Antidepressant medication is considered the current standard for severe depression, and cognitive therapy is the most widely investigated psychosocial treatment for depression. However, not all patients want to take medication, and cognitive therapy has not demonstrated consistent efficacy across trials. Moreover, dismantling designs have suggested that behavioral components may account for the efficacy of cognitive therapy. The present study tested the efficacy of behavioral activation by comparing it with cognitive therapy and antidepressant medication in a randomized placebo-controlled design in adults with major depressive disorder (N = 241). In addition, it examined the importance of initial severity as a moderator of treatment outcome. Among more severely depressed patients, behavioral activation was comparable to antidepressant medication, and both significantly outperformed cognitive therapy. The implications of these findings for the evaluation of current treatment guidelines and dissemination are discussed.

We dedicate this study and manuscript to the late Neil S. Jacobson, Ph.D. Dr. Jacobson was the originator of this study and shaped every aspect of its inception and implementation. His untimely death in 1999 left an irreplaceable gap, but his ideas about behavior therapy and his commitment to empirical inquiry have continued to serve as an inspiration and guide. Sandra Coffman and Christopher Martell provided onsite supervision and treatment for the cognitive therapy and behavioral activation conditions, respectively. Steve Sholl and David Kosins provided cognitive therapy. Ruth Herman-Dunn and Tom Linde provided behavioral activation therapy. Linda Cunning, Steven Dager, Kerri Halfant, Helen Hendrickson, and Alan Unis provided pharmacotherapy. Carolyn Bea and Chris Budech coordinated the pharmacotherapy conditions. Peggy Martin completed medical evaluations for the study. Lisa Roberts, and Elizabeth Shilling assisted in the coordination of the study, and David Markley assisted in the training and supervision of the clinical evaluators. Patty Bardina, Evelyn Mercier, Mandy Steiman, and Dan Yoshimoto were project evaluators. Melissa McElrea, Kim Nomensen, and Eric Gortner provided research support. Marina Smith, Jennifer Jones, Patricia Symons, Sonia Venkatraman, and Melissa Wisler conducted the adherence ratings. Virginia Rutter has been an unwavering supporter of this research, for which we are extremely grateful. NIH Public Access AbstractThis study followed treatment responders from a randomized controlled trial of adults with major depression. Patients treated with medication but withdrawn onto pill-placebo had more relapse through one year of follow-up, compared to patients who received prior behavioral activation, prior cognitive therapy, or continued medication. Prior psychotherapy was also superior to medication withdrawal in the prevention of recurrence across the second year of follow-up. Specific comparisons indicated that patients previously exposed to cognitive therapy were significantly less likely to relapse following treatment termination than patients withdrawn from medication, and patients previously exposed to behavioral activation did almost as well relative to medication withdrawal at the level of a nonsignificant trend. Differences between behavioral activation and cognitive therapy were small in magnitude and not significantly different across the full two-year follow-up, and each was at least as efficacious as continuation medication. These findings suggest that behavioral activation may be nearly as enduring as cognitive therapy, and that both psychotherapies are less expensive and longerlasting alternatives to medication in the treatment of depression. KeywordsBehavioral Activation; Cognitive Therapy; Antidepressant Medication; Major Depression; Relapse; Recurrence Antidepressant medication (ADM) has been shown to prevent the return of symptoms associated with major depression for as long as it is continued or maintained (APA, 2000). However, there is little evidence that having taken ...

Objective: We sought to evaluate two approaches with varying time and complexity in engaging adolescents with an Internet-based preventive intervention for depression in primary care. We conducted a randomized controlled trial comparing primary care physician motivational interview (MI, 10–15 minutes) + Internet program versus brief advice (BA, 2–3 minutes) + Internet program. Setting: Adolescent primary care patients in the United States, ages 14–21. Participants: 83 individuals (40% non-white) at increased risk for depressive disorders (sub-threshold depressed mood > 3–4 weeks) were randomly assigned to either the MI group (n=43) or the BA group (n=40). Main Outcome Measures: Patient Health Questionnaire (PHQ-A) – Adolescent and Center for Epidemiologic Studies Depression Scale (CES-D). Results: Both groups substantially engaged the Internet site (MI, 90.7% versus BA 77.5%). For both groups, CES-D-10 scores declined (MI, 24.0 to 17.0 p < 0.001; BA, 25.2 to 15.5, p < 0.001). The percentage of those with clinically significant depression symptoms based on CES-D-10 scores declined in both groups from baseline to twelve weeks, (MI, 52% to 12%, p < 0.001; BA, 50% to 15%, p < 0.001). The MI group demonstrated declines in self-harm thoughts and hopelessness and was significantly less likely than the BA group to experience a depressive episode (4.65% versus 22.5%, p = 0.023) or to report hopelessness (MI group of 2% versus 15% for the BA group, p=0.044) by twelve weeks. Conclusions: An Internet-based prevention program in primary care is associated with declines in depressed mood and the likelihood of having clinical depression symptom levels in both groups. Motivational interviewing in combination with an Internet behavior change program may reduce the likelihood of experiencing a depressive episode and hopelessness.

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This study presents 2-year follow-up data of a comparison between complete cognitive-behavioral therapy for depression (CT) and its 2 major components: behavioral activation and behavioral activation with automatic thought modification. Data are reported on 137 participants who were randomly assigned to 1 of these 3 treatments for up to 20 sessions with experienced cognitive-behavioral therapists. Long-term effects of the therapy were evaluated through relapse rates, number of asymptomatic or minimally symptomatic weeks, and survival times at 6-, 12-, 18-, and 24-month follow-ups. CT was no more effective than its components in preventing relapse. Both clinical and theoretical implications of these findings are discussed.

The structure of evaluative space shapes emotional life. Although behavior may be constrained to a single bipolar dimension, for example as defined by the opposing movements of approach and withdrawal, the mechanisms underlying the affect system must be capable of an astonishing range of emotional experience and expression. The model of evaluative space (ESM; J. T. Cacioppo, W. L. Gardner, & G. G. Berntson, 1997, 1999) proposes that behavioral predispositions are the ultimate output of the affect system, which is defined by operating characteristics that differ both for positivity and negativity, as well as across levels of the nervous system. In this article, we outline the current status of theory and research on the structure of evaluative space. First, we summarize the basic tenets of the model, as well as recent research supporting these ideas and counterarguments that have been raised by other theorists. To address these counterarguments, we discuss the postulates of affective oscillation and calibration, two mechanistic features of the affect system proposed to underlie the durability and adaptability of affect. We summarize empirical support for the functional consequences of the principles of affective oscillation and calibration, with a focus on how oscillation and the “stickiness” of affect can lead to the emergence of ambivalence, whereas affective calibration and the flexibility of the affect system produce asymmetries in affective processing (e.g., the negativity bias). Finally, we consider the clinical implications of disorder in the structure of evaluative space for the comprehension and treatment of depression and anxiety.

We summarize and integrate research on cognitive vulnerability to depression among children and adolescents. We first review prospective longitudinal studies of the most researched cognitive vulnerability factors (attributional style, dysfunctional attitudes, and self-perception) and depression among youth. We next review research on information processing biases in youth. We propose that the integration of these two literatures will result in a more adequate test of cognitive vulnerability models. Last, we outline a program of research addressing methodological, statistical, and scientific limitations in the cognitive vulnerability literature.

This study investigates the extent to which participants with major depression differ from healthy comparison participants in the irregularities in affective information processing, characterized by deficits in facial expression recognition, intensity categorization, and reaction time to identifying emotionally salient and neutral information. Data on diagnoses, symptom severity, and affective information processing using a facial recognition task were collected from 66 participants, male and female between ages 18 and 54 years, grouped by major depressive disorder (N=37) or healthy non-psychiatric (N=29) status. Findings from MANCOVAs revealed that major depression was associated with a significantly longer reaction time to sad facial expressions compared with healthy status. Also, depressed participants demonstrated a negative bias towards interpreting neutral facial expressions as sad significantly more often than healthy participants. In turn, healthy participants interpreted neutral faces as happy significantly more often than depressed participants. No group differences were observed for facial expression recognition and intensity categorization. The observed effects suggest that depression has significant effects on the perception of the intensity of negative affective stimuli, delayed speed of processing sad affective information, and biases towards interpreting neutral faces as sad.