Summary: For decades, mental health care has focused on reducing sadness as the main route to treating depression. New research reframes that view: the most damaging feature for many patients is not negative emotion but the loss of positive emotion—anhedonia. A targeted therapy called Positive Affect Treatment (PAT) aims to restore joy, motivation, and reward processing rather than simply eliminate sadness.
Anhedonia affects up to 90% of people with major depression and commonly co-occurs with anxiety disorders, PTSD, substance use disorders, and schizophrenia. It strongly predicts a longer, more severe course of illness, a higher risk of relapse, and suicidal behavior. Despite its prevalence and risk, conventional therapies rarely focus on rebuilding the brain’s capacity to experience pleasure and meaning.
Key Facts
- Treatment gap: Traditional therapies prioritize reducing negative symptoms such as sadness, fear, and anxiety. PAT shifts emphasis to increasing positive affect by targeting the brain’s reward circuitry directly.
- Paradoxical healing: In trials, patients receiving PAT improved on both positive measures (pleasure, motivation) and negative measures (depression, anxiety), even though the therapy did not directly address negative emotions.
- Hopelessness versus helplessness: Lead researcher Alicia E. Meuret distinguishes helplessness—which still includes a desire to change—from hopelessness, where a person believes nothing can change. Anhedonia often reflects this hopeless state.
- Savoring and reward learning: PAT uses structured exercises such as savoring, gratitude practices, and loving-kindness to retrain how the brain anticipates and learns from rewarding experiences.
- Superior outcomes: In a randomized trial of 98 adults, PAT showed greater improvements in overall clinical status than a conventional therapy focused on negative affect and reduced markers tied to suicide risk and relapse.
Most people equate depression with sadness, but for many the core problem is a diminished ability to feel positive emotions.
Patients frequently report that regaining positive feelings—joy, interest, satisfaction, and connection—is their primary goal. However, until recently, treatments emphasized symptom reduction: lowering anxiety, neutralizing fear, and dampening sadness. That approach can leave the underlying impairment in reward processing unaddressed, so people remain disengaged and vulnerable to relapse.
A team led by Alicia E. Meuret at Southern Methodist University (SMU), with collaborators Thomas Ritz and Michelle G. Craske at UCLA, developed Positive Affect Treatment (PAT), a 15-session individual psychotherapy that directly trains the brain’s reward systems. The approach is the product of more than a decade of mechanistic and clinical research and was evaluated in a multicenter randomized clinical trial reported in JAMA Network Open.
Targeting the brain’s reward system
PAT focuses exclusively on strengthening positive affect: how people anticipate rewards, respond when they occur, and learn from those experiences. Therapy sessions use behavioral activation with a reward-learning emphasis, attention training toward positive cues, and intentional practices—gratitude exercises, savoring techniques, and loving-kindness meditations—to rebuild neural pathways related to anticipation, motivation, and pleasure.
Unlike treatments that explicitly target fear or sadness, PAT aims to put the brain’s “positive system” back into functional use. In clinical trials, this reward-centered approach led to improvements in both positive affect and reductions in depressive and anxious symptoms, suggesting that restoring positive capacity can produce broad clinical gains.
Evidence from randomized clinical testing
In the randomized, assessor-blinded trial, 98 adults with severely low positive affect and moderate to severe depression or anxiety were assigned to either PAT (15 weekly sessions) or a comparison therapy focused on negative affect (NAT). Participants were recruited from outpatient centers in Los Angeles and Dallas. Outcomes included self-reported positive affect, interviewer-rated anhedonia, and measures of depression and anxiety, plus multiple reward- and threat-processing targets measured via self-report, behavioral tasks, and physiological assessments.
PAT produced greater overall improvements in clinical status than the negative-affect-focused comparison, and this advantage persisted at one-month follow-up. PAT participants showed meaningful gains in reward anticipation and response to reward attainment. Several self-report measures of reward and threat processing statistically mediated clinical improvement, supporting the hypothesis that modulation of reward systems is a central therapeutic mechanism. Behavioral and physiological measures showed less consistent mediation.
Reducing risks associated with depression and anxiety
Because impaired reward processing and low positive affect are linked to suicidality and relapse, a treatment that directly restores positive emotion targets critical risk pathways. “It’s not enough to take away the bad,” Meuret says. Effective treatment should ask whether activities are meaningful, whether they produce joy or accomplishment, and whether they foster social connection—factors that sustain recovery and resilience.
PAT’s structured exercises help patients re-engage with rewarding activities, relearn anticipation and reinforcement, and accumulate experiences that rebuild motivation. For many people with severe anhedonia, reinstating a sense of meaning and pleasure is essential to breaking the cycle of hopelessness and preventing long-term disability.
Frequently asked questions
A: Negative and positive emotions are regulated by different neural systems. Treating negative affect can stop distress, but it does not automatically reactivate the brain circuits responsible for anticipation, pleasure, and motivation—the systems PAT targets.
A: PAT applies principles of reward learning and repetition. By intentionally engaging in meaningful actions, practicing savoring of small positive moments, and reinforcing successful experiences, patients can gradually rebuild neural pathways that support reward anticipation and motivation—similar to physical rehabilitation for movement.
A: No. Anxiety and sadness remain important treatment targets. The key takeaway is that positive affect restoration should be added as a primary goal, especially for individuals with marked anhedonia, because increasing positive emotion often drives broader recovery.
Editorial notes
- This article was edited by a Neuroscience News editor.
- The journal paper was reviewed in full by editorial staff.
- Additional context and synthesis were added to clarify clinical implications.
Research attribution and publication details
Author: Alicia E. Meuret
Source: SMU (Southern Methodist University)
Contact: Alicia E. Meuret – SMU
Image: Image credit: Neuroscience News
Original research: Positive Affect Treatment for Depression, Anxiety, and Low Positive Affect. JAMA Network Open. DOI: 10.1001/jamanetworkopen.2026.7403
Abstract (summary)
Importance: Targeting impaired reward processing that underlies anhedonia is essential to reduce key risks in depression and anxiety, including suicidality and relapse.
Objectives: To evaluate whether a reward-focused psychosocial intervention engages reward systems more than a mechanistically distinct comparison therapy and whether changes in reward and threat processing mediate clinical outcomes.
Design, setting, and participants: An assessor-blinded, parallel-group, multisite randomized clinical superiority trial conducted from December 2021 to January 2024 with final assessment in July 2024. Participants were treatment-seeking adults with severely low positive affect and moderate to severe, functionally impairing depression or anxiety, recruited from outpatient academic centers in Los Angeles and Dallas. Analyses followed intent-to-treat principles.
Intervention: Fifteen weekly individual therapy sessions of Positive Affect Treatment (PAT) versus an active comparison therapy focused on negative affect (NAT).
Main outcomes and measures: Clinical status included self-reported positive affect, interviewer-rated anhedonia, and self-reported depression and anxiety. Target measures assessed reward anticipation and motivation, response to reward attainment, reward learning, and threat processing using self-report, behavioral tasks, and physiological assessments.
Results: Ninety-eight participants (mean age 32.8 years; 66.3% female) were randomized to PAT (n=51) or NAT (n=47). PAT produced greater overall clinical improvement than NAT, with benefits maintained at one-month follow-up. Improvements in reward anticipation and response to reward attainment were observed, and multiple self-report reward and threat measures mediated clinical gains.
Conclusions: In adults with severely low positive affect, a reward-focused intervention produced superior clinical outcomes, suggesting that modulation of reward and threat processes is a central mechanism for improvement. Trial registration: ClinicalTrials.gov Identifier: NCT05203861.