Introduction and methodology

Unipolar depression is a common and debilitating mental illness that often first occurs in adolescence (Mendelson & Tandon, Reference Mendelson and Tandon2016). Adolescent depression is associated with distressing and destabilizing experiences, including substance misuse and social and educational difficulties (Thapar, Collishaw, Pine, & Thapar, Reference Thapar, Collishaw, Pine and Thapar2012). The illness is also the most significant risk factor for suicide in adolescence (Galaif, Sussman, Newcomb, & Locke, Reference Galaif, Sussman, Newcomb and Locke2007), which is one of the major global causes of death for this age group (World Health Organization, 2024). Concerningly, rates of adolescent depression have risen over the past few years (Cohen & Thakur, Reference Cohen and Thakur2022).

Around half of adults with a depression diagnosis have had depression as an adolescent (Zwolińska, Dmitrzak-Węglarz, & Słopień, Reference Zwolińska, Dmitrzak-Węglarz and Słopień2023), but differences in outcomes suggest adult- and adolescent-onset depression may be caused by distinct factors (Rice et al., Reference Rice, Riglin, Lomax, Souter, Potter, Smith, Thapar and Thapar2019). Adolescent-onset cases are typically more chronic and persistent than those beginning in adulthood (Wilson & Dumornay, Reference Wilson and Dumornay2022). Furthermore, earlier-onset depression is associated with more severe symptoms and an increased likelihood of experiencing comorbid psychiatric diagnoses (Fernando et al., Reference Fernando, Carter, Frampton, Luty, McKenzie, Mulder and Joyce2011).

Effective interventions for adolescent depression can help individuals feel better and prevent difficulties being maintained into adulthood (Martin & Oliver, Reference Martin and Oliver2019). However, current interventions have limited effectiveness (Singh, Gorelik, Stave, & Gotlib, Reference Singh, Gorelik, Stave and Gotlib2024), partly because they were originally developed for adults and have not been sufficiently tailored for the younger age group (Bylund & Reed, Reference Bylund and Reed2007). As an added problem, the mechanisms that drive depression and recovery in young people are not fully understood, although they warrant separate investigation, as they are likely to differ from those seen in adult depression (Izaki, Reference Izaki2021). Furthermore, access to treatment is a particular challenge in adolescence, with fewer than half of young people in the United Kingdom with mental health issues receiving appropriate help (Knapp et al., Reference Knapp, Ardino, Brimblecombe, Evans-Lacko, Iemmi, King, Snell, Murgia, Mbeah-Bankas, Crane, Harris, Fowler, Hodgekins and Wilson2016), a problem that is exacerbated for adolescents from lower-income families (Grossberg & Rice, Reference Grossberg and Rice2023). Collectively, these findings highlight the importance of having effective, accessible, and economical treatments for adolescents in place.

An increasing body of evidence suggests that reward function, which is related to the symptom of anhedonia (a loss of pleasure or the motivation to pursue pleasurable activities), may be a promising treatment target in adolescents. Reward function is impaired in both adults and adolescents with depression, but evidence suggests that reward may be particularly relevant for adolescents with depression, who typically have greater reward sensitivity than adults (O’Callaghan & Stringaris, Reference O’Callaghan and Stringaris2019).

Behavioral Activation (BA) is an effective and feasible psychotherapeutic intervention for adults with depression (Richards et al., Reference Richards, Ekers, McMillan, Taylor, Byford, Warren, Barrett, Farrand, Gilbody, Kuyken, O’Mahen, Watkins, Wright, Hollon, Reed, Rhodes, Fletcher and Finning2016) that is centered on reinforcing rewarding behaviors. Although originally developed for adults, BA’s focus on reward may be especially well-suited for adolescents, given the significance of reward in this age group (Viduani et al., Reference Viduani, Arenas, Benetti, Wahid, Kohrt and Kieling2024). Three systematic reviews looking at the efficacy of BA for adolescents with depression have found that BA is an effective treatment for adolescents with depression (Martin & Oliver, Reference Martin and Oliver2019; Tindall et al., Reference Tindall, Mikocka-Walus, McMillan, Wright, Hewitt and Gascoyne2017, Reference Tindall, Kerrigan, Li, Hayward and Gega2024), but standalone BA is absent from national treatment guidelines for young people with depression (National Institute for Health and Care Excellence [NICE], 2019). While BA is increasingly being offered by local National Health Service providers, a paucity of focused research on the mechanisms of reward and BA in young people means that we still do not know how BA response and recovery work in this age group, or why some adolescents do not get better after receiving BA treatment.

This narrative review seeks to bridge the gaps between recent developments in neuroscience, psychology, and clinical practice to provide an integrated understanding of reward function and BA in adolescence. Relevant literature was identified through searches of PubMed from April 2025 to June 2026, using keywords relating to reward function, reward impairment, Behavioral Activation, adolescent/adolescence, teenaged/r, and depression. Additional articles were identified by screening reference lists of identified articles (backward and forward snowballing). Studies were selected for inclusion in the review on the basis that they fell within the scope of the narrative review topics, they demonstrated sufficient methodological quality, and they contributed to the theoretical basis of the topics. Only full-text articles published in English were included. We used a narrative approach to integrate cross-disciplinary literature, with the priority being to synthesize existing knowledge, identify major gaps and contradictions in the research, and to highlight key areas for future research.

In this review, we present a summary of key findings from cross-disciplinary literature, with the aim of improving our understanding of how reward function relates to adolescent depression and allowing us to identify key areas for future investigation. In this review, we first examine the relevance of reward function and discuss why it is an important treatment target for adolescents with depression. We then evaluate findings from the emerging literature looking at BA in adolescents, before highlighting outstanding questions and areas for future research.

Reward function and adolescent depression

Reward function refers to a set of complex processes that are underpinned by the ways in which the brain responds to rewarding information. These processes are primarily mediated by cortico-limbic-striatal networks and involve dopaminergic pathways (Pizzagalli, Reference Pizzagalli2022). While different models of reward function have been proposed (Berridge & Kringelbach, Reference Berridge and Kringelbach2013; Berridge & Robinson, Reference Berridge and Robinson2003; Borsini et al., Reference Borsini, Wallis, Zunszain, Pariante and Kempton2020), it is broadly understood to consist of different subcomponents, including experiencing pleasure from rewards; being motivated to pursue rewards; and adapting behavior based on (un)rewarding feedback. In healthy adults, reward function underpins a range of essential behaviors and emotions, including pleasure, social engagement, motivation, learning, and decision-making.

Adolescents have greater reward sensitivity than adults (O’Callaghan & Stringaris, Reference O’Callaghan and Stringaris2019). As observed in different species, adolescents typically display more reward-focused behaviors, such as risk-taking, compared to adults (Luciana, Reference Luciana2013), possibly because the reward processing systems mature before the prefrontal cortex and associated higher cognitive processes, like forward-planning, are fully developed (Ely et al., Reference Ely, Nguyen, Tobe, Walker and Gabbay2021; Izaki, Reference Izaki2021). Magnetic resonance imaging (MRI) studies reveal that adolescents and adults have the same basic reward system, with both groups showing activation of the same network of subcortical regions in reward processing – namely the ventral and dorsal striatum, insula, and posterior cingulate cortex. However, unlike adults, adolescents do not show consistent activation in higher-order cortical regions, suggesting that adolescents’ reward-focused behavior is more likely driven by emotion and anticipation of rewards and less by forward planning or long-term consequences (Silverman, Jedd, & Luciana, Reference Silverman, Jedd and Luciana2015). There is also some evidence that dopamine-driven reward motivation peaks in adolescence in healthy individuals, rising from childhood and declining into adulthood (Luciana, Reference Luciana2013).

A key mechanism in adult depression is reward impairment (Whitton, Treadway, & Pizzagalli, Reference Whitton, Treadway and Pizzagalli2015). This impairment can be observed across different domains in adults with depression. Neurochemically, impaired reward processes are underpinned by reduced levels of dopamine, as evidenced in rodent and nonhuman primate models (Luking, Pagliaccio, Luby, & Barch, Reference Luking, Pagliaccio, Luby and Barch2016); neurobiologically, depression is associated with reduced striatal activation during reward anticipation and receiving reward (Whitton, Treadway, & Pizzagalli, Reference Whitton, Treadway and Pizzagalli2015); and psychologically, depression is associated with impaired reward learning, as observed through neuropsychological tasks (Vrieze et al., Reference Vrieze, Pizzagalli, Demyttenaere, Hompes, Sienaert, De Boer, Schmidt and Claes2013). The precise mechanisms of reward function are not fully understood. This is in part due to a lack of research and to conflicting findings in the available research, stemming from differences in study design and measures used to determine reward sensitivity (Galvan, Reference Galvan2010) (see Table 1). Despite these uncertainties, existing research suggests that the extent to which the reward function is impaired varies across individuals with depression. The symptom of anhedonia is associated with greater deficits in reward processing, compared to those without this symptom (Rizvi et al., Reference Rizvi, Quilty, Sproule, Cyriac, Bagby and Kennedy2015).

Table 1.

Summary of reward function in adults with depression and adolescents with and without depression

Table 1. Long description

The table consists of four columns and seven rows including the header. The columns are categorized as: Category, Healthy adolescents, Adults with depression, and Adolescents with depression.

* Reward-related behavior: Healthy adolescents show high reward sensitivity and risk-taking. Adults with depression show reduced learning, motivation, and anhedonia. Adolescents with depression show withdrawal and anhedonia.

* Striatal activity: Healthy adolescents show heightened activity. Adults with depression show reduced activity in response to decision-making and positive stimuli. Adolescents with depression show reduced activity compared to healthy peers during decision-making and anticipation.

* m P F C activity: In healthy adolescents, it is still developing with conflicting reports on activity levels. Adults with depression show increased or sometimes reduced activity. Adolescents with depression show dysregulated activity.

* Dopamine: Levels peak in healthy adolescence. Both adults and adolescents with depression show reduced dopamine signaling compared to their healthy counterparts.

* Implications: Healthy adolescents are sensitive to social rejection. In adults, impairment links to depression severity. In adolescents, impairment predicts outcomes and contributes to social or educational difficulties.

* Limitations and outstanding questions: Notes include the need for more research on neurobiology in depressed adolescents, the impact of study design on conflicting findings, and the distinction between mechanisms across age groups.

Bringing together these two ideas – that reward sensitivity is heightened in adolescence, and that reward impairment is associated with depression (and anhedonia) – has led some researchers to interrogate whether reward impairment could be a key mechanism in adolescent depression specifically. Relatively little research has been done in this area, while the available research shows some conflicting findings, due to differences in study design and individual differences in reward processing (Galvan, Reference Galvan2010), as well as differences in the types of reward being studied (Luking et al., Reference Luking, Pagliaccio, Luby and Barch2016), and challenges of associating precise mechanisms with behaviors (Opendak et al., Reference Opendak, Meyer, Callaghan, Abramson, John, Bath, Lee, Tottenham and Sullivan2025).

Preliminary evidence, however, suggests that reward impairment is an important mechanism in adolescent depression. Findings show that disrupted reward processing in adolescence could predict adolescent depression (Auerbach, Stanton, Proudfit, & Pizzagalli, Reference Auerbach, Stanton, Proudfit and Pizzagalli2015; Gabbay et al., Reference Gabbay, Johnson, Alonso, Evans, Babb and Klein2015) and poorer response to treatment (McMakin et al., Reference McMakin, Olino, Porta, Dietz, Emslie, Clarke, Wagner, Asarnow, Ryan, Birmaher, Shamseddeen, Mayes, Kennard, Spirito, Keller, Lynch, Dickerson and Brent2012). For example, a study looking at healthy female adolescents found that blunted reward positivity predicted first-onset depression and greater depression severity after 18 months (Nelson, Perlman, Klein, Kotov, & Hajcak, Reference Nelson, Perlman, Klein, Kotov and Hajcak2016). Another study looking at healthy adolescents found that individuals with more depressive symptoms showed less activity in the striatum (related to reward function) but more activity in the medial prefrontal cortex (mPFC) (evaluative processing), suggesting that depressive symptoms are linked to impaired reward function in adolescents (Forbes et al., Reference Forbes, Ryan, Phillips, Manuck, Worthman, Moyles and Dahl2010).

Furthermore, there may be a more pronounced relationship between some domains of reward impairment and adolescent-onset depression compared to adult-onset depression. In a meta-analysis looking at functional MRI and electroencephalogram studies, a significant association was found between depression and Feedback-Related Negativity (FRN) – a term that refers to an individual’s neurobiological response to a ‘worse than expected’ outcome – in individuals aged below 18 years, but not in those over 18 years (Keren et al., Reference Keren, O’Callaghan, Vidal-Ribas, Buzzell, Brotman, Leibenluft, Pan, Meffert, Kaiser, Wolke, Pine and Stringaris2018). FRN is thought to be associated with the processing and learning from negative feedback, and higher levels of FRN have previously been associated with depression (Fan et al., Reference Fan, Kong, Zhang, Lin, Zhao, Ji, Fang, Wang, Yao, Li and Wang2021). Such findings may indicate that adolescents with depression may be especially vulnerable to negative recall and associated avoidant behaviors. However, it is not currently possible to make any firm conclusions from the limited amount of research.

Additionally, the symptom of anhedonia, which can be understood as an observable impairment to healthy reward function, is increasingly being recognized as an important symptom of adolescent depression (Gabbay et al., Reference Gabbay, Johnson, Alonso, Evans, Babb and Klein2015). Anhedonia appears in over half of adolescents with diagnosed depression (Goodyer et al., Reference Goodyer, Reynolds, Barrett, Byford, Dubicka, Hill, Holland, Kelvin, Midgley, Roberts, Senior, Target, Widmer, Wilkinson and Fonagy2017) and it is associated with several poor outcomes, such as chronicity and severity of depression, and suicidality (Gabbay et al., Reference Gabbay, Johnson, Alonso, Evans, Babb and Klein2015). A study looking at 334 adolescents with depression found that anhedonia was the only symptom that predicted increased remission time, even when controlling for depression severity (McMakin et al., Reference McMakin, Olino, Porta, Dietz, Emslie, Clarke, Wagner, Asarnow, Ryan, Birmaher, Shamseddeen, Mayes, Kennard, Spirito, Keller, Lynch, Dickerson and Brent2012). In contrast to the reward-focused behaviors displayed by healthy adolescents, withdrawal from activities is one of the most frequently reported symptoms of adolescent depression (Viduani et al., Reference Viduani, Arenas, Benetti, Wahid, Kohrt and Kieling2024), suggesting a deviation from typical reward-focused behaviors in adolescents with depression.

More research is needed to identify the specific neurobiological mechanisms of reward impairment in adolescent depression, and to link the neurobiology of reward impairment to other potential biomarkers of anhedonia, such as inflammation (Bekhbat, Treadway, & Felger, Reference Bekhbat, Treadway and Felger2022; Colasanto, Madigan, & Korczak, Reference Colasanto, Madigan and Korczak2020; Zonca et al., Reference Zonca, Marizzoni, Saleri, Zajkowska, Manfro, Souza, Viduani, Sforzini, Swartz, Fisher, Kohrt, Kieling, Riva, Cattaneo and Mondelli2024). However, because adolescence is typically characterized by heightened reward sensitivity compared to adults, adolescents with depression show greater relative reward impairment for their age group (Forbes & Dahl, Reference Forbes and Dahl2012). This may explain why anhedonia – a symptom linked to reward impairment – is indicative of depression severity in adolescents (Gabbay et al., Reference Gabbay, Johnson, Alonso, Evans, Babb and Klein2015).

An important and understudied area of research is the association between reward function and depression in autistic adolescents, given the relevance of reward function in autism. Typically, autistic individuals are less responsive to social rewards, as observed through reduced striatal response and atypical dopamine signaling (Dichter & Rodriguez-Romaguera, Reference Dichter and Rodriguez-Romaguera2022). Research shows that even in nondepressed autistic people, striatal reward processing impairment is similar to that seen in people with depression who are not autistic (Baumeister et al., Reference Baumeister, Moessnang, Bast, Hohmann, Aggensteiner, Kaiser, Tillmann, Goyard, Charman, Ambrosino, Baron-Cohen, Beckmann, Bölte, Bourgeron, Rausch, Crawley, Dell’Acqua, Dumas and Durston2023). A sizeable body of evidence suggests that autistic adolescents are at an increased risk of depression compared to neurotypical adolescents (Pezzimenti, Han, Vasa, & Gotham, Reference Pezzimenti, Han, Vasa and Gotham2019), something which may be partly explained by the similarities in reward impairment.

Reward impairment in adolescent depression may also partly explain why earlier onset depression is associated with poorer outcomes than adult-onset depression (Wilson & Dumornay, Reference Wilson and Dumornay2022). Associated behaviors, such as withdrawal from activities and relationships, may also contribute to the social and educational difficulties commonly seen alongside depression in adolescence (Thapar, Collishaw, Pine, & Thapar, Reference Thapar, Collishaw, Pine and Thapar2012). These findings suggest that reward-focused interventions may be particularly important for adolescents, and for autistic adolescents specifically. Crucially, adolescence is when the reward processing systems in the brain are most plastic, enabling a significant opportunity for early intervention with therapies that target this system (Ely et al., Reference Ely, Nguyen, Tobe, Walker and Gabbay2021). As such, BA – a reward-focused psychotherapy – may be particularly useful for adolescents, with NICE calling for further research into its efficacy in this age group (2019).

Behavioral activation

BA is a psychological treatment for depression centered on reinforcing rewarding behaviors. It is based on the theory that a decrease in positive activities leads to low mood, which makes it harder to seek rewarding, necessary, or mood-enhancing activities, such as socializing or accomplishing daily tasks. BA is designed to disrupt this negative cycle by increasing an individual’s level of activities that align with their values and goals, while minimizing avoidant behaviors (Andersson et al., Reference Andersson, Ahlen, Mataix-Cols, Lenhard, Henje, Månsson, Sahlin, Beckman, Serlachius and Vigerland2022), with the goal of helping to lift mood over time (Nagy et al., Reference Nagy, Cernasov, Pisoni, Walsh, Dichter and Smoski2020).

BA has been found to be one of the most effective treatments for depression in adults, and it is recommended by NICE (2022) as a first-line treatment. It is often administered as part of a comprehensive cognitive-behavioral therapy (CBT) program, but it can also be offered as a standalone treatment. CBT and BA are both based on the principle that thoughts, feelings, and behaviors impact one another. Both therapies utilize this dynamic interaction, but while CBT focuses on changing thought patterns, BA focuses specifically on making simple and gradual behavioral changes. Research has found that standalone BA is as beneficial as full CBT packages in reducing symptoms of depression in adults (Uphoff et al., Reference Uphoff, Ekers, Robertson, Dawson, Sanger, South, Samaan, Richards, Meader and Churchill2020), with the benefit of being simpler and more cost-effective than CBT (Richards et al., Reference Richards, Ekers, McMillan, Taylor, Byford, Warren, Barrett, Farrand, Gilbody, Kuyken, O’Mahen, Watkins, Wright, Hollon, Reed, Rhodes, Fletcher and Finning2016), something which may help to ease the burden of increasing waiting lists for treatment (Andersson et al., Reference Andersson, Ahlen, Mataix-Cols, Lenhard, Henje, Månsson, Sahlin, Beckman, Serlachius and Vigerland2022; Pass, Whitney, & Reynolds, Reference Pass, Whitney and Reynolds2016). Importantly, BA is effective even when delivered by nonspecialists (Ekers et al., Reference Ekers, Webster, Van Straten, Cuijpers, Richards and Gilbody2014; Richards et al., Reference Richards, Ekers, McMillan, Taylor, Byford, Warren, Barrett, Farrand, Gilbody, Kuyken, O’Mahen, Watkins, Wright, Hollon, Reed, Rhodes, Fletcher and Finning2016), and it has clear effects on mood even at minimal doses as low as one session (Gawrysiak, Nicholas, & Hopko, Reference Gawrysiak, Nicholas and Hopko2009; Nasrin et al., Reference Nasrin, Rimes, Reinecke, Rinck and Barnhofer2017).

The exact mechanisms of BA are not fully understood, although researchers have hypothesized that reward function may be implicated in recovery, given that BA is centered on engagement with rewarding behaviors (Forbes, Reference Forbes2020). As such, some researchers suggest that BA may be particularly helpful in targeting the distinct presentation of adolescent depression compared to other therapies (McCauley et al., Reference McCauley, Gudmundsen, Schloredt, Martell, Rhew, Hubley and Dimidjian2016), given the heightened reward sensitivity in this age group.

Renewed interest in the potential of BA for adolescents stems in part from limitations to existing treatments for adolescent depression. Adolescents with depression have been found to respond less well to treatments generally than adults with depression (Singh, Gorelik, Stave, & Gotlib, Reference Singh, Gorelik, Stave and Gotlib2024), and among those who do respond, up to 50% still experience residual symptoms rather than full remission of the condition (Kennard et al., Reference Kennard, Silva, Vitiello, Curry, Kratochvil, Simons, Hughes, Feeny, Weller, Sweeney, Reinecke, Pathak, Ginsburg, Emslie and March2006).

Psychological therapies are recommended in most new cases of adolescent depression. However, CBT, the most common and studied of these treatments, only has a small-to-medium post-treatment effect size for adolescents with depression (Klein, Jacobs, & Reinecke, Reference Klein, Jacobs and Reinecke2007; Weisz, McCarty, & Valeri, Reference Weisz, McCarty and Valeri2006). Furthermore, some adolescents may struggle to engage with the complex concepts of CBT (Pass, Brisco, & Reynolds, Reference Pass, Brisco and Reynolds2015; Wagner, Horn, & Maercker, Reference Wagner, Horn and Maercker2014). Although medication is not recommended as an initial treatment in most cases, rates of antidepressant prescriptions for adolescents have been increasing over recent years (Jack et al., Reference Jack, Hollis, Coupland, Morriss, Knaggs, Butler, Cipriani, Cortese and Hippisley-Cox2020). There is evidence that fluoxetine, a selective serotonin reuptake inhibitor, can be effective for adolescents with moderate to severe depression (Zhou et al., Reference Zhou, Teng, Zhang, Del Giovane, Furukawa, Weisz, Li, Cuijpers, Coghill, Xiang, Hetrick, Leucht, Qin, Barth, Ravindran, Yang, Curry, Fan, Silva and Xie2020), but this is limited by varied research quality (Cipriani et al., Reference Cipriani, Zhou, Del Giovane, Hetrick, Qin, Whittington, Coghill, Zhang, Hazell, Leucht, Cuijpers, Pu, Cohen, Ravindran, Liu, Michael, Yang, Liu and Xie2016; Murphy et al., Reference Murphy, Capitão, Giles, Cowen, Stringaris and Harmer2021). Concerns have also been raised around an increased risk of suicide for children and adolescents using antidepressants (Hammad, Laughren, & Racoosin, Reference Hammad, Laughren and Racoosin2006; March et al., Reference March, Silva, Petrycki, Curry, Wells, Fairbank, Burns, Domino, McNulty, Vitiello and Severe2007). Although the validity of this concern has been scrutinized more recently, the risk-benefit profile of antidepressants still needs to be considered at an individual level (Murphy et al., Reference Murphy, Capitão, Giles, Cowen, Stringaris and Harmer2021). There is also a need to address the ever-increasing waiting lists of adolescents who require support for depression (British Medical Association, 2025), while balancing issues of high dropout rates for psychological therapies (Watson et al., Reference Watson, Harvey, Pass, McCabe and Reynolds2021). Collectively, these findings demonstrate the need for improved psychological treatments for adolescent depression.

We identified three systematic reviews on the topic, all of which have found BA to be at least as effective as other established treatments for reducing symptoms of depression in affected adolescents (Martin & Oliver, Reference Martin and Oliver2019; Tindall et al., Reference Tindall, Mikocka-Walus, McMillan, Wright, Hewitt and Gascoyne2017, Reference Tindall, Kerrigan, Li, Hayward and Gega2024). The existing research findings also suggest that BA is a cost-effective treatment option for depression, and it may be preferred by adolescents and their families over antidepressant drug treatment (Murphy et al., Reference Murphy, Capitão, Giles, Cowen, Stringaris and Harmer2021). However, the small number and varied quality of included studies limit the strength of these findings, and adequately powered randomized controlled trials (RCTs) are still needed to determine long-term clinical efficacy (Martin & Oliver, Reference Martin and Oliver2019).

In several primary data studies looking at the effects of BA in adolescents with depression, BA has been found to reduce depressive symptoms (Pass, Lejuez, & Reynolds, Reference Pass, Lejuez and Reynolds2018; Ritschel, Ramirez, Cooley, & Craighead, Reference Ritschel, Ramirez, Cooley and Craighead2016; Ritschel, Ramirez, Jones, & Craighead, Reference Ritschel, Ramirez, Jones and Craighead2011; Wallis et al., Reference Wallis, Roeger, Milan, Walmsley and Allison2012; Weersing et al., Reference Weersing, Brent, Rozenman, Gonzalez, Jeffreys, Dickerson, Lynch, Porta and Iyengar2017). This was also found in the largest RCT to date looking at BA in 60 clinically referred adolescents with depression (McCauley et al., Reference McCauley, Gudmundsen, Schloredt, Martell, Rhew, Hubley and Dimidjian2016), although it should be noted that this is still relatively small for an RCT, and larger controlled studies are required to strengthen this evidence base. Furthermore, in the limited amount of research that has investigated follow-up results, sustained positive treatment effects of BA have been found (Ritschel, Ramirez, Cooley, & Craighead, Reference Ritschel, Ramirez, Cooley and Craighead2016).

Some evidence suggests that BA may have important therapeutic effects beyond merely reducing symptoms of depression in adolescents, such as increasing levels of hope (Ritschel, Ramirez, Jones, & Craighead, Reference Ritschel, Ramirez, Jones and Craighead2011) and improving self-reported quality of life (Takagaki et al., Reference Takagaki, Okamoto, Jinnin, Mori, Nishiyama, Yamamura, Yokoyama, Shiota, Okamoto, Miyake, Ogata, Kunisato, Shimoda, Kawakami, Furukawa and Yamawaki2016). Although more research is needed to determine whether BA has a unique positive effect compared to the effect of group interventions, these findings warrant further investigation, as people with depression report valuing treatments that may help to restore previous functioning (Fusar-Poli et al., Reference Fusar-Poli, Estradé, Stanghellini, Esposito, Rosfort, Mancini, Norman, Cullen, Adesina, Jimenez, da Cunha Lewin, Drah, Julien, Lamba, Mutura, Prawira, Sugianto, Teressa, White and Maj2023) and have a positive impact in different domains in life (Battle et al., Reference Battle, Uebelacker, Friedman, Cardemil, Beevers and Miller2010).

Several studies indicate that adolescents like the goal-directed and practical format of BA (Arnott et al., Reference Arnott, Kitchen, Ekers, Gega and Tiffin2020; Lewis-Smith, Pass, Jones, & Reynolds, Reference Lewis-Smith, Pass, Jones and Reynolds2021) and appreciate the framing of their goals and activities as a choice rather than a chore (Watson et al., Reference Watson, Harvey, Pass, McCabe and Reynolds2021). Working with adolescents’ own values, rather than those imposed by others, has been welcomed by adolescents receiving BA (Pass, Brisco, & Reynolds, Reference Pass, Brisco and Reynolds2015), something which is consistent with previous findings that indicate that adolescents’ perceived autonomy is an important component of successful treatment response (Wisdom, Clarke, & Green, Reference Wisdom, Clarke and Green2006).

Retention in studies looking at BA for adolescents is generally very high, with one study noting that their retention rate of 88% in a 12-week/14-session treatment program outperformed those seen in groups receiving either CBT, fluoxetine, or combined treatment over 12 weeks as part of the Treatment for Adolescents with Depression study (c. 83% retention; March et al., Reference March, Silva, Petrycki, Curry, Wells, Fairbank, Burns, Domino, McNulty, Vitiello and Severe2007; McCauley et al., Reference McCauley, Gudmundsen, Schloredt, Martell, Rhew, Hubley and Dimidjian2016). Prioritizing treatments that are accepted by young people, such as BA, may help to address the high dropout rates of adolescents receiving psychotherapy for depression.

An additional benefit of BA is that it can be adapted for different sociocultural contexts, allowing participants to meaningfully engage with the treatment, as identified in a case series in which BA was successfully adapted for African American adolescents (Jacob, Keeley, Ritschel, & Craighead, Reference Jacob, Keeley, Ritschel and Craighead2013). While more research is needed in this area, treatments that complement an individual’s values may encourage adherence which may, in turn, improve treatment outcomes.

BA can also be adapted into brief formats (e.g. single session), which may be particularly helpful in cases where participant drop-out is a concern (Pass, Whitney, & Reynolds, Reference Pass, Whitney and Reynolds2016). Researchers have also adapted BA for internet delivery, with even a single session of internet-delivered BA reducing symptoms of depression in adolescents and being rated as acceptable by participants (Schleider et al., Reference Schleider, Mullarkey, Fox, Dobias, Shroff, Hart and Roulston2022). Internet-delivered BA could provide support to individuals who would otherwise remain on waiting lists (Andersson et al., Reference Andersson, Ahlen, Mataix-Cols, Lenhard, Henje, Månsson, Sahlin, Beckman, Serlachius and Vigerland2022; Ruggiero, Morris, Hopko, & Lejuez, Reference Ruggiero, Morris, Hopko and Lejuez2007), and for those to whom internet formats could be preferable, such as neurodivergent adolescents (Mohamed et al., Reference Mohamed, Russell, Palmer, Simonoff and Hollocks2024). Other researchers have successfully adapted BA as a school-based intervention (Brett, Reynolds, Totman, & Pass, Reference Brett, Reynolds, Totman and Pass2020; Lewis-Smith, Pass, Jones, & Reynolds, Reference Lewis-Smith, Pass, Jones and Reynolds2021; Riley & Gaynor, Reference Riley and Gaynor2014). Such approaches may be helpful for the large portion of adolescents who display symptoms of depression without meeting the full criteria for a diagnosis (Noyes et al., Reference Noyes, Munoz, Khalid-Khan, Brietzke and Booij2022), particularly as BA has been found to reduce levels of depression in adolescents experiencing low mood at a subclinical level (Schleider et al., Reference Schleider, Mullarkey, Fox, Dobias, Shroff, Hart and Roulston2022). However, the efficacy and appropriateness of school mental health interventions is a contested issue that extends beyond the scope of this review (Andrews & Foulkes, Reference Andrews and Foulkes2025).

The literature search identified that BA may also be an effective transdiagnostic treatment for depression and anxiety. This is important because depression and anxiety often occur together (Chu, Colognori, Weissman, & Bannon, Reference Chu, Colognori, Weissman and Bannon2009), possibly because they share similar mechanistic underpinnings. Avoidance is a key maintaining factor in anxiety (Treanor & Barry, Reference Treanor and Barry2017) as well as adolescent depression (McCauley et al., Reference McCauley, Gudmundsen, Schloredt, Martell, Rhew, Hubley and Dimidjian2016). Similarly, inhibited reward processing is associated with both depression and anxiety in adolescence (Luckhardt et al., Reference Luckhardt, Mühlherr, Schütz, Jarczok, Jungmann, Howland, Veit, Althen and Freitag2023), and anhedonia is associated with both conditions (Nagy et al., Reference Nagy, Cernasov, Pisoni, Walsh, Dichter and Smoski2020). Preliminary evidence suggests BA has positive results as a treatment for co-occurring anxiety and depression in adolescents (Chu et al., Reference Chu, Hoffman, Johns, Reyes-Portillo and Hansford2015; Weersing et al., Reference Weersing, Brent, Rozenman, Gonzalez, Jeffreys, Dickerson, Lynch, Porta and Iyengar2017), although this research requires further examination to ensure individuals with anxiety are actively recruited for, rather than just examined in co-occurrence with depression (Tindall et al., Reference Tindall, Kerrigan, Li, Hayward and Gega2024).

NICE have called for further research looking at the effectiveness of BA for adolescents with neurodivergences or for individuals who may find accessing and labeling cognitions challenging (2019). For these individuals, the simpler approach of BA compared to the more comprehensive CBT program may be more effective. As discussed above, reward function shows similar impairments in nondepressed autistic individuals and in non-autistic individuals with depression. Our literature search identified a paucity of research in this area, with only two studies investigating BA as a treatment specifically for autistic adolescents (Menezes et al., Reference Menezes, Burroughs, Pappagianopoulos, Sadikova, Fuhrmann, Bohac, Cross, Witte, Brinkmann, Lemley, Sukhodolsky and Mazurek2024; Mohamed et al., Reference Mohamed, Russell, Palmer, Simonoff and Hollocks2024). In a pilot study that adapted BA for adolescents with autism and depression, participants reported finding the BA therapy helpful and something they would recommend to others, and retention in the small sample was high (Mohamed et al., Reference Mohamed, Russell, Palmer, Simonoff and Hollocks2024). Another pilot study found that an adapted form of BA improved symptoms of depression in autistic adolescents (Menezes et al., Reference Menezes, Burroughs, Pappagianopoulos, Sadikova, Fuhrmann, Bohac, Cross, Witte, Brinkmann, Lemley, Sukhodolsky and Mazurek2024). However, more research is needed to link the neurobiological mechanisms of reward and BA in adolescents with autism, and to investigate the preferred format of BA for these adolescents.

Limitations and outstanding questions

This review highlighted several gaps in our understanding of reward and BA in adolescents with depression.

The role of reward function in adolescents receiving BA has been notably under-researched, and hardly ever compared to a true control (Nagy et al., Reference Nagy, Cernasov, Pisoni, Walsh, Dichter and Smoski2020). These mechanisms are particularly relevant in BA and depression (Forbes, Reference Forbes2020), and further research is required to uncover how reward function underpins BA response. Such research could inform our understanding of how reward impairment in adolescent depression interacts with reward-based treatments, which may help us address the question of why BA can be helpful for some adolescents and not for others (Weersing, Gonzalez, Campo, & Lucas, Reference Weersing, Gonzalez, Campo and Lucas2008).

Relatedly, research on adults has indicated that BA may only be partially effective in improving anhedonia (Alsayednasser et al., Reference Alsayednasser, Widnall, O’Mahen, Wright, Warren, Ladwa, Button, Mohr, Watkins, Turner, Byng, Crane, Lanham, Radhakrishnan, Lewis, Richards and Dunn2022), while individuals with depression may show a greater likelihood of responding to BA treatment when their reward function is more like that of healthy controls (Nagy et al., Reference Nagy, Cernasov, Pisoni, Walsh, Dichter and Smoski2020). This indicates that, while reward-focused therapies may be particularly important for individuals with decreased reward function, these therapies may also be harder for such individuals to access. Accordingly, more work is needed to link the neurobiology of reward function and anhedonia to the mechanisms of BA in young people.

Due to the small number of adequately powered studies (Kitchen et al., Reference Kitchen, Tiffin, Lewis, Gega and Ekers2021), it is not possible to make any strong conclusions about the optimal format of BA in different contexts. There is a tension in the research: some suggest that BA must be sufficiently detailed and complex to facilitate positive and sustained therapeutic effects; others suggest that BA should be brief and simple to ensure participants are able to understand the content and feel able to commit to the course of treatment (Martin & Oliver, Reference Martin and Oliver2019). While brief versions of BA may address feasibility challenges (Pass, Brisco, & Reynolds, Reference Pass, Brisco and Reynolds2015), some adolescents find brief BA too rushed, limiting their ability to connect with their therapist, develop strong skills, and maintain these skills after treatment (Lewis-Smith, Pass, Jones, & Reynolds, Reference Lewis-Smith, Pass, Jones and Reynolds2021). Furthermore, while BA can be delivered by nonspecialists (Pass, Hodgson, Whitney, & Reynolds, Reference Pass, Hodgson, Whitney and Reynolds2018), qualitative research indicates that adolescents prefer to receive treatments from trained clinicians (Bradley, McGrath, Brannen, & Bagnell, Reference Bradley, McGrath, Brannen and Bagnell2010). All these issues must be considered in relation to feasibility, cost-effectiveness, efficacy, and attrition, given the need for effective treatments for adolescents and the long waiting list for treatments.

Most research has been conducted in high-income settings, and more work is urgently needed to understand whether BA can be feasible in different settings for different populations (Martin & Oliver, Reference Martin and Oliver2019). This is especially important given the treatment gap between socioeconomic groups (Hazell, Thornton, Haghparast-Bidgoli, & Patalay, Reference Hazell, Thornton, Haghparast-Bidgoli and Patalay2022).

Further focused research is needed to inform the development of BA for coexisting conditions, as the nature of the condition will inform different modifications. For example, traits of anxiety may cause specific challenges with engaging in BA compared to individuals with standalone depression (Watson et al., Reference Watson, Harvey, Pass, McCabe and Reynolds2021). Despite a clinical need for bespoke treatments for depression for autistic adolescents, to date, a limited amount of research has sought to adapt BA for this group. More research is needed to identify how reward function is implicated in autistic adolescents with depression, and whether reward impairment in autism and depression impacts response to BA. Additionally, studies are required to determine adolescents’ preferences for receiving treatment when experiencing autism and depression, as these may differ from those preferred by neurotypical adolescents.