A Comprehensive Review of Behavioral Activation Treatment for Depression Xiaoxia Wang1, Zhengzhi Feng2,* 1 Department of Basic P

1 A comprehensive review of behavioral activation treatment for depression 2 Xiaoxia Wang1, Zhengzhi Feng2,* 3 1 Department of Basic Psychology, College of Psychology, Army Medical University, 4 Chongqing, China 5 2 College of Psychology, Army Medical University, Chongqing, China 6 Abstract Behavioral activation (BA) treatment has evolved from a component of 7cognitive behavioral therapy (CBT) and has become standalone psychotherapy for depression. 8The rapid increasing application of tele-mental health approaches such as telephone-, internet-, 9and smartphone-based interventions with BA were emphasized. With its efficacy comparable to 10traditional CBT, and its evidenced-based cost-effectiveness, BA is promising to be developed 11into a guided self-help intervention. The efficacy across diagnoses and effective components of 12BA treatment were reviewed. With the rise of the third wave of psychotherapy, therapeutic 13components across diagnoses will be incorporated into behavioral activation therapy. However, 14extensive studies are required to examine the neural and modulatory mechanism of BA for 15depression, and to explore the feasibility and necessity of tele-mental health BA application into 16the healthcare system. 17 Keywords behavioral activation treatment; depression; tele-mental health; cost- 18effectiveness; guided self-help intervention 19 20 During its developmental process, cognitive behavioral therapy (CBT) for depression has 21gradually incorporated and integrated problem-solving therapy, self-control therapy, traditional 22cognitive therapy, and other therapeutic components [1]. The unique role of behavioral activation 23(BA) therapy has gradually been recognized, with the increasing accumulation of evidence-based 24BA for depression that systematically reinforces patients' behaviors related to environmental 25reinforcement and improves negative thinking, emotions, and overall quality of life [2]. The 26National Institute of Mental Health (NIMH) (2005) claims “behavioral activation as a more 27simply behavioral form of CBT”. Contemporary behavioral activation therapies also include 28many variations, which add certain therapeutic components to address factors that sustain or 29exacerbate depressive symptoms [3]. 30 As a behavioral therapy strategy for depression, behavioral activation is derived from 31Lewinsohn’s pleasant events scheduling [4]. Rehm proposed a self-control model of depression 32and defined self-control as the process of an individual changing their response frequency in the 33absence of immediate external support [5]. He also proposed a self-control therapy program that 34promotes cognitive and behavioral changes through self-monitoring, self-evaluation, and self- 35reinforcement [5]. 36 Beck integrated the behavioral activation strategy into the framework of cognitive 37therapy and stated that behavioral activation should be the first treatment step for depression, 38especially for severe depression. Therefore, the goal of behavioral activation should precede 11 Correspondence: Dr. Zhengzhi Feng, [email protected]. 2 1 3 39cognitive monitoring and modification. One of the contributions of Beck's cognitive therapy to 40behavioral strategies is standardizing behavioral monitoring and programs. This facilitated the 41integration of cognitive orientation and behavioral orientation and gave birth to cognitive 42behavioral therapy (CBT). 43 Behavioral activation therapy can be regarded as the return of behavioral orientation after 44CBT. David Barlow proposed that the common strategy of many psychotherapy methods is to 45adjust behavioral orientation at the time of emotional disorders—when used to treat specific 46disorders, emotional and behavioral activation is a powerful tool, especially for specific contexts. 47Hollon and Garber define behavioral activation as a series of treatment programs during 48cognitive therapy [6]. Jacobson and his colleagues used this term to describe behavioral 49interventions through cognitive therapy [7]. They analyzed the components of CBT and found for 50the first time that the treatment effect of behavioral activation was equivalent to that of CBT, 51including the three components of behavioral activation, cognitive reconstruction of automatic 52thinking, and cognitive reconstruction of core beliefs [2]. In the subsequent literature, behavioral 53activation therapy was described as a standalone therapy for depression [7]. 54 1 Psychopathological models of behavioral activation therapy 55 Studies on the causes of behavior mainly use two animal models: response-based and 56action-based model [8]. The response-based model offers a mechanistic explanation for the 57causes of behavior. It assumes that behavior occurs in response to elicited, released, or triggered 58stimuli; therefore, behavior is regarded as a type of response, including physiological reflexes, 59ecological fixed behavior patterns, and conditional and unconditional psychological responses. 60The action-based model offers a teleological explanation that behaviors are not triggered by 61stimuli but are controlled by animals' perceptions of the consequences of actions. Such behaviors 62are regarded as intentional and purpose-oriented and thus are actions. For goal-oriented systems 63(organisms), changes in motivation or a new understanding of goals and values can lead to 64changes in goals and values [8]. Both models are reflected in behavior-oriented psychopathology 65models of depression. 66 1.1 Response-based reinforcement model 67 According to the psychopathological model of depression, the loss, reduction, or long- 68term low level of positive reinforcement leads to behavioral and emotional changes in depressed 69individuals. Houston, for example, argues that the absence of reinforcement (such as foraging 70animals) or the withdrawal of reinforcement (such as expecting to be rewarded again) leads to 71the extinction of behaviors, with frustrated, emotional, and arousal behaviors such as irritability 72and attacks. Generalization of such extinction to other contexts will produce behaviors similar to 73absence of anhedonia; this behavior model is known as extinction-induced depression (EID) [9]. 74Regarding the nature of reinforcement, researchers have assumed either positive reinforcement 75or negative reinforcement. For example, Lewinsohn believes that the withdrawal/reduction in 76response-contingent positive reinforcement (RCPR) can fully explain the occurrence of 77depression [10]. Behavioral activation mediates the increase in RCPR and decrease in depressive 78symptoms [11]. Other researchers have focused on the role of negative reinforcement on 79avoidance and withdrawal. For example, Ferster argues that the withdrawal of discriminative 80stimuli can lead to avoidance and withdrawal and that depression is caused by negative 81reinforcement of avoidance and escape behavior [12, 13]. Martell also suggests that negative 4 2 5 82emotions associated with low-level positive reinforcement and aversive stimuli in the 83environment can lead to persistent and excessive avoidance/escape behavior [14]. 84 The goal of behavioral activation therapy is to enhance behavioral activation (activity), 85which then leads to more positive reinforcement to improve depressive symptoms [15]. 86Therefore, individualized behavioral activation therapy includes (1) discerning the living 87environment that induces depression—for example, a decrease in positive reinforcement of 88healthy behaviors and an increase in positive reinforcement (or negative reinforcement) of 89depressive behaviors lead to increased depression—and (2) clarifying the coping pattern that 90sustains and exacerbates depression. When depressed individuals identify environmental stimuli 91as aversive and threatening, they will adopt avoidance behaviors, i.e., trigger-response-avoidance 92pattern (TRAP), thus exhibiting less behavioral activation and more avoidance and depressive 93behaviors. Non-adaptive coping patterns will further lead to a decrease in positive reinforcement 94of healthy behaviors and an increase in positive reinforcement (or negative reinforcement) of 95depressive behaviors in the environment, leading to more depressive symptoms. Accordingly, the 96aim of behavioral activation therapy is to teach patients behavioral activation techniques, in order 97to enhance behavioral activation and reduce avoidance and depressive behaviors, thereby 98promoting the trigger-response-alternative cope (TRAC) pattern, which breaks the TRAP 99between the depressive living environment and the non-adaptive coping pattern and helps 100individuals adopt an adaptive pattern to cope with adverse stimuli. 101 1.2 Action-based models 102 With the development of cognitive neuroscience, current behavioral activation therapy is 103paying more attention to the role of cognitive components such as goals and values in activating 104behaviors. 105 According to the psychopathological models of behavioral activation therapy, two 106components may have a therapeutic effect. The first is the actual rewards received, and the 107second is the expectation of possible rewards. According to the depression decision model, the 108vigor and frequency of individual instrumental behaviors are determined in part by expectations 109of average rewards. If the expectation is low, individuals will demonstrate sloth, i.e., lower 110tendency for individual action, diminishing the individual’s ability to receive rewards and 111sustaining his/her incorrect estimate of the

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