Derek R. Hopko

Considered a third-wave behavior therapy, behavioral activation is a therapeutic process emphasizing structured attempts to increase overt behaviors likely to bring patients into contact with reinforcing environmental contingencies and corresponding improvements in thoughts, mood, and quality of life. In the past two decades, behavioral activation has emerged as an empirically supported treatment for depression that has effectively been provided to patients with diverse clinical presentations and in multiple therapeutic contexts. This chapter focuses on providing a brief historical context of behavioral activation, a description of the principles and procedures underlying contemporary behavioral activation therapies, a review of assessment strategies particularly relevant to this approach, a comprehensive analysis of treatment outcome studies, and a presentation of limitations and future directions that need to be addressed to further solidify the status of behavioral activation as an effective and feasible approach to treating clinical depression and other mental health problems.

The Institute of Medicine advocates the examination of innovative models of care to expand mental health services available for older adults. This article describes training and supervision procedures in a recent clinical trial of cognitive behavioral therapy (CBT) for older adults with generalized anxiety disorder (GAD) delivered by bachelor-level lay providers (BLPs) and to Ph.D.-level expert providers (PLPs). Supervision and training differences, ratings by treatment integrity raters (TIRs), treatment characteristics, and patient perceptions between BLPs and PLPs are examined. The training and supervision procedures for BLPs led to comparable integrity ratings, patient perceptions, and treatment characteristics compared with PLPs. These results support this training protocol as a model for future implementation and effectiveness trials of CBT for late-life GAD, with treatment delivered by lay providers supervised by a licensed provider in other practice settings.

Clinical depression affects many people and is associated with several risk factors that include being diagnosed with a serious medical illness such as breast cancer. Objectives of this chapter were to elucidate the prevalence of depression in breast cancer patients, the impact of depression as it pertains to life functioning and quality of life, highlight the bidirectional relationship of breast cancer and depression, outline assessment strategies and measurement issues relevant to assessing depression, and review the treatment outcome literature addressing the efficacy of psychosocial interventions for depressed breast cancer patients. Depression is highly prevalent among breast cancer patients, significantly impacts life functioning, may be associated with cancer progression and mortality, and is bidirectionally related to breast cancer through several pathways. Many behavioral assessment strategies may be useful for recognizing depression in breast cancer patients, and, although methodological weaknesses are evident, several psychosocial interventions show substantial promise as effective treatments for depressed breast cancer patients.

Functional neuroimaging is an innovative but at this stage underutilized method to assess the efficacy of psychotherapy for depression. Functional magnetic resonance imaging (fMRI) was used in this case study to examine changes in brain activity in a depressed breast cancer patient receiving an 8-session Behavioral Activation Treatment for Depression (BATD), based on the work of Hopko and Lejuez (2007). A music listening paradigm was used during fMRI brain scans to assess reward responsiveness at pre- and posttreatment. Following treatment, the patient exhibited attenuated depression and changes in blood oxygenation level dependence (BOLD) response in regions of the prefrontal cortex and the subgenual cingulate cortex. These preliminary findings outline a novel means to assess psychotherapy efficacy and suggest that BATD elicits functional brain changes in areas implicated in the pathophysiology of depression. Further research is necessary to explore neurobiological mechanisms of change in BATD, particularly the potential mediating effects of reward responsiveness and associated brain functioning.

Gender differences in the prevalence of depression are well documented. To further explore the relation between gender and depression, this study used daily diaries to examine gender differences within thirteen behavioral domains and whether differential frequency of overt behaviors and environmental reward mediated the relationship between gender and depression severity. The sample included 82 undergraduate students [66% females; 84% Caucasian; Mean age = 20.2 years]. Overall, females engaged in a significantly greater breadth of behavioral domains and reported a higher level of environmental reward. Females spent more time in the domains of health/hygiene, spiritual activities, and eating with others. Males spent more time in the domains of physical activity, sexual activity, and hobbies and recreational experiences. Females found social activities, passive/sedentary behaviors, eating with others, and engagement in “other” activities more rewarding. Gender had a significant direct effect on depression severity, with females reporting increased depression. This effect was attenuated by the mediator (total environmental reward) such that to the extent females exhibited increased environmental reward, the gender effect on depression was attenuated. These data support behavioral models of depression, indicate increased reinforcement sensitivity among females, and have clinical relevance in the context of assessment and behavioral activation interventions for depression.

Behavioral activation (BA) has come to be recognized as an empirically supported treatment for depression. Despite the general success of the approach, many patients experience treatment failure. Based on behavioral models of depression, we present several reasons for treatment failure in BA, including patient inability to understand and adopt the treatment rationale, lack of awareness or ability to articulate and behave according to life values, behavioral noncompliance, and ineffectiveness of contingency management to increase exposure to environmental rewards and reduce contact with both aversive environmental events and reinforcement of depressed behavior. A case study of treatment failure with a depressed breast cancer patient is presented, along with recommendations to reduce failure rates in BA. © 2011 Wiley Periodicals, Inc. J Clin Psychol: In Session 67:1–11, 2011.