Behavioral Activation Therapy Treats Depression in Patients with Heart Failure


A new study found behavioral activation therapy is just as effective as antidepressants for treating depressive symptoms in patients with heart failure, with both treatments having a 50% reduction at months 3, 6, and 12.

Behavioral Activation Therapy Treats Depression in Patients with Heart Failure

Waguih W. IsHak, MD

Credit: Cedars-Sinai

A new study found behavioral activation therapy treats depression symptoms in patients with heart failure as well as antidepressant medication.1

There was no statistically significant difference in the effectiveness of behavioral activation therapy and antidepressants, with both treatment approaches yielding a 50% reduction in the severity of depressive symptoms.

“The most important finding here is that patients experiencing depression have a choice in terms of their treatment between therapy or medications,” said lead investigator Waguih W. IsHak, MD, vice chair of education and research in the department of psychiatry and behavioral neurosciences at Cedars-Sinai, in a press release. “Patients who prefer not to be on medication can do behavioral activation therapy with similar results.”

Heart failure affects nearly 6 million adults in the US and approximately half of them (50%) experience symptoms of depression. Prior research found patients with heart failure and depression have lower cardiac function, more emergency department or hospital visits, greater caregiver burden, and poorer quality of life.

IsHak and colleagues conducted a pragmatic randomized comparative effectiveness trial from 2018 – 2022 with 1-year follow-up.2 The primary outcome was depressive symptom severity at 6 months, assessed by the Patient Health Questionnaire 9-item (PHQ-9). They also assessed for the secondary outcomes of physical and mental health-related quality of life (via Short-Form 12-item version 2), heart failure-specific quality of life (Kansas City Cardiomyopathy Questionnaire), caregiver burden (Caregiver Burden Questionnaire for Heart Failure), emergency department visits, readmissions, days hospitalized, and mortality at months 3, 6, and 12.

The study enrolled 416 patients with a mean age of 60.71 years and 58.4% males (n = 243), 82.69% not Hispanic or Latinx, 56.01% White, 29.33% African American or Black, 14.42% Hispanic or Latinx, and 5.05% Asian. Participants were randomized 1:1 to behavioral activation therapy and medication. Mean PHQ-9 scores at baseline were 14.54 in the behavioral activation therapy group and 14.31 in the medication group.

Both participants in the behavioral activation therapy and medication experienced nearly a 50% reduction in depressive symptoms at months 3, 6, and 12 months, with a mean score at 12 months of 7.62 for behavioral activation therapy (P < .001) and 7.98 for MEDS (P < .001). The investigators observed no statistically significant difference between behavioral activation therapy and MEDS in depressive symptom severity at 6 months (7.53 vs. 8.09; P = .88).

However, the behavioral activation therapy group experienced small improvements in the physical health-related quality of life at 6 months, compared to the MEDS group (mean SF-12 physical score: 38.82 vs 37.12; P = .04). The behavioral activation therapy group also had fewer emergency department visits for months 3 (38%; P = .005) 6 (30%; P = .008), and 12 (27%; P = .001), as well as fewer hospital visits months 3 (17%; P = .002), 6 (19%; P = .005), and 12 (36%; P = .001).

Limitations the team highlighted included having no control group, being unable to collect data for emergency visits, readmissions, and hospital stays outside of California, and not having access to treatment preference at baseline.

The investigators stated how deciding between psychotherapy and medication is a frequent dilemma as behavioral activation therapy requires more engagement and effort but has no pharmacological effects, and MEDS takes less time and effort but includes risks of adverse effects and drug interactions. Since the 2 treatment forms are equally as effective, the team explained how patients can make decisions based on personal preferences, values, and availability of services.

“This study, which was conducted in a real-world setting, demonstrates that it is entirely feasible to incorporate psychiatric treatment into specialty medical care,” said study investigator Itai Danovitch, MD, MBA, chair of the department of psychiatry and behavioral neurosciences from Cedars Sinai, in a press release.1 “Integrating psychiatric treatment into medical care is an effective way to reduce stigma, increase access and improve outcomes for people who struggle with mental health problems alongside their chronic medical conditions.”


  1. Therapy Versus Medication: Comparing Treatments for Depression in Heart Disease. News Wise. January 18, 2024. Accessed January 24, 2024.
  2. IsHak WW, Hamilton MA, Korouri S, et al. Comparative Effectiveness of Psychotherapy vs Antidepressants for Depression in Heart Failure: A Randomized Clinical Trial. JAMA Netw Open. 2024;7(1):e2352094. Published 2024 Jan 2. doi:10.1001/jamanetworkopen.2023.52094
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