Abstract
BackgroundBehavioral activation (BA), either as a stand-alone treatment or as part of cognitive behavioral therapy, has been shown to be effective for treating depression. The theoretical underpinnings of BA derive from Lewinsohn et al’s theory of depression. The central premise of BA is that having patients engage in more pleasant activities leads to them experiencing more pleasure and elevates their mood, which, in turn, leads to further (behavioral) activation. However, there is a dearth of empirical evidence about the theoretical framework of BA.ObjectiveThis study aims to examine the assumed (temporal) associations of the 3 constructs in the theoretical framework of BA.MethodsData were collected as part of the “European Comparative Effectiveness Research on Internet-based Depression Treatment versus treatment-as-usual” trial among patients who were randomly assigned to receive blended cognitive behavioral therapy (bCBT). As part of bCBT, patients completed weekly assessments of their level of engagement in pleasant activities, the pleasure they experienced as a result of these activities, and their mood over the course of the treatment using a smartphone-based ecological momentary assessment (EMA) application. Longitudinal cross-lagged and cross-sectional associations of 240 patients were examined using random intercept cross-lagged panel models.ResultsThe analyses did not reveal any statistically significant cross-lagged coefficients (all P>.05). Statistically significant cross-sectional positive associations between activities, pleasure, and mood levels were identified. Moreover, the levels of engagement in activities, pleasure, and mood slightly increased over the duration of the treatment. In addition, mood seemed to carry over, over time, while both levels of engagement in activities and pleasurable experiences did not.ConclusionsThe results were partially in accordance with the theoretical framework of BA, insofar as the analyses revealed cross-sectional relationships between levels of engagement in activities, pleasurable experiences deriving from these activities, and enhanced mood. However, given that no statistically significant temporal relationships were revealed, no conclusions could be drawn about potential causality. A shorter measurement interval (eg, daily rather than weekly EMA reports) might be more attuned to detecting potential underlying temporal pathways. Future research should use an EMA methodology to further investigate temporal associations, based on theory and how treatments are presented to patients.Trial RegistrationClinicalTrials.gov, NCT02542891, https://clinicaltrials.gov/ct2/show/NCT02542891; German Clinical Trials Register, DRKS00006866, https://tinyurl.com/ybja3xz7; Netherlands Trials Register, NTR4962, https://www.trialregister.nl/trial/4838; ClinicalTrials.Gov, NCT02389660, https://clinicaltrials.gov/ct2/show/NCT02389660; ClinicalTrials.gov, NCT02361684, https://clinicaltrials.gov/ct2/show/NCT02361684; ClinicalTrials.gov, NCT02449447, https://clinicaltrials.gov/ct2/show/NCT02449447; ClinicalTrials.gov, NCT02410616, https://clinicaltrials.gov/ct2/show/NCT02410616; ISRCTN registry, ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725
Highlights
Most psychotherapeutic treatments for depression are underpinned by a clear theoretical framework of how a specific therapy is supposed to engender change in patients’ mood states
The results were partially in accordance with the theoretical framework of behavioral activation (BA), insofar as the analyses revealed cross-sectional relationships between levels of engagement in activities, pleasurable experiences deriving from these activities, and enhanced mood
In light of the fact that various psychotherapies have been proven to be effective for treating depression, one would perhaps assume that theoretical frameworks are evidence based
Summary
Most psychotherapeutic treatments for depression are underpinned by a clear theoretical framework of how a specific therapy is supposed to engender change in patients’ mood states. Conducting a verification of the underlying theoretical framework of a form of psychotherapy can help optimize treatment strategies (eg, [6,7,8,9,10]), that is, direct better, stronger, or different treatment strategies that underpin the critical processes of the treatment (eg, [6,7,8,9,10]) One such effective psychotherapeutic intervention for depression is behavioral activation (BA). BA is based on Lewinsohn et al’s [14,15] theory of depression, which purports that when a person is depressed, they tend to engage less in pleasant or meaningful activities, resulting in them experiencing less pleasure, which, in turn, leads to an increased depressed mood, and so on. There is a dearth of empirical evidence about the theoretical framework of BA
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