To Treat Depression, Take Action

By Michael Craig Miller, M.D.
Content provided by the Faculty of the Harvard Medical School

I have always resented that commercial urging us to "just do it." For people with depression, it's insulting — and useless — because the smallest task can seem like a huge obstacle. There are many times in life when moving forward requires bearing discomfort. Transitions from middle school to high school to college, or from one job to another, challenge us to master new skills. But people with depression sometimes have a tougher time during these periods because they have less confidence than the average person or because of their talent for imagining the worst — not because they are less capable than anyone else.

But the results of a new study show that, with the right kind of coaching, encouragement and education, action may be a pretty effective treatment for depression.

Earlier this year, a group of psychologists at the University of Washington compared four types of depression treatment: "behavioral activation," cognitive-behavioral therapy, an antidepressant and a placebo pill.

They assigned about 250 people with major depression to one of the four treatment groups After four months patients in the behavioral activation (BA) group did at least as well as those receiving an antidepressant medication. The results were a surprise, especially since standard guidelines say that cognitive therapy and antidepressants are the most effective treatments for depression.

In one way, BA was better than antidepressants — fewer patients receiving BA dropped out of treatment than those taking a pill. Also intriguing: among the most severely depressed patients, BA was more effective than cognitive therapy.

What is "Behavior Activation Therapy?"

Behavioral Activation is not a practice of telling patients to "just do it." It is, however, a technique that helps depressed people do what they tend to avoid.

Proponents of this type of therapy believe it works because depressed people tend to withdraw from stressful situations. They get some relief in the short run because they spare themselves the pain of confronting tough problems. But they also miss out on the rewards. For example, a depressed man may call in sick to avoid an unpleasant interaction with a co-worker. In the long run, however, he misses out on the satisfaction that could come from getting his job done and earning a living. And avoidance leaves the original problem unchanged. Inaction just makes problems worse and deepens depression. It only becomes more difficult to get out of bed in the morning.

Logic is behind BA, not shaming or blaming the person for his problems. Inaction deprives the person of the satisfactions (environmental reinforcers) that come from engaging in life and can help relieve depression. He is taught to monitor his reactions and adhere to a daily schedule. The therapist also tries to help the patient interrupt the circular, self-critical thinking and pay attention to the present moment and actions that help reach long-term goals.

Behavior therapy and cognitive therapy differ in important ways. A cognitive therapist will spend time reviewing negative and distorted thinking and self-defeating beliefs. According to the cognitive therapy model, thinking must change before behavior can. A behavior therapy model such as the BA technique, turns this completely around and asks the patient not to think too much. It focuses on simple strategies like goal-setting, problem-solving, and attending to the task at hand rather than the overwhelming big picture. The two approaches have been closely linked in recent years through an approach called cognitive- behavior therapy (CBT), which purposely blends the two.)

Focus on the Functioning

A happier life does not depend on a victory of "just do it" over "getting in touch with your feelings." The answer, as usual, lies somewhere in the middle. You don't want a life of grinding through tasks without feeling anything. The trick is to turn your attention away from thoughts and feeling that undermine your functioning, and towards those that promote it. Proponents of behavioral activation ask their patients to notice when they are dwelling on unproductive thoughts and think instead about direct experience, such as the immediate sights and smells around them. Once you begin to function better, it's easier and more useful to go back from a position of strength and understand how your thoughts got so negative in the first place.

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Research shows that more women than men experience depression. This could be because women are more likely than men to report and seek help for depressed feelings.