7232019 Takagaki 2014

httpslidepdfcomreaderfulltakagaki-2014 14

Brief report

Behavioral characteristics of subthreshold depression

Koki Takagaki an Yasumasa Okamoto a Ran Jinnin ab Asako Mori a Yoshiko Nishiyama aTakanao Yamamura a Yoshitake Takebayashi c Akiko Ogata d Yuri Okamoto bYoshie Miyake b Haruki Shimoda e Norito Kawakami e Shigeto Yamawaki a

a Department of Psychiatry and Neurosciences Hiroshima University 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japanb Health Service Center Hiroshima University Japanc Graduate school of Integrated Arts and Sciences Hiroshima University Japand Department of Psychology Hiroshima University Japane Department of Mental Health The University of Tokyo Japan

a r t i c l e i n f o

Article history

Received 27 June 2014

Accepted 8 July 2014Available online 23 July 2014

Keywords

Depression

Subthreshold depression

Behavioral characteristics

a b s t r a c t

Background This study examines differences in behavioral characteristics among individuals who are

not depressed and individuals with subthreshold depression and depression

Methods We conducted structured interviews with 111 undergraduate students who also completed

self-report scales The participants were divided into a non-depression group a subthreshold depression

group and a depression group based on results of the structured interview and the BDI-II

Results There were signi1047297cant differences in avoidance between depression group and other two

groups Also for the environmental rewards there were signi1047297cant difference between the non-

depressed group and the other two groups

Limitations The sample of depressed participants was small The overall sample consisted only under-

graduate students

Conclusions This study reported that there are different behavioral characteristics among non-depres-

sion subthreshold depression and depression groups Whereas depression group is characterized by

high frequency of avoidance and low environmental rewards subthreshold depression group is

characterized by only low environmental rewardsamp 2014 Elsevier BV All rights reserved

1 Introduction

It has been reported that the 12-month prevalence of depres-

sion in Japan was 29 (Kawakami et al 2005) Moreover in recent

years subthreshold depression has received considerable atten-

tion (Bertha and Balazs 2013) Subthreshold depression is de1047297ned

as clinically signi1047297cant depressive symptoms that do not meet

diagnostic criteria for Major Depressive Disorder (MDD Pincus

et al 1999) Subthreshold depression is known to be a risk factorfor depression (Bertha and Balazs 2013) The incidence of MDD in

people with subthreshold depression is higher than in people

without subthreshold depression (Cuijpers and Smit 2004) There-

fore there is a need to investigate subthreshood depression in

addition to investigating depression

Ferster (1973) suggested that many activities of depressed indi-

viduals are characterized by avoidance of aversive life experiences

and a concomitant reduced frequency of positively reinforced beha-

viors It has been demonstrated that clients react to depressed

feelings with avoidance behaviors (Kanter et al 2010) Moreover

several studies have reported that depressive people responded

poorly to reward conditions (Henriques and Davidson 2000) It has

been suggested that depression is characterized by impairments in

reinforcements processing and that depressed patients are less able

to modulate their behavior in response to reinforcements (Eshel and

Roiser 2010) As a result depressed individuals have an increasedfrequency of avoidance as well as a decrease in the degree of positive

reinforcements compared to healthy people However no study to

date has investigated the behavioral characteristics related to sub-

threshold depression

The possibility of signi1047297cant differences in the degrees of avoidance

and positive reinforcement between subthreshold depression and

depression suggest the need to use difference behavioral interventions

for depression and subthreshold depression Therefore the purpose of

this study was to compare differences in behavioral characteri-

stics between individuals with subthreshold depression and non-

depressed and depressed individuals

Contents lists available at ScienceDirect

journal homepage wwwelseviercomlocatejad

Journal of Affective Disorders

httpdxdoiorg101016jjad201407018

0165-0327amp 2014 Elsevier BV All rights reserved

n Corresponding author Tel thorn81 82 257 5208 fax thorn81 82 257 5209

E-mail address kokitakagakigmailcom (K Takagaki)

Journal of Affective Disorders 168 (2014) 472ndash475

7232019 Takagaki 2014

httpslidepdfcomreaderfulltakagaki-2014 24

2 Methods

21 Participants

We screened 2308 freshmen BDI-II before entered Hiroshima

University Recruitment took place through email on a public

information sharing center We contacted students who had BDI-II

scores greater than or equal to 10 by email After providing informed

consent the participants were 111 (48 women 63 men) Japaneseundergraduate students Their mean age was 1876 yr (SDfrac14 66)

22 Measures

221 The Japanese version of the behavioral activation for

depression scale (BADS Takagaki et al 2013)

The original BADS was developed by Kanter et al (2007) and

consisted of 25 items that are rated on a 7-point scale (0 Not at all

to 6 Completely) The BADS consists of four subscales The

Activation subscale (BADS-AC) measures goal-directed activation

and the completion of scheduled activities The AvoidanceRumi-

nation subscale (BADS-AR) measures the avoidance of a negative

aversive state and engaging in rumination rather than active

problem solving The WorkSchool Impairment subscale (BADS-WS) measures the consequences of inactivity and passivity on

work and school responsibilities The Social Impairment (BADS-SI)

subscale measures similar social consequences and social isolation

Takagaki et al (2013) developed and demonstrated the reliability

and validity of the Japanese version of the BADS

222 The Japanese version of the environmental reward observation

scale (EROS Kunisato et al 2011)

The original EROS was developed by Armento and Hopko

(2007) The EROS consists of 10 items that are scored on a 4-

point scale (1 Strongly disagree to 4 Strongly agree) and is used

to measure the exposure to environmental rewards deemed

essential for increasing response-contingent positive reinforce-

ment Kunisato et al (2011) developed the Japanese version theEROS and reported the reliability and validity of this scale

223 The Japanese version of the beck depression inventory 2nd

version (BDI-II Kojima and Furukawa 2003)

The original BDI-II was developed by Beck et al (1996) This

scale consists of 21 self-report items that are scored on a 4-point

scale and is used to measure depressive symptoms Kojima and

Furukawa (2003) developed the Japanese version of the BDI-II and

demonstrated the reliability and validity of the BDI-II

224 Composite international diagnostic interview (CIDI Kessler

and Ustun 2004)

The CIDI is a widely used structured interview for assessing

mental disorders We used the computerized version (Kessler andUstun 2004) Also each participant was assessed for their lifetime

history of MDD and Bipolar Disorder (BD) We used the Japanese

version of the CIDI (Kawakami et al 2005)

23 Procedure

Approval for the study was obtained from the ethics committee

of Hiroshima University Recruitment took place through email on

a public information sharing center After obtaining informed

consent a trained interviewer conducted a telephone structured

interview (CIDI) with each participant We sent self-report scales

to 113 participants through the Internet The 111 participants

completed self-report scales through the Internet The collection

rate of self-report scales was 9823 in this study Nobody met

diagnostic criteria for BD in this study Individuals who did not

meet criteria for MDD in their lifetime history and who had BDI-II

scores lower than 13 were allocated to the non-depressed group

Individuals who did not meet criteria for MDD in their lifetime

history and who had BDI-II scores greater than or equal to 14 were

allocated to the subthreshold depression group Individuals who

met diagnostic criteria for MDD in their lifetime history and who

had BDI-II scores greater than or equal to 14 were allocated to the

depression group Also we excluded individuals who met diag-nostic criteria for MDD in their lifetime history and who had BDI-II

scores lower than 13

24 Statistical analysis

First we reported the descriptive data Second ANOVAs were

conducted for the behavioral characteristics data to examine

differences among the three groups

3 Results

31 Descriptive data for the non-depressed group subthreshold

depression group and depression group

Based upon the telephone structured interview and the BDI-II

the participants were classi1047297ed into groups 50 participants in the

non-depressed group (BDI-IIfrac14748) 41 in the subthreshold

depression group (BDI-IIfrac141798) 11 in the depression group

(BDI-IIfrac142118) 9 in the exclusion criteria (BDI-IIfrac14756) The mean

scores on the measures are shown in Table 1 We examined

whether there are signi1047297cant differences of age and gender

balance among three groups The reported that there were no

signi1047297cant difference of age and gender balance among three

groups

32 Differences of behavioral factors among the three groups

Table 1 shows the mean scores and signi1047297cant differencesbetween the groups One-way ANOVAs yielded signi1047297cant differ-

ences among the non-depressed group the subthreshold depres-

sion group and the depression group for scores on the BADS-Total

[F (2 99)frac141264 po 01]BADS-AR [F (2 99)frac141069 po 01]

Table 1

Descriptive data among three groups

Non-depression

Group

Subthreshold

Depression

Group

Depression

Group

N = 50 N = 41 N = 11

Femalemale 1931 1625 83

Mean Age 1880 (67) 1871 (64) 1882 (87)

BDI-II 748 (329) 1798 (497) 2118 (767)

BADS-Total 9954 (1633) a 8885 (1856) b 7146 (2011) c

BADS-AC 1530 (878) 1334 (890) 1146 (664)

BADS-AR 1318 (768) a 1720 (799) a 2500 (891) b

BADS -SI 386 (454) a 559 (499) a 1073 (725) b

BADS-WS 6 72 (4 42 ) a 971 (534) b 1227 (543) b

EROS 2588 (440) a 2200 (471) b 2046 (508) b

Note Values in parentheses represent standard deviation

There are signi1047297cant difference between different shoulder alphabet(a b c)

( po 05)

BDI-II Beck Depression Inventory ndashII

BADS-Total Behavioral Activation for Depression Scale-Total scores

BADS-AC Behavioral Activation for Depression Scale-Activation

BADS-AR Behavioral Activation for Depression Scale-Avoidance Rumination

BADS-SI Behavioral Activation for Depression Scale-Social Impairment BADS-WS

Behavioral Activation for Depression Scale-WorkSchool Impairment

EROS Environmental Reward Observation Scale

K Takagaki et al Journal of Affective Disorders 168 (2014) 472ndash475 473

7232019 Takagaki 2014

httpslidepdfcomreaderfulltakagaki-2014 34

BADS-SI[F (2 99)frac14842 po 01] BADS-WS [F (2 99)frac14776

po 01] and EROS [F (2 99)frac141097 po 01] We next conducted

multiple comparisons for each scales The results yielded signi1047297-

cant differences among the three groups for BADS-Total There

were signi1047297cant differences between the depression group and the

other two groups in BADS-AR and BADS-SI There were signi1047297cant

differences between the non-depressed group and the other two

groups in the BADS-WS and the EROS A one-way ANOVA yielded

no signi1047297cant difference among the three groups for the BADS-AC[F (2 99)frac14115 pfrac14 32]

4 Discussion

The current study investigated the behavioral characteristics of

people with subthreshold depression The higher scores of the

BADS-Total represented increased activation (Kanter et al 2007)

Based upon these 1047297ndings for the BADS-Total BADS-AR BADS-AC

and EROS the behavioral characteristics of the subthreshold

depression group in this study were more active compared to

the depression group Also the subthreshold depression group

was also characterized by receiving less rewards from the envir-

onment they had dysfunctions in their college life Decreased

response-contingent positive reinforcement can provide a suf 1047297-

cient explanation of depression (Dimidjian et al 2011) Adolescent

with a current depressive disorder were less reward seeking than

adolescents without a psychopathology (Rawal et al 2013)

Therefore the subthreshold depression group was characterized

by hyposensitivity to rewards Moreover Behavioral characteristics

of subthreshold depression group became of less avoidant beha-

viors compared with depression group

Findings of this study indicated that behavioral characteristics

of the depression group were characterized by a lack of increased

activation Moreover the depression group was characterized by a

high frequency of avoidance and obtaining fewer rewards from the

environment Furthermore the results of BADS-SI and BADS-WS

indicated that the depression group had dysfunctions in social

situations and college life Avoidance contributes to the onset and

maintenance of depression (Manos et al 2010 Trew 2011) and it

is a risk factor for depression (Ottenbreit and Dobson 2008) The

highest avoidance score of the depression group in this study was

similar to that of a previous study (Ottenbreit and Dobson 2008)

The low level of environmental rewards experienced by depressed

students indicated that these students were not exposed to

environmental rewards

Behavioral activation is an empirically supported intervention

for depression (Sturmey 20 09) The goal of behavioral activation is

to increase activated behaviors while decreasing avoidant beha-

viors as well as restoring an environment characterized by diverse

and stable sources of positive reinforcement (Manos et al 2010)

Because depressed people have a high frequency of avoidance and

low environmental rewards it is necessary to increase theiractivated behavior while decreasing avoidance and thereby

increase their access to positively reinforcing events On the other

hand the results of this study indicated that the main behavioral

characteristic of subthreshold depression group is the low fre-

quency of environmental rewards Therefore primary target in

interventions for subthreshold depression is increasing access to

positively reinforcing events and activities which is similar to

initial behavioral activation (Lewinsohn et al 1978)

It is important to point out two limitations of the present study

The number of participants in the depression group was small

Next the participants consisted of only undergraduate students In

order to generalize the results to the general population it would

be important to replicate this study using a larger and a more

diverse sample of participants Despite the above limitations

however the results of this study are important in that they

identi1047297ed differences in behavioral characteristics between indi-

viduals suffering from depression and subthreshold depression

People with subthreshold depression have different behavioral

characteristics from non-depressed and depression people People

with depression are characterized by a high frequency of avoid-

ance and low access to environmental rewards whereas those

with subthreshold depression are characterized only by low

accesses to environmental rewards We hypothesized that increas-ing access to positively reinforcing events and activities similar to

initial behavioral activation (Lewinsohn et al 1978) would be the

primary aim of interventions for people with subthreshold depres-

sion However the effectiveness of such interventions for indivi-

duals with subthreshold depression was not examined in this

study It is suggested that future studies should investigate

whether interventions aimed at increasing access to positively

reinforcing events and activities would be an effective intervention

for people with subthreshold depression

Role of funding source

This research was supported by the Grant-in-Aid for Scienti1047297c Research on

Innovative Areas by the Ministry of Education Culture Sports Science and

Technology of Japan and the Strategic Research Program for Brain Sciences by theMinistry of Education Culture Sports Science and Technology of Japan

Con1047298ict of interest

All authors report no potential con1047298icts of interest

Acknowledgments

None

References

Armento ME Hopko DR 2007 The Environmental Reward Observation Scale(EROS) development validity and reliability Behav Ther 38 107ndash119

Beck AT Steer RA Brown GK 1996 Beck Depression Inventory Manual 2nd

ed The Psychological Corp San Antonio TexasBertha EA Balazs J 2013 Subthreshold depression in adolescence a systematic

review Eur Child Adolesc Psychiatry 22 589ndash603Cuijpers P Smit F 2004 Subthreshold depression as a risk indicator for major

depressive disorder a systematic review of prospective studies Acta PsychiatrScand 109 325ndash331

Dimidjian S Barrera Jr M Martell C Munoz RF Lewinsohn PM 2011 Theorigins and current status of behavioral activation treatment for depressionAnnu Rev Clin Psychol 7 1ndash38

Eshel N Roiser JP 2010 Reward and punishment processing in depression BiolPsychiatry 68 118ndash124

Ferster CB 1973 A functional analysis of depression Am Psychol 28 857 ndash870Henriques JB Davidson RJ 2000 Decreased responsiveness to reward in

depression Cognit Emot 14 711ndash724Kanter JW Mulick PS Busch AM Berlin KS Martell CR 2007 The Behavioral

Activation for Depression Scale (BADS) psychometric properties and factorstructure J Psychopathol Behav Assess 29 191ndash202

Kanter JW Manos RC Bowe WM Baruch DE Busch AM Rusch LC 2010

What is behavioral activation A review of the empirical literature ClinPsychol Rev 30 608ndash620Kawakami N Takeshima T Ono Y Uda H Hata Y Nakane Y Nakane H Iwata N

Furukawa TA Kikkawa T 2005 Twelve-month prevalence severity and treat-ment of common mental disorders in communities in Japan preliminary 1047297ndingfrom the World Mental Health Japan Survey 2002ndash2003 Psychiatry Clin Neurosci59 441ndash452

Kessler RG Ustun TB 2004 The World Mental Health (WMH) survey initiativeversion of the World Health Organization (WHO) Composite InternationalDiagnostic Interview (CIDI) Int J Methods Psychiatr Res 13 93ndash121

Kojima M Furukawa T 2003 Japanese Version of the Beck Depression Inventory2nd ed Nippon-Hyoron-sha Co Tokyo

Kunisato Y Takagaki K Okajima I Nakajima S Ishikawa S Kanai Y Okamoto YSakano Y Yamawaki S 2011 Development of Japanese version of EnvironmentalReward Observation Scale (EROS) Jpn J Behav Ther 37 21ndash31

Lewinsohn PM Muntildeoz RF Youngren MA Zeiss AM 1978 Control YourDepression Prentice Hall Press New York

Manos RC Kanter JW Busch AM 2010 A critical review of assessmentstrategies to measure the behavioral activation model of depression Clin

Psychol Rev 30 547ndash

561

K Takagaki et al Journal of Affective Disorders 168 (2014) 472ndash475474

7232019 Takagaki 2014

httpslidepdfcomreaderfulltakagaki-2014 34

BADS-SI[F (2 99)frac14842 po 01] BADS-WS [F (2 99)frac14776

po 01] and EROS [F (2 99)frac141097 po 01] We next conducted

multiple comparisons for each scales The results yielded signi1047297-

cant differences among the three groups for BADS-Total There

were signi1047297cant differences between the depression group and the

other two groups in BADS-AR and BADS-SI There were signi1047297cant

differences between the non-depressed group and the other two

groups in the BADS-WS and the EROS A one-way ANOVA yielded

no signi1047297cant difference among the three groups for the BADS-AC[F (2 99)frac14115 pfrac14 32]

4 Discussion

The current study investigated the behavioral characteristics of

people with subthreshold depression The higher scores of the

BADS-Total represented increased activation (Kanter et al 2007)

Based upon these 1047297ndings for the BADS-Total BADS-AR BADS-AC

and EROS the behavioral characteristics of the subthreshold

depression group in this study were more active compared to

the depression group Also the subthreshold depression group

was also characterized by receiving less rewards from the envir-

onment they had dysfunctions in their college life Decreased

response-contingent positive reinforcement can provide a suf 1047297-

cient explanation of depression (Dimidjian et al 2011) Adolescent

with a current depressive disorder were less reward seeking than

adolescents without a psychopathology (Rawal et al 2013)

Therefore the subthreshold depression group was characterized

by hyposensitivity to rewards Moreover Behavioral characteristics

of subthreshold depression group became of less avoidant beha-

viors compared with depression group

Findings of this study indicated that behavioral characteristics

of the depression group were characterized by a lack of increased

activation Moreover the depression group was characterized by a

high frequency of avoidance and obtaining fewer rewards from the

environment Furthermore the results of BADS-SI and BADS-WS

indicated that the depression group had dysfunctions in social

situations and college life Avoidance contributes to the onset and

maintenance of depression (Manos et al 2010 Trew 2011) and it

is a risk factor for depression (Ottenbreit and Dobson 2008) The

highest avoidance score of the depression group in this study was

similar to that of a previous study (Ottenbreit and Dobson 2008)

The low level of environmental rewards experienced by depressed

students indicated that these students were not exposed to

environmental rewards

Behavioral activation is an empirically supported intervention

for depression (Sturmey 20 09) The goal of behavioral activation is

to increase activated behaviors while decreasing avoidant beha-

viors as well as restoring an environment characterized by diverse

and stable sources of positive reinforcement (Manos et al 2010)

Because depressed people have a high frequency of avoidance and

low environmental rewards it is necessary to increase theiractivated behavior while decreasing avoidance and thereby

increase their access to positively reinforcing events On the other

hand the results of this study indicated that the main behavioral

characteristic of subthreshold depression group is the low fre-

quency of environmental rewards Therefore primary target in

interventions for subthreshold depression is increasing access to

positively reinforcing events and activities which is similar to

initial behavioral activation (Lewinsohn et al 1978)

It is important to point out two limitations of the present study

The number of participants in the depression group was small

Next the participants consisted of only undergraduate students In

order to generalize the results to the general population it would

be important to replicate this study using a larger and a more

diverse sample of participants Despite the above limitations

however the results of this study are important in that they

identi1047297ed differences in behavioral characteristics between indi-

viduals suffering from depression and subthreshold depression

People with subthreshold depression have different behavioral

characteristics from non-depressed and depression people People

with depression are characterized by a high frequency of avoid-

ance and low access to environmental rewards whereas those

with subthreshold depression are characterized only by low

accesses to environmental rewards We hypothesized that increas-ing access to positively reinforcing events and activities similar to

initial behavioral activation (Lewinsohn et al 1978) would be the

primary aim of interventions for people with subthreshold depres-

sion However the effectiveness of such interventions for indivi-

duals with subthreshold depression was not examined in this

study It is suggested that future studies should investigate

whether interventions aimed at increasing access to positively

reinforcing events and activities would be an effective intervention

for people with subthreshold depression

Role of funding source

This research was supported by the Grant-in-Aid for Scienti1047297c Research on

Innovative Areas by the Ministry of Education Culture Sports Science and

Technology of Japan and the Strategic Research Program for Brain Sciences by theMinistry of Education Culture Sports Science and Technology of Japan

Con1047298ict of interest

All authors report no potential con1047298icts of interest

Acknowledgments

None

References

Armento ME Hopko DR 2007 The Environmental Reward Observation Scale(EROS) development validity and reliability Behav Ther 38 107ndash119

Beck AT Steer RA Brown GK 1996 Beck Depression Inventory Manual 2nd

ed The Psychological Corp San Antonio TexasBertha EA Balazs J 2013 Subthreshold depression in adolescence a systematic

review Eur Child Adolesc Psychiatry 22 589ndash603Cuijpers P Smit F 2004 Subthreshold depression as a risk indicator for major

depressive disorder a systematic review of prospective studies Acta PsychiatrScand 109 325ndash331

Dimidjian S Barrera Jr M Martell C Munoz RF Lewinsohn PM 2011 Theorigins and current status of behavioral activation treatment for depressionAnnu Rev Clin Psychol 7 1ndash38

Eshel N Roiser JP 2010 Reward and punishment processing in depression BiolPsychiatry 68 118ndash124

Ferster CB 1973 A functional analysis of depression Am Psychol 28 857 ndash870Henriques JB Davidson RJ 2000 Decreased responsiveness to reward in

depression Cognit Emot 14 711ndash724Kanter JW Mulick PS Busch AM Berlin KS Martell CR 2007 The Behavioral

Activation for Depression Scale (BADS) psychometric properties and factorstructure J Psychopathol Behav Assess 29 191ndash202

Kanter JW Manos RC Bowe WM Baruch DE Busch AM Rusch LC 2010

What is behavioral activation A review of the empirical literature ClinPsychol Rev 30 608ndash620Kawakami N Takeshima T Ono Y Uda H Hata Y Nakane Y Nakane H Iwata N

Furukawa TA Kikkawa T 2005 Twelve-month prevalence severity and treat-ment of common mental disorders in communities in Japan preliminary 1047297ndingfrom the World Mental Health Japan Survey 2002ndash2003 Psychiatry Clin Neurosci59 441ndash452

Kessler RG Ustun TB 2004 The World Mental Health (WMH) survey initiativeversion of the World Health Organization (WHO) Composite InternationalDiagnostic Interview (CIDI) Int J Methods Psychiatr Res 13 93ndash121

Kojima M Furukawa T 2003 Japanese Version of the Beck Depression Inventory2nd ed Nippon-Hyoron-sha Co Tokyo

Kunisato Y Takagaki K Okajima I Nakajima S Ishikawa S Kanai Y Okamoto YSakano Y Yamawaki S 2011 Development of Japanese version of EnvironmentalReward Observation Scale (EROS) Jpn J Behav Ther 37 21ndash31

Lewinsohn PM Muntildeoz RF Youngren MA Zeiss AM 1978 Control YourDepression Prentice Hall Press New York

Manos RC Kanter JW Busch AM 2010 A critical review of assessmentstrategies to measure the behavioral activation model of depression Clin

Psychol Rev 30 547ndash

561

K Takagaki et al Journal of Affective Disorders 168 (2014) 472ndash475474

7232019 Takagaki 2014

httpslidepdfcomreaderfulltakagaki-2014 44

Ottenbreit ND Dobson KS 2008 Avoidance In Dobson KS Dozois DJA(Eds) Risk Factors in Depression Academic Press London pp 447ndash470

Pincus HA Davis WW McQueen LE 1999 Subthreshold mental disorders areview and synthesis of studies on minor depression and other brand namesBr J Psychiatry 174 288ndash296

Rawal A Collishaw S Thapar A Rice F 2013 The risk of playing it safe aprospective longitudinal study of response to reward in the adolescent off-spring of depressed parents Psychol Med 43 27ndash38

Sturmey P 2009 Behavioral activation is an evidence-based treatment fordepression Behav Modif 33 818ndash829

Takagaki K Okajima I Kunisato Y Nakajima S Kanai Y Ishikawa S Sakano Y2013 Development and validation of the Japanese version of the BehavioralActivation for Depression Scale (BADS) Arch Psychiatr Diagn Clin Eval 676ndash85

Trew JL 2011 Exploring the roles of approach and avoidance in depression anintegrative model Clin Psychol Rev 31 1156ndash1168

K Takagaki et al Journal of Affective Disorders 168 (2014) 472ndash475 475