When clinical trials test depression treatments, they almost always measure what symptoms decrease, and stop getting worse.
They track less crying, less hopelessness, and less dread. The metrics are built around subtraction. Whether a person can feel good again is not the focus of the results.
A new trial is directly challenging these former assumptions. In contrast, researchers have designed a therapy around activating the capacity for joy.
This has been tested against the standard approach and proved that the joy-centered therapy was far more effective.
Studying PAT therapy
The therapy is called positive affect treatment, or PAT. Its target is anhedonia, defined as the loss of the ability to feel pleasure or interest in things that used to feel good.
Anhedonia shows up in most cases of depression and in many anxiety disorders.
It’s the symptom most strongly linked to relapse and suicidal thoughts, and standard care often leaves it untouched.
Dr. Alicia Meuret at Southern Methodist University (SMU) in Dallas led the trial. She noted that therapies for depression chase the only negative side of the story, solely observing dread, hopelessness and racing thoughts.
Patients are left waiting for joy and happiness to return on its own once the pain fades. But, for many of them, it never really does.
Understanding PAT therapy
PAT trains people in skills aimed at the reward system of the brain – the circuitry that lights up when someone anticipates something positive.
That neurological system goes quiet and dormant, retreating in the presence of depression.
Patients learn to plan small, pleasant activities and practice savoring them in vivid detail. They rehearse positive scenes mentally and practice deliberate acts of generosity.
A common exercise was conducted at a dinner with friends. Patients were told to notice the taste of the food, the sound of a laugh, and the warmth of being included.
Not everything has to be pleasant, or huge displays of happiness. Patients also learned to mine ordinary experiences for small positive details – and to credit themselves for them.
Two different regions
The trial enrolled 98 adults in Dallas and Los Angeles. All were experiencing differing levels of moderate to severe depression or anxiety.
Half were randomly assigned to PAT. The rest got negative affect treatment, called NAT.
NAT is built around the practice of facing feared situations, challenging distorted thinking, and doing breathing exercises to reduce tension.
Both therapies ran 15 weekly sessions over video. Therapists and patients didn’t learn their assignment until the first session. Symptoms were tracked every session, after treatment, and in the month following.
Data from the clinic
PAT therapy pulled ahead. By the end of the program, people in PAT had improved more on a combined measure of depression, anxiety, and joy than those in NAT.
The advantage showed even a month after treatment ended. Strikingly, the largest gap was on the depression and anxiety scale – which NAT was designed to target specifically.
Researchers had suspected reward circuitry was a useful target, and therapy designed around joy was far more effective.
Rewiring the rewards
Dr. Michelle Craske at the University of California, Los Angeles (UCLA) and a co-investigator on the project claim that something neurobiological is happening under the surface.
PAT graduates seem to respond more intensely to positive cues, Craske noted. Earlier related work hints that brain regions for anticipation and pleasure may be recalibratingg.
Exactly what is happening at the neural level, however, remains uncertain for the time being.
On six out of seven self-report measures, the change tracked the clinical improvement.
Other research mapped both the brain’s reward and threat systems as being viable targets.
Replicated three times
The result is not a one-off. Meuret’s team has tested PAT therapy against a control therapy in three separate trials, and the method has won each time.
“This was a really important finding, especially because we were able to replicate it three times,” said Meuret.
Replication is rare in this corner of psychology, as most promising therapies wilt the second time around. Three trials pointing in the same direction is good news.
Limitations still remain
Moving forward, Meuret’s team can show that gains in reward sensitivity tracked clinical improvement. However, they cannot yet prove that one caused the other.
Behavioral tasks and heart-rate readings didn’t track the change – only self-reporting did.
Whether the lab measures are too blunt, or the actual mechanism lives elsewhere remains an open question.
A sample of 98 adults is modest, and all sessions were conducted virtually, over video.
Researchers believe in-person delivery might have strengthened PAT’s specific effect on joy, the one measure that didn’t reach significance.
Future of PAT therapy
Regardless, the takeaway is concrete. The PAT therapy method has proven to teach patients how to once again savor the small joys of life, focusing on relishing positive moments.
Moreover, PAT outperformed the NAT therapy approach that has been used in standard care for decades.
According to the study, anhedonia finally has a treatment that centers upon the absence of joy itself. Clinicians can begin including PAT in ongoing care, and many techniques translate easily.
This data may transform the way the therapy field defines success, not as the mere absence of sadness, but the return of joy.
The study is published in JAMA Network Open.
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