Treating Subthreshold Depression in Primary Care: A Randomized Controlled Trial of Behavioral Activation With Mindfulness
Open accessAbstract
PURPOSE We undertook a randomized controlled trial to assess the efficacy of group-based behavioral activation with mindfulness (BAM) for treating subthreshold depression in primary care in Hong Kong. METHODS We recruited adult patients aged 18 years or older with subthreshold depression from public primary care clinics and randomly assigned them to a BAM intervention group or a usual care group. The BAM group was provided with eight 2-hour weekly BAM sessions by trained allied health care workers. Patients in the usual care group received usual medical care with no additional psychological interventions. The primary outcome was depressive symptoms measured by the Beck Depression Inventory-II at 12 months. Secondary outcomes included incidence of major depressive disorder at 12 months. We assessed quality of life, activity and circumstances change, functional impairment, and anxiety at baseline, end of intervention, 5 months, and 12 months. RESULTS We randomly allocated 115 patients to the BAM intervention and 116 patients to usual care. At 12 months, compared with usual care peers, BAM patients had a slightly more favorable change in levels of depressive symptoms on the Beck Depression Inventory-II (between-group mean difference in score = −3.85; 95% CI, −6.36 to −1.34; Cohen d = −0.46, 95% CI, −0.76 to −0.16). Incidence of major depressive disorder was lower with BAM (10.8% vs 26.8%, P = .01), whereas groups did not differ significantly on other secondary outcomes at 12 months. CONCLUSIONS Group BAM appears to be efficacious for decreasing depressive symptoms and reducing the incidence of major depression among patients with subthreshold depression in primary care, although generalizability of our findings may be limited.
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The use and exploration of mindfulness within general practice is limited.
“the use and exploration within general practice is limited [26, 27].”
From Exploring patient experiences with a mindfulness course in a general practice setting: a qualitative study. (2025) · cites this paper as [27]
The Introduction (page unavailable) says that no large study had evaluated behavioral activation combined with mindfulness and identifies a gap in research on group behavioral activation for subthreshold depression in a Chinese population. That supports limited exploration of this specific intervention, but not the broader claim that mindfulness use and exploration throughout general practice are limited. (LLM, conf=0.82)
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(2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.22.pr7
(2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.22.pr8
(2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.22.pr5
(2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.22.pr3
Cuijpers, P. J. (2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.22.pr6
(2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.22.pr4
(2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.22.pr2
Cuijpers, P. J. (2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.22.pr1
ประสทธผลของการกระตนพฤตกรรมทมตอภาวะซมเศราของผสงอาย
อยุธยา, ว. ส. ณ. (2019) · doi:10.58837/chula.the.2019.721
Associations among subthreshold depression, cognitive bias, and mentalization in university students
Zeng, Y., Liu, B., Yu, H., Jia, Y., Chen, H., Zheng, P., & Qian, H. (2025) · BMC Public Health · doi:10.1186/s12889-025-25930-z · Cited by 1 · see citing works
“Currently, interventions for subthreshold depression include CBT [69], mindfulness-based interventions [70], and group-based behavioural activation with mindfulness [71].”
Tuerxun, R., Cui, J., & Cui, L. (2025) · Psychiatric Quarterly · doi:10.1007/s11126-025-10248-1 · Cited by 1 · see citing works
Pan, D., & Rehbein, C. (2025) · Ecopsychology · doi:10.1177/19429347251406250
“…the challenges that face some NBTs. Recent research on the combination of Behavioral Activation with Mindfulness (BAM) has been shown to be specifically effective at improving depressive symptoms (McIn-doo, File, Preddy, Clark, & Hopko, 2016; Sun, Wong, Zhang, Chen, & Yip, 2021; Wong et al., 2018).”
Francisco, C., Pedro, L. M. R., Silva, C., Pereira, M., Fonseca, A., & Canavarro, M. C. (2026) · Clinical Case Studies · doi:10.1177/15346501261456300
“These criteria were determined on the basis of prior research involving subclinical populations using these instruments (e.g., Sousa et al., 2015; Wong et al., 2018).”
Clarifying Subthreshold Depression in Adolescents: A Concept Analysis for Mental Health Nursing
Li, S., Fu, Y., Cui, D., He, A., Wang, J., Wang, H., Yu, J., Li, X. Y., & Huang, J. (2026) · Issues in Mental Health Nursing · doi:10.1080/01612840.2026.2674275
“…teens might not show functional impairment through obvious withdrawal from work or school but may instead distance themselves from age-appropriate activities such as peer interactions, school involvement, and identity development (McGregor et al., 2025; Sawyer et al., 2012; Wong et al., 2018).”
- Authors
- Wong, S. Y. S., Sun, Y. Y., Chan, A. T. Y., Leung, M. K. W., Chao, D. V. K., Li, C. C. K., Chan, K. K. H., Tang, W. K., Mazzucchelli, T., Au, A. M. L., & Yip, B. H. K.
- Affiliations
- Hospital Authority (HK)
- ORCID
- Venue
- The Annals of Family Medicine
- Publisher
- Annals of Family Medicine
- Published
- 2018-03
- Volume
- 16
- Issue
- 2
- Pages
- 111-119
- ISSN
- 1544-1709 (ISSN-L)
- 1544-1717
- PMC
- PMC5847348
- OpenAlex
- W2792181444
- Cited by
- 60
- References
- 58
- Citations by year
- 2026: 3 · 2025: 7 · 2024: 2 · 2023: 23 · 2022: 4 · 2021: 8 · 2020: 6 · 2019: 4 · 2018: 3
- FWCI
- 6.16
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Locations
- The Annals of Family Medicine (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- eSpace (Curtin University) (submittedVersion)
- PolyU Institutional Research Archive (Hong Kong Polytechnic University) (submittedVersion)
- Funders
- Health and Medical Research Fund (11120501)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- subthreshold depression, behavioral activation, mindfulness, group therapy, primary care, depressive symptoms, quality of life, functional disability, anxiety
- MeSH terms
- Adult, Aged, Cost-Benefit Analysis, Depression, Major Depressive Disorder, Female, Hong Kong, Humans, Male, Middle Aged, Primary Health Care, Psychiatric Status Rating Scales, Quality of Life, Logistic Models, Mindfulness
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