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Cognitive Behavioral Therapy for Depressionunlocked

Cognitive Behavioral Therapy for Depressionunlocked

  • Stirling MooreyStirling MooreySouth London and Maudsley NHS Foundation Trust, Centre for Anxiety Disorders and Trauma
  •  and Steven D. HollonSteven D. HollonDepartment of Psychology, Vanderbilt University

Summary

Cognitive behavioral therapy (CBT) has the strongest evidence base of all the psychological treatments for depression. It has been shown to be effective in reducing symptoms of depression and preventing relapse. All models of CBT share in common an assumption that emotional states are created and maintained through learned patterns of thoughts and behaviors and that new and more helpful patterns can be learned through psychological interventions. They also share a commitment to empirical testing of the theory and clinical practice. Beck’s Cognitive Therapy sees negative distorted thinking as central to depression and is the most established form of CBT for depression. Behavioral approaches, such as Behavioral Activation, which emphasize behavioral rather than cognitive change, also has a growing evidence base. Promising results are emerging from therapies such as Mindfulness Based Cognitive Therapy (MBCT) and rumination-focused therapy that focus on the process of managing thoughts rather than their content. Its efficacy-established CBT now faces the challenge of cost-effective dissemination to depressed people in the community.

Keywords

Subjects

  • Psychology and Other Disciplines

Origins and Development of Behavioral and Cognitive Models of Depression

Behavioral models of depression have been largely based on Skinnerian or operant conditioning theory. Ferster (1973) proposed a model that saw depression as characterized by a decrease in the frequency of positively reinforced activities. Factors such as decreased environmental reward (e.g., resulting from a significant loss), avoidance or escape from aversive stimuli, schedules of reinforcement, and suppressed anger contribute to a reduction in the depressed person’s behavioral repertoire which in turn leads to less rewarding experiences. Lewinsohn (1974) developed this model further, as did Staats and Helby (1985) (see Dimidjian, Barrera, Martell, Muñoz, & Lewinsohn, 2011). However, this did not lead to significant developments in treatment or in outcome research, partly due to the surge in interest in Beck’s cognitive approach to depression that resulted from publication of the first randomized controlled trial to show that a psychological treatment could be as effective as antidepressants in depression (Rush, Beck, Kovacs, & Hollon, 1977). Beck first identified the importance of thoughts in depression in the early 1960s (Beck, 1963, 1964). In contrast to behavioral approach that saw “internal” self-talk as a covert behavior, Beck suggested that cognition was central to depression. Beck noted that the dreams and self-reports of depressed patients were pervasively negative: They experienced a stream of negative automatic thoughts in response to events. In depression, he hypothesized, there was a shift in information processing such that stimuli which might usually be perceived as neutral or positive are seen as negative: a systematic cognitive bias. Underlying this bias are cognitive structures or schemas, often expressed as dysfunctional attitudes which, when activated by an event or accumulation of events, skew the interpretations and evaluations the person makes about the world. Examples of these include beliefs such as, “If I fail at something it means I’m a complete failure” or “If I don’t have someone to love and accept me it means I’m unlovable.” This results in an increasingly negative view of the self (“I am a failure; I am unlovable”), the world (“the world is unrewarding; others will reject me”), and the future (“I will never achieve my goals”) during the course of a depressive episode. Reduced expectations of being valued or succeeding at what the depressed person undertakes lead to avoidance and passivity that further reinforces the depressed mood and negative beliefs (Beck, 1967, 1987).

Adverse life events and experiences in childhood lead to underlying assumptions, often expressed in conditional form: “If . . . then . . . .” For instance, the belief “If I fail at something, I’m a complete failure” may be laid down over years of being on the receiving end of demanding parental expectations. A significant failure experience in adult life, such as not passing an exam, will lead to activation of this schema and consequent depression (see Figure 1). Evidence for the cognitive model has accumulated since its original presentation (Beck & Alford, 2009; Clark & Beck, 1999). The association between negative thoughts and depression is particularly robust and seems to apply across cultures (Beshai, Dobson, Adel, & Hanna, 2016). Beck has modified the model to take account of research findings to include the concept of cognitive reactivity. People who are prone to depression will have a greater activation of negative beliefs than those who are not when they experience mood shifts in response to the vicissitudes of life (Scher, Ingram, & Segal, 2005). While major life events may be needed to trigger first-onset depression, repeated episodes make it easier for mild events to produce depression: the so-called kindling effect (Kendler, Thornton, & Gardner, 2000).

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Figure 1. Developmental formulation.

Cognitive approaches such as Beck’s and Alloy and Abramson’s hopelessness model of depression (Abramson et al., 1989) generated the most research in the last decades of the 20th century, but in the first decades of the 21st century, behavioral models of depression experienced a resurgence, initially stimulated by the finding in a dismantling trial that the behavioral component of cognitive therapy was as effective as the full package (Jacobson et al., 1996). Contemporary behavioral activation models, based on Lewinsohn’s more integrative model (Lewinsohn, Hoberman, Teri, & Hautzinger, 1985), have a more sophisticated account of positive reinforcement, pay more attention to cognition by targeting ruminations, and emphasize the importance of avoidance of interpersonal situations in maintaining depression. There has also been a shift away from cognitive content (i.e., negative thoughts) to an interest in cognitive processes such as ruminations. Post-Beckian cognitive models emphasize the importance of how one relates to one’s thoughts as a factor in maintaining depression. Trying to analyze why one is depressed or fix one’s perceived inadequacies leads to cycles of rumination that dig one deeper into depression. Metacognitive therapy, rumination-focused cognitive behavioral therapy (CBT), and mindfulness-based cognitive therapy are examples of these more process-oriented forms of CBT (Segal, Williams, & Teasdale, 2013; Watkins, 2018; Wells, 2011). Table 1 summarizes the CBT models for depression in chronological order.

Table 1. Current Cognitive Behavior Therapies for Depression

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Varieties of CBT for Depression

Key Authors

Cognitive therapy

Beck, Rush, Shaw, & Emery (1979)

Behavioral couple therapy

For distressed couples where one partner is depressed.

Jacobson et al. (1991)

Behavioral activation

Jacobson et al. (1996)

Mindfulness Based Cognitive Therapy (MBCT)

Relapse prevention for people with recurrent depression who are currently in remission or have residual symptoms.

Segal, Williams, and Teasdale (2002)

Acceptance and Commitment Therapy (ACT) for depression

Zettle (2004)

Metacognitive therapy

Wells et al. (2009)

Rumination focused CBT

Watkins et al. 2011
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Beck’s Cognitive Therapy

Outline of Treatment

This form of cognitive behavioral therapy (CBT) is the best known and most researched, so it is described here in some detail. Cognitive therapy for depression (CT) is a relatively brief (20 sessions), structured, problem-focused treatment, firmly based on the cognitive model of depression. It can be understood to have a hierarchy of aims:

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to reduce hopelessness and suicidality

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to resolve target problems related to depression by teaching strategies to manage mood

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to reduce vulnerability to future depression by modifying underlying beliefs and developing a relapse prevention plan

Target problems and goals are established at the beginning of therapy and each session is structured to use time as effectively as possible; an agenda is set which generally follows the plan:

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bridge to last session with review of risk and current mood

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review of homework

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two to three agreed topics to address

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setting homework

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summary and feedback

Treatment is based on an individualized formulation which is developed in partnership with the patient. This initially focuses on the way in which thoughts, feelings, and behaviors interact to maintain the depression. The patient learns to identify situations that trigger a lowering of mood and the link between their negative thoughts and the mood shift. Similarly, the resulting patterns of behavior, such as withdrawal, are recognized. As therapy progresses, this conceptualization is deepened: Repeating sets of negative automatic thoughts reveal themes of underlying beliefs. The developmental conceptualization (Figure 1) links past learning experiences to these underlying beliefs or schemas and helps the patient see how these have made them vulnerable to depression. Because patients will be asked to examine deeply held beliefs, therapy tries to be as collaborative as possible. Rather than telling the patient their beliefs are maladaptive, the therapist encourages the patient to enter into a partnership to explore the validity and usefulness of them. Beliefs are turned into hypotheses that can then be tested through verbal discussion (Socratic questioning) or direct action (behavioral experiments). Depressed patients discover that their thoughts may be biased by their mood and learn to identify cognitive distortions or thinking errors. This process of putting beliefs to the test is referred to as “collaborative empiricism.” Therapy consists of a variety of cognitive and behavioral techniques. At the beginning of therapy, particularly if the patient is more deeply depressed, techniques will be more behavioral. These often begin with monitoring activities and rating them for the degree to which they are pleasurable or give a sense of achievement (mastery). Patients are then encouraged to engage in activities that promote pleasure or mastery and to note the effect on their mood. In contrast to Behavioral Activation that seeks behavioral change for its own sake, the activity work in cognitive therapy is always used in the service of cognitive change and, wherever possible, framed as an experiment to test negative thoughts. For instance, someone may predict that if they call a friend, they won’t be interested in them. The therapist can help them devise an experiment in which they take the risk of telephoning and evaluate the result: They may find that it took them half an hour to end the call because the friend was so pleased to hear from them! The next phase of therapy is for the patient to learn to recognize and evaluate their thoughts. This begins with monitoring of negative automatic thoughts as they arise in everyday situations. Patients learn to recognize how the depression biases their thinking in a negative direction. The therapist then uses Socratic questioning to evaluate the thoughts with the patient in the session, asking questions to help them examine their view of the situation. The touchstone for evaluating the thoughts is their logical consistency and the evidence available. Patients then practice identifying thoughts, asking questions such as: “What’s the evidence for and against this thought?”; “What’s the effect of thinking in this way? Is it helpful to me?”; and “Could there be an alternative explanation or way of testing my thoughts?” as homework between sessions. In the third phase of therapy, beliefs are elicited and tested that underlie the distorted thinking and make the patient vulnerable to future depression. So, for instance, a belief that “I must always succeed” or “I’m a failure” may be associated with perfectionistic behavior. The person may stay late at work, spend twice as long as their colleagues writing reports, and check them several times. The belief that “If I don’t do things perfectly, I’ll be found out and seen as a failure” can be tested through experiments where the patient spends less time preparing and checking reports and discovers that the result is just as good. They can then move on to deliberately making small mistakes and may discover that no one notices. In this final phase of therapy, the patient is encouraged to develop a blueprint or relapse prevention plan that summarizes as follows:

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what she has learned from therapy

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what techniques she needs to continue practicing (e.g., “make sure I structure my week so I don’t have long periods where I can ruminate”)

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what risk factors and early warning signs to look out for

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what she can do if her mood starts to drop

Efficacy of Cognitive Therapy for Depression

The first randomized controlled trial of CT (Rush et al., 1977) demonstrated a slight superiority of psychological treatment over tricyclic antidepressants with respect to acute response, but largely because the medications were tapered too soon such that early relapse was confounded with a lack of response. In the succeeding 40 years, numerous studies have compared Beck’s therapy with tricyclics and with specific serotonin reuptake inhibitors (SSRIs) and consistently found the two approaches to be equally effective (see reviews by Butler, Chapman, Forman, & Beck, 2006; Cuijpers et al., 2013a; Cuijpers, Cristea, Karyotaki, Reijnders, & Huibers, 2016), though an individual patient data meta-analysis suggests there may be a slight advantage of medication over CBT (Weitz et al., 2015). There is evidence that combining CBT and medication adds to the effects of both (Cuijpers et al., 2014), although that effect appears to be heavily moderated (Hollon et al., 2014) and may come at the expense of undercutting CBT’s enduring effect (DeRubeis et al., 2020). CBT is significantly more effective than waiting list controls, treatment as usual, or placebo (effect size 0.71; Cuipers et al., 2013a), while head to head comparisons of CBT with other evidence-based therapies, such as interpersonal therapy, tend to show both therapies to be equally effective (e.g., Luty et al., 2007). CBT is not only effective with mild-moderate levels of depression but also for the moderate-severe range when delivered by well-trained therapists (DeRubeis et al., 2005). Despite these encouraging findings that place CBT as the psychological treatment with the most robust empirical support, only 60% of patients achieve remission. When publication bias and use of waiting list controls are accounted for, the effect size of studies reduces considerably (Cuijpers, Cristea, Karyotaki, Reijnders, & Huibers, 2016; Driessen, Hollon, Bockting, Cuijpers, & Turner, 2015), as for antidepressant medications (Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008). Table 2 summarizes comparisons between CBT (not exclusively Beck’s cognitive therapy), antidepressant medication, waiting list control, treatment as usual, and other psychotherapies.

Table 2. Efficacy of CBT for Depression

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Comparison

Effect Size (Hedges g)

CBT versus WL, TAU, placebo

0.71

NNT = 2.6

CBT + ADM versus ADM

0.49

NNT = 3.7

CBT versus ADM

0.03

NS

CBT versus other psychotherapy

−0.02–0.25

NS
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Notes: WL = waiting list; TAU = treatment as usual; ADM = antidepressant medication; NNT = number needed to treat.

Source: Data adapted from Cuijpers et al. (2013a).

Relapse Prevention

Early randomized controlled trials comparing CBT with antidepressant medication that was withdrawn at the end of the trial reported relapse rates of 15–28% for CBT compared to 50–60% with a tricyclic (Evans et al., 1992; Simons, Murphy, Levine, & Wetzel, 1986). Biological psychiatrists argued that the antidepressant may have been withdrawn too soon for a fair comparison, since the recommendation is that medication be continued for 6–9 months after symptoms remit, but the differential relapse does indicate that CBT has an enduring effect. Later studies then compared CBT with maintenance medication. The relapse rates for patients receiving continuation medication were equivalent at 30% to patients receiving CBT alone (Cuijpers et al., 2013b). In effect, CBT cuts risk of relapse among remitted patients by more than half relative to prior medications, and the two studies that compared prior CBT found that the enduring effect extended to the prevention of recurrence relative to recovered patients withdrawn after a year of continuation medication (Dobson et al., 2008; Hollon et al., 2005). In partially recovered depressed outpatients, adding CT to maintenance medication reduces relapse rates more than maintenance medication alone, and the beneficial effects of CBT persist for up to 3½ years (Paykel et al., 1999, 2005). There is strong support in these studies for an enduring relapse prevention effect from CBT (Clarke, Mayo-Wilson, Kenny, & Pilling, 2015). However, it has been argued that rather than CBT preventing relapse, it is antidepressant discontinuation that promotes it (Andrews, Kornstein, Halberstadt, Gardner, & Neale, 2011). SSRIs increase serotonin available in the synapse by blocking reuptake but over time the system responds by reducing serotonin synthesis in the presynaptic neurone and reducing postsynaptic receptor sensitivity. This would explain why it seems to be so difficult to take patients off SSRIs without triggering a relapse (Hollon et al., 2019). Further research will hopefully answer this question.

Mediating Factors

Research into the factors that mediate outcome of CBT for depression fall into two categories: dismantling studies that attempt to identify active elements of treatment, and correlational studies that assess the relationship between treatment variables and reduction in depressive symptoms. Cuijpers, Cristea, Karyotaki, Reijnders, and Hollon (2019a) recently carried out a meta-analysis of component studies to date and concluded that few had sufficient power to detect differences. Hundt, Mignogna, Underhill, and Cully (2013) reviewed the evidence for the impact of CBT skills on outcome and found that the small number of studies to date provided evidence that the frequency and quality of skill use influenced outcome. Click or tap here to enter text.Segal et al. (2019) found that the use of CBT skills post therapy was linked to reduced relapse and that this was mediated by the extent to which patients “decentered” from their negative thinking. Strunk and colleagues found that those patients who best mastered the skills taught in CBT were those least likely to relapse following treatment termination (Strunk, DeRubeis, Chiu, & Alvarez, 2007). The inclusion of homework has a significant effect on therapy outcome (Kazantzis, Whittington, & Dattilio, 2010). The therapeutic alliance is associated with therapy outcome across a range of different therapies (see Moorey & Lavender [2018] for a discussion of the importance of the therapeutic relationship in CBT). In CBT for depression, it may be the agreement on tasks and goals of therapy that is the most important aspect of this. Patients who accept the cognitive model and experience early symptom gains are likely to report a better therapeutic alliance and to make greater gains in therapy (Webb et al., 2011).

Behavioral Treatments for Depression

In 1996, Neil Jacobson and colleagues reported the results of a three-way dismantling study that compared the behavioral activation (BA) component of Beck’s cognitive therapy (CT) for depression with BA plus thought challenging (AT), and with the full CT package. Each proved equally effective and the results held up at follow-up (Jacobson et al., 1996; Gortner et al., 1998). This revitalized the interest in behavioral models of treatment for depression and led to the development of a new therapy: BA. Like earlier behavioral approaches, BA sees depression as a result of a reduction in positive reinforcement which leads to a reduction in behavior and further low mood. In contrast to earlier models, this approach emphasizes the role of negative reinforcement of avoidance behavior: Social withdrawal and avoidance of responsibility and rumination bring temporary relief from painful affect but lead to more passivity and inactivity. BA uses activity monitoring and scheduling to encourage healthy behaviors and teaches patients to do their own functional analysis. Patients identify triggers for avoidance (Triggers, Reactions, and Avoidance Patterns—TRAPs) and replace them with coping responses (Triggers, Reactions, and Coping response—TRACs). A range of other techniques, including graded task assignment, mental rehearsal, problem-solving, and skills training, may all be employed (Martell, Addis, & Jacobson, 2001; Martell, Dimidjian, & Herman-Dunn, 2010). Behavioral activation is simpler and easier to teach than cognitive therapy (Ekers, Dawson, & Bailey, 2013) and there is a growing body of evidence for its effectiveness. Meta-analysis has found that there is a large effect size in comparison with controls (standardized mean difference [SMD] of −0.74) and a moderate superiority of BA over medication (SMD −0.42) (Ekers et al., 2014).

Behavioral couple therapy (BCT) is a brief (12–20 sessions) intervention that can be applied when there is relationship distress and at least one partner is depressed. There is an interaction between the couple’s behavior and the depression such that intimacy and support is reduced and conflict increased. BCT seeks to improve the relationship through communication training, fostering positive exchanges between partners and teaching joint problem-solving skills. The approach is based on the groundbreaking work of Neil Jacobson (Jacobson et al., 1991, 1993) but has developed over the subsequent 20 years. BCT improves both depression and the quality of the relationship (Christensen, Atkins, Yi, Baucom, & George, 2006) and is recommended in a number of guidelines such as the NICE guidelines for depression. A recent Cochrane review advised caution since the quality of randomized controlled trials (RCTs) of couples therapies and sample sizes are relatively low (Barbato, D’Avanzo, & Parabiaghi, 2018).

Process-Oriented Cognitive Behavioral Therapies

In contrast to cognitive behavioral therapy (CBT) for anxiety disorders, which has progressed through delineating specific models for the subgroups of anxiety diagnoses (panic, social phobia, etc.), depression has resisted this type of subcategorization beyond perhaps the distinction between acute and chronic depression. The research has therefore focused on refining the methodology of trials using Beck’s manualized cognitive therapy and more latterly behavioral activation (BA). Alternative cognitive approaches that have developed over the past 20 years have moved the focus from cognitive content (i.e., distorted negative thinking) to cognitive processes (e.g., rumination): the “third wave” behavior therapies. Well’s metacognitive therapy was first applied to anxiety and then later depression. It addresses the positive beliefs (“If I can understand why I am depressed I will be able to find a way out”) and negative (“I can’t control this rumination”) beliefs that drive worry and rumination and associated attentional processes (Papageorgiou & Wells, 2009; Wells, 2011). A meta-analysis suggests this approach may be more effective than standard CBT (Normann, van Emmerik, & Morina, 2014). A related approach is Watkins’ rumination-focused CBT which helps depressed patients shift their thinking style from abstract, overgeneralized thinking that maintains depression to more concrete, problem-focused thinking (Watkins, 2018). A randomized controlled trial has demonstrated its superiority over treatment as usual in residual depression (Watkins et al., 2011). One of the most influential developments in CBT in recent years has been mindfulness-based cognitive therapy (MBCT). This was originally developed as a relapse prevention program for recurrent depression. Relapse is understood to involve “a reactivation, at times of lowering mood, of patterns of negative thinking similar to the thought patterns that were active during previous episodes of depression” (Segal, Williams, & Teasdale, 2013, p. 65). Rather than working with the cognitive appraisals, MBCT seeks to help people develop a “meta-awareness” of thoughts, feelings, and physical sensations so that there is a decentering or defusion from these patterns rather than identification with them. Mindfulness is the awareness that arises when one pays attention to one’s experiences in the present moment and in an accepting, nonjudgmental way. MBCT is delivered in groups of from 8 to 15 people and uses a combination of regular formal and informal meditation practices and insights from CBT. Meta-analysis suggests there is a relative risk reduction of 43% for those with three or more depressive episodes (Piet & Hougard, 2011) and that MBCT may be more effective for those with residual or fluctuating depressive symptoms (Kuyken et al., 2016; Segal et al., 2010). Acceptance and Commitment Therapy (ACT) is another “third wave” approach that is now being applied to depression with evidence for its efficacy (Bai, Luo, Zhang, Wu, & Chi, 2020; Zettle, 2004). The initial results from these process-oriented therapies are very encouraging, but sample sizes are small and more research is needed to determine what benefits they may have over the established behavioral and cognitive therapies for depression.

Application of Cognitive Behavioral Therapy to Various Populations

Cognitive behavioral therapy (CBT) has been successfully applied across the life cycle. CBT for adolescent depression is an effective intervention and in many ways similar to individual CBT for adults; it has also been used in a group format and with parental involvement. Parental engagement is understandably more important with the younger depressed patient (see David-Ferdon & Kaslow, 2008) for a meta-analysis of CBT for depression in children and adolescents, and Amberg & Ost [2014] in children from 8 to 12 years of age). CBT has also been successfully adapted for older people (Chand & Grossberg, 2013; Pinquart, Duberstein, & Lyness, 2007). Studies generally support the delivery of CBT to people with physical illness and associated depression (Beltman, Voshaar, & Speckens, 2010). Adaptations may be required to take account of difficulties in carrying out behavioral activation strategies that require physical exertion, and sensitivity in the way therapists help patients manage negative thoughts that may often have some basis in reality (Moorey, 1997). CBT appears to be effective across a range of health conditions (Okuyama, Akechi, Mackenzie, & Furukawa, 2017), including life-threatening illnesses such as cancer (Anderson, Watson, & Davidson, 2008; Moorey & Greer, 2011). Many of these trials, however, have small samples and a recent large-scale RCT comparing CBT with treatment as usual in patients with depression and advanced cancer failed to find an effect of therapy (Serfaty et al., 2020). CBT originated in a Western context, and the concept of collaborative empiricism assumes a relationship of equals in which clients share their thoughts and feelings and work toward solving problems and achieving their goals. In Eastern cultures, however, relationships may be structured more hierarchically. People may be less used to openly expressing and sharing their thoughts and feelings, and they may have a far more interdependent view of their goals. Adaptations of CBT in non-Western countries have tended to keep the content of the intervention relatively unchanged but have modified the forms of language used, the context, and the mode of delivery (Chowdhary et al., 2014). Preliminary evidence suggests that CBT can be transported cross-culturally with no loss of its effectiveness (see, e.g., a discussion of CBT in Japan: Ono et al. [2011]; Kobori et al. [2014]).

Disseminating Cognitive Behavioral Therapy

Much of the research in cognitive behavioral therapy (CBT) has been in the form of efficacy trials carried out in academic settings delivered by well-trained therapists. More effectiveness studies are needed to establish its usefulness in depression in “real world settings,” but perhaps more importantly, ways are needed to disseminate the techniques to the wider population. Freud’s model of the weekly 50-minute hour consultation has persisted into the 21st century. The prevalence of depression means it will never be possible to train enough therapists to deliver face-to-face CBT to those who need it. One solution is to move the treatment out of the one-to-one setting using groups or technology to improve cost-effectiveness. Another innovation in the United Kingdom has been the Improving Access to Psychological Therapies program that attempts to standardize evidence-based therapy nationwide. Briefer CBT delivered by nonprofessionals has been trialed in low- and middle-income countries. These three areas are described here as examples of alternative ways to deliver CBT more widely.

Alternative Formats to Individual CBT: Group, Computer, Internet, and Telephone

Group CBT is widely practiced but has not received as much research attention as individual therapy. It is usually delivered in a psychoeducational structured format (Scott, 2011). It may not be acceptable to about one third of patients, and the need for individual orientation sessions to prepare and engage patients means that it may not be as cost-effective as it appears on the surface. A naturalistic study, however, found that individual CBT was 1.5 times more expensive than groups that included 8–12 participants (Brown et al., 2011). A meta-analysis found that individual CBT was slightly superior post-treatment, but there was no difference at 3 months follow-up (Huntley, Araya, & Salisbury, 2012). Computerized CBT (cCBT) has become very popular because of its potential cost-effectiveness. Hofman, Pollitt, Broeks, Stewart, and Van Stolk (2017) carried out a systematic review of the available cCBT platforms and their effectiveness. They found large within-group effect sizes averaging 1.23. The findings overall do support its use in depression, but it may not be reaching groups who are less computer literate: The average cCBT participant was a female in her late 30s with a university degree who was in full-time employment. There should also be caution in assuming that participants will make full use of the program without any assistance: Reviews have consistently found guided self-help to be more effective than unguided (Andersson & Cuijpers, 2009). With the increased availability of the internet, online CBT programs are also being used more widely. For instance, a web-based program for depression has been shown to be more effective than treatment as usual (Farrer, Christensen, Griffiths, & Mackinnon, 2011). Finally, telephone CBT also appears to be an effective treatment for depression (Castro et al., 2020). Cuijpers and colleagues carried out a network meta-analysis comparing individual, group, telephone-administered, guided self-help, and unguided self-help for people with depression (Cuijpers, Noma, Karyotaki, Cipriani, & Furukawa, 2019b). All approaches were equally effective and superior to a waiting list and care as usual. Guided self-help appeared to be less acceptable than individual, group, or telephone formats.

The U.K. Improving Access to Psychological Therapies Initiative (IAPT)

Psychotherapy has traditionally been something of a “cottage industry,” with an emphasis on the individual skill and discretion of the therapist, but not organized in a systematic, nationwide fashion. Provision has been patchy and many patients have not had access to evidence-based therapies. The U.K. Improving Access to Psychological Therapies (IAPT) program has been developed to redress this balance and to show that locally based therapy services that have clear targets, the means to evaluate outcomes, and are cost effective can work. In 2007, the economist Richard Layard and the psychologist David Clark joined forces to lobby for a much-needed expansion of psychological therapies in the United Kingdom. They argued that anxiety and depression had significant deleterious effects on the economy (Layard, 2006). They suggested that the costs of increasing psychological therapies services would be outweighed by the benefits in savings to the health service and treasury through increased tax revenues and reduced spending on benefits. The IAPT program implements psychological treatments that have been shown to be effective and monitors their impact. The services set challenging targets for access (16% of the community prevalence of anxiety and depression) and outcomes (50% recovery: defined as PHQ-9 and GAD-7 scores falling below 10). Treatment follows a stepped care model. Low-intensity (LI) therapy is delivered by Personal Wellbeing Practitioners (PWPs). LI treatment includes guided self-help, computerized CBT, behavioral activation, and psychoeducational groups.

High-intensity therapy (HI) involves weekly face-to-face therapy delivered by fully trained CBT therapists. Patients with less severe problems are initially treated with LI and stepped up to HI if necessary, while more severe problems are treated with HI as the first intervention. A total of 36% of people receive only LI, 28% HI, and 34% both (Clark, 2018). IAPT services now treat nearly one million patients a year and achieve recovery in 50% of cases as well as reliable improvement in 66% (Clark, 2018), with evidence of substantial change in depression scores and a moderate impact on functioning (Wakefield et al., 2020). Over the 10 years IAPT has been operating services, recovery rates have been improving year by year. IAPT has received criticism on the grounds that it relies too heavily on quantitative measures that may give a falsely optimistic indication of improvement: There may be a mismatch between outcome measures and the client’s reported experience of distress (Bendall & McGrath, 2020), and also for its “managerialism” and perceived emphasis on efficiency over person-centered care (Dalal, 2018). Services do not always deliver the full “dose” of CBT for depression recommended in the NICE guidelines, and there is evidence that comorbid personality difficulties and complexity affect outcome and re-referral after treatment (Cairns, 2014; Goddard, Wingrove, & Moran, 2015). That being said, recovery rates have climbed from a percentage in the mid-30s to over 50% over the past decade (Clark, 2018). There is nothing like these rates elsewhere in the world.

CBT in Low- and Middle-Income Countries

The challenge of delivering CBT in developing countries where there are few psychiatrists and psychotherapists is substantial, but a number of programs are rising to the challenge. Community mental health workers can be trained to carry out brief CBT interventions with beneficial effects (e.g., Rahman, Malik, Sikander, Roberts, & Creed’s [2008] study of CBT for perinatal depression in rural Pakistan, and Bolton et al.’s [2014] study of CBT for depression, anxiety, and PTSD in Burmese refugees). The World Health Organisation (WHO) is rolling out a program called Problem Management Plus which trains lay helpers to deliver five weekly individual face-to-face sessions of 90 minutes for a range of problems, including depression. They teach simple evidence-based strategies such as relaxation, problem-solving, behavioral activation, and ways to strengthen social support (Rahman et al., 2016; WHO, 2016). Patel and colleagues found that from six to eight sessions of a culturally adapted version of behavioral activation, called the Healthy Activity Program delivered by lay counselors with no prior psychiatric training, was more efficacious than enhanced treatment as usual in a general practice setting in rural India (Patel et al., 2017), and that gains made in treatment largely held across a 9-month follow-up (Weobong et al., 2017).

Future Directions

The cognitive and behavioral interventions (if adequately implemented) can be as efficacious as medications in the treatment of even more severe depression (DeRubeis et al., 2005; Dimidjian et al., 2006) and have an enduring effect that medications simply lack (Dobson et al., 2008; Hollon et al., 2005). That being said, not everyone responds to either intervention, and there is emerging evidence that differential response to CBT versus medications can be predicted in advance. DeRubeis and colleagues used regression equations to combine multiple predictors of differential response into a single Personalized Advantage Index (PAI) and found that overall response could have been improved by as much as the typical drug-placebo difference if each patient had been given his or her optimal intervention (DeRubeis et al., 2014). This group has now moved on to using machine learning to generate precision treatment rules (PTRs) that can predict the optimal treatment for a given patient, and it should revolutionize the field (Cohen & DeRubeis, 2018). Even in the absence of making treatments better, overall efficiency of mental health delivery can be improved by getting each patient what he or she most needs.

Dissemination can be improved as well. Efforts to task-shift to lay counselors in low- and middle-income countries (LMIC) have shown that lay counselors with no prior psychiatric experience can be trained to deliver cognitive and behavioral therapies in an efficacious manner (Singla et al., 2017). The treatment gap is clearly largest in LMICs, but too few resources are available in high-income countries as well and, as IAPT has shown so well, a stepped-care approach can extend resources in a most salubrious fashion. It may well be that task-sharing approaches developed out of necessity in LMICs may readily transfer to other parts of the world also.

Finally, there is reason to think that nonpsychotic common mental disorders (including depression and anxiety) may represent adaptations that evolved to increased inclusive fitness (the propagation of one’s gene line) in our ancestral past (Hollon, Cohen, Singla, & Andrews, 2019). Most such “disorders” revolve around negative affects that motivate a differentiated response to different environmental challenges (Hollon, DeRubeis, Andrews, & Thompson, in press). To the extent that that is true, then simply “anesthetizing the pain” with medications may do little to resolve the problems that brought the symptoms about. Those psychosocial interventions (cognitive and behavior therapies and interpersonal psychotherapy) that teach problem-solving and interpersonal skills are likely to have broader and more enduring effects that sole reliance on pharmacological interventions (Hollon, in press).

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