Behavioural activation therapy for depression in adults
Open accessAbstract
BACKGROUND: 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. OBJECTIVES: 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. SEARCH METHODS: 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trials registries via the World Health Organization's trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished or ongoing trials. SELECTION CRITERIA: 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. DATA COLLECTION AND ANALYSIS: 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. MAIN RESULTS: 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 R
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To allow for meaningful meta-analyses in a relatively homogeneous patient population, people with comorbidities were excluded from the review.
“To allow for meaningful meta-analyses in a relatively homogeneous patient population, people with comorbidities were excluded from the review.”
From Behavioural activation therapy for depression in adults with non-communicable diseases (2020) · cites this paper as Uphoff 2020
The Comorbidity section says trials involving participants with comorbid physical or common mental disorders were eligible when the comorbidity was not the trial's focus. The review excluded trials focused on a specific comorbid population, not people with comorbidities generally. No page number is provided in our copy. (LLM, conf=0.90)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredA recent Cochrane Review of behavioural activation for adults with depression showed low- to moderate-certainty evidence that behavioural activation is as effective as most other psychological therapies and more effective than most non-active comparators.
“A recent Cochrane Review of behavioural activation for adults with depression showed low- to moderate-certainty evidence that behavioural activation is as effective as most other psychological therapies and more effective than most non-active comparators (Uphoff 2020).”
From Behavioural activation therapy for depression in adults with non-communicable diseases (2020) · cites this paper as Uphoff 2020
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredWe followed methods described in the published protocol 'Behavioural activation therapies for depression in adults' where possible.
“For consistency and to facilitate interpretation of the results of this review in the wider context of evidence on behavioural activation for depression, we followed methods described in the published protocol 'Behavioural activation therapies for depression in adults' where possible (Uphoff 2020).”
From Behavioural activation therapy for depression in adults with non-communicable diseases (2020) · cites this paper as Uphoff 2020
The review’s methods describe analyses planned under a protocol and changes made in practice (subgroup-analysis section; page unavailable). Its reference section identifies the published protocol, ‘Behavioural activation therapies for depression in adults,’ as Uphoff et al. 2019, DOI 10.1002/14651858.CD013305. The cited 2020 source is the review, not the published protocol whose methods the sentence says it followed. (LLM, conf=0.83)
Experimental — accuracy not yet measuredThis indirect evidence suggests that behavioural activation may be effective for the treatment of depression in people with NCDs, although it is not known whether evidence can be applied to this specific population.
“This indirect evidence suggests that behavioural activation may be effective for the treatment of depression in people with NCDs, although we do not currently know whether evidence can be applied to this specific population, who may face different challenges in overcoming depression.”
From Behavioural activation therapy for depression in adults with non-communicable diseases (2020) · cites this paper as Uphoff 2020
The Authors’ Conclusions (Implications for practice; page unavailable) say behavioural activation may help treat depression in adults, but confidence in the findings is limited. The Comorbidity section (page unavailable) says trials focused on people with physical comorbidities were excluded. The review therefore provides the indirect evidence described, but does not itself establish effectiveness for people with NCDs; the citing sentence appropriately acknowledges that uncertainty. (LLM, conf=0.84)
Experimental — accuracy not yet measuredSubject headings and free-text words were identified for use from previous systematic reviews (Hooper 2018; Uphoff 2020; Usmani 2017), the Information Specialist, and the project team members.
“Subject headings and free-text words were identified for use from previous systematic reviews (Hooper 2018; Uphoff 2020; Usmani 2017), the Information Specialist, and the project team members.”
From Behavioural activation therapy for depression in adults with non-communicable diseases (2020) · cites this paper as Uphoff 2020
Treatment acceptability was similar between behavioural activation and most comparison groups in the recent Cochrane Review.
“Treatment acceptability was similar between behavioural activation and most comparison groups.”
From Behavioural activation therapy for depression in adults with non-communicable diseases (2020) · cites this paper as Uphoff 2020
The recent Cochrane Review showed 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.
“It showed 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 (Uphoff 2020).”
From Behavioural activation therapy for depression in adults with non-communicable diseases (2020) · cites this paper as Uphoff 2020
One recent Cochrane Review of behavioural activation in depression for adults included evidence from 53 studies.
“One recent Cochrane Review of behavioural activation in depression for adults included evidence from 53 studies.”
From Behavioural activation therapy for depression in adults with non-communicable diseases (2020) · cites this paper as Uphoff 2020
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- Authors
- Uphoff, E., Ekers, D., Robertson, L., Dawson, S., Sanger, E., South, E., Samaan, Z., Richards, D., Meader, N., & Churchill, R.
- Affiliations
- University of York (GB)
- Lanchester Road Hospital (GB)
- University of Bristol (GB)
- McMaster University (CA)
- University of Exeter (GB)
- Centre for Reviews and Dissemination; University of York; York UK
- ORCID
- Venue
- Cochrane Database of Systematic Reviews
- Publisher
- Wiley
- Published
- 2020-07-06
- Volume
- 2020
- Issue
- 7
- Pages
- CD013305-CD013305
- ISSN
- 1361-6137 (ISSN-L)
- 1465-1858
- PMC
- PMC7390059
- OpenAlex
- W2940050455
- Cited by
- 98
- References
- 186
- Citations by year
- 2026: 12 · 2025: 13 · 2024: 33 · 2023: 14 · 2022: 12 · 2021: 8 · 2020: 6
- FWCI
- 0.79
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Cochrane Database of Systematic Reviews (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Open Research Exeter (University of Exeter) (publishedVersion)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- Figshare (submittedVersion)
- Bristol Research (University of Bristol) (submittedVersion, other-oa)
- Funders
- National Institute for Health and Care Research (NF-SI-0611-10203, 10/50/14)
- National Institutes of Health
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Keywords
- behavioral activation, depression, adults, psychotherapy, antidepressants, subthreshold depression, treatment efficacy, cost-effectiveness, relapse prevention, medication adherence, waitlist control, psychotherapy comparison, brief psychotherapy, treatment discontinuation
- MeSH terms
- Adult, Antidepressive Agents, Anxiety, Behavior Therapy, Depression, Humans, Placebos, Quality of Life, Social Adjustment, Waiting Lists, Cognitive Behavioral Therapy, Confidence Intervals, Randomized Controlled Trials as Topic, Psychotherapy, Psychodynamic
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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