Behavioral activation and prevention of depression in at-risk adults: A meta-analysis

Cognitive-behavioral interventions are effective for depression prevention but face challenges with adherence and cost. This meta-analysis evaluated the effectiveness of behavioral activation (BA) in reducing depressive symptoms in selective and indicated prevention.

We searched Scopus, PsycINFO, and MEDLINE, screening 2858 studies. RCTs applying core BA principles (activity scheduling and monitoring) in indicated or selective prevention were included. BA interventions were compared with active or passive controls. Random-effects meta-analysis was conducted, and subgroup analyses examined prevention indication, risk of bias, and number of sessions.

By January 2025, 23 RCTs (N = 3213) met inclusion criteria. Studies targeted older adults (n = 9), caregivers (n = 6), adults (n = 2), stroke patients (n = 1), and students (n = 1). Post-intervention analysis (k = 19) showed a significant moderate effect favoring BA (g = -0.56; 95% CI [-0.78, -0.33]). Exploratory analysis at one-year follow-up (k = 7) yielded a small, non-significant effect (g = -0.31; 95% CI [-0.68, 0.07], p = .09). Heterogeneity was substantial (I² = 79.7%), and publication bias was borderline significant. Limited evidence was found for differences in risk of bias or prevention indication. Delivery method significantly moderated effects, whereas session number did not. According to GRADE, evidence quality was low.

BA appears to be an effective and lower-cost alternative for depression prevention, but the robustness of the findings is low. Hence, better quality studies are needed in other populations.