Behavioural activation (BA) is a treatment for depression built on one move: you plan specific activities that matter to you and do them whether or not you feel like it, so that action comes before motivation. Trials found it eased depression more than control conditions, and one large trial found it was not inferior to CBT at 12 months. [ekers-2014-ba-meta-analysis] [richards-2016-cobra] This guide covers what BA is, what the research shows, how it compares with medication and CBT, and how to start. Our overview of depression covers the condition itself.
What is behavioural activation?
Behavioural activation is a structured talking therapy that links what you do to how you feel. NICE describes it as identifying the link between a person’s activities and their mood, spotting patterns, and planning practical changes that reduce avoidance and focus on behaviours linked to better mood. It does not directly target thoughts and feelings. [nice-ng222-behavioural-activation]
The idea behind it is a loop. Low mood makes activity feel pointless, doing less removes the small rewards that lift mood, and mood drops further. BA steps in at the behaviour end: you schedule activities that matter to you and do them first, and let the mood follow. NICE says it may be helpful when depression has led to social withdrawal, doing fewer things or inactivity, or has followed a change of circumstances or routine. [nice-ng222-behavioural-activation] Our guides to bed rotting and anhedonia cover two versions of that pattern.
Does behavioural activation work for depression?
On average, yes, with a medium-to-large effect by the usual rule of thumb. A review of 26 trials with 1,524 people found that BA eased depression more than control conditions, with an effect size of 0.74. [ekers-2014-ba-meta-analysis] Most of the trials scored poorly on quality and follow-up periods were brief, so the figure is a guide and not a promise. [ekers-2014-ba-meta-analysis]
| Study | Who and what | What it found | What limits it |
|---|---|---|---|
| Ekers and colleagues (2014) | Review of 26 trials, 1,524 people | BA beat control conditions (0.74) and had a smaller, borderline edge over antidepressants (0.42, four trials) | Most trials were of poor quality, and follow-up was brief |
| Dimidjian and colleagues (2006) | One trial of 241 adults with major depression: BA, cognitive therapy or paroxetine | BA did about as well as paroxetine; in more severe depression it matched the medication and beat cognitive therapy | A single trial, so it needs replication |
| Richards and colleagues (2016) | COBRA trial of 440 adults: BA from junior mental health workers, or CBT from psychological therapists | At 12 months the average depression score was 8.4 in both groups, BA was not inferior to CBT, and BA cost less | It tests whether BA is not worse than CBT, not whether it is better |
The COBRA result is worth a closer look. The BA therapists were junior mental health workers with brief training, and the CBT therapists were psychological therapists, yet depression scores at 12 months were the same, an average of 8.4 on the PHQ-9 questionnaire in both groups. [richards-2016-cobra] That suggests BA can be delivered by a wider range of staff than CBT.
How does behavioural activation compare with medication and CBT?
It held its own against both in trials, though not with certainty. In a trial of 241 adults with major depression, BA performed about as well as the antidepressant paroxetine, and among people with more severe depression it was comparable to the medication and did better than cognitive therapy. [dimidjian-2006-ba-cognitive-therapy-medication] A review that pooled four trials against antidepressants found a smaller, borderline advantage for BA, with an effect size of 0.42 and a confidence interval that just reached zero. [ekers-2014-ba-meta-analysis]
Against CBT, the COBRA trial found BA was not inferior at 12 months. [richards-2016-cobra] Our guide to CBT for depression covers how the two fit together, since BA is also one half of CBT.
None of this is a reason to stop medication. If you take an antidepressant, speak to the person who prescribes it before changing anything, and ask whether BA could be added or offered instead.
How do you do behavioural activation yourself?
Start small and write things down. NICE lists structured BA self-help, delivered with support from a trained practitioner, as one option, so the steps below are our practical outline and not a tested protocol. [nice-ng222-behavioural-activation]
- Track for a week. Note what you do each day and rate your mood from 0 to 10 a few times.
- Name what matters. Choose areas that matter to you, such as health, connection, work or creativity, rather than only what feels fun.
- Pick one small activity. Make it specific and short, with a time and a place, such as a ten-minute walk after lunch.
- Do it whether or not you feel like it. Rate your mood afterwards.
- Review and add one more. Keep what lifts your mood even a little, change what does not, and add one new activity at a time.
| Day | Activity (small and specific) | What it matters for | Mood before (0 to 10) | Mood after (0 to 10) |
|---|---|---|---|---|
| Mon | Ten-minute walk after lunch | Health | ||
| Tue | Text a friend and suggest a call | Connection | ||
| Wed | Tidy one corner of the room | Home |
Copy that table onto paper or into a notes app and fill in your own. Our guide to exercise for depression covers one of the activities with the most trial evidence behind it.
Ten minutes to plan one activity
Pick one small activity that matters to you, such as a short walk, a message to a friend or one tidy corner. Write down when and where you will do it tomorrow, and rate your mood now from 0 to 10.
5:00
Keep it small enough that you could do it on a bad day. The aim is to do it whether or not you feel like it, then rate your mood again afterwards. If you feel unsafe, contact your local emergency services or a crisis helpline.
Done. Do it at the time you wrote down, then rate your mood afterwards.
Who might behavioural activation suit?
NICE says BA may be helpful for people whose depression has led to withdrawal, doing fewer things or inactivity, and notes again that it does not directly target thoughts and feelings. The person needs to be willing to complete homework between sessions. [nice-ng222-behavioural-activation] NICE describes individual BA as usually 12 to 16 regular sessions, group BA as usually eight sessions with about eight participants, and guided self-help as usually six to eight structured sessions. [nice-ng222-behavioural-activation]
NICE also notes that in more severe depression, choices with more therapist contact should be carefully considered before guided self-help or group exercise. [nice-ng222-behavioural-activation] So if your depression is severe, see a doctor rather than relying on a worksheet.
Has depression changed what you do?
Tick anything that is true for you at the moment. This is a prompt for reflection, not a test, and it produces no diagnosis.
0 of 5 ticked
Several of these are true for you, which is the pattern BA is built for. A doctor or therapist can help you start with support, and the depression self-assessment can help you decide whether to have that conversation.
Some of these are true. A small scheduled activity is a reasonable first experiment, and tracking your mood will show whether it helps.
Few of these are true right now. If your mood is low for other reasons, the depression self-assessment can help you see where you stand.
When to seek help
Speak to a doctor if low mood, loss of interest or a feeling that nothing is worth doing has lasted most days for two weeks or more, or if it is affecting your work, relationships or sleep. A doctor can discuss BA alongside other treatments. Our depression self-assessment is a screener and not a diagnosis, and it can help you decide whether to have that conversation. Our guide to how to deal with depression covers the wider options.
If you feel unable to keep yourself safe, contact your local emergency services or a crisis helpline.
How MyFreud can help
BA runs on noticing which activities actually lift your mood, and low mood makes that hard to judge from memory. Daily mood tracking in MyFreud shows the pattern across weeks, so you can compare the days you did a planned activity with the days you did not. It does not replace a therapist or a doctor.
Download MyFreud and start today: App Store or Google Play.