Not all clients benefit from behavioral activation.This was the case with one of my clients, Sam. When we were setting goals, I asked him, “How would your life look different if you were not depressed?” Sam told me that absolutely nothing would be different.
My client Charlie had a stressful situation with the doorman at his friends’ apartment building. He was asked to sign in, which he did not want to do and hadn’t had to do in the past, and assumed the doorman was wielding his power.
The following blog was written by a research assistant who had been exposed to CBT in her job. She had recently attended the Depression and Suicidality workshop at the Beck Institute.
Depressed clients often isolate themselves from others and withdraw from life. A depressed client of mine I’ll call Adam did exactly this. He began feeling depressed after his marriage ended. He stopped responding to calls and social invitations from friends and family members. He also stopped going to the gym and gave up his favorite hobby, golfing. When clients withdraw from life, they give up any chance of meaningful or pleasurable experiences, so their depression is more likely to continue and become more intense.
To counter the isolation and withdrawal common to depression, therapists can introduce behavioral activation. This strategy entails getting clients more active and involved in life by scheduling activities that have the potential to improve their mood. Research suggests that behavioral activation alone is an evidence-based treatment for depression, and may be particularly well-suited for chronically depressed clients (Sturmey, 2009). The following tip from the Beck Institute therapists can help make behavioral activation even more effective.
It’s important to focus on valued or meaningful activities instead of, or in addition to pleasurable activities as part of behavioral activation. Many depressed clients (especially those with chronic or severe depression) state that there aren’t any activities that give them a sense of pleasure. They may also come to the following session feeling frustrated and hopeless because they didn’t enjoy the activities as much as they had before they became depressed, or they didn’t enjoy them at all. While emotions and moods are temporary, values tend to be more stable and can serve as a guide for behavioral activation. We can obtain the client’s values by listing different value categories and then asking the client to rate the strength of each category from 0 (not valuing it at all) to 10 (the most they can value something). The categories we include are work, self-education/learning, volunteering, intimacy, family, friendship, religion/spirituality, entertainment/recreation, and health/fitness. Adam’s most valued categories were friendship (10), family (9), recreation/entertainment (8), and health/fitness (8).
The client’s value ratings indicate the best place to begin with behavioral activation. Start with the highest value rating, which, for Adam, was friendship. We ask our clients, “Why is [the value] important to you?” Adam responded that friendship was important to him because it provided mutual support and shared experiences. We then ask the client to list specific, concrete activities that make up the value category. For friendship, Adam’s list of activities included: poker night, golfing, watching sports together, going out to dinner, and regular phone calls. We then repeat these steps for the remaining high value categories. Typically, we won’t ask about a category if the client rated it below a 5 out of 10.
Finally, we help the client decide which valued activities to engage in. Instead of telling the client what to do, we collaboratively ask the client which activities they want to schedule. In his friendship category, Adam decided to call his friend, Matt, to inform him that he would be attending their weekly poker night on Wednesday. During poker night, Adam decided to seek support from his friends by talking about having a difficult time after his divorce and making additional plans for the weekend with whoever was available. He agreed to suggest they play a round of golf on Sunday.
Sturmey, P. (2009). Behavioral activation is an evidence-based treatment for depression. Behavior Modification, 33, 818-829.
Learn more about treating depression at the CBT for Depression and Suicide workshop.
Aaron T. Beck and Keith Bredemeier – Department of Psychiatry, University of Pennsylvania
We propose that depression can be viewed as an adaptation to conserve energy after the perceived loss of an investment in a vital resource such as a relationship, group identity, or personal asset. Tendencies to process information negatively and experience strong biological reactions to stress (resulting from genes, trauma, or both) can lead to depressogenic beliefs about the self, world, and future. These tendencies are mediated by alterations in brain areas/networks involved in cognition and emotion regulation. Depressogenic beliefs predispose individuals to make cognitive appraisals that amplify perceptions of loss, typically in response to stressors that impact available resources. Clinical features of severe depression (e.g., anhedonia, anergia) result from these appraisals and biological reactions that they trigger (e.g., autonomic, immune, neurochemical). These symptoms were presumably adaptive in our evolutionary history, but are maladaptive in contemporary times. Thus, severe depression can be considered an anachronistic manifestation of an evolutionarily based “program.”
Background: Major depressive disorder (MDD) causes a massive disease burden worldwide. Cognitive behavioural therapy (CBT) is an important treatment approach for depression. Cost-utility analysis (CUA) is a method to support decisions on efficient allocation of resources in health policy. The objective of our study was to systematically review CUA of CBT in the treatment of patients suffering from MDD.
Methods: We conducted a systematic literature search in Medline, Embase, PsycINFO and National Health Service Economic Evaluation Database (NHS EED) to identify CUA of CBT for MDD. Cost data were inflated to the year 2011 and converted into USD using purchasing power parities (USD PPP) to ensure comparability of the data. Quality assessment of CUA was performed.
Results: Twenty-two studies were included in this systematic review. No study employed a time horizon of more than 5 years. In most studies, individual and group CBT as well as CBT for maintenance showed acceptable incremental cost-utility ratios (<50,000 USD PPP/quality-adjusted life year). The CUA results of CBT for children and adolescents and of computerized CBT were inconsistent.
Discussion: We found consistent evidence that individualized CBT is cost-effective from the perspective of a third-party payer for short-term treatment and for relapse prevention of MDD in the adult population.
Brettschneider C., Djadran H., Härter M., Löwe B., Riedel-Heller S., & König H.H. (January 2015). Cost-utility analyses of cognitive-behavioral therapy of depression: A systematic review. Psychotherapy and Psychosomatics (84), 1, 6-21.
Adolescents whose parents have a history of depression are at risk for developing depression and functional impairment. The long-term effects of prevention programs on adolescent depression and functioning are not known.
To determine whether a cognitive-behavioral prevention (CBP) program reduced the incidence of depressive episodes, increased depression-free days, and improved developmental competence 6 years after implementation.
Design, Setting, and Participants
A 4-site randomized clinical trial compared the effect of CBP plus usual care vs usual care, through follow-up 75 months after the intervention (88% retention), with recruitment from August 2003 through February 2006 at a health maintenance organization, university medical centers, and a community mental health center. A total of 316 participants were 13 to 17 years of age at enrollment and had at least 1 parent with current or prior depressive episodes. Participants could not be in a current depressive episode but had to have subsyndromal depressive symptoms or a prior depressive episode currently in remission. Analysis was conducted between August 2014 and June 2015.
The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Usual care consisted of any family-initiated mental health treatment.
Main Outcomes and Measures
The Depression Symptoms Rating scale was used to assess the primary outcome, new onsets of depressive episodes, and to calculate depression-free days. A modified Status Questionnaire assessed developmental competence (eg, academic or interpersonal) in young adulthood.
Over the 75-month follow-up, youths assigned to CBP had a lower incidence of depression, adjusting for current parental depression at enrollment, site, and all interactions (hazard ratio, 0.71 [95% CI, 0.53-0.96]). The CBP program’s overall significant effect was driven by a lower incidence of depressive episodes during the first 9 months after enrollment. The CBP program’s benefit was seen in youths whose index parent was not depressed at enrollment, on depression incidence (hazard ratio, 0.54 [95% CI, 0.36-0.81]), depression-free days (d = 0.34, P = .01), and developmental competence (d = 0.36, P = .04); these effects on developmental competence were mediated via the CBP program’s effect on depression-free days.
Conclusions and Relevance
The effect of CBP on new onsets of depression was strongest early and was maintained throughout the follow-up period; developmental competence was positively affected 6 years later. The effectiveness of CBP may be enhanced by additional booster sessions and concomitant treatment of parental depression.
Brent, D. A., Brunwasser, S. M., Hollon, S. D., Weersing, V. R., Clarke, G. N., Dickerson, J. F., Beardslee, W. R., … Garber, J. (January 01, 2015). Effect of a cognitive-cehavioral prevention program on depression 6 years after implementation among at-risk adolescents: A randomized clinical trial. Jama Psychiatry, 72, 11, 1110-8.
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