Treating Depression – Re-emerging Options in Therapy
by Courtney Chorba, MPH and Beth A. D. Nolan, PhD
In PAC, we understand that depression is a clinical condition that can often accompany dementia. In treating depression, there are two, often overlapping, approaches that are backed by clinical evidence: medication and Cognitive Behavioral Therapy (CBT). While in many instances medication may be a necessary and extremely beneficial route, other therapeutic options that often supplement the medication or are used in absence of medication, can have an additive affect for the person living with depression. For some, the availability of these non-medicinal options is essential, as some medications can have side effects that are unpleasant, dangerous, and in extreme cases, life-threatening.
Behavioral Activation (BA) Therapy is a method of behavioral therapy used for treating depression. There are two foundational beliefs upon which BA is built. The first is that thoughts, behaviors, and physical symptoms are interconnected, such that altering one of these elements has the potential to change the other two. The second belief is that given the option of changing those three things (thoughts, behaviors, and physical symptoms), changing behaviors would be the most feasible. As such, BA focuses on changing or activating behaviors. In theory, activating behaviors will affect the person’s thoughts and physical symptoms. This is done through having the individual engage in positive, meaningful activities that they once enjoyed, which they now may be avoiding as a result of their depressive symptoms (e.g., spending time with friends, engaging in a hobby). As well, persons in treatment are encouraged to avoid activities that may trigger or exacerbate their depression, such as substance abuse or overeating, and replace them with positive behaviors and activities in which to engage. This is accomplished in part through scheduling activities in advance, rather than acting in accordance with a particular mood.
BA is in many ways comparable to Cognitive Behavioral Therapy (CBT), but where CBT focuses on changing thoughts as well as behaviors, BA focuses solely on changing behaviors. BA can be conducted by mental health workers with basic training, and is less intensive than CBT.
BA Therapy has been an option for some time, but recently has acquired more supporting evidence. The COBRA (Cost and Outcome of BehavioRal Activation) study (Richards, et al., 2016), conducted from 2012 – 2014 in Great Britain, compared the effectiveness of BA with CBT. Study results found BA to be just as effective in treating depression among the study sample (221 adults 18 years of age or older with major depressive disorder), and less expensive. The advantage of BA as compared to CBT from a cost-effectiveness standpoint is due to the ability of BA to be conducted by mental health workers with basic training, rather than psychotherapists with advanced training as required by CBT.
While the studies conducted on BA thus far are not without limitations, findings are still promising. For instance, one limitation with the COBRA study was that participants in both the BA and CBT groups were taking anti-depressant medication, which may have influenced results, and about one third of the participants chose not to complete the pre-planned dosage of treatment.
In PAC, we believe that filling the day with meaning matters to everyone. The evidence around the meaningful, positive activities supported in BA can be a testament to the importance in engaging in positive, meaningful occupation, and how that can have an effect on our mental and even physical well-being.
Richards, D, A., et al. (2016). Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. The Lancet, 388, 871-880.