This Month’s Expert: Behavioral Activation for Depression by Steven Hollon, PhD
TCPR: Dr. Hollon, your work as a psychologist and researcher focuses on the treatment and etiology of depression. What in particular do you study?
Dr. Hollon: I’m interested in how cognitive and behavioral interventions compare to medication in the treatment of depression, and what their enduring effects are.
TCPR: Would some of our patients do better with psychological treatments vs. medication treatments?
Dr. Hollon: Medications work well, are relatively safe, and a lot of people respond to them, so of course they are a popular treatment choice. In terms of what makes patients who respond to therapy different than those who respond to medication, there aren’t many clear differences. However, there are differences between the effects of medication and the effects of nonmedication treatment.
TCPR: What are some of the differences?
Dr. Hollon: A main difference is in how enduring the treatment effects are. There is no indication that taking medication for depression protects you from getting depressed again once you stop taking it. It’s like taking insulin for diabetes; it is protective when you are taking it, but it doesn’t keep working after you are done.
TCPR: How are the effects of therapy different?
Dr. Hollon: Research shows that cognitive and behavioral interventions have lasting effects, even after they are stopped. Actually, it appears that they cut the risk of depression relapse by about half. That is, patients treated to remission with cognitive behavioral therapy are only about half as likely to relapse following treatment termination than patients treated to remission with medications (Dobson et al., J Consult Clin Psychol 2008;76(3):468–477; Hollon et al., Arch Gen Psych 2005;62(4):417–422).
TCPR: So there appears to be something specific about therapy that appears to provide long-lasting protection. Do you know what that something is?
Dr. Hollon: What it looks like is that people learn skills to help them manage their depression. Studies show that the specific patients who are more successful at learning cognitive and behavioral skills are those who are better protected from relapse. This is true for even short-term therapy—as little as three or four months.
TCPR: How well do patients respond to therapy? Is it comparable to medication?
Dr. Hollon: If you take a fairly short-term course of cognitive therapy, you get about a 60% response rate, or 30% full remission—which is about the same as medication. But once you stop therapy, these people are no more likely to relapse than the ones who stay on medication (DeRubeis RJ et al., Arch Gen Psych 2005;62(4):409–416).
TCPR: What specifically are the skills that we should be teaching our patients to help them prevent a depression relapse?
Dr. Hollon: There are a couple things. The first is behavioral activation. This is encouraging people not to wait until they feel like doing something, but just to go ahead and do it. When in doubt, do. Often, it’s not that people who are depressed can’t do things, it’s just that they can’t start things.
TCPR: So you encourage them to become active. What is the second skill?
Dr. Hollon: The second is questioning the accuracy of negative self beliefs. Most of the time people who are depressed are unduly negative. They underestimate what they are capable of doing—like getting a job or having a relationship. So you can teach them to do something anyway—break their tasks down to size and act on them, even if they have negative views of the outcome. So, if you think you can’t get a job, well, you should just put in the job application anyway.
TCPR: You’ve described two main curative principles: behavioral activation and questioning negative beliefs. What kind of research convinces you of their effectiveness?
Dr. Hollon: Among patients who responded to cognitive therapy for depression in a recent outcome trial, those who were able to exhibit those two skills were the least likely to relapse following treatment termination (Strunk DR et al., J Consult Clin Psychol 2007;75(4):523–530).
TCPR: But is behavioral activation any different from what most psychiatrists do with many of their patients anyway? I know I am frequently advising patients, “Get out there, get a job, get a relationship,” etc.
Dr. Hollon: You need to tell them how. You need to show them how to break things down into manageable chunks. For example, say your patient wants to get a job. First he needs to find out who is hiring. Then he needs to put together an application. There may be half a dozen steps to get through. It’s like trying to get up a slippery hill. You could try to climb up the slope, but it’s easier to take the stairs. For someone who is depressed, a step-by-step approach makes accomplishing things much easier.
TCPR: So literally, you might have a patient bring in the classified section of the newspaper to his appointment?
Dr. Hollon: Absolutely. I will get the process started right in the session, because getting started is really where depressed people have trouble. I might have them look for jobs on the computer in my office or work with them on their resumes during a session. If someone is severely depressed, I might sit down with him and write out a schedule of everything he is going to do between now and our next session. Things as simple as, “stop at Starbucks on the way home,” and “fold the laundry at 4 o’clock.”
TCPR: So this is like personal coaching.
Dr. Hollon: That’s exactly what it is. I might even go with him to Starbucks and encourage him to start a conversation with the barista, for example. Sometimes we have to help structure things for the patient. Because when you’re depressed you always have two things to do: you have to decide what to do, and you have to do it. If we can help a depressed patient decide in advance, all he has to do is carry it out.
TCPR: Thank You, Dr. Hollon.
Hollon,, S. (2013). This Month’s Expert: Behavioral Activation for Depression by Steven Hollon, PhD. Psych Central. Retrieved on January 16, 2018, from https://pro.psychcentral.com/this-months-expert-behavioral-activation-for-depression-by-steven-hollon-phd/