A client-level session-by-session evaluation of behavioral activation’s mechanism of action

Abstract

Background and Objectives Our understanding of how Behavioral Activation (BA) for depression works is limited. BA is theorized to lead to changes in depression through changes in activation. While distal support for activation as a mechanism has been obtained, more research is needed before definitive conclusions can be drawn. Research on mechanism should consider the appropriate time-frame for examining changes in the theorized mechanism variable and whether the proposed mechanism is expected to exert causal influence in all BA cases. These issues were considered in the current study in which a post-hoc analysis was conducted to explore BA’s mechanism using single-subject data obtained at each session during the course of treatment. Methods Activation and depression data were obtained from a randomized-controlled trial of BA for Latinos (BAL) compared to treatment-as-usual (TAU). Cross-lagged correlations were computed to test whether activation changes preceded, co-occurred with, or lagged behind changes in depression in a sample of 21 clients (BAL n = 14; TAU n = 7). Differences among participants based on activation-depression patterns were examined. Results For 79% of the BAL sample, changes in activation preceded or co-occurred with changes in depression, while no clients in the TAU sample evidenced this pattern. Limitations Use of more proximal and objective measures of the constructs of interest and a higher dosage of BA may have served as a stronger test of the treatment’s mechanism. Conclusions More time-sensitive measurement of changes in variables of interest is needed.

Behavioural activation by mental health nurses for late-life depression in primary care: a randomized controlled trial

“…This has been demonstrated in a recent small scaled study that found that changes in activation preceded or co-occurred with changes in depression in adults, while in TAU this pattern was not found [39]. Another potential therapy-specific mechanism of BA is rumination.…”

Reward Network Modulation as a Mechanism of Change in Behavioral Activation

“…Despite initial evidence supporting the temporal relationship between activation and changes in depression symptom scores, further research is needed to fully elucidate the relationship between changes in BA and changes in symptoms. Specifically, questions remain related to the appropriate time frame required to evaluate the impact of activation and dose of BA treatment needed to make this claim (Santos et al, 2017). Temporal links between activation, reward, and changes in anhedonic symptoms may be further clarified with objective ratings of activation as well as proximal measures (Santos et al, 2017), such as momentary time sampling and electronic monitoring tools (e.g., Global Positioning System [GPS], pedometer).…”

“…In that study, availability of potential rewards at baseline predicted depressive symptoms 8 months later, an effect that was mediated by self-reported BA levels 4 months after baseline assessment. A separate study by Santos and colleagues (2017) evaluated activation and depression symptom data from an RCT comparing BA with TAU in a population of Latino immigrants. Using cross-lagged correlation analyses, results showed that the vast majority of clients receiving BA (79%) demonstrated a pattern wherein changes in activation preceded or co-occurred with changes in depression symptoms, yet no clients in the TAU condition evidenced this pattern.…”

“…Specifically, questions remain related to the appropriate time frame required to evaluate the impact of activation and dose of BA treatment needed to make this claim (Santos et al, 2017). Temporal links between activation, reward, and changes in anhedonic symptoms may be further clarified with objective ratings of activation as well as proximal measures (Santos et al, 2017), such as momentary time sampling and electronic monitoring tools (e.g., Global Positioning System [GPS], pedometer). In addition, behavioral measures of components of reward processing such as effort valuation (e.g., effort expenditure for rewards task [EEfRT]; Treadway, Buckholtz, Schwartzman, Lambert, & Zald, 2009) and reward-based learning (e.g., probabilistic reward task [PRT]; Pizzagalli, Iosifescu, Hallett, Ratner, & Fava, 2008) can provide additional specificity into the aspects of reward that are affected by BA.…”

Activity and subsequent depression levels: a causal analysis of behavioural activation group treatment with weekly assessments over 8 weeks

“…For example, changes in activity preceded depression reduction by 2 weeks in a small study (Santos et al, ), and BA predicted the decrease of depressive symptoms after 4 months (Hill, Buitron, & Pettit, ). In line with this, therapeutic compliance—operationalized as assigned activities—was positively related to subsequent depression reduction in breast cancer patients treated with BA (Ryba et al, ); however, this effect could not be shown when quantitative measures of activities were used.…”