Journal of Behavioral Medicine

, Volume 42, Issue 3, pp 522–533 | Cite as

Psychosocial factors associated with treatment outcomes in women with obesity and major depressive disorder who received behavioral activation for depression

  • Daniel KernEmail author
  • Andrew Busch
  • Kristin L. Schneider
  • Steven A. Miller
  • Bradley M. Appelhans
  • Molly E. Waring
  • Matthew C. Whited
  • Sherry Pagoto


Behavioral activation is an empirically supported treatment for depression, but much is unknown about factors associated with treatment response. The present study aimed to determine whether baseline levels and subsequent changes in psychosocial factors were associated with improvement in depression in women with comorbid obesity who received behavioral activation treatment for depression and a lifestyle intervention. Multilevel modeling was used to estimate the associations between psychosocial factors and change in depression scores during the first 10 weeks of treatment and associations between changes in psychosocial factors from baseline to 6-month follow-up and change in depression over the same time period. No baseline psychosocial factors were associated with depression improvement during treatment (p = 0.110–0.613). However, greater improvement in hedonic capacity (p = 0.001), environmental reward (p = 0.004), and social impairment (p = 0.012) were associated with greater reductions in depression over 6 months. Findings highlight the differential relationship specific psychosocial factors have with depression treatment outcomes.


Behavioral therapy Comorbidity Treatment response Hedonic capacity Environmental reward Social engagement 



Partial support for Dr. Waring provided by NIH Grant KL2TR000160 and for Dr. Whited by NIH Grant 5K23HL109620.

Compliance with ethical standards

Conflict of interest

Daniel Kern, Andrew Busch, Kristin L. Schneider, Steven A. Miller, Bradley M. Appelhans, Molly E. Waring, Matthew C. Whited, and Sherry Pagoto declare that they have no conflict of interest.

Human and animal rights and Informed consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.


  1. Armento, M., & Hopko, D. (2007). The environmental reward observation scale (EROS): Development, validity, and reliability. Behavioral Therapy, 38, 107–119.CrossRefGoogle Scholar
  2. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.Google Scholar
  3. Busch, A., Uebelacker, L., Kalibatseva, Z., & Miller, I. (2010). Measuring homework completion in behavioral activation. Behavior Modification, 34, 310–329.CrossRefGoogle Scholar
  4. Busch, A., Whited, M., Appelhans, B., Schneider, K., Waring, M., DeBiasse, M., et al. (2013). Reliable change in depression during behavioral weight loss treatment among women with major depression. Obesity, 21, E211–E218.CrossRefGoogle Scholar
  5. Carey, M., Small, H., Yoong, S., Boyes, A., Bisquera, A., & Sanson-Fisher, R. (2014). Prevalence of comorbid depression and obesity in general practice: A cross-sectional survey. British Journal of General Practice, 64, 122–127.CrossRefGoogle Scholar
  6. Carvalho, J., Gawrysiak, M., Hellmuth, J., McNulty, J., Magidson, J., Lejuez, C., et al. (2011a). The reward probability index: design and validation of a scale measuring access to environmental reward. Behavior Therapy, 42, 249–262.CrossRefGoogle Scholar
  7. Carvalho, J. P., Trent, L. R., & Hopko, D. R. (2011b). The impact of decreased environmental reward in predicting depression severity: Support for behavioral theories of depression. Psychopathology, 44, 242–252.CrossRefGoogle Scholar
  8. Collado, A., Calderón, M., MacPherson, L., & Lejuez, C. (2016). The efficacy of behavioral activation treatment among depressed Spanish-speaking Latinos. Journal of Consulting and Clinical Psychology, 84, 651–657.CrossRefGoogle Scholar
  9. Cuijpers, P., van Straten, A., & Warmerdam, L. (2007). Behavioral activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27, 318–326.CrossRefGoogle Scholar
  10. Curran, P. J., & Bauer, D. J. (2011). The disaggregation of within-person and between person effects in longitudinal models of change. Annual Review of Psychology, 62, 583e619.CrossRefGoogle Scholar
  11. Daughters, S., Magidson, J., Lejuez, C., & Chen, Y. (2016). Let’s act: A behavioral activation treatment for substance use and depression. Advances in Dual Diagnosis, 9, 74–84.CrossRefGoogle Scholar
  12. Dichter, G. S., Felder, J. N., Petty, C., Bizzell, J., Ernst, M., & Smoski, M. J. (2009). The effects of psychotherapy on neural responses to rewards in major depression. Biological Psychiatry, 1, 886–897.CrossRefGoogle Scholar
  13. Dimidjian, S., Barrera, M., Martell, C., Muñoz, R., & Lewinsohn, P. (2011). The origins and current status of behavioral activation treatments for depression. Annual Review of Clinical Psychology, 7, 1–38.CrossRefGoogle Scholar
  14. DPP Research Group. (2002). The Diabetes Prevention Program (DPP): Description of lifestyle intervention. Diabetes Care, 25, 2165–2171.CrossRefGoogle Scholar
  15. Ekers, D., Richards, D., & Gilbody, S. (2008). A meta-analysis of randomized trials of behavioural treatment of depression. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences., 38, 611–623.CrossRefGoogle Scholar
  16. Fawcett, J., Clark, D. C., Scheftner, W. A., & Gibbons, R. D. (1983). Assessing anhedonia in psychiatric patients: The Pleasure Scale. Archives of General Psychiatry, 40, 79–84.CrossRefGoogle Scholar
  17. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.Google Scholar
  18. Henriques, J. B., & Davidson, R. J. (2000). Decreased responsiveness to reward in depression. Cognition and Emotion, 14, 711–714.CrossRefGoogle Scholar
  19. Hoffman, L., & Stawski, R. S. (2009). Persons as contexts: evaluating between person and within-person effects in longitudinal analysis. Research in Human Development, 6, 97e120.CrossRefGoogle Scholar
  20. Hopko, D. R., Armento, M. E. A., Cantu, M., Chambers, L., & Lejuez, C. W. (2003a). The use of daily diaries to assess the relations among mood state, overt behavior, and reward value of activities. Behaviour Research and Therapy, 41, 1137–1148.CrossRefGoogle Scholar
  21. Hopko, D. R., Bell, J. L., Armento, M. E. A., Hunt, M. K., & Lejuez, C. W. (2005). Behavior therapy for depressed cancer patients in primary care. Psychotherapy: Theory, Research, Practice, Training, 42, 236–243.CrossRefGoogle Scholar
  22. Hopko, D. R., Cannity, K., McIndoo, C. C., File, A. A., Ryba, M. M., Clark, C. G., et al. (2015a). Behavioral therapy for depressed breast cancer patients: Predictors of treatment outcome. Journal of Consulting and Clinical Psychology, 83, 225–231.CrossRefGoogle Scholar
  23. Hopko, D. R., Clark, C. G., Cannity, K., & Bell, J. L. (2015b). Pretreatment depression severity in breast cancer patients and its relation to treatment response to behavior therapy. Health Psychology, 35, 10–18.CrossRefGoogle Scholar
  24. Hopko, D. R., Lejuez, C. W., & Hopko, S. D. (2004). Behavioural activation as an intervention for coexistent depressive and anxiety symptoms. Clinical Case Studies, 3, 37–48.CrossRefGoogle Scholar
  25. Hopko, D. R., Lejuez, C. W., LePage, J. P., Hopko, S. D., & McNeil, D. W. (2003b). A brief behavioral activation treatment for depression: A randomized pilot trial within an inpatient psychiatric hospital. Behavior Modification, 27, 458–469.CrossRefGoogle Scholar
  26. Hopko, D. R., Lejuez, C. W., Ruggiero, K. J., & Eifert, G. H. (2003c). Contemporary behavioral activation treatments for depression: Procedures, principles, and progress. Clinical Psychology Review, 23, 699–717.CrossRefGoogle Scholar
  27. Hopko, D. R., & Mullane, C. M. (2008). Exploring the relation of depression and overt behavior with daily diaries. Behaviour Research and Therapy, 46, 1085–1089.CrossRefGoogle Scholar
  28. Hopko, D. R., Robertson, S. M. C., & Colman, L. (2008). Behavioral activation for depressed cancer patients: Factors associated with treatment outcome and attrition. International Journal of Behavioral Consultation and Therapy, 4, 319–327.CrossRefGoogle Scholar
  29. Kanter, J. W., Busch, A. M., Weeks, C. E., & Landes, S. J. (2008a). The nature of clinical depression: Symptoms, syndromes, and behavior analysis. The Behavior Analyst, 31, 1–21.CrossRefGoogle Scholar
  30. Kanter, J. W., Dieguez-Hurtado, G., Rusch, L. C., Busch, A. M., & Santiago-Rivera, A. (2008b). Behavioral activation for Latinos with depression. Clinical Case Studies, 7, 491–506.CrossRefGoogle Scholar
  31. Kanter, J. W., Mulick, P. S., Busch, A. M., Berlin, K. S., & Martell, C. R. (2006). The Behavioral Activation for Depression Scale (BADS): Psychometric properties and factor structure. Journal of Psychopathology and Behavioral Assessment, 29, 191–202.CrossRefGoogle Scholar
  32. Kanter, J. W., Rusch, L. C., Busch, A. M., & Sedivy, S. K. (2009). Confirmatory factor analysis of the behavioral activation for depression scale (BADS) in a community sample with elevated depressive symptoms. Journal of Psychopathology and Behavioral Assessment, 31, 36–42.CrossRefGoogle Scholar
  33. Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology, 3, 1–27.CrossRefGoogle Scholar
  34. Keedwell, P. A., Andrew, C., Williams, S. C., Brammer, M. J., & Phillips, M. L. (2005). The neural correlates of anhedonia in major depressive disorder. Biological Psychiatry, 58, 843–853.CrossRefGoogle Scholar
  35. Lejuez, C. W., Hopko, D., LePage, J., Hopko, S., & McNeil, D. (2001a). A brief behavioral activation treatment for depression. Cognitive and Behavioral Practice, 8, 164–175.CrossRefGoogle Scholar
  36. Lejuez, C. W., Hopko, D. R., & Hopko, S. D. (2001b). A brief behavioral activation treatment for depression. Treatment manual. Behavior Modification, 25, 255–286.CrossRefGoogle Scholar
  37. Leventhal, A., Chasson, G., Tapia, E., Miller, E., & Pettit, J. (2006). Measuring hedonic capacity in depression: A psychometric analysis of three anhedonia scales. Journal of Clinical Psychology, 62, 1545–1558.CrossRefGoogle Scholar
  38. Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. M. Friedman & M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research. New York: Wiley.Google Scholar
  39. Loas, G., Perot, J. M., Hardy, P., & Jouvent, R. (1994). Physical anhedonia and subtypes of major depressive disorder. European Psychiatry, 9, 304–306.Google Scholar
  40. Luppino, F. S., deWit, L. M., Bouvy, P. F., Stijnen, T., Cuijpers, P., Penninx, B. W. J. H., et al. (2010). Overweight, obesity, and depression: A systematic review and meta-analysis of longitudinal studies. Archives of General Psychiatry, 67, 220–229.CrossRefGoogle Scholar
  41. MacPherson, L., Tull, M. T., Matusiewicz, A. K., Rodman, S., Strong, D. R., Kahler, C. W., et al. (2010). Randomized controlled trial of behavioral activation smoking cessation treatment for smokers with elevated depressive symptoms. Journal of Consulting and Clinical Psychology, 78, 55–61.CrossRefGoogle Scholar
  42. Magidson, J. F., Gorka, S. M., MacPherson, L., Hopko, D. R., Blanco, C., Lejuez, C. W., et al. (2011). Examining the effect of the Life Enhancement Treatment for Substance Use (LETS ACT) on residential substance abuse treatment retention. Addictive Behaviors, 36, 615–623.CrossRefGoogle Scholar
  43. Manos, R. C., Kanter, J. W., Rusch, L. C., Turner, L. B., Roberts, N. A., & Busch, A. M. (2009). Integrating functional analytic psychotherapy and behavioral activation for the treatment of relationship distress. Clinical Case Studies, 8, 122–138.CrossRefGoogle Scholar
  44. Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided action. New York: Norton.Google Scholar
  45. Mayberg, H. S. (1997). Limbic-cortical dysregulation: A proposed model of depression. The Journal of Neuropsychiatry and Clinical Neurosciences, 9, 471–481.CrossRefGoogle Scholar
  46. Mazzucchelli, T., Kane, R., & Rees, C. (2009). Behavioral activation treatments for depression in adults: A meta-analysis and review. Clinical Psychology: Science and Practice, 16, 383–411.Google Scholar
  47. Molenaar, P. C. M., & Campbell, C. G. (2009). The new person-specific paradigm in psychology. Current Directions in Psychology, 18, 112–117.CrossRefGoogle Scholar
  48. Pagoto, S., Schneider, K., Whited, M., Oleski, J., Merriam, P., Appelhans, B., et al. (2013). Randomized controlled trial of behavioral treatment for comorbid obesity and depression in women: The be active trial. International Journal of Obesity, 37, 1427–1434.CrossRefGoogle Scholar
  49. Pagoto, S. L., Schneider, K. L., Appelhans, B., Curtin, C., & Hajduk, A. (2011). Psychological co-morbidities of obesity. In S. L. Pagoto (Ed.), Psychological co-morbidities of physical illness: A behavioral medicine perspective. 1. New York, NY: Springer.CrossRefGoogle Scholar
  50. Pan, A., Sun, Q., Czernichow, S., Kivimaki, M., Okereke, O. I., Lucas, M., et al. (2012). Bidirectional association between depression and obesity in middle-aged and older women. International Journal of Obesity (London), 36, 595–602.CrossRefGoogle Scholar
  51. Reynolds, E. K., MacPherson, L., Tull, M. T., Baruch, D. E., & Lejuez, C. W. (2011). Integration of the brief behavioral activation treatment for depression into a college orientation program: Depression and alcohol outcomes. Journal of Counseling Psychology, 58, 555–564.CrossRefGoogle Scholar
  52. Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., et al. (2016). Cost and Outcome of behavioural activation versus cognitive behavioural therapy for depression (COBRA): A randomised, controlled, non-inferiority trial. The Lancet, 388, 871–880.CrossRefGoogle Scholar
  53. Roberts, R. E., Deleger, S., Strawbridge, W. J., & Kaplan, G. A. (2003). Prospective association between obesity and depression: Evidence from the Alameda County Study. International Journal of Obesity and Related Metabolic Disorders, 27, 514–521.CrossRefGoogle Scholar
  54. Ross, J., Teesson, M., Lejuez, C., Mills, K., Kaye, S., Brady, K., et al. (2016). The efficacy of behavioural activation treatment for co-occurring depression and substance use disorder (the activate study): a randomized controlled trial. BMC Psychiatry, 16, 221.CrossRefGoogle Scholar
  55. Rovner, B., Casten, R., Hegel, M., Massof, R., Leiby, B., Ho, A., et al. (2014). Low vision depression prevention trial in age-related macular degeneration. Ophthalmology, 121, 2204–2211.CrossRefGoogle Scholar
  56. Sachs-Ericsson, N., Burns, A. B., Gordon, K. H., Eckel, L. A., Wonderlich, S. A., Crosby, R. D., et al. (2007). Body mass index and depressive symptoms in older adults: The moderating roles of race, sex, and socioeconomic status. American Journal of Geriatric Psychiatry, 15, 815–825.CrossRefGoogle Scholar
  57. Schneider, K. L., Bodenlos, J. S., Ma, Y., Olendzki, B., Oleski, J., Merriam, P., et al. (2008). Design and methods for a randomized clinical trial treating co-morbid obesity and major depressive disorder. BMC Psychiatry, 8, 1–11.CrossRefGoogle Scholar
  58. Sloan, D. M., Strauss, M. E., & Wisner, K. L. (2001). Diminished response to pleasant stimuli by depressed women. Journal of Abnormal Psychology, 110, 488–493.CrossRefGoogle Scholar
  59. Snarski, M., Scogin, F., DiNapoli, E., Presnell, A., McAlpine, J., & Marcinak, J. (2011). The effects of behavioral activation therapy with inpatient geriatric psychiatry patients. Behavior Therapy, 42, 100–108.CrossRefGoogle Scholar
  60. Spitzer, R. L., Williams, J. B., Gibbon, M., & First, M. B. (1992). The structured clinical interview for DSM-III-R (SCID). I: History, rationale, and description. Archives of General Psychiatry, 49, 624–629.CrossRefGoogle Scholar
  61. Sturmey, P. (2009). Behavioral activation is an evidence-based treatment for depression. Behavior Modification, 33, 818–829.CrossRefGoogle Scholar
  62. Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved February 16, 2018, from
  63. Vittengl, J. (2018). Mediation of the bidirectional relations between obesity and depression among women. Psychiatry Research, 264, 254–259.CrossRefGoogle Scholar
  64. Vogelzangs, N., Kritchevsky, S. B., Beekman, A. T., Brenes, G. A., Newman, A. B., Satterfield, S., et al. (2010). Obesity and onset of significant depressive symptoms: results from a prospective community-based cohort study of older men and women. Journal of Clinical Psychiatry, 71, 391–399.CrossRefGoogle Scholar
  65. Wang, C. E., Brennen, T., & Holte, A. (2006). Decreased approach motivation in depression. Scandinavian Journal of Psychology, 47, 505–511.CrossRefGoogle Scholar
  66. Wang, Y., & Gorenstein, C. (2013). Psychometric properties of the Beck Depression Inventory II: A comprehensive review. Revista Brasileira de Psiquiatria, 35, 416–431.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PsychologyRosalind Franklin University of Medicine and ScienceNorth ChicagoUSA
  2. 2.Centers for Behavioral and Preventive MedicineThe Miriam HospitalProvidenceUSA
  3. 3.Department of Psychiatry and Human BehaviorAlpert Medical School of Brown UniversityProvidenceUSA
  4. 4.Department of MedicineUniversity of Massachusetts Medical SchoolWorcesterUSA
  5. 5.Department of Preventative MedicineRush University Medical CenterChicagoUSA
  6. 6.Department of PsychologyEast Carolina UniversityGreenvilleUSA
  7. 7.Department of Allied Health SciencesUniversity of ConnecticutStorrsUSA
  8. 8.Departments of Quantitative Health Sciences and Obstetrics & GynecologyUniversity of Massachusetts Medical SchoolWorcesterUSA

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