Contact with others and engaging in activities are often seen by depressed patients as unpleasant or undesirable. Because of this discomfort, depressed patients often avoid pleasurable or even routine activities. This may have the impact of increasing depressive symptoms. Behavioral activation seeks to interrupt this process and bring about symptom relief through increasing positive interactions with others and their environment. Two meta-analyses of a combined 50 studies published over the past 40 years have demonstrated that behavioral activation produces improvement in depression comparable with other manualized treatments for depression (such as cognitive behavioral therapy). Moreover, follow-up assessments showed that the improvements in depression persisted after the active treatment had been discontinued (Mazzucchelli, 2009; Cuijpers, 2007).

The efficacy of behavioral activation is fairly clear as compared with traditional psychotherapy. It may even be as effective as antidepressant medications (Dimidjian, 2006). Given the problem of medication side effects, behavioral activation provides for an attractive intervention for the treatment of depression. It is also a relatively easy treatment to administer, furthering its appeal.

Activity scheduling is an attractive treatment approach for individuals who may be difficult to treat, such as depressed dementia patients or depressed elderly patients. Regular outings and get-togethers, participation in a senior day care program, participation in available nursing home activities, etc., are all likely to reduce depression in the elderly (Cuijpers, 2007).

Given the benefits of this procedure, low risks and the relative ease of incorporating it into ongoing treatment, whether with traditional psychotherapy, antidepressant medications or both, it seems that this would be a prudent intervention to add almost across the board.

Based on the work group members' experience with using behavioral activation, consider following when doing behavioral activation with the patients:

• The role of the clinician is to help patients increase their exposure to the positive life experiences they had prior to onset of depression. Reinforce the positive to slowly replace the negative coping skills they have learned.
• Goals should be focused on external factors (resuming activities that patients have been avoiding) and not on internal factors (waiting for patients to be motivated to make a change).
• Help patients set priorities for long- and short-term goals and to understand the difference.
• Help patients decide what changes are necessary to reach their goal – the what, when, where. Goals should be SMART (specific, measurable, attainable, realistic, timely).
• Do not recommend new life or health goals (smoking cessation, weight loss, etc.) even though this may feel like a great time to encourage them to reinvent themselves.
• If the patient recommends a new goal, discourage him/her from taking on a new life challenge. This sets patients up for high risk of failure and frustration, which will only worsen their depression. Use language: "That sounds like a very challenging goal. I think it would be better if we started with something a little less complex. How does that sound to you?"
• When you see patients for follow-up, ask them about the progress on their goals. It reinforces that you care and that you find all their effort important (positive experience).
• If they don't achieve the goal, congratulate them on their efforts and whatever parts they did accomplish. Ask them about what they struggled with. It provides insight into the hurdles they face on a daily basis, which is likely having an effect on the other aspects of their health care.

More about generating goal ideas:

• What was the patient doing when he/she was not depressed? One way to ask is this: "When you think back to when you were last happy, what did your life look like?" (Ask him/her to describe the environment – what was he/she doing, who is around him/her, etc.).
• What activities have they been avoiding – work, time with friends, hobbies, hygiene, housework, parenting, etc.?
• What activities have they found to be fun in the past? Choosing a fun goal can help them rebuild positive experiences. They may not initially find the activity as fun as it had been in the past, but it is the baby steps that will help get them back on track.

More about setting goals with the patients:

1. Help patients break down their goal idea into action steps.
2. Help them arrange the steps from simple to complex.
3. Set a goal with one simple step to accomplish the first week. It is important that you start this process with a goal that has a high likeliness of success, as early wins will encourage them to keep going and tackle more complex goals that were identified in step 2.
4. Week two goal is to accomplish the second action step identified in step 2 above, week three builds on week two goal, etc.
5. Encourage patients to set a reward at the end of the week for accomplishing goals. For some patients, they may struggle at this initially because they don't find themselves worthy of a reward.