Does Behavioral Activation Cure Depression?

Q: I keep hearing about antidepressants having terrible side effects. Are there any real cures for depression? – JT

Dear JT,

behavioral activation for depressionI come from hearty stock. In my family, the word “depression” refers to an economic event that coincided with the great Dust Bowl. Ah, the good old days of blinding poverty, blinding dust storms, and Grandpa hustling pool to pay the mortgage. I’m glad I showed up late.

It wasn’t until high school that I learned “depression” also describes a mood disorder. Prior to that, I understood depressive symptoms (loss of interest, feelings of hopelessness, sadness, and so on) simply as “feeling sorry for yourself.” Since every family has its own language and ours is admittedly unrefined, allow me to translate.

“Feeling sorry for yourself” (their words, not mine) is shorthand for reduced activity: oversleeping, avoiding social commitments, difficulty thinking, etc. One feature of depression is the cyclical nature of slowing down. When person begins to miss out on regular interactions and activities, he or she begins to lose the patterns and rhythms (“zeitgebers”) that make up daily life. Losing those patterns, in turn, further isolates the person. Soon, she is withdrawn, sad, and moving slowly.

Imagine a person who feels so depressed that she takes a sick day from work. The act of staying home has powerful short-term rewards. Let’s face it, it feels good to stay home sometimes – especially when you can avoid unpleasant tasks. But there are long-term costs. Staying home eliminates positive social interactions, it causes work to pile up, it disconnects the person from the daily happenings of his job, and so on.

These long-term costs are precisely the types of effects that are difficult to recognize in the midst of a depressed mood. The short-term relief of sleeping, eating, drinking, and other forms of avoidance simply overpowers long-term considerations. This is not a question of willpower or weakness. It’s just the nature of living creatures – we are programmed to respond to immediate consequences and worry about the future when we get there.

The family cure, modeled by many who have come before me, is to get back into the pattern of daily life. Grandpa might have been heard to say something like this: “It doesn’t matter whether you feel like it, do your chores and then come to the dinner table.” It usually had a positive effect. Psychologists like me now find ourselves saying something similar, though saying it differently, based on research that breaks from traditional treatment.

Traditional treatments for depression are based on the common notion that a mood must change before actions can change – that is, people must feel good before they can act like they feel good. This has given rise to moderately successful forms of talk therapy. Antidepressant medication is based on the same premise: lift a person’s mood so that she can resume a normal life. While they’re successful enough to justify continued use, meds can come with side effects that are unpleasant at best and occasionally deadly. And there’s nothing to prevent relapse after cessation.

Do Be Do Be Do

Grandpa took a different approach. He didn’t seem to believe that changes in mood must come before changes in action. Research is beginning to bear that out. In fact, there’s evidence that changes in action can lead to lasting changes in mood with an equal or better success rate and a lower incidence of relapse.

(Grandpa’s response from beyond: “No kidding, Dr. Smartypants.”)

Now here’s the hard part. The idea that mood must precede action is so ingrained to most of us that tackling the problem in a reverse order is counterintuitive – particularly when we’re in the throes of depression. That’s where a good psychologist can step in. Simply engaging in behaviors that “feel good,” like taking a walk or sitting in a hot tub, is not enough. Successful treatment for depression involves getting back into the swing of daily life, including the perks and the duties. Both tend to have antidepressant effects.

A good shrink can help re-establish old routines or create new ones. It’s a process that must be tailored to the individual, and it isn’t as simple as it sounds. If it were, there would be no depression. What makes it difficult, you ask?

Jacobson, Martell, & Dimidjian (2001) tell the story of a man whose depression was greatly exacerbated by alienation from his children. The researchers helped the man create routines that put him in regular contact with his kids. The result: his depression didn’t improve at all, which further discouraged the man.


These are the situations that separate the men from the boys. I’ve seen too many clinicians cry “uncle” in similar situations and report that the patient was stubborn, irrational, and incurable. “Put ‘em on meds,” they’ve said, “I’m going on break.”

Feh, I say. Jacobson and his partners didn’t give up so easily, and neither did their patient. Life is worth fighting for. On further exploration they learned that while the man did, in fact, begin spending more time with his kids, he spent most of that time lost in thoughts about how difficult his life was. In other words, while he was with his kids, he wasn’t with his kids, if you’ll pardon the 1970s tinge. Once the shrinks showed the man new ways to respond to old thoughts, he began to engage more fully with his children and his depression began to lift. He transferred those skills to other areas of his life and his mood improved greatly.

Action before mood, JT. It takes hard work from both patient and psychologist, but there are no ugly side effects and the skills can last a lifetime. When it came to treating depression, Grandpa had the wisdom if not the finesse.


Dimidjian, S., Hollon, S.D., Dobson, K.S., Schmaling, K.B., Kohlenber, R.J., et al., (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658-670.

Jacobson, N.S., Martell, C.R., & Dimidjian, S. (2001). Behavioral activation treatment for depression: Returning to contextual roots. Clinical Psychology: Science and Practice, 8(3), 255-270.

LeJuez, C.W., Hopko, D.R., & Hopko, S.D. (2001). A brief behavioral activation treatment for depression. Behavior Modification, 25(2), 255-286.