How Does Behavioural Activation Work? A Systematic Review of the Evidence on Potential Mediators
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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.
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Avoidance is a risk factor for depression, anxiety, and stress, which can negatively impact the reward system and self-efficacy.
“Existing literature in behavioral activation also supports this view, identifying the avoidance as a risk factor for depression, anxiety, and stress, which can negatively impact the reward system and self-efficacy.58”
From Differential associations of Acceptance and Commitment Therapy processes with psychological distress across racial groups. (2026) · cites this paper as [58]
The “Looking beyond the BA Theory” section reports reduced reward-system function in depressed patients, and “Competing Theories” discusses self-efficacy in relation to behavioural activation for depression. Neither section identifies avoidance as a risk factor for depression, anxiety, or stress, or links avoidance to changes in reward processing or self-efficacy. The only exact mention of avoidance found is in a reference title. (LLM, conf=0.78)
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- Authors
- Janssen, N. P., Hendriks, G.-J., Baranelli, C. T., Lucassen, P., Oude Voshaar, R., Spijker, J., & Huibers, M. J. H.
- Affiliations
- Radboud University Nijmegen (NL)
- Radboud University Medical Center (NL)
- Vrije Universiteit Amsterdam (NL)
- Venue
- Psychotherapy and Psychosomatics
- Publisher
- S. Karger AG
- Published
- 2020-09-08
- Volume
- 90
- Issue
- 2
- Pages
- 85-93
- ISSN
- 0033-3190 (ISSN-L)
- 1423-0348
- OpenAlex
- W3084264570
- Cited by
- 71
- References
- 67
- Citations by year
- 2026: 10 · 2025: 10 · 2024: 11 · 2023: 20 · 2022: 15 · 2021: 5
- FWCI
- 1.46
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Psychotherapy and Psychosomatics (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (publishedVersion, cc-by-nc-nd)
- Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
- Radboud Repository (Radboud University) (submittedVersion)
- VU Research Portal (submittedVersion, other-oa)
- Radboud Repository (Radboud University) (submittedVersion, other-oa)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, cc-by-nc-nd)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
- Keywords
- behavioral activation, depression, therapeutic mechanisms, mediators, activation, environmental reward, reward motivation, mediation analysis
- MeSH terms
- Humans, Prospective Studies, Surveys and Questionnaires, Treatment Outcome
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