Behavioural activation for major depression (MEQ)

(i) Definition and model. BA is a structured, collaborative psychotherapy that increases contact with response-contingent positive reinforcement and reduces avoidance/escape patterns that maintain depression.[8][14][15] Ferster/Lewinsohn-line models emphasise reduced adjustive behaviour and low reinforcement; avoidance is negatively reinforced short-term but shrinks the repertoire long-term. Outside-in principle: scheduled action can precede motivation.[8][14]

(ii) Contrasts. Full CT adds systematic cognitive restructuring and often schema work; Jacobson dismantling showed activation components can match fuller packages acutely.[3] BATD/BATD-R are brief manualised activation packages emphasising life areas, contracts, and graduated goals rather than a long cognitive curriculum.[14][15]

(iii) Assessment and early plan. Assess diagnosis, bipolar screen, suicide risk (passive death wishes need safety plan and review), substance/medical factors, values, and 1–2 weeks activity–mood monitoring with mastery/pleasure.[14][15] Session 1: psychoeducation, diary set-up, tiny evening alternative to bed (for example 10-minute walk or shower at fixed time). Session 2: review diary; identify TRAP (Trigger evening alone → low mood → bed avoidance) and TRAC alternative coping; grade two more valued tasks (for example brief colleague message; prepare school materials for 15 minutes). Homework every session.[15]

(iv) Evidence. Jacobson 1996 component analysis; Dimidjian 2006 BA competitive with CT and antidepressant medication acutely; Dobson 2008 enduring BA/CT benefits vs medication withdrawal among responders; COBRA 2016 BA non-inferior to CBT with junior-worker cost advantages; Ekers meta-analyses and Uphoff Cochrane support effectiveness with appropriate caution about certainty.[1][2][3][5][6][12]

(v) Defer pure elective BA. Examples: imminent suicide risk needing higher-intensity risk management/admission pathways; emerging mania/hypomania; severe self-neglect/medical emergency; incapacity for collaborative work until stabilised. Respectful micro-routines may still help, but safety leads.[12][14]