While CT has a good track record as a treatment for depression, questions have been raised regarding whether the "cognitive" component of CT is really necessary. A component analysis of CT (Jacobson, et al, 1996) found that the behavioral activation (BA) component of CT alone produced as much change as the entire CT package and did not have a higher relapse rate over a two-week follow-up (Gortner, et al, 1998). A recent study (Dimidjian, et al, 2006) has followed up on these provocative findings with a randomized trial comparing BA, CT, and antidepressant medication to a pill placebo in treating depression. 241 adults who met DSM criteria for Major Depression were recruited, screened, and then assigned randomly to one of the four conditions.

The BA treatment was based on the behavioral interventions recommended in Beck's CT of Depression but included an additional emphasis on counteracting avoidance behaviors and included behavioral strategies targeting rumination. The central idea behind the BA model is that when individuals avoid distressing situations, the demands of daily life, distressing thoughts and feelings, etc., this may minimize distress in the short term but reduces opportunities to contact potentially antidepressant environmental reinforcers and creates or exacerbates problems as a side effect of decreased activity. Dimidjian et al (2006) write "suppose a patient responds to conflict with a coworker by avoiding work for multiple days. Although this avoidance minimizes aversive interactions with her coworker, the patient also misses the experience of accomplishing tasks at work, which has served an antidepressant function for her in the past. Staying home also creates new problems, such as earning less money and engendering frustration on the part of her supervisor, while doing nothing to address the original problem with the coworker. To interrupt this cycle, the BA model uses focused activation strategies to explicitly target such avoidance patterns and associated functional consequences." Interventions included self-monitoring, structuring and scheduling daily activities, rating the degree of pleasure and accomplishment experienced when engaged in daily activities, exploring alternative behaviors relevant to accomplishing personal goals, and using role-play to address skill deficits. There was an increased focus on assessing and treating avoidance behaviors, establishing and maintaining regularized routines, and behavioral strategies for targeting ruminations. These strategies consisted of an emphasis on the function (and consequences) of rumination and on shifting attention from rumination to a focus on immediate, direct experience. The BA condition did not include any interventions that explicitly attempted to identify dysfunctional cognitions and change their content.

The CT treatment was standard CT for depression as described by A. T. Beck et al (1979) and J. Beck (1995). Therapists could utilize the full range of behavioral activation strategies described in these texts but not the BA strategies targeting avoidance behavior and targeting ruminations described in the previous paragraph. CT strategies were used in the integrative way that they normally are, not the sequential manner that was requires in the Jacobson, et al study. Both treatments met twice weekly for 8 weeks then once weekly for 8 weeks for a maximum of 24 sessions.

It is interesting that no results were reported comparing the effectiveness of the treatments over all of the subjects. Subjects were divided into "high severity" and "low severity" groups on the basis of pre-treatment scores on the Hamilton Rating Scale for Depression (HRSD ≥ 20 and HRSD ≤ 19 respectively). Results were reported separately for the "high severity" group and the "low severity" group. Note that both groups were clinically depressed. The "high severity" group had a mean BDI score of 35.3 while the "low severity" group had a mean BDI score of 27.6. From now on I'll refer to the "high severity" group as severely depressed and the "low severity" group as moderately depressed because those labels seem more accurate to me.

When the data was analyzed in terms of level of depression (BDI scores and HRSD scores), for the moderately depressed group, all treatments were effective (mean post-treatment BDIs ranged from 7.9 to 11) and there were no significant between-treatment differences in effectiveness. For the severely depressed group, all treatments were effective but BA and medication were significantly more effective than CT (post-treatment BDIs were 8.75 and 7.78 respectively compared with CT's 17.44). The poor performance of CT relative to BA and medication was partly due to a sub-group of extreme non-responders. In the severely depressed group, 7 of the CT participants had BDI scores greater than 30 at post-test, the other 18 did much better. The average post-test BDI for the group of severely depressed individuals who responded to CT was not reported but according to my math it should have been less than 12.55.

When the data for the severely depressed group was analyzed in terms of rates of response to treatment and rates of remission rather than in terms of level of depression, there were no significant differences between treatments but there was a non-significant trend for BA to produce superior results on one of two measures. With the moderately depressed group, there were no significant differences between treatments.

There are several things that would be useful to know in trying to interpret the relevance of these findings to clinical practice. First, it would be interesting to know if BA was superior to CT overall, but unfortunately that result is not reported. It also would be very interesting to know something about the characteristics of the subgroup of the severely depressed individuals who did not respond to CT but that data is not reported. It also would be really, really interesting to know if the CT received by the non-responders differed in any identifiable way from the CT received by the responders. Finally, it would be useful to know what the CT therapists did with the individuals who were not responding to CT after six sessions or so. Normally, when a depressed individual is not responding to CT we'd revisit our conceptualization, we'd focus more on behavioral interventions, and we'd consider antidepressant medication. We know that therapists in this study didn't add antidepressant medication (since that wasn't allowed) but there is no mention of how they did deal with non-responders.


So, do these findings mean that we should quit doing CT and switch to BA? Note that BA was only superior with the seriously depressed individuals and was no better than CT with the moderately depressed individuals. Also note that a small sub-group of non-responders seems to account for much of the difference in effectiveness between BA and CT with the severely depressed individuals. The authors suggest that "The results underscore the value of sustained use of simple behavioral strategies, such as goal setting, self-monitoring, activity scheduling, problem-solving, and graded task assignment in the treatment of depression." They also observe that "A. T. Beck and colleagues (1979) have long suggested that therapists focus on behavioral strategies early in treatment when patients are more depressed and return to that emphasis later if patients start to worsen." I would agree whole-heartedly. It may be that the CT therapists became so enamored of thought sheets and rational responses that they overused these interventions and short-changed the behavioral interventions that are likely to be more effective with severe depression. However, if this happens, I'd argue that it isn't a shortcoming of CT, it is a poor implementation of CT.

It's not that I have a low opinion of BA. It clearly is an effective treatment for depressed individuals and some of the interventions that have been added in the current iteration would be useful to keep in mind when doing CT. We've focused on the role of avoidance in anxiety disorders for decades and more recently we've recognized the role of avoidance behavior in other problems. Before this article, I don't remember seeing much of a discussion of the role of avoidance behavior in depression. However, the example in paragraph 2 of this post is a good one (the individual who has a conflict with a coworker and therefore stays home from work). In situations such as this it seems obvious that we need to address the avoidance of conflict and help the individual deal with the situation in more adaptive ways. I would hope that cognitive therapists would have more sense than to spend their time generating rational responses without addressing the avoidance.

The strategies BA uses for dealing with depressive ruminations (assessing their function, pointing out the consequences of rumination, having the individual shift their focus of attention from the ruminations to immediate experience) seem like a fine way to deal with ruminations. In my mind, it raises the question of how the CT therapists in this study dealt with depressive rumination. If they were trained only in CT of depression and didn't have any training in CT for OCD or GAD (this is possible for 2 of the 3 CT therapists), they may have tried using rational responses as a way of dealing with rumination. Unfortunately, doing so usually is quite counter-productive. The BA approach is a fine way to deal with ruminations in CT but there are a number of other good options. The approach I prefer is to assess the function of the rumination, address any beliefs that encourage rumination, and then to teach the individual to replace prolonged periods of rumination with focused periods of problem-solving. Again, if CT therapists were trying to deal with ruminations by generating rational responses, this isn't a short-coming of CT, it is a poor implementation of CT.

One of the selling points of BA is that it is intended to be easier to learn than CT. Certainly, if it turns out that CT produced worse results because the CT therapists were under-utilizing behavioral interventions, over-using rational responses, or dealing with ruminations in counter-productive ways, this would support the idea that one of CT's shortcomings is that it is hard for therapists to master. The therapists in this study were trained and supervised by Steve Hollon and Keith Dobson and were certified by the Academy of Cognitive Therapy. The idea of developing a treatment protocol that is easy to teach to ordinary practitioners makes a lot of sense.

One question I have is how broadly applicable BA is. It seems to work well as a treatment for depression but many individuals seeking treatment for depression have other problems as well. For example, in this study 23.7% of participants had a concurrent anxiety disorder, 42.3% had a history of substance abuse, and 20.3% had concurrent avoidant, dependent, obsessive-compulsive, or depressive personality disorder. Does BA produce improvement on these disorders as well or do we need to train therapists in other treatment protocols if these problems are to be treated? One advantage of CT is that it is a versatile approach that can be used effectively with a wide range of problems.

What do you think about all this? (also see the thread "Is it improtant to change the client's dysfunctional cognitions? " in this forum.)