JMIR Publications

ABSTRACT

Background:

Behavioral activation (BA), either as a stand-alone treatment or as part of cognitive behavioral therapy (CBT), has been shown to be effective for treating depression. The theoretical underpinnings of BA derive from Lewinsohn and colleagues’ 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.

Objective:

This study aims to examine the assumed temporal pathways in the theoretical framework of BA.

Methods:

Data were collected as part of the E–COMPARED trial among patients who were randomly assigned to receive blended cognitive behavioral therapy (bCBT). As part of bCBT, 240 patients completed weekly assessments of their level of engagement in pleasant activities, the pleasure they experienced as a result of these activities as well as their mood over the course of the treatment using a smartphone–based Ecological Momentary Assessment (EMA) application. Longitudinal cross–lagged and cross–sectional associations were examined using Random Intercept–Cross Lagged Panel Models (RI–CLPM).

Results:

The 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 increased slightly over the duration of the treatment. Alongside this, mood seemed to carry-over over time, while both level of engagement in activities and pleasurable experiences did not.

Conclusions:

The results were partially in accordance with the theoretical framework of BA, insofar as the analyses revealed cross–sectional relations between levels of engagement in activities, pleasurable experiences deriving from these activities and enhanced mood. However, given that no statistically significant temporal relations 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 utilize an EMA methodology to further investigate temporal associations, based on theory and how treatments are presented to patients. Clinical Trial: France: ClinicalTrials.gov, NCT02542891 (September 4th 2015); Germany: German Clinical Trials Register, DRKS00006866 (December 2nd 2014); The Netherlands: Netherlands Trials Register, NTR4962 (January 5th 2015); Poland: ClinicalTrials.Gov, NCT02389660 (February 18th 2015); Spain: ClinicalTrials.gov, NCT02361684 (January 8th 2015); Sweden: ClinicalTrials.gov, NCT02449447 (March 30th 2015); Switzerland: ClinicalTrials.gov, NCT02410616 (April 2nd 2015); United Kingdom: ISRCTN registry, ISRCTN12388725 (March 20th 2015).