Summary: For decades, mental health care has largely equated recovery from depression with removing sadness. New research challenges that assumption, arguing the most dangerous element of depression is not negative feeling but the loss of positive emotion — anhedonia. This condition, present in the vast majority of patients, undermines motivation, increases suicide risk, and resists conventional therapies that focus mainly on reducing negative symptoms.
Anhedonia affects up to 90% of people with major depression and often predicts a longer, more severe illness course. In response, researchers developed Positive Affect Treatment (PAT), a 15-session psychotherapy that emphasizes rebuilding the brain’s capacity for joy, reward, and purpose rather than directly “fixing” sadness. The approach aims to retrain the brain’s reward system so patients can anticipate, enjoy, and learn from positive experiences again.
Key Facts
- The Treatment Gap: Many standard treatments concentrate on reducing negative emotions — anxiety, fear, sadness — but they often leave impaired positive affect unaddressed. PAT redirects treatment toward restoring positive affect by targeting reward-related brain processes.
- Paradoxical Healing: Clinical trials show that focusing only on positive affect can produce improvements in both positive and negative symptoms, even when negative emotions are not discussed in therapy.
- Hopelessness vs. Helplessness: Lead researcher Alicia E. Meuret differentiates “helplessness,” which still contains a will to change, from “hopelessness” — the sense that nothing can change. Anhedonia often manifests as hopelessness and is not resolved simply by removing negative feelings.
- The Power of Savoring: PAT uses structured practices — savoring, gratitude exercises, and loving-kindness techniques — to retrain how people anticipate and remember rewards, strengthening motivation and pleasure.
- Superior Outcomes: In a randomized trial of 98 adults with severe low positive affect and clinically impairing depression or anxiety, PAT led to better overall clinical status and lower relapse and suicide-related risk than a conventional treatment focused on negative affect.
Source: SMU
Rethinking depression: more than sadness
Many patients describe their core struggle with depression not as persistent sadness but as an inability to feel pleasure, hope, or motivation. Anhedonia diminishes the capacity for rewarding experiences and is common across several psychiatric diagnoses, including anxiety disorders, PTSD, substance use disorders, and schizophrenia. Yet traditional therapies and many medications primarily aim to reduce negative affect, often leaving patients still unable to enjoy life.
The new research, published in JAMA Network Open and led by SMU psychologists Alicia E. Meuret and Thomas Ritz along with Michelle G. Craske at UCLA, evaluates Positive Affect Treatment (PAT). Over more than a decade of clinical development, PAT emerged as a structured, 15-week individual therapy built to restore enjoyment, motivation, and reward learning.
Targeting the brain’s reward system
PAT is explicitly designed to engage the brain’s reward circuitry — the systems that control anticipation, pursuit, and enjoyment of positive experiences. Therapists guide patients through behavioral activation that emphasizes meaningful activities, attention training to notice positive events, and practices like gratitude and savoring that magnify emotional responses to small wins.
Unlike treatments that focus on reducing fear or sadness, PAT concentrates exclusively on reactivating positive affect. The distinction matters: in the trial, participants receiving PAT improved on measures of both positive affect and negative symptoms, even though the therapy did not target negative affect directly.
In a randomized controlled trial including 98 adults with severely low positive affect and moderate to severe depression or anxiety, PAT produced greater gains in overall clinical status than a comparator therapy focused on negative affect, and that advantage persisted at one-month follow-up. Participants also showed significant reductions in depression and anxiety symptoms, with changes in reward-related processes identified as central mechanisms of improvement.
Reducing key risk factors in depression and anxiety
The researchers conclude that addressing impaired reward processing is essential for lowering major risks associated with depression and anxiety, including suicidality and relapse. Meuret emphasizes that effective treatment must go beyond removing negative states to ask whether activities are meaningful, rewarding, and socially connecting for the patient.
The study tracked changes using multiple measures across three reward domains — anticipation/motivation, response to reward attainment, and reward learning — as well as threat-processing indicators. Most self-reported reward and threat measures mediated clinical improvements, suggesting subjective changes in how patients experience and anticipate reward were key to recovery. Behavioral and physiological measures in this study did not show the same mediating effects.
Study co-authors include David Rosenfield and Emily Wang of SMU and Christina Hough of UCLA.
Key Questions Answered:
A: Negative and positive emotions are driven by different neural systems. Reducing negative affect can stop distress, but it does not automatically engage the brain systems that create pleasure, motivation, and anticipation of reward.
A: PAT uses repeated, structured reward learning: engaging in meaningful activities, practicing savoring of small positive moments, and reinforcing anticipation and memory of rewards. Over time this can strengthen neural pathways related to motivation and pleasure, similar to rehabilitation exercises for physical injury.
A: No. The point is not to abandon treatments that reduce negative symptoms but to add a clear, focused effort to restore positive affect. For many patients with severe anhedonia, rebuilding a sense of accomplishment and connection is essential to break cycles of hopelessness and reduce long-term disability and suicide risk.
Editorial Notes:
- This article was edited by a Neuroscience News editor.
- The journal paper was reviewed in full.
- Additional context was provided by staff.
About this depression research news
Author: Alicia E. Meuret
Source: SMU
Contact: Alicia E. Meuret – SMU
Image: The image is credited to Neuroscience News
Original Research: Closed access. “Positive Affect Treatment for Depression, Anxiety, and Low Positive Affect” by Alicia E. Meuret, David Rosenfield, Emily Wang, Christina M. Hough, Thomas Ritz, and Michelle G. Craske. JAMA Network Open
DOI: 10.1001/jamanetworkopen.2026.7403
Abstract
Positive Affect Treatment for Depression, Anxiety, and Low Positive Affect
Importance
Targeting impaired reward processing that underlies anhedonia and diminished positive affect is essential to reduce major risks in depression and anxiety, including suicidality and relapse. Mechanistic research on interventions that specifically engage reward processes remains limited.
Objectives
To determine whether a novel psychosocial intervention (PAT) more effectively engages reward systems than a mechanistically distinct comparison therapy, and whether changes in reward and threat processing mediate clinical outcomes.
Design, Setting, and Participants
This assessor-blinded, parallel-group, multisite randomized clinical superiority trial recruited participants from December 2021 to January 2024, with final assessment in July 2024. Participants were treatment-seeking adults from outpatient centers in Los Angeles and Dallas with severely low positive affect and moderate to severe, functionally impairing depression or anxiety. Analyses followed intent-to-treat principles.
Intervention
Participants received 15 weekly individual therapy sessions of either Positive Affect Treatment (PAT) or Negative Affect Treatment (NAT).
Main Outcomes and Measures
Primary clinical outcomes included self-reported positive affect (Positive and Negative Affect Schedule–Positive subscale), interviewer-rated anhedonia (embedded in the SCID-5), and self-reported depression and anxiety (Depression, Anxiety, and Stress Scale). Target measures included 14 self-report, behavioral, and physiological measures spanning reward anticipation/motivation, response to reward attainment, reward learning, and threat processing. Analyses used mixed-effects multilevel models.
Results
Ninety-eight participants (mean age 32.8 years; 66.3% female) were randomized to PAT (n=51) or NAT (n=47). Multivariate analyses showed greater improvement in clinical status with PAT than with NAT (b = −0.06; 95% CI, −0.11 to −0.01; t = 2.43; P = .02; d = 0.27), with better clinical status for PAT at one-month follow-up (b = −0.21; 95% CI, −0.41 to −0.02; t = 2.11; P = .04; d = 0.21). Improvements in reward anticipation-motivation (b = 0.02; 95% CI, 0.01–0.03; t = 4.36; P < .001; d = 0.40) and reward attainment (b = 0.04; 95% CI, 0.01–0.06; t = 3.16; P = .002; d = 0.18) were comparable across treatments. Six of seven self-reported reward and threat measures mediated clinical outcomes; behavioral and physiological measures did not show the same mediation. Evidence for moderated mediation was limited.
Conclusions and Relevance
Among adults with severely low positive affect, depression, and anxiety, modulation of reward and threat processes appeared central to therapeutic improvement. A reward-focused intervention produced superior clinical outcomes relative to a negative-affect-focused therapy.
Trial Registration
ClinicalTrials.gov Identifier: NCT05203861