Review article
Behavioral activation treatments of depression: A meta-analysis

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Abstract

Activity scheduling is a behavioral treatment of depression in which patients learn to monitor their mood and daily activities, and how to increase the number of pleasant activities and to increase positive interactions with their environment. We conducted a meta-analysis of randomized effect studies of activity scheduling. Sixteen studies with 780 subjects were included. The pooled effect size indicating the difference between intervention and control conditions at post-test was 0.87 (95% CI: 0.60~1.15). This is a large effect. Heterogeneity was low in all analyses. The comparisons with other psychological treatments at post-test resulted in a non-significant pooled effect size of 0.13 in favor of activity scheduling. In ten studies activity scheduling was compared to cognitive therapy, and the pooled effect size indicating the difference between these two types of treatment was 0.02. The changes from post-test to follow-up for activity scheduling were non-significant, indicating that the benefits of the treatments were retained at follow-up. The differences between activity scheduling and cognitive therapy at follow-up were also non-significant. Activity scheduling is an attractive treatment for depression, not only because it is relatively uncomplicated, time-efficient and does not require complex skills from patients or therapist, but also because this meta-analysis found clear indications that it is effective.

Introduction

It is already more than three decades ago that research showed that there is a significant relationship between mood and the number of pleasant activities engaged in (Lewinsohn and Graf, 1973, Lewinsohn and Libet, 1972, Gallagher, 1981); that depressed individuals find fewer activities pleasant, engage in pleasant activities less frequently, and obtain therefore less positive reinforcement than other individuals (MacPhillamy & Lewinsohn, 1974).

Based on these premises, Lewinsohn, Biglan and Zeiss (1976) developed a behavioral treatment of depression, in which patients learn techniques to monitor their mood and daily activities, and to see the connection between these. Then the patients learn how to develop a plan to increase number of pleasant activities and to increase positive interactions with their environment. In this approach, specific attention is paid to social skills and interactions with other people.

In the seventies and eighties, several trials were conducted in which the effects of this approach were examined (Barrera, 1979, McNamara and Horan, 1986, Zeiss et al., 1979). Most of these studies found promising results. Other cognitive behavioral treatments developed in that period integrated activity scheduling into their manual as one of the basic elements. The most important examples of these treatments include cognitive therapy as developed by Beck, Rush, Shaw and Emery (1979), and the “Coping with Depression” course, as developed by Lewinsohn, Antonuccio, Steinmetz and Teri (1984). Both treatment modalities have been examined in dozens of studies, and there is no doubt that these treatments are effective. However, it is not clear what the contribution of activity scheduling is to these effects.

Since that period, activity scheduling has not received much attention by researchers, except for an important dismantling study (Jacobson et al., 1996), and the use of activity scheduling in specific patient groups in which other psychological treatments are less feasible. In the dismantling study by Jacobson and colleagues in the nineties the core elements of cognitive behavioral treatment were compared to each other and to the full package (Jacobson et al., 1996). Although this study indicated that activity scheduling is an effective treatment for depression on its own, this has not prompted researchers to further examine the effects of this approach.

Other more recent approaches have used activity scheduling in difficult target populations, in which more complex approaches are not feasible. For example, it has been used with success in dementia patients, after the training of their caregivers in the principles of activity scheduling (Teri, Logsdon, Uomoto & McCurry, 1997). Because activity scheduling is a relatively uncomplicated and time-efficient method for treating depression, it has also been used recently with success in a pilot project with psychiatric inpatients (Hopko, Lejuez, Lepage, Hopko & McNeil, 2003).

Although activity scheduling seems to be an interesting treatment approach for depression, and recent studies show that it is a useful method for specific target populations, no formal meta-analysis of activity scheduling has been conducted until now (NICE, 2004). We decided, therefore, to conduct a meta-analysis to examine the effects of activity scheduling on depression, on the relative effects of activity scheduling compared to other treatments, and on the longer term effects.

Section snippets

Identification and selection of studies

Studies were traced by means of several methods. First, we used a large database of 777 papers on the psychological treatment of depression in general. This database was developed through a comprehensive literature search (from 1966 to March 2005) in which we examined 5178 abstracts in Pubmed (1224 abstracts), Psycinfo (1336), Embase (1118) and the Cochrane Central Register of Controlled Trials (1500). We identified these abstracts by combining terms indicative of psychological treatment

Description of studies

Sixteen studies, with a total of 780 subjects (241 in the Activity scheduling conditions, 367 in other intervention conditions, and 172 in the control conditions) met the inclusion criteria and were included in the current study. Selected characteristics of the included studies are described in Table 1.

In 10 studies, subjects were recruited from the community, while in four studies subjects were recruited from clinical settings (in the two other studies, a mixed recruitment method was used or

Discussion

We found clear indications that activity scheduling is effective in the treatment of depression in adults. The overall effect size of 0.87 is large (Lipsey & Wilson, 1993), and comparable to effect sizes found for other psychological treatments and treatment with antidepressants (Churchill et al., 2001, Gloaguen et al., 1998). The low heterogeneity in our meta-analyses indicated that the studies, target populations and interventions are probably highly comparable to each other.

Several of the

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