How Does Behavioural Activation Work? A Systematic Review of the Evidence on Potential Mediators

Abstract

Introduction: Behavioural activation is an effective treatment for depression, but little is known about its working mechanisms. Theoretically, its effect is thought to rely on an interplay between activation and environmental reward. Objective: The present systematic review examines the mediators of behavioural activation for depression. Methods: A systematic literature search without time restrictions in Medline, EMBASE, PsycINFO, The Cochrane Library, and CINAHL resulted in 14 relevant controlled and uncontrolled prospective treatment studies that also performed formal mediation analyses to investigate their working mechanisms. After categorising the mediators investigated, we systematically compared the studies’ methodological quality and performed a narrative synthesis of the findings. Results: Most studies focused on activation or environmental reward, with 21 different mediators being investigated using questionnaires that focused on psychological processes or beliefs. The evidence for both activation and environmental reward as mediators was weak. Conclusions: Non-significant results, poor methodological quality of some of the studies, and differences in questionnaires employed precluded any firm conclusions as to the significance of any of the mediators. Future research should exploit knowledge from fundamental research, such as reward motivation from neurobiology. Furthermore, the use of experience sampling methods and idiographic analyses in bigger samples is recommended to investigate potential causal pathways in individual patients.

Use of behavioural activation to manage pain: a scoping review protocol

“…A systematic review examined mediators that could explain the effectiveness of BA. 17 Fourteen studies were included: ten RCTs involving 1252 patients and four uncontrolled studies involving 94 patients. The mediators described were activity, using the BA for Depression Scale, and environmental influences, measured using the Environmental Reward Observation Scale.…”

Examining the Theoretical Framework of Behavioral Activation for Major Depressive Disorder: Smartphone-Based Ecological Momentary Assessment Study

“…Currently, there is a relative dearth of empirical evidence available concerning the assumed causal pathways in the theoretical framework of BA [10,[18][19][20]. Janssen et al [20] sought to address this gap in extant knowledge by conducting a systematic review in which they investigated the mediators of BA for depression.…”

“…Currently, there is a relative dearth of empirical evidence available concerning the assumed causal pathways in the theoretical framework of BA [10,[18][19][20]. Janssen et al [20] sought to address this gap in extant knowledge by conducting a systematic review in which they investigated the mediators of BA for depression. In this review [20], the evidence for the mediating role played by both engaging in pleasant activities and experiencing pleasure was not consistently replicated across the considered studies.…”

“…Janssen et al [20] sought to address this gap in extant knowledge by conducting a systematic review in which they investigated the mediators of BA for depression. In this review [20], the evidence for the mediating role played by both engaging in pleasant activities and experiencing pleasure was not consistently replicated across the considered studies. However, the authors did conclude that their review was not without its limitations.…”

Editorial: Contemporary Issues in Defining the Mechanisms of Cognitive Behavior Therapy

“…Various CBTs have well-documented efficacy (3,4) that have led to considerable dissemination efforts (5), but the literature on mechanisms of action is less evolved (6)(7)(8)(9). This literature can be classified into three groups: (1) research designed to identify patient features that may serve as prognostic predictors, as well as moderators or mediators of treatment effects (10-12); (2) research focused on generic relational processes in psychotherapy, such as foundational counseling skills, typically assessed as empathy, warmth, positive regard, and agreement on goals and tasks of therapy, comprising the combined construct of working alliance (13,14); as well as (3) research aiming to examine specific aspects of the delivery of CBT, such as collaborative-empiricism, Socratic dialogue (15) and facilitation of homework assignments (16,17).…”