evidence that behavioural activation had greater short-term efficacy than treatment as usual (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.10 to 1.78; 7 RCTs, 1533 participants), although this difference was no longer evident in sensitivity analyses using a worst-case or intention-to-treat scenario. Compared with waiting list, behavioural activation may be more effective, but there were fewer data in this comparison and evidence was of low certainty (RR 2.14, 95% CI 0.90 to 5.09; 1 RCT, 26 participants). No evidence on treatment efficacy was available for behavioural activation versus placebo and behavioural activation versus no treatment.
We found moderate-certainty evidence suggesting no evidence of a difference in short-term treatment efficacy between behavioural activation and CBT (RR 0.99, 95% CI 0.92 to 1.07; 5 RCTs, 601 participants). Fewer data were available for other comparators. No evidence of a difference in short term-efficacy was found between behavioural activation and third-wave CBT (RR 1.10, 95% CI 0.91 to 1.33; 2 RCTs, 98 participants; low certainty), and psychodynamic therapy (RR 1.21, 95% CI 0.74 to 1.99; 1 RCT,60 participants; very low certainty). Behavioural activation was more effective than humanistic therapy (RR 1.84, 95% CI 1.15 to 2.95; 2 RCTs, 46 participants; low certainty) and medication (RR 1.77, 95% CI 1.14 to 2.76; 1 RCT; 141 participants; moderate certainty), but both of these results were based on a small number of trials and participants. No evidence on treatment efficacy was available for comparisons between behavioural activation versus interpersonal, cognitive analytic, and integrative therapies.
There was moderate-certainty evidence that behavioural activation might have lower treatment acceptability (based on dropout rate) than treatment as usual in the short term, although the data did not confirm a difference and results lacked precision (RR 1.64, 95% CI 0.81 to 3.31; 14 RCTs, 2518 participants). Moderate-certainty evidence did not suggest any difference in short-term acceptability between behavioural activation and waiting list (RR 1.17, 95% CI 0.70 to 1.93; 8 RCTs. 359 participants), no treatment (RR 0.97, 95% CI 0.45 to 2.09; 3 RCTs, 187 participants), medication (RR 0.52, 95% CI 0.23 to 1.16; 2 RCTs, 243 participants), or placebo (RR 0.72, 95% CI 0.31 to 1.67; 1 RCT; 96 participants; low-certainty evidence). No evidence on treatment acceptability was available comparing behavioural activation versus psychodynamic therapy.
Low-certainty evidence did not show a difference in short-term treatment acceptability (dropout rate) between behavioural activation and CBT (RR 1.03, 95% CI 0.85 to 1.25; 12 RCTs, 1195 participants), third-wave CBT (RR 0.84, 95% CI 0.33 to 2.10; 3 RCTs, 147 participants); humanistic therapy (RR 1.06, 95% CI 0.20 to 5.55; 2 RCTs, 96 participants) (very low certainty), and interpersonal, cognitive analytic, and integrative therapy (RR 0.84, 95% CI 0.32 to 2.20; 4 RCTs, 123 participants).
Results from medium- and long-term primary outcomes, secondary outcomes, subgroup analyses, and sensitivity analyses are summarised in the text.