essay on cbt and depression

Cognitive Behavioral Therapy in Treating Depression Essay

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Introduction

Cbt principles, how it works, reference list.

Commonly referred as CBT, Cognitive Behavioural Therapy is a psychotherapeutic approach through which people change the way they think (cognitive) and what they do (behaviour) 1 . These changes come through changes resulting from setting goals and achieving them.

In treating depression, CBT has found wide application due to its satisfying positive results. Instead of dealing or addressing the causes of depression, CBT concerns itself with coming up with ways that would address depression here and now. It is only concerned with finding solutions to the present state of depression. CBT owes its roots to Aaron beck and Albert Ellis who designed it in late 1950s.

Nemade, Reiss, and Dombeck 2 note, “Cognitive behavioural therapy is founded on the single basic idea that cognition, in the form of thoughts and preconceived judgments, precedes and determines people’s emotional responses.” Principally, depression results from people viewing situations from a negative point of view and this disposition leads them to act in a particular manner hence their behaviour.

CBT works on the principle that positive thoughts and behaviour heralds positive moods and this is something that can be learned; therefore, by learning to think and behave positively, someone may substitute negative thoughts with positive ones and do away with depression.

As aforementioned, depression is a product of maladaptive practices and dysfunctional thoughts arising from the way someone views a situation. “These maladaptive thought patterns are also known as negative or maladaptive schemas, or core beliefs. Core beliefs are fundamental assumptions people have made that influence how they view the world and themselves.” 2

As people think in a given way for prolonged time, these thoughts become habits and people stop questioning them as they become part of life. With time, people accept these core values as realities for they govern their life. Because these core behaviours are only perceptions, not necessarily reality, CBT seeks to fix them and change them from negative thoughts to positive thoughts.

By substituting these negative thoughts with positive ones, the core values changes and people start viewing themselves from another perspective. Feeding the mind with positive thoughts continuously makes these positive thoughts automatic and every time someone is in a given situation, these thought occur effortlessly thus enabling one to deal with life stresses and hassles effectively.

CBT works in a simple manner by breaking down problems into small fragments and addressing them one at a time. A psychologist identifies a problem, that is, the depressing situation. From this situation, a psychologist monitors one’s thoughts, emotions, feelings, and actions.

After this identification, the therapist helps the patient to come up with positive thoughts that would enable him/her view the depressing situation from a positive perspective. CBT utilises the principle that thoughts determine feelings and feelings determine actions 3 . CBT thus holds that, a situation evokes given thoughts, which in turn arouse given feelings leading to given actions.

Therefore, by correcting one’s thoughts to look at every situation positively, one changes his/her feelings thus changing actions leading to changed behaviour. In other words, CBT focuses on changing the cognitive, which in turn changes the behaviour. As aforementioned, the process of dealing with depression using CBT is quite simple.

A depressed person meets with a therapist for some time according to agreed time usually weekly and the patient, with the help of the therapist breaks down a problem into small parts. After this, the therapist lists different positive thoughts, which the patient may utilize every time he/she is faced with the depressing situation. The patient embarks on dealing with one problem at a time and this involves keeping a dairy of what to do when, coupled with goal setting both short-term and long-term.

Through analysis of patient’s different thoughts to determine how they would affect him/her, the psychologist helps the patient to replace bad or negative results with good and positive ones. Given the fact that it is easier said than done, the psychologists assigns the patient some homework whereby he/she applies these thoughts in the depressing situation.

Another meeting ensues where the therapist evaluates how a patient is doing to see whether to add or remove some activities from the list. With time, depressed people realize the things that were depressing them were things of their own creation, and in some instances, they are not real. For instance, someone may think he/she would be happy only if everyone liked him or her and failure to this leads to depression.

However, by replacing these negative thoughts with positive thoughts as ‘I am happy regardless of whether people like me or not, changes the situation. In this case, this situation was not realistic; it only existed in the mind of the individual.

In contemporary times, there are computerised CBT programs that enable depressed individuals deal with depression without the help of a therapist. However, this new form of CBT requires one to be responsible and accountable to his/her actions to ensure that the program runs smoothly and successfully.

CBT works as efficiently as antidepressants 4 . With the introduction of computerised CBT, which replaces a therapist, people can now access this psychotherapeutic intervention more easily at a cheaper price.

This is the preferred form of treatment instead of using antidepressants, which may have some side effects 5 . The basic principle of this treatment is that situations evoke thoughts, thoughts determine one’s feelings, and feelings result into actions, which in turn define one’s behaviour.

Therefore, by changing one’s thoughts through systematic replacement of negative thoughts with positive thoughts changes ones feelings, feelings change actions and these actions define one’s behaviour hence the name cognitive behavioural therapy. In most cases, people are depressed by things of their own creation and by changing their perception their behaviours.

CBT is a psychotherapeutic approach that seeks to change ones thinking patterns to conform them to the desired results. This approach works behind the principle that thoughts (cognition) determines ones feelings, which in turn directs ones behaviour. Depression is a product of unproductive, negative, and distorted thinking pattern where an individual builds his/her perceptions regarding a given situation.

With time, these perceptions turn into beliefs (core values) that govern ones perception of different situations. In most cases, depressing conditions are not real; they are only created perceptions that exist only in the ‘world’ of the perceiver. CBT addresses this issue from the perspective that thoughts determine ones feelings.

Given that depressed people are only victims of negative thoughts, CBT seeks to replace these thoughts with new positive thoughts. As positive thoughts regarding the depressing situation take root in the depressed person’s mind, depression fades away but it requires efforts either from a therapist or computer programs as guide on the way out.

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Article contents

Cognitive behavioral therapy for depression.

• Stirling Moorey Stirling Moorey South London and Maudsley NHS Foundation Trust, Centre for Anxiety Disorders and Trauma
•  and  Steven D. Hollon Steven D. Hollon Department of Psychology, Vanderbilt University
• https://doi.org/10.1093/acrefore/9780190236557.013.837
• Published online: 23 February 2021

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.

• cognitive behavior therapy
• cognitive therapy
• behavior therapy
• evidence-based therapy

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 ).

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

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:

to reduce hopelessness and suicidality

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

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:

bridge to last session with review of risk and current mood

review of homework

two to three agreed topics to address

setting homework

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:

what she has learned from therapy

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”)

what risk factors and early warning signs to look out for

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

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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David Maloney   PRACTICAL TOOLS FOR CHANGE

An essay on cognitive behavioural therapy.

In this article I will outline a critique of cognitive therapy (CT), a therapeutic approach most famously associated with the psychologist Aaron Beck (see Beck, 1967). Firstly, the philosophical underpinnings of the approach will be discussed such as the focus on conscious verses unconscious thought processes, as well as the mechanisms of dysfunctional thought such as the cognitive triad, negative self-schemas, and errors in logic. Next, typical features of how the approach is applied therapeutically are discussed as well as some important strengths and weaknesses outlined in the literature. Finally, I discuss how I utilize the cognitive approach in my own practice with clients.

Cognitive Therapy: Philosophical Principals

In the decades that followed Freud’s work (see Freud, 1915; Ellenberger, 2008), the rise of behaviourism and the subsequent ‘cognitive revolution’ eventually led to the development of cognitive therapy (Javel, 1999; Wedding, 1995). Beck, the founder of the approach, had indeed once applied Freudian principals in his earlier therapeutic work. However, while conducting Freudian free association techniques, Beck observed that thoughts were not as unconscious as described by Freud (Oatley, 2008). For Beck, it was largely the conscious negative thought patterns that were the root cause of psychological dysfunction.

According to Beck (1967) psychological dysfunction, and particularly depression, are caused by three main mechanisms. These are:

- The cognitive Triad (of negative automatic thinking).

- Negative self-schemas .

- Errors in Logic (i.e. faulty information processing).

The Cognitive triad: Generally, CT focuses directly on beliefs about helplessness and unloveability (Beck, 1995). According to beck, people who suffer from depression tend to generate negative thoughts about themselves, the world, and the future – a cognitive triad. These thoughts come seemingly spontaneously to the person and such spontaneous thoughts Beck felt were particularly important to therapeutic practice: “There is a whole level of mentation going on that isn't being tapped through our analytic methods” (Beck, 1997, p. 277). Spontaneous negative thoughts may arise in light of a specific stimulus and lead to a related emotional reaction. For instance, a person’s partner may forget about their anniversary. This may prompt a negative interpretation of the world (They really don’t care about me), themselves (Why would anyone love me), and feelings of helplessness (Nothing I ever do in relationships works). Each of these three negative assumptions may strengthen the others, leading to a downward spiral of negative thinking.

Negative self-schemas: Beck described the tendency for sufferers of depression to hold particularly negative or pessimistic views about themselves. These beliefs may have manifested as a result of traumatic childhood experiences (e.g., bullying, parental rejection/neglect). Often, the negative self-schema is upheld even in the face of abundant contradictory evidence. This highlights the illogical conclusions that can be drawn when an individual holds core beliefs that go unchallenged (Beck, 1967). However, by gradually uncovering the automatics thoughts of clients, underlying assumptions which influence how related events are perceived can be unearthed. The goal here is to challenge these core beliefs and change them if possible (Beck, 1976).

Errors in logic: An important feature of CT is that it identifies classifiable errors in reasoning typically found in clients seeking therapy (Beck, 1967). These include:

Arbitrary interference , whereby a largely irrelevant piece of information is assigned deeper implications (e.g., The weather in this country is awful and my life is depressing).

Selective abstraction , whereby a single piece of a story is illogically chosen as causal (e.g., I forgot to buy the right birthday cake and I’ve ruined my friends’ birthday).

Magnification , whereby the importance of a negative event is overblown (e.g., I only got a B in my term paper. I’m such a loser).

Minimization , whereby positive feedback is ignored without good reason (e.g., They told me I was an incredible singer but they’re just being nice. I’m not talented),

Overgeneralization , whereby broad conclusions are based on a single incident (e.g., My friend practically ignored me at the party. I feel our relationship is over), and...

Personalization , whereby an individual determines that they must be the cause of another person’s negativity (e.g., My lecturer never smiles. I think he hates me).

Identification and categorization of though, particularly dysfunctional thoughts, is a central aspect of CT (Brewin, 1996).

The Therapeutic Process

According to Beck (1995), the role of the therapist is to identify dysfunctional thought patterns and seek to guide the client through the process of cognitively reframing their interpretation of the stimulus.

In CT, there is little reliance on the therapists’ theories. Rather, CT is evidence based. A good illustration of this is in how Beck addressed the issue of clients’ defense mechanisms. For Beck, individuals often engage in various cognitive maneuvers in order to avoid facing undesirable thoughts, feelings or memories. CT suggests that the stance of the therapist is worth considering here. In psychoanalysis there is a tendency to presume that the analysts’ interpretations are accurate (Beck, 1995). Thus, if the client disagrees, they may be accused of being ‘in denial’. In CT however, the therapists’ interpretations should be regarded as hypotheses to be tested. Little to no assumption should be made.

In general, CT focuses on specific problems. In sessions, specific issues or problematic thinking are identified and addressed. Thus, CT is largely goal oriented. Clients working with their therapists are often asked to define specific goals for therapy. Long-term goals may take several sessions to address while some short-term goals may be addressed relatively quickly. During CT patients are expected to take an active role in sessions and even between sessions. They are often given homework assignments at the end of each session. During sessions, CT may involve multiple strategies such as Socratic questioning, role playing, imagery, guided discovery, and behavioural experiments (Gilbert & Procter, 2006).

Strengths and Limitations of Cognitive Therapy

Perhaps the most impressive aspect of CT is that it has been empirically proven to be effective. Butler and Beck (2000) examined the peer-reviewed empirical studies of therapeutic applications and concluded that approximately 80% of the sample benefited from the therapy. Their research also indicated that the therapy was more successful than drug therapy, with a significantly lower rate of relapse. This finding suggests strongly that there is indeed a cognitive basis for depression and that understand this mechanism can have a positive impact in improving people’s lives. CT has been very effective not only for treating depression (Hollon & Beck, 1994), but also for anxiety problems (Beck & Steer, 1993).

CT is founded in a cognitive theory of psychopathology. Moreover, cognitive theories lend themselves to testing. In a particularly illuminative study, Rimm and Litvak (1969) actually tried to control the independent variable (dysfunctional negative thinking). The hypothesis was that if there is in fact a cognitive basis for depression, participants should show signs of this psychopathology. This is exactly what the researchers found; participants encouraged to engage in dysfunctional thought patterns became more anxious and depressed.

Limitations:

While the Rimm and Litvak study indicates a clear role for cognition in psychopathology, not all researchers concur. The precise relationship between cognition and psychological dysfunction has not been fully determined. It may be the case that dysfunction thinking is merely a consequence of psychopathology and not its primary driver.

One study which suggest this is that of Lewinsohn (1981). Lewinson observed a group of people before any of them became depressed. Later, Lewinson observed that those who developed depression were no more likely to have engaged with dysfunctional thinking than those who remained psychologically well-adjusted. Thus, it may be that the ‘negative thinking leads to depression’ model is an oversimplification. In fact, the oversimplification argument has been a more general criticism of CT. Rossello and Bernal (1999) argue that thinking is just one part of human functioning, and that broader issues need to be addressed.

How I use Cognitive Therapy in my practice with clients

In this editorial section of the report, I will identify what I consider the most useful aspects of CBT; those that I use in my own practice. In my view, CBT should play a central part in the therapeutic process. This being said, I initally assess the clients’ readiness to engage with the process. Questioning the clients’ belief systems and potentially dysfunctional though processes can be a difficult undertaking. There may need to be a significant level of trust built in the client/therapist relationship before this process may begin. In general, using a person-centred approach may be a more appropriate way to initiate sessions. Over time, as the relationship grows stronger, the client may then feel prepared to engage with the challenging work of CBT.

CBT is a vital piece of the puzzle. I always maintain that it is a basic tool in our toolkit for mental health. In cases where trauma is an issue (PTSD, C-PTSD) more body-focused modalities are often more important. However, it's usually a matter of when CBT is used rather than if.

This report has examined the philosophical underpinnings as well as the therapeutic application of CT. While there is rigorous debate as to whether dysfunctional thinking is the primary cause of psychopathology, there is good evidence to suggest that CT is a particularly effective treatment for a number of psychological maladies.

On a personal level, I regard CT as a particularly important tool in helping clients reframe their maladaptive cognitive perceptions of particular life situations. However, as Beck himself noted, the therapeutic relationship is very important in CT and is based on therapist and client collaboration in guided discovery (Beck & Freeman, 1990). Before CT can be truly effective, it may first be necessary to develop a client/therapist relationship in which the process can be successfully applied.

Bibliography

Beck, A. T. (1967). Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: Meridian.

Beck, A. T., & Freeman, A. (81). Associates (1990). Cognitive therapy of personality disorders.

Beck, A. T, & Steer, R. A. (1993). Beck Anxiety Inventory Manual. San Antonio: Harcourt Brace and Company.

Beck, A. T. (1997). The Past and Future of Cognitive Therapy. Journal of Psychotherapy Practice and Research, 6(4), 276-284.

Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.

Brewin, C.R. (1996). Theoretical foundations of cognitive-behavior therapy for anxiety and depression. Annual review of psychology, 47(1), pp.33-57.

Butler, A. C., & Beck, J. S. (2000). Cognitive therapy outcomes: A review of meta-analyses. Journal of the Norwegian Psychological Association, 37, 1-9.

Ellenberger, H. F. (2008). The discovery of the unconscious: The history and evolution of dynamic psychiatry. Basic Books.

Freud, S. (1915). The unconscious. SE, 14: 159-204.

Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and self‐criticism: Overview and pilot study of a group therapy approach. Clinical Psychology & Psychotherapy, 13(6), pp.353-379.

Hollon, S. D., & Beck, A. T. (1994). Cognitive and cognitive-behavioral therapies. In A. E. Bergin & S.L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 428—466). New York: Wiley.

Javel, A.F. (1999). The freudian antecedents of cognitive–behavioral therapy. Journal of Psychotherapy Integration, 9(4), pp.397-407.

Oatley, K. (2008). Emotions: A brief history. John Wiley & Sons.

Rimm, D. C., & Litvak, S. B. (1969). Self-verbalization and emotional arousal. Journal of Abnormal Psychology, 74(2), 181.

Rossello, J. & Bernal, G., 1999. The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of consulting and clinical psychology, 67(5), p.734.

Wedding, D. (1995). Current psychotherapies. John Wiley & Sons, Inc.

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Routine Cognitive Behavioural Therapy for Anxiety and Depression is More Effective at Repairing Symptoms of Psychopathology than Enhancing Wellbeing

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The primary focus of classic cognitive behavioural therapy (CBT) for depression and anxiety is on decreasing symptoms of psychopathology. However, there is increasing recognition that it is also important to enhance wellbeing during therapy. This study investigates the extent to which classic CBT for anxiety and depression leads to symptom relief versus wellbeing enhancement, analysing routine outcomes in patients receiving CBT in high intensity Improving Access to Psychological Therapy (IAPT) Services in the UK. At intake, there were marked symptoms of anxiety and depression (a majority of participants scoring in the severe range) and deficits in wellbeing (a majority of participants classified as languishing, relative to general population normative data). CBT was more effective at reducing symptoms of anxiety and depression than repairing wellbeing. As a result, at the end of treatment, a greater proportion of participants met recovery criteria for anxiety and depression than had moved from languishing into average or flourishing levels of wellbeing. Given the importance of wellbeing to client definitions of recovery, the present results suggest a greater emphasis should be placed on enhancing wellbeing in classic CBT.

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Anxiety and depressive disorders are prevalent, recurrent, frequently comorbid mental health conditions that are a significant cause of worldwide disability (WHO 2017 ; Kessler et al. 2005 , 2007 ). Psychological therapies for depression and anxiety predominantly focus on decreasing symptoms of psychopathology, conceptually underpinned by disease models arguing that recovery from mental illness equates to an absence of symptoms. Recovery is defined as falling beneath a cut-off on symptom measures, which moves individuals from a ‘clinical’ range to a ‘normal’ range.

When asking patients what recovery involves, a different perspective is increasingly emerging. A key component of recovery is the capacity to experience increased wellbeing, which can be defined as experiencing positive emotional states, feeling connected to and valued by others, and having a sense of meaning and purpose in life (Keyes 2002 , 2005 ). Wellbeing enhancement is at least as important a part of recovery to patients as relief from symptoms (Zimmerman et al. 2006 ; Demyttenaere et al. 2015 ) and predicts future resilience (Garland et al. 2010 ; Wood and Joseph 2010 ). This perspective resonates with the broader recovery movement arguing that recovery means individuals living a valued and enjoyable life and minimising the extent to which symptoms impede this goal (Slade 2010 ).

There are different conceptual views as to how distinct wellbeing and symptoms are from one another. A single continua model sees symptoms and wellbeing as two opposite ends of a bipolar dimension. Recovery involves moving individuals from the symptomatic end of the distribution and as far as possible into the wellbeing end of the distribution (Huppert 2014 ). An alternative perspective is that symptoms and wellbeing represent orthogonal dimensions (the dual-continua model: Tudor 1996 ; Provencher and Keyes 2011 ), based on findings that the two constructs are only moderately correlated in some samples and are best accounted for as two latent dimensions rather than a single latent dimension (Keyes 2005 , 2006, 2007). Irrespective of which of these positions is adopted, treatment for anxiety and depression should aim to move individuals from a position of ‘languishing’ (low wellbeing, high mental illness) to one of ‘flourishing’ (high wellbeing, low mental illness) (Keyes and Lopez 2002 ; Coulombe et al. 2016 ). Moreover, regardless of which of these frameworks is correct, it is likely that different intervention strategies will be required to develop wellbeing as opposed to reduce symptoms.

One of the most robustly validated and extensively deployed treatment modalities for anxiety and depression is cognitive therapy (CT), in UK contexts more often referred to as cognitive behavioural therapy (CBT). Classic CBT approaches focus on correcting negative biases in information processing and avoidant behaviour in an effort to reduce symptoms of depression and anxiety (e.g. Beck et al. 1979 ; Clark and Beck 2010 ). Footnote 1 There is good evidence that classic CBT is effective (although not optimally so) in reducing depression symptoms during acute episodes and to some extent minimising the risk of subsequent relapse (Cuijpers et al. 2013 ). Similarly, there is evidence of acute and sustained benefit for CBT protocols for specific anxiety disorders, but nevertheless with a subset of clients not responding or showing a chronic, relapsing course (Hofmann and Smits 2008 ; Ali et al. 2017 ). This mirrors effective, but nevertheless sub-optimal, outcomes observed following other psychological and pharmacological treatment modalities for anxiety and depression. Moreover, recovery rates in routine practice may be substantially lower than those observed in clinical trials (Lambert 2017 ).

Given the disease model underpinning classic CBT, it may well be better at reducing symptoms of mental illness than building wellbeing and adaptations are likely required to existing treatments to maximise wellbeing gains. In particular, symptom relief could be a necessary but not sufficient component for enhancement of wellbeing. To optimise wellbeing, treatment may require symptom relief and also systematic attention to improving day-to-day positive mood, functioning, broader quality of life, and social connection/identity. However, very few classic CBT trials have reported wellbeing outcomes, so the relative efficacy of the approach in repairing symptoms relative to wellbeing is yet to be definitively established.

We are aware of a handful of studies that indirectly examine the extent to which classic CBT repairs symptoms relative to wellbeing. These all used CBT as a control condition in small scale randomised controlled trials evaluating novel positive psychotherapies. One trial evaluated the efficacy of group CBT, relative to a group positive psychology intervention, in treating acute depression and dysthymia using a broad array of symptom and wellbeing measures (Chaves et al. 2017 ). Pre-post effect sizes in CBT were larger for clinical variables (including depression; Cohen’s d  = 0.44) than for positive functioning variables (including wellbeing; Cohen’s d  = 0.26). Three other studies did not report pre-post effect sizes for both wellbeing and symptoms, but we calculated these using the means and standard deviations described in the papers. We report Hedges g, as this is appropriate for smaller sample sizes. Footnote 2 Fava et al. ( 1998a ) randomized 20 individuals with residual symptoms of affective disorder to receive 8 sessions of either group CBT or group wellbeing therapy. Individuals in the CBT arm showed large improvements on interviewer-rated depression ( g  = 1.35) and reported small improvements on self-rated wellbeing ( g  = 0.36). Fava et al. ( 2005 ) randomized 16 individuals with acute generalized anxiety disorder to receive either 8 sessions of CBT or 8 sessions of CBT combined with wellbeing therapy. In the CBT only arm, there were large improvement in interviewer rated depression ( g  = 0.96) and anxiety ( g  = 1.86) but only medium improvements in self-reported wellbeing ( g  = 0.52). Geschwind et al. ( 2019 ) allocated 40 acutely depressed participants to receive a combination of individual CBT and a novel positive form of CBT (CBT +) in different orders, using a cross-over randomized controlled trial design. It is possible to isolate the pre-post effects in the 20 depressed participants who were randomized to CBT followed by CBT + , by focusing solely on observed change in the first treatment block only. After the first 8 CBT sessions, these participants showed a large effect size improvement in depression symptoms ( g  = 1.01) and a medium effect size improvement in wellbeing ( g  = 0.67).

This pattern of findings suggests that CBT is more effective at repairing symptoms than wellbeing. However, this conclusion is undermined by a number of methodological issues. None of these studies directly compared the magnitude of symptom versus wellbeing repair. As all of the studies had relatively small sample sizes, there are wide confidence intervals around the effect sizes reported above. Some of the studies used interviewer scales to assess symptoms and self-report scales to assess wellbeing, which may influence the size of the effects observed.

There is also a parallel body of work looking at how well CBT enhances quality of life (QoL), which has significant overlap with wellbeing as a concept. A recent meta-analysis examined the impact of classic CBT and drug treatment for depression on symptom and QoL measures in 37 randomised controlled trials (Hofmann et al. 2017 ). This found a large pre-post effect on depression severity ( g  = 1.30; 95% CI 1.16–1.45). In contrast, there were only medium effects on QoL ( g  = 0.69; 95% CI 0.61–0.78). However, while QoL has clear overlap with wellbeing as a construct, it is not directly analogous (Salvador-Carulla et al. 2014 ). In particular, many QoL measures have a relatively narrow health/disease focus rather than a more holistic wellbeing focus, and so may miss broader benefits of treatment (e.g. see Al-Janabi et al. 2012 ).

Therefore, it is not possible to conclude to what extent classic CBT repairs wellbeing relative to symptoms on the basis of the extant literature and further research is needed. One efficient way to achieve this goal is to look at outcomes in routine clinical practice. The Improving Access to Psychological Therapy (IAPT) initiative in the UK presents a good way to achieve this, as high volumes of patients are given protocol adherent classic CBT for depression and anxiety and routine outcome data are collected. IAPT services run a stepped care model, where mild to moderate presentations are first treated with low intensity evidence-based approaches (for example, brief guided self-help) and are only ‘stepped up’ to higher intensity interventions like individual CBT if they fail to respond. Individuals with a more complex, recurrent or severe presentation can be offered high intensity as a first line treatment. Therefore, high intensity waiting lists are characterised by more severe, complex, and often treatment resistant presentations of depression and anxiety.

While wellbeing measures are not a standard part of the national IAPT outcome data set, they have been included as an additional outcome measure in some services. In particular, Somerset Partnership Foundation Trust (SPFT) supplemented the minimum IAPT data set with a wellbeing measure (the Warwick Edinburgh Mental Wellbeing Scale; WEMWBS, Tennant et al. 2007 ) between 2012 and 2017. The present study analyses wellbeing relative to symptom outcomes in this service, focusing on those individuals allocated to high intensity CBT treatment for either depression or anxiety (typically between 8 and 20 sessions of individual therapy). The primary aims are: (i) to evaluate to what extent ‘high intensity’ CBT repairs symptoms versus wellbeing; and (ii) to assess the extent to which wellbeing and symptom deficits are ‘normalised’ by the end of treatment.

Some thought is required about how to operationalise change and recovery on wellbeing measures. When using symptom-focused measures, the objective is to eliminate symptoms and to ensure individuals fall under some cut-off that indicates recovery. For example, the depression outcome measure used in IAPT is the Patient Health Questionnaire (PHQ-9; Kroenke et al. 2001 ) and scoring nine or less is used to indicate remission. It is less clear cut what indicates sufficient repair of wellbeing. One approach is to examine where a patient falls in the general population distribution before and after treatment using large scale normative data. The WEMWBS has been well validated on the UK general population, with data collected on over 7000 individuals as part of the UK Health of the Nation Survey. Therefore, it is possible to express WEMWBS scores for individual IAPT clients in terms of where they sit in this general population distribution. Individuals scoring in the bottom third of the distribution can be viewed as ‘languishing’ and those scoring in the top third of the distribution can be viewed as ‘flourishing’. Recovery can be defined as scoring in the average or flourishing parts of the general population distribution.

We predict that CBT will lead to a greater magnitude repair of symptoms than wellbeing (Hypothesis One) and that at the end of treatment more individuals will meet recovery criteria for symptoms than wellbeing (Hypothesis Two). We will additionally explore to what extent wellbeing and symptom measures are associated with one another and whether the extent of wellbeing and symptom repair is related to number of sessions attended. We had no a priori hypotheses for these exploratory analyses.

Participants

Routine outcome data were collected on individuals being treated with high intensity CBT for depression and/or anxiety in the Somerset IAPT service between 2012 and 2017. Inclusion criteria for the IAPT service were being over 18 years of age and presenting with a primary problem of depression or anxiety that met IAPT clinical criteria at the point they were put on the waiting list (PHQ-9  >  10 or GAD-7  >  8). A subset of individuals no longer met these caseness criteria at the point they started treatment. Following national IAPT guidelines, participants were not offered treatment if they presented with comorbid psychosis, bipolar disorder; if drug and alcohol misuse was the primary presenting problem; if there was a moderate to severe impairment of cognitive function; and if they presented with a high level of risk to self or others that could not be safely managed in the service context. We extracted from the database the subset of data for clients who were allocated to high intensity CBT. South West Frenchay Health Research Authority granted ethical approval for the study (15/SW/0352, IRAS ID 163179). As patient data were anonymised and could not be linked back to individuals, patient consent was not required to access the data.

Measures and Procedure

The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS, Tennant et al. 2007 ) was used to measure wellbeing. Participants rate to what extent they have felt the way described in 14 wellbeing statements (e.g. “I’ve been feeling optimistic about the future”) over the last 2 weeks, on a scale ranging from 1 (none of the time) to 5 (all of the time). Scores range from 14 (low wellbeing) to 70 (high wellbeing). Normative WEMWBS data are available for 7020 individuals in the UK general population as part of the Health Survey for England 2011 (Mean = 51.61, SD = 8.71). As far as we are aware, there are no normative data for a depressed population. The WEMWBS has been found in previous studies to have good internal reliability (Cronbach’s α = 0.91) and acceptable one-week test–retest reliability (intraclass correlation = 0.83) (Tennant et al. 2007 ; Stewart-Brown et al. 2009 , 2011 ). In the present sample, internal reliability was also acceptable (intake α = .91). There are no agreed reliable or clinically significant change criteria for the WEMWBS.

The Patient Health Questionnaire (PHQ-9; Kroenke et al. 2001 ) was used to measure depression symptom severity. Participants rate how many days over the past 2 weeks they have experienced the nine DSM-V symptoms of depression (e.g. “little interest or pleasure in doing things”), on a scale ranging from 0 (not at all) to 3 (nearly every day). Scores range from 0 (asymptomatic) to 27 (severely depressed), with scores of 5, 10, 15 and 20 representing mild, moderate, moderately severe and severe depression respectively. A cut off score of 10 has been found to be a good proxy for meeting diagnostic criteria for a major depressive episode as measured by structured clinical interview, with 88% specificity and 88% sensitivity (Kroenke et al. 2010 ). This is also the cut-off used in UK IAPT services to indicate a clinical presentation. Normative data are available on 5018 individuals in the general population from face-to-face household surveys conducted in Germany between 2003 and 2008 (Mean = 2.91, SD = 3.52) (Kocalevent et al. 2013 ). Studies find the PHQ-9 has good internal reliability (α = .89) and test–retest reliability (intraclass correlation = .84) (Kroenke et al. 2001 ). In the present sample, internal reliability was also acceptable (intake α = .85).

The Generalized Anxiety Disorder scale (GAD-7; Spitzer et al. 2006 ) was used to measure anxiety symptom severity. Participants rate how many days over the past 2 weeks they have experienced seven symptoms of anxiety (e.g. “feeling nervous, anxious, or on edge”), on a scale ranging from 0 (not at all) to 3 (nearly every day). Scores range from zero (asymptomatic) to 21 (severely anxious), with scores of 5, 10 and 15 representing mild, moderate and severe symptoms respectively. A cut off score of 10 was reported to have optimal sensitivity (89%) and specificity (82%) to confirm a diagnosis of generalized anxiety disorder based on structured clinical interview (although in UK IAPT services, a cut-off of ≥ 8 is used to indicate a clinically significant presentation). Normative data are available on 5030 individuals in the general population from a nationally representative face-to-face household survey conducted in Germany (Löwe et al. 2008 ) (Mean = 2.95, SD = 3.41). The GAD-7 has been found to have good internal reliability (α = .92) and test–retest reliability (intraclass correlation = .83) (Spitzer et al. 2006 ). In the present sample, internal reliability was also acceptable (intake α = .85).

The PHQ-9 and GAD-7 form part of the routine national data set administered prior to each session in IAPT, while the WEMWBS was only administered at first and last treatment session.

Analysis Plan

All analyses used two-tailed tests with an alpha of .05. The proportion of individuals scoring above clinical cut-offs for anxiety and depression at each time point was reported (using standard IAPT criteria of PHQ-9 scores  >  10 and GAD-7 scores  >  8). We also describe the proportion of individuals who were languishing, showing average wellbeing, and flourishing (scoring in the bottom third [< 47], middle third [47–57], and top third [> 57] of the general population distribution respectively). We used these cut-offs to determine the proportion of individuals at each time point who fell into each category in the Provencher and Keyes ( 2011 ) model of complete mental health. This is a two (symptomatic, asymptomatic in terms of anxiety and depression symptoms) by three (languishing, averaging, flourishing in terms of wellbeing) affective space. To allow a direct comparison of recovery rates for symptoms versus wellbeing, we compared the proportion of participants at each assessment point who met recovery criteria for symptoms (defined as scoring < 10 on the PHQ-9 and  < 8 on the GAD-7) and wellbeing (defined as scoring in the average or flourishing part of general distribution; > 46) using McNemar tests for paired samples.

To analyse the extent of repair in each measure, we used two different analytic methods. If the same conclusions emerge across these different strategies, this suggests they are likely to be robust. First, paired sample t-tests were run on pre- and post- scores. We reported Hedges g (and its 95% confidence interval) as a measure of effect size for each analysis. Second, the importance of tracking individual level as well as group level outcomes is increasingly realised (Guidi et al. 2018 ). Therefore, the proportion of individuals showing reliable improvement and reliable deterioration on each measure from first to last session was calculated (cf. Jacobson and Truax 1991 ). Reliable improvement/deterioration was defined as an improvement/deterioration of more than 1.96 times the standard error of difference for the scale. We used the standard deviation estimates from the present sample and estimates of test–retest reliability from scale validation studies in these analyses. The proportion of reliable improvement/deterioration on each measure was compared using a series of pairwise McNemar tests.

Association between intake scores, change scores, and number of sessions were analysed using Pearson’s correlation coefficients (reporting simple r and attenuation corrected r).

There was a relatively high degree of missing WEMWBS data at the final session assessment, so analyses were run on both a complete case basis and a multiple imputation basis (to simulate missing values). This is because there is ongoing debate in the literature about how best to analyse data were there is a relatively high proportion of missing data, where there is reason to think data may be ‘missing not at random’ (MNAR), and where there is a limited pool of auxiliary variables to use to predict missing values (Jakobsen et al. 2017 ; Madley-Dowd et al. 2019 ; van Ginkel et al. 2019 ). If an identical pattern of findings emerges with both analytic approaches, this suggests that the bias inherent in either method is unlikely to have substantially contaminated the results. Imputation was conducted using a Markov Chain Monte Carlo (MCMC) algorithm, with 70 imputation runs (based on guidance that the number of imputations should exceed the percentage of missing data; White et al. 2010 ). All variables used in subsequent analysis models (intake and final-session WEMWBS, PHQ-9, and GAD-7) as well as auxiliary variables that might predict variables with missing data were included in the imputation model. Auxiliary variables were age, gender, ethnicity, sessions attended, intake score on the IAPT phobia scale, intake score on the Work and Social Adjustment Scale (WSAS; Mundt et al. 2002 ), and intake score on the Standard Assessment of Personality abbreviated scale (SAPAS; Moran et al. 2003 ). Multiple imputation analyses used pooled data across these 70 imputations. The imputed data set can be viewed as an intention-to-treat sample.

Data Completeness

Intake WEMWBS, PHQ-9 and GAD-7 data were available for 1854 participants. Of these individuals, only 618 (39%) had final session data on all three measures. Complete case change and final session analyses were conducted on the subset of 618 individuals with complete data at final session; all other analyses were implemented on the entire sample.

Independent sample t-tests were run comparing intake demographic and clinical characteristics and symptom change score in individuals with and without complete data (see Table  1 ). At intake, there were small but nevertheless statistically significant differences between these groups. Those with complete WEMWBS data were significantly older, t(1596) = 2.45, p = .01; had significantly lower PHQ-9 scores, t(1596) = 2,95, p < .001, had significantly higher WEMWBS scores, t(1596) = 3.29, p < .001, and tended to have lower GAD-7 scores at the level of a non-significant trend, t(1596) = 1.87, p = .06, compared to those without complete WEMWBS data. There were no significant gender differences, χ 2  < 1. There were significant and slightly greater magnitude differences in treatment responsiveness between the groups also. Those with complete WEMWBS data showed a greater improvement during treatment in PHQ-9 depression, t(1579) = 10.16, p < .001, and GAD-7 anxiety, t(1579) = 9.70, p < .001, than those without complete WEMWBS data. Those with complete WEMWBS data also attended a greater number of treatment sessions, t(1596) = 13.59, p < .001, than those without complete WEMWBS data. In summary, participants with WEMWBS data are a subgroup of individuals who are slightly older, less depressed and anxious at intake; attend more sessions; and are more treatment responsive.

Wellbeing and Symptom Levels at Assessment

Table  2 reports intake and final session wellbeing, depression, and anxiety scores for participants (including both complete case and imputed estimates for final session data). The sample scored below the wellbeing general population levels (mean score of 33 compared to general population average of 51). 1707/1854 (92%) were classified as languishing; 125/1854 (7%) were classified as having adequate mental health; and 22/1854 (1%) were classified as flourishing (8% in total meeting recovery criteria for WEMWBS). Similarly, the sample had elevated levels of depression and anxiety at intake. 1724 participants scored above IAPT cut-offs for either GAD-7 ( >  8) or PHQ-9 ( >  10), while 130 met symptom recovery criteria. 622 participants (33%) were in the severe range for depression (PHQ-9 > 19) and 1020 participants (55%) were in the severe range for anxiety (GAD-7 > 14). The proportion of individuals meeting recovery criteria at intake did not significantly differ for symptoms versus wellbeing, McNemar test p = .178.

Wellbeing and Symptom Change During High Intensity CBT

Paired sample t-tests showed a significant WEMWBS improvement (average increase of 10.94 points [SD = 10.99] for complete case data; average increase of 7.12 points [SD = 10.46] for imputed data), complete case paired-sample t(617) = 24.75, p < .001, imputed paired-sample t(1853) = 23.926, p < .001. There was also a significant reduction in depression symptoms (mean drop of 7.78 points [SD = 6.20] for complete case data; mean drop of 5.26 points [SD = 6.25] for imputed data), complete case t(617) = 31.21, p < .001, imputed t(1853) = 36.07, p < .001. Similarly, there was a significant reduction in anxiety symptoms (mean drop of 7.02 points [SD = 5.73] for complete case data; mean drop of 4.77 points [SD = 5.79] for imputed data), complete case t(617) = 30.48, p < .001, imputed t(1853) = 35.38, p < .001. Figure  1 plots the effect size (and 95% confidence interval) for change in each outcome measure for complete case data and imputed data. All effects were of a large magnitude ( g  > 0.8) for complete case data and of a large or medium effect size ( g  > 0.5 < 0.8) for imputed data according to rules of thumb (Cohen 1988 ). The anxiety and depression effects sizes were numerically greater than the wellbeing effect size in both the complete case and the imputed analyses.

Pre-post effect sizes for each measure on complete data (n = 618; a ) and imputed data (n = 1854; b ). Note : Data are mean (95% confidence interval) values

Reliable improvement was observed for 291 individuals (48%) for wellbeing, 339 individuals (55%) for depression and 364 individuals (59%) for anxiety in complete case analyses. A greater proportion of individuals showed reliable improvement in depression relative to wellbeing, McNemar, p < .001, anxiety relative to wellbeing, McNemar p < .001, and anxiety relative to depression, McNemar p = .046. Reliable deterioration was observed for 9 individuals (1%) for the WEMWBS, 8 individuals (1%) for depression, and 4 individuals (< 1%) for anxiety. There were no significant differences in the rates of deterioration for each outcome measure, McNemar ps > .266.

When using imputed data, reliable improvement was seen for 622.6 individuals (34%) for wellbeing, 727.1 individuals (39%) for depression, and 777.1 individuals (42%) for anxiety. More individuals improved for depression than wellbeing, McNemar p < .001, for anxiety than wellbeing, McNemar p < .001, and for anxiety than depression, McNemar p = .013. Reliable deterioration was seen for 52.4 individuals (3%) for wellbeing, for 44.3 individuals (2%) for depression, and for 33.7 individuals (2%) for anxiety. There were no significant differences in the rates of deterioration for wellbeing and depression, McNemar p = .500, anxiety and depression, McNemar p = .206, or wellbeing and anxiety, McNemar p = .066.

Wellbeing and Symptom Levels at Final Treatment Session

At the final treatment session, on average the sample continued to score below the wellbeing general population average (complete case mean score = 45; imputed mean score = 40). Using complete case data, 339 individuals (55%) were languishing, 191 individuals (31%) were in the average range, and only 88 individuals (14%) were flourishing. Using scoring in the average or flourishing range as a proxy for recovery, in total 44% had recovered on the WEMWBS. Using multiple imputation data, 1263.1 individuals (68%) were languishing, 429.6 individuals (23%) were in the average range, and 161.3 individuals (9%) were flourishing, with 32% in total in recovery.

In terms of symptom outcomes, using complete case data 242 individuals (40%) fell in the clinical range on one or both of the PHQ-9 and GAD-7, while the remaining 376 individuals (60%) scored beneath caseness on both measures (the IAPT definition of recovery, Clark and Oates 2014 ) at the final treatment session. In total, 206 individuals failed to recover on either symptoms or wellbeing, 243 individuals recovered on both symptoms and wellbeing, 36 individuals recovered just on wellbeing, and 133 individuals recovered just on symptoms. A significantly greater proportion of individuals met recovery criteria for symptoms relative to wellbeing, McNemar p < .001.

Using imputed data, 1104.6 individuals (60%) fell in the clinical range on one or both symptom measures, while 749.4 individuals (40%) scored beneath caseness (i.e. had recovered in IAPT terms) at the final treatment session. 975.6 individuals failed to recover on either symptoms or wellbeing, 287.5 individuals recovered on symptoms but not wellbeing, 129.0 individuals recovered on wellbeing but not symptoms, and 461.9 individuals recovered on both symptoms and wellbeing. A greater proportion of individuals recovered for symptoms than wellbeing, McNemar test, p < .001.

Finally, we considered the percentage of participants falling in each space of the Provencher and Keyes model at final treatment session. Only 13% were in the optimal space of asymptomatic and flourishing (8% using imputed data). 26% were asymptomatic and had average wellbeing (17% using imputed data); 22% were asymptomatic and were languishing (15% using imputed data); < 1% were flourishing but symptomatic (< 1% using imputed data); 5% were symptomatic and had average wellbeing (6% using imputed data); and 33% were symptomatic and languishing (53% using imputed data). Footnote 3

Exploratory Association Analyses

Greater intake WEMWBS was significantly associated with lower depression (Pearsons’s r = − .645, p < .001; correcting for attenuation r = − .739) and anxiety (r = − .515, p < .001; correcting for attenuation r = − .602). Greater anxiety was also significantly associated with greater depression (r = .661, p < .001; correcting for attenuation r = .752). Greater increase in wellbeing over the course of treatment was significantly associated with a greater drop in depression (Pearson’s r on complete case data = − .604, p < .001, correcting for attenuation r = − .682, using imputed data r = − .631, p < .001) and anxiety (complete case r = − .599, p < .001; correcting for attenuation r = − .671; imputed data r = − .613, p < .001). Greater depression repair was significantly associated with greater anxiety repair (complete case r = .713, p < .001; correcting for attenuation r = .807; imputed data r = .749, p < .001). Attending more sessions was significantly linked to greater PHQ-9 repair (complete case r = − .130, p = .001; imputed data r = − .095, p < .001) and GAD-7 repair (complete case r = − .090, p = .025; imputed data r = − .095, p < .001) but was not significantly linked to wellbeing improvements (complete case r = .038, p = .344; imputed data r = .024, p = .440).

This study investigated the extent to which routinely delivered classic CBT repairs symptoms versus enhances wellbeing in a sample of individuals with anxiety and depression (using registry data from a high intensity UK IAPT service). At intake, there were marked deficits for both wellbeing and symptoms, with a vast majority of individuals showing clinically significant levels of anxiety (GAD-7 > 7) or depression (PHQ-9 > 9) and languishing in wellbeing terms (falling in the bottom third of the general population distribution). Participants on average attended around 9 treatment sessions and there was a significant increase in wellbeing and decrease in depression and anxiety symptoms between first and last treatment session.

Two different analytic techniques showed CBT had a larger effect on symptoms than wellbeing (supporting Hypothesis One). Pre-post effect sizes were numerically larger and a greater proportion of individuals showed reliable improvement of symptoms relative to wellbeing. While these two analytic methods both have their strengths and limitations, all reach the same conclusion. Unsurprisingly given the smaller magnitude of wellbeing relative to symptom repair, at the final treatment session a smaller proportion of the sample met recovery criteria on the wellbeing (no longer falling in the languishing third of the general population distribution) than met recovery criteria for symptoms (no longer showing clinically significant levels of depression and anxiety). Only a very small number of individuals were flourishing at the end of treatment. Therefore, Hypothesis Two was also supported. The same pattern of results emerged in both complete case analyses and when using multiple imputation to simulate missing data. Overall outcomes were superior in the complete-case analyses relative to the imputed data set on all variables (large versus medium pre-post effect sizes), but critically the relative magnitude of symptom versus wellbeing repair was the same in both sets of analyses.

This result broadly mirrors findings in previous trials that have included classic CBT as a comparator for novel positive psychology or wellbeing interventions (Chaves et al. 2017 ; Geschwind et al. 2019 ; Fava et al. 1998a ; Fava et al. 2005 ) and also is consistent with meta-analytic findings that CBT and drug treatments for depression have a bigger effect on symptoms than quality of life (Hofmann et al. 2017 ). It extends them by directly comparing wellbeing and symptom deficits in a large clinical sample, giving greater precision to the estimates observed.

We also explored whether number of sessions predicted wellbeing and symptom repair. Attending a greater number of sessions attended was not significantly associated with wellbeing repair, despite being robustly associated with greater anxiety and depression repair. Therefore, it is unlikely to be sufficient to enhance wellbeing outcomes simply by offering a longer treatment dose of existing CBT protocols (although of course correlational data of this kind cannot be used to test causal claims).

Given the present results show CBT is less effective at building wellbeing than reducing depression (and that increasing number of sessions alone will not resolve this issue), it is important to consider alternative treatment approaches. One way forward is to adapt the delivery of classic CT so that it more explicitly addresses positive affect and wellbeing deficits (see Dunn, in press ). This could include a greater focus on identifying values to help clients build meaning, more systematic targeting of underlying mechanisms that block positive affect (e.g. dampening: Burr et al. 2017 ; experiential processing; Gadeikis et al. 2017 ), and incorporation of a more explicit recovery focus (see Medalia et al. 2019 ).

A second way forward way could be to evaluate the potency of other established acute mood disorder treatments in repairing wellbeing, for example behavioural activation (BA; see Mazzucchelli et al. 2010 ). However, given there is significant content overlap between the activity scheduling aspects of CBT and BA protocols, it seems unlikely that BA will lead to significantly enhanced wellbeing outcomes relative to CBT. There may be greater potential in ‘third wave’ cognitive treatments like Acceptance and Commitment Therapy (ACT; Hayes et al. 2012 ). However, what little evidence exists suggests that ACT may not optimally repair wellbeing. For example, a recent secondary analysis of an RCT found that a brief online version of ACT is also less effective at repairing wellbeing relative to symptoms (Trompetter et al. 2017 ).

A third approach could be to offer staged treatments, where classic CBT is used to treat symptoms and then a bespoke wellbeing therapy is offered afterwards as a second step treatment (for example, Wellbeing Therapy; Fava 2016 ). There is good clinical trial evidence that Wellbeing Therapy helps prevent relapse in depression (Fava et al. 1998b ; Fava et al. 2004 ; Stangier et al. 2013 ), but wellbeing outcomes were not reported in these trials unfortunately. In two pilot trials that did include wellbeing measures, mixed results have emerged. Fava et al. ( 2005 ) showed superior wellbeing outcomes for Wellbeing Therapy relative to CBT in treating acute generalized anxiety disorder. The Wellbeing Therapy arm generated large effect size pre-post wellbeing improvement, whereas the CBT arm only led to small effect size improvement. However, Fava et al. ( 1998a ) found no superiority of Wellbeing Therapy relative to CBT in treating residual affective disorders (small wellbeing pre-post effect sizes observed in each arm). Alternatives to Wellbeing Therapy as staging treatments are also starting to emerge. For example, Geschwind et al. ( 2019 ) demonstrate a large pre-post wellbeing effect size for CBT followed by a positive CBT protocol (albeit this wellbeing improvement was smaller than that observed for symptom relief).

Finally, novel acute therapies could be delivered that explicitly target wellbeing from the outset. Application of positive psychology approaches in clinical populations have had limited success in repairing wellbeing. For example, Chaves et al. ( 2017 ) found no significant difference between group CBT and a group positive psychology intervention for acute depression, with both producing small to medium pre-post effect sizes. However, other treatments are being developed to target positive valence system deficits that have encouraging preliminary results on positive affect and wellbeing (e.g. Taylor et al. 2017 ; Positive Affect Treatment, Craske et al. 2019 ; Augmented Depression Therapy, Dunn et al. 2019 ). These novel therapies now require more robust evaluation in definitive trials in diagnosed depressed and anxious populations.

The findings also open opportunities for personalised approaches to care, whereby treatment selection could be tailored depending on the type of deficits the client presents with. For example, clients with particularly marked wellbeing deficits may benefit from approaches explicitly targeting positive outcomes, whereas clients presenting with particularly marked deficits in symptoms may benefit from existing approaches such as CBT. Emerging analytical techniques have the potential to match patients to the most effective treatments in this way (e.g. The Personalised Advantage Index; DeRubeis et al. 2014 ).

We provide an estimate of wellbeing deficits at intake as measured by WEMWBS in a real world clinical sample (a high intensity IAPT population). Our results suggest wellbeing levels in this high intensity IAPT sample are over two standard deviations on average below general population averages. This may be useful for benchmarking purposes for future work (although see the caveats raised below about generalisability of the present sample).

The present data speak to the debate about whether wellbeing and symptoms should be viewed as at two ends of a single dimension or as orthogonal constructs. Wellbeing showed a strong (but not perfect) negative association with anxiety and depression symptoms at intake, which became even stronger when correcting for attenuation. Similarly, there was a strong negative association between wellbeing change and symptom change during treatment, which became more marked when attenuation was corrected for. This is more consistent with the single dimension account (Huppert 2014 ). This deviates from other studies showing that wellbeing and symptom repair are only weakly correlated (for example, Trompetter et al. 2017 ). It may be that this discrepancy in part reflects the choice of wellbeing measure used. We deployed the WEMWBS to measure wellbeing, which has a high degree of content overlap with symptom measures (particularly with the PHQ-9). The WEMWBS can be critiqued as simply a positively rather than negatively framed measure of the same underlying symptom features tapped by the PHQ-9. Bifactor analyses have not shown the WEMWBS to be distinct from symptom measures in a large community sample (Böhnke and Croudace 2016 ). In contrast, Trompetter et al. ( 2017 ) used the Mental Health Continuum short-form, which may be a purer measure of wellbeing that is more distinct from psychopathology.

Even if wellbeing and symptoms are to some extent measuring the same underlying construct, it is still beneficial to measure them separately. Goal setting theory argues objectives are more likely to be achieved if they are couched in approach rather than avoidance terms (Elliot et al. 1997 ; Roskes et al. 2014 ). Reducing levels of depression and anxiety is an avoidance goal, whereas enhancing levels of wellbeing is an approach goal. Moreover, symptom measures may be relatively insensitive to the upper half of a single mental health continuum (measuring movement from negative to neutral mental health but not from neutral to positive mental health). It is noteworthy that of the individuals who met recovery criteria for symptoms, many were still languishing and very few were flourishing in wellbeing terms.

Limitations of the present study need to be held in mind. First, and most critically, there was a substantial degree of missing WEMWBS data at follow-up and these data were potentially ‘missing not at random’ (MNAR). Those with complete data were older, had less marked symptoms and higher wellbeing, were more treatment responsive, and attended more sessions. These differences may reflect client willingness to fill in extra measures as a function of whether they felt they benefitted, therapist implicit biases in who they gave post-treatment WEMWBS to, or the fact that WEMWBS was only given at planned discharge (where response rates are likely to be superior). These characteristics of the completer sample may be biasing results, in particular artificially inflating effect sizes on all outcome variables. Partially offsetting this concern, it is reassuring that an identical pattern of findings emerged when analysing the imputed dataset (effectively an intention-to-treat sample). There is ongoing debate about the reliability of multiple imputation with a high degree of missing data, when the data may be MNAR and when only a limited set of auxiliary variables are available to predict missing values (van Ginkel et al. 2019 ; Jakobsen et al. 2017 ; Madley-Dowd et al. 2019 ). Nevertheless, multiple imputation may provide less biased results than list wise deletion when data are MNAR. Overall, while it is encouraging that the same pattern of findings (greater repair of symptoms relative to wellbeing) emerged in both complete-case and multiple imputation-based analyses, neither method are free from bias when data are MNAR. Therefore, caution needs to be taken when generalising these findings to other samples.

Second, this is an uncontrolled study using routine registry data, meaning that factors such as spontaneous recovery over time and treatment expectancy are not accounted for. Moreover, we only had the demographic and clinical information that is routinely collected in IAPT services (which is less extensive than that which is typically captured in research studies). This limits the extent to which detailed comparisons can be made to other research samples and also precluded moderation analyses being conducted. Future research should examine which baseline variables predict wellbeing repair during CBT. Third, the sample is also not entirely representative of IAPT services, as it was part of a personality disorder demonstration site rather than routine IAPT care. This meant that the service had latitude to take on clients with a greater degree of comorbid personality pathology than is typically deemed eligible for IAPT and also had more flexibility about the number of sessions they could offer to clients. This should be taken into account when using this data to estimate how well high intensity CBT in more routine IAPT settings will perform in repairing wellbeing (given that previous work suggests those with more marked personality disorder features do less well in IAPT generally; Goddard et al. 2015 ).

Fourth, it is important to recognise that the pattern of results regarding magnitude of change of wellbeing versus symptoms do not necessarily generalise beyond the specific measures used (the PHQ-9, GAD-7, and WEMWBS). It may simply be the case that the measures are differentially sensitive to change, with the PHQ-9 and GAD-7 being more sensitive than the WEMWBS. The findings require replication using a broader array of outcome measures. Fifth, the sample was selected on the basis of scoring above cut-offs on the PHQ-9 and GAD-7, reflecting standard practice in IAPT settings. While these scores have been shown to predict diagnostic status with a reasonable degree of accuracy, it would have been methodologically stronger to have diagnostically interviewed participants. Sixth, greater repair of symptoms relative to wellbeing could simply reflect regression to the mean, in that the sample was further away from the general population average scores for symptoms than wellbeing at intake. Seventh, definitions of positive recovery focus on optimising functioning (i.e. being able to perform in key life areas like vocation, family, relationships, and hobbies) as well as wellbeing. We did not consider functioning outcomes here. Eighth, reflecting the way in which the GAD-7 is used in IAPT services, we are equating changes in this scale with changes in overall anxiety. However, the GAD-7 was originally designed as a screening tool and severity indicator for generalized anxiety disorder specifically rather than anxiety more broadly. Finally, we did not have accurate data on the use of psychotropic medications, so possible interactions between drug and psychological therapy could not be examined.

In conclusion, notwithstanding the above caveats, our findings suggest that classic CBT does a better job of repairing symptoms than building wellbeing. There is a need to enhance existing treatments, and potentially to develop novel treatments, that better target wellbeing enhancement in addition to symptom relief.

Over the past forty years cognitive protocols have evolved and proliferated. CBT can therefore be broadly defined as a family of interventions that aim to change how an individual thinks and behaves in an effort to repair mood. We are restricting our analysis to ‘classic’ Beckian protocols. By this we mean ‘second wave’ treatments that combine behavioural and cognitive approaches to modify negatively biased cognitive content in anxiety and depression. We distinguish these from more recent ‘third wave’ cognitive protocols that change the relationship to as well as the content of cognition. These ‘third wave approaches include Acceptance and Commitment Therapy, Dialectical Behaviour Therapy, and Mindfulness Based Cognitive Therapy. CBT protocols have also recently been adapted to have a more explicit recovery focus.

In these studies, the pre-post correlation for each measure was never described, so we assumed in all cases it was 0.5.

The analyses comparing the magnitude of recovery for symptoms versus wellbeing are relying on essentially arbitrary definitions of recovery, particularly for the WEMWBS where no cut-off has yet been established. Another criteria that has been used in the literature is to define anyone who scores no more than one SD below the general population average as being in recovery (which results in a lower cut-off score of 44 for the WEMWBS). Using this approach, at intake a greater proportion of individuals were in recovery for WEMWBS relative to symptoms, McNemar p<.001. At post-treatment, a greater proportion of individuals met recovery for symptoms relative to wellbeing, McNemar, p=.002. We also conducted additional continuous analyses on change on each measure in Z-score units (relative to general population averages) and proportion change units (relative to scale range). These continuous analyses do not rely on arbitrary cut-offs to define recovery. These reached an identical conclusion to the categorical analyses, with greater repair of symptoms relative to wellbeing (see supplementary materials for details).

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Widnall, E., Price, A., Trompetter, H. et al. Routine Cognitive Behavioural Therapy for Anxiety and Depression is More Effective at Repairing Symptoms of Psychopathology than Enhancing Wellbeing. Cogn Ther Res 44 , 28–39 (2020). https://doi.org/10.1007/s10608-019-10041-y

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The History of CBT

Treating depression, video: cognitive behavioral therapy explained.

Both Beck and Ellis began working on their versions of the therapy in and around the late 1950s and early 60s.

In other words, what people think about an event that has occurred determines how they will feel about that event .

Depression happens because people develop a disposition to view situations and circumstances in habitually negative and biased ways, leading them to habitually experience negative feelings and emotions as a result.

• Depression is caused by a combination of an unhelpful dysfunctional thought process and by maladaptive behaviors motivated by that thought process .
• Because these dysfunctional thoughts and behaviors are learned, people with depression can also learn new, more adaptive skills that raise their mood and increase their ability to cope with daily hassles and stressors.

Therefore, if a person changes their thoughts and behavior, a positive change in mood will follow .

Core Beliefs

Core beliefs are fundamental assumptions people have made that influence how they view the world and themselves. People get so used to thinking in these core ways that they stop noticing them or questioning them.

Core beliefs serve as a filter through which people see the world. Core beliefs influence the development of "intermediate beliefs," which are related attitudes, rules and assumptions that follow from core beliefs.

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The cognitive aspect of CBT involves learning to identify these distorted patterns of thinking and forming judgments.

Intermediate Beliefs

Intermediate beliefs can influence people's view of a particular situation by generating "automatic thoughts," the actual thoughts or images that people experience flitting through their minds.

• Automatic thoughts are evaluative cognitions which occur in response to a particular situation. They are spontaneous (hence the term automatic), rather than the result of deliberate extended thinking or the logical reasoning that occurs when someone concentrates.
• Automatic thoughts occur effortlessly, more or less all the time. Most of the time we are unaware that they are occurring, not because they are unconscious sorts of things but rather because we're so used to them that we don't notice them anymore. Automatic thoughts influence emotions and behaviors and can provoke physiological responses .

To continue the above example, if a friend of our depressed person does not return a phone call, our depressed person might think, "He's not calling me back because he hates me."

• It may never occur to her to generate alternative and less irrational explanations for the lack of a callback such as, "He must be really busy today."

Because the automatic thought "he hates me" is allowed to stand unchallenged, our depressed person starts feeling hated, and thus depressed .

• Catastrophizing - always anticipating the worst possible outcome to occur (e.g., expecting to be criticized or fired when the boss calls).
• Filtering - exaggerating the negative and minimizing the positive aspects of an experience (e.g., focusing on all the extra work that went into a promotion rather than on how nice it is to have the promotion).
• Personalizing - automatically accepting blame when something bad occurs even when you had nothing to do with the cause of the negative event (e.g., He didn't return my phone call because I am a terrible friend or a boring person; I caused him to not call.).
• (Over)Generalizing - viewing isolated troubling events as evidence that all following events will become troubled (e.g., having one bad day means that the entire week is ruined ).
• Polarizing - viewing situations in black or white (all bad or all good) terms rather than looking for the shades of gray (e.g., "I missed two questions on my exam, therefore I am stupid", instead of "I need to study harder next time, but hey - I did pretty good anyway!").
• Emotionalizing - allowing feelings about an event to override logical evaluation of the events that occurred during the event. (e.g., I feel so stupid that it's obvious that I'm a stupid person).

Dysfunctional Beliefs

Distorted though they may be, dysfunctional beliefs are all people typically have to help them make sense out of the events that happen to them. Snap judgments are made (called Cognitive Appraisals) based on the assumptions present within dysfunctional beliefs, and those judgments end up being, not surprisingly, biased and irrational.

People look to their appraisals of stressful situations to know how to react, and when they do, they see that situations look simply awful (worse than it really would appear if some reality testing were to occur). They react to that false or exaggerated sense of awfulness and correspondingly, experience depressive symptoms.

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Major depressive disorder: Validated treatments and future challenges

Rabie karrouri.

Department of Psychiatry, Moulay Ismaïl Military Hospital, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez 30070, Morocco

Zakaria Hammani

Roukaya benjelloun.

Department of Psychiatry, Faculty of Medicine, Mohammed VI University of Health Sciences, Casablanca 20000, Morocco

Yassine Otheman

Department of Psychiatry, Moulay Ismaïl Military Hospital, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez 30070, Morocco. [email protected]

Corresponding author: Yassine Otheman, MD, Associate Professor, Chief Doctor, Department of Psychiatry, Moulay Ismaïl Military Hospital, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, 1893, Km 2.2 road of Sidi Hrazem, Fez 30070, Morocco. [email protected]

Depression is a prevalent psychiatric disorder that often leads to poor quality of life and impaired functioning. Treatment during the acute phase of a major depressive episode aims to help the patient reach a remission state and eventually return to their baseline level of functioning. Pharmacotherapy, especially selective serotonin reuptake inhibitors antidepressants, remains the most frequent option for treating depression during the acute phase, while other promising pharmacological options are still competing for the attention of practitioners. Depression-focused psychotherapy is the second most common option for helping patients overcome the acute phase, maintain remission, and prevent relapses. Electroconvulsive therapy is the most effective somatic therapy for depression in some specific situations; meanwhile, other methods have limits, and their specific indications are still being studied. Combining medications, psychotherapy, and somatic therapies remains the most effective way to manage resistant forms of depression.

Core Tip: Depression is a persistent public health problem for which treatments must be codified and simplified to enhance current practice. Several therapies have been suggested worldwide, with varying levels of validity. This article explores effective and valid therapies for treating depression by addressing current and future research topics for different treatment categories.

INTRODUCTION

Depression is a common psychiatric disorder and a major contributor to the global burden of diseases. According to the World Health Organization, depression is the second-leading cause of disability in the world and is projected to rank first by 2030[ 1 ]. Depression is also associated with high rates of suicidal behavior and mortality[ 2 ].

Treatments administered during the acute phase of a major depressive episode aim to help the patient reach a remission state and eventually return to their baseline level of functioning[ 3 ]. Acute-phase treatment options include pharmacotherapy, depression-focused psychotherapy, combinations of medications and psychotherapy, and somatic therapies such as electroconvulsive therapy (ECT). Nevertheless, managing the acute phase of depression is only the first step in a long therapy process that aims to maintain remission and prevent relapses. In this article, we discuss various treatment options implemented by clinicians, highlighting the role that each option plays in actual psychiatric practice.

PHARMACOTHERAPY

While selective serotonin reuptake inhibitors (SSRIs) remain the gold-standard treatment for depression, new antidepressants are always being developed and tested. The ultimate goal is to discover a molecule that exhibits quick effectiveness with as few side effects as possible.

Daniel Bovet studied the structure of histamine (the causative agent in allergic responses) to find an antagonist, which was finally synthesized in 1937[ 4 ]. Since then, many researchers have studied the link between the structures and activities of different antihistaminic agents, contributing to the discovery of almost all antidepressants[ 5 ].

In the following subsections, we list the main classes of antidepressants in chronological order of apparition, highlighting the most widely used molecules in daily psychiatric practice.

Monoamine oxidase inhibitors

Iproniazid was the first drug defined as an antidepressant; it was later classified as a monoamine oxidase inhibitor (MAOI)[ 6 , 7 ]. Several other MAOIs have been introduced since 1957[ 8 ]. Due to their irreversible inhibition of monoamine oxidase, MOAIs have numerous side effects, such as hepatotoxicity and hypertensive crises, that can lead to lethal intracranial hemorrhages. Consequently, MAOIs have become less commonly used over time[ 9 ].

Trials have demonstrated that MAOIs’ efficacy is comparable to that of tricyclic antidepressants (TCAs)[ 10 , 11 ]. However, considering MAOIs’ drug interactions, dietary restrictions, and potentially dangerous side effects, they are now almost exclusively prescribed for patients who have not responded to several other pharmacotherapies, including TCAs[ 9 ]. Furthermore, MAOIs have demonstrated specific efficacy in treating depression with atypical features, such as reactive moods, reverse neuro-vegetative symptoms, and sensitivity to rejection[ 12 ].

MAOIs are also a potential therapeutic option when ECT is contraindicated[ 13 ]. MAOIs’ effectiveness is still unclear for treating depression in patients who are resistant to multiple sequential trials with SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs)[ 14 ]. Nevertheless, psychiatrists’ use of MAOIs has declined over the years[ 15 , 16 ]. The use of MAOIs is generally restricted to patients who do not respond to other treatments.

The first TCA was discovered and released for clinical use in 1957 under the brand name Tofranil[ 5 , 17 ]. Since then, TCAs have remained among the most frequently prescribed drugs worldwide[ 9 ]. TCAs-such as amitriptyline, nortriptyline, protriptyline, imipramine, desipramine, doxepin, and trimipramine-are about as effective as other classes of antidepressants-including SSRIs, SNRIs, and MAOIs-in treating major depression[ 18 , 19 ].

However, some TCAs can be more effective than SSRIs when used to treat hospitalized patients[ 20 ]. This efficacy can be explained by the superiority of TCAs over SSRIs for patients with severe major depressive disorder (MDD) symptoms who require hospitalization[ 21 - 24 ]. However, no differences have been detected in outpatients who are considered less severely ill[ 18 , 20 ]. In most cases, TCAs should generally be reserved for situations when first-line drug treatments have failed[ 25 ].

In December 1987, a series of clinical studies confirmed that an SSRI called fluoxetine was as effective as TCAs for treating depression while causing fewer adverse effects[ 26 ]. After being released onto the market, its use expanded more quickly than that of any other psychotropic in history. In 1994, it was the second-best-selling drug in the world[ 7 ].

Currently available SSRIs include fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, and escitalopram. They have elicited different tolerance rates and side effects-mostly sexual and digestive (nausea and loss of appetite), as well as irritability, anxiety, insomnia, and headaches[ 27 ]. Nevertheless, SSRIs have a good tolerability profile[ 28 ].

In most systematic reviews and meta-analyses, SSRIs have demonstrated comparable efficacy to TCAs[ 18 , 19 , 29 ], and there is no significant evidence indicating the superiority of any other class or agent over SSRIs[ 29 - 31 ]. Furthermore, studies show no differences in efficacy among individual SSRIs[ 29 , 31 - 34 ]. Therefore, most guidelines currently recommend SSRIs as the first-line treatment for patients with major depression[ 25 ].

Norepinephrine reuptake inhibitors

Other monoamine (norepinephrine, serotonin, and dopamine) neurotransmitter reuptake inhibitors called SNRIs emerged during the 1990s to protect patients against the adverse effects of SSRIs[ 35 ]. Currently available SNRIs are venlafaxine, desvenlafaxine (the principal metabolite of venlafaxine), and duloxetine. The extended-release form of venlafaxine is the most commonly used drug in this class. Clinical guidelines commonly recommend prescribing SNRI to patients who do not respond to SSRIs[ 25 ].

In individual studies, venlafaxine and duloxetine are generally considered effective as SSRIs[ 36 ]. Also, venlafaxine’s efficacy is comparable to that of TCAs[ 37 , 38 ].

According to some meta-analyses, reboxetine (a selective noradrenaline reuptake inhibitor) seems less efficacious than SSRIs[ 39 ]. However, these findings could be due to the relatively poor tolerance of reboxetine[ 40 ].

Other antidepressants

Trazodone is the oldest medication of the so-called “other antidepressants” group that is still in wide use[ 41 , 42 ]. It has been shown to be an effective antidepressant in placebo-controlled research. However, in contemporary practice, it is much more likely to be used in low doses as a sedative-hypnotic than as an antidepressant[ 41 , 42 ].

Nefazodone’s structure is analogous to that of trazodone, though it has different pharmacological properties[ 43 ]. Its efficacy and overall tolerability are comparable to those of SSRIs, as indicated by comparative trials[ 43 ]. However, its use is associated with rare (but fatal) cases of clinical idiosyncratic hepatotoxicity[ 44 ].

Bupropion’s mechanism of action remains unclear, though it is classified as a norepinephrine and dopamine reuptake inhibitor[ 45 ]. It appears to have a more activating profile than SSRIs that are modestly superior to bupropion in patients with MDD[ 46 ]. However, for individuals with low to moderate levels of anxiety, the efficacy of bupropion in treating MDD is comparable to that of SSRIs[ 46 ]. Moreover, bupropion has a better tolerability profile than SSRIs, with minimal weight gain (or even leading to weight loss)[ 46 ]. In addition, bupropion is more likely than some SSRIs to improve symptoms of fatigue and sleepiness[ 47 ].

Mirtazapine and mianserin are tetracyclic compounds believed to increase the availability of serotonin or norepinephrine (or both), at least initially. Mirtazapine’s ability to antagonize serotoninergic subtypes receptors, <5-HT2A> and <5-HT2C>, could also increase norepinephrine and dopamine release in cortical regions[ 25 ]. Mirtazapine is about as effective as SSRIs[ 48 ].

Recently, drugs have been developed that block serotonin reuptake while affecting a variety of 5-HT receptor subtypes. The advantages of these agents ( e.g. , vilazodone and vortioxetine) over SSRIs are not fully clear. However, they appear to produce less sexual dysfunction and, in the specific case of vortioxetine, have particular benefits in depression-related cognitive impairment[ 49 ]. Indeed, vortioxetine is a very recent antidepressant with a multimodal mechanism that is thought to have a high affinity for serotonin transporters and 5-HT3, 5HT1A, 5HT7 receptors. Such a specific profile seems to indicate a level of efficacy to other antidepressants with a specific action on cognitive impairments[ 50 , 51 ].

In conclusion, no significant differences have been found between different classes of antidepressants in terms of their efficacy[ 52 ], though some drugs show some weak-to-moderate evidence indicating they are more effective than some other drugs[ 53 ]. Concerning the acceptability of these drugs, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine have been deemed more tolerable than other antidepressants, whereas amitriptyline, clomipramine, duloxetine, fluvoxamine, trazodone, and venlafaxine had the highest dropout rates[ 53 ] because of their more frequent and severe side effects. Nausea and vomiting were the most common reasons for treatment discontinuation; sexual dysfunction, sedation, priapism, and cardiotoxicity were also reported[ 31 , 41 ].

Ketamine and related molecules

In intravenous sub-anesthetic doses, ketamine has very quick effects on resistant unipolar (and, possibly, bipolar) depression and acute suicidal ideation[ 54 , 55 ]. The antidepressant effect of ketamine can persist for several days but eventually wanes. A few reports are have cited oral and intranasal formulations of ketamine for treatment-resistant depression[ 56 , 57 ], but there is still no data about the potential link between the onset of action and the route of administration.

Common adverse effects of ketamine include dizziness, neurotoxicity, cognitive dysfunction, blurred vision, psychosis, dissociation, urological dysfunction, restlessness, headache, nausea, vomiting, and cardiovascular symptoms[ 58 ]. Such adverse effects tend to be brief in acute, low-dose treatments[ 36 ], whereas prolonged exposure may predispose patients to neurotoxicity and drug dependence[ 56 ]. Lastly, since ketamine is associated with a higher risk of drug abuse and addiction, it cannot be recommended in daily clinical practice[ 59 , 60 ].

Ketamine is not a miracle drug, and many important factors still need to be defined, such as the most effective dose and the optimal administration route[ 61 , 62 ]. The current lack of guidelines about the therapeutic monitoring of ketamine treatment for depression further complicates the expanding use of this treatment[ 56 ]. Even though ketamine might never reach the market, it has stimulated research in the neurobiology of depression, including studies on potential fast and long-lasting antidepressants.

Ketamine has an active metabolite (hydroxynorketamine) that can produce rapid and sustained glutamatergic stimulation. It also seems to be free of many of the safety problems associated with ketamine and, thus, should be studied.

Research on the S-enantiomer of ketamine (S-ketamine, or esketamine, especially intranasal) could also be valuable, as it has a 3 to 4 times greater affinity than ketamine for the N-methyl-D-aspartate (NMDA) receptor[ 40 ]. It was approved by the United States Food and Drug Administration in March 2019 for treatment-resistant depression. However, current knowledge about the effects of prolonged esketamine therapy is still preliminary. In addition, regarding the potential risk of abuse, esketamine use must be carefully monitored[ 63 - 65 ].

Other glutamate receptor modulators have been evaluated in small studies as monotherapy agents or as adjuncts to other antidepressants. Examples include noncompetitive NMDA receptor antagonists (memantine, dextromethorphan/quinidi-ne, dextromethorphan/bupropion, and lanicemine), NR2B subunit-specific NMDA receptor antagonists (traxoprodil), NMDA receptor glycine site partial agonists (D-cycloserine, rapastinel), and metabotropic glutamate receptor antagonists (basimglurant, declogurant)[ 66 - 68 ] (Table ​ (Table1). 1 ).

Main classes of antidepressants with their date of approval, contributions, and disadvantages

NMDA: N-methyl-D-aspartate; SSRI: DSelective serotonin reuptake inhibitors; MDD: Major depressive disorder; MAOI: Monoamine oxidase inhibitor.

Perspectives

A purely neurotransmitter-based explanation for antidepressant drug action-especially serotonin-inhibiting drugs-is challenged by the significant percentage of patients who never achieve full remission[ 6 ] and the delayed clinical onset, which varies from two to four weeks. Moreover, studies show an acute increase in monoamines in the synaptic cleft immediately following treatment[ 69 ], even when the depletion of tryptophan (serotonin’s precursor) does not induce depressive-like behavior in healthy humans[ 70 , 71 ].

This finding shows that research on the pharmacological options for treating depression must go beyond monoaminergic neurotransmission systems. Research on the development of new antidepressants should explore several mechanisms of action on several types of receptors: Antagonism, inhibition of the reuptake of neurotransmitters, and modulators of glutamate receptors, as well as interactions with α-amino-3-acid receptors, hydroxy-5-methyl-4-isoxazolepropionic, brain-derived neurotrophic factor, tyrosine kinase B receptor (the mechanistic target of rapamycin), and glycogen synthase kinase-3[ 72 ].

Identifying the cellular targets of rapid-acting agents like ketamine could help practitioners develop more effective antidepressant molecules by revealing other receptors involved in gamma-aminobutyric acid regulation and glutamate transmission[ 73 ].

PSYCHOTHERAPY

Psychotherapeutic interventions are widely used to treat and prevent most psychiatric disorders. Such interventions are common in cases of depression, psychosocial difficulties, interpersonal problems, and intra-psychic conflicts. The specific psychotherapy approach chosen for any given case depends on the patient’s preference, as well as on the clinician’s background and availability[ 74 ] . Psychotherapy for patients with depression strengthens the therapeutic alliance and enables the patient to monitor their mood, improve their functioning, understand their symptoms better, and master the practical tools they need to cope with stressful events[ 75 ]. The following subsections briefly describe psychotherapeutic interventions that have been designed specifically for patients with depression.

Overview of psychotherapy in depression

Depression-focused psychotherapy is typically considered the initial treatment method for mild to moderate MDD. Based on significant clinical evidence, two specific psychotherapeutic methods are recommended: Cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). Supportive therapy (ST) and psychoeducational intervention (PEI) have also been recommended, those the evidence supporting these methods s not as strong. In more cases of severe depression, ST and PEI are used only to augment pharmacological treatments.

After remission, CBT, PEI, and mindfulness-based cognitive therapy (MBCT) are proposed to maintain and prevent depression. However, when psychotherapy has been effective during the initial phases of a depressive episode, it should be continued to maintain remission and prevent relapses while reducing the frequency of sessions[ 25 , 75 , 76 ].

Specific and intensive psychotherapeutic support is recommended for patients with chronic depression because of high rates of comorbidity with personality disorders, early trauma, and attachment deficits. The European Psychiatric Association recommends using the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for treating chronic depression and utilizing specific approaches suited to each patient’s preferences[ 77 ]. All these therapeutic options are summarized in Figure ​ Figure1 1 .

Overview of psychotherapy in different clinical situations of depression. MDD: Major depressive disorder; CBT: Cognitive-behavioral therapy; IPT: Interpersonal therapy; ST: Supportive therapy; PEI: Psycho-educational intervention; MBCT: Mindfulness based cognitive therapy; SIPS: Specific and intensive psychotherapeutic support; CBASP: Cognitive Behavioral Analysis System of Psychotherapy.

Structured psychotherapies

Cognitive and behavioral therapies: Based on robust evidence, CBT is one of the most well-documented and validated psychotherapeutic methods available. Interventional strategies are based on modifying dysfunctional behaviors and cognitions[ 77 ]. CBT targets depressed patients’ irrational beliefs and distorted cognitions that perpetuate depressive symptoms by challenging and reversing them[ 3 ]. Thus, CBT is a well-known effective treatment method for MDD[ 78 ] and has been recommended in most guidelines as a first-line treatment[ 79 - 81 ].

However, the effectiveness of CBT depends on patient’s capacity to observe and change their own beliefs and behaviors. Some simple techniques were developed to overcome this issue, especially in primary care management. Behavioral activation is one such technique, consisting of integrating pleasant activities into daily life to increase the number and intensity of the positive interactions that the patient has with their environment[ 82 , 83 ].

Acceptance and commitment therapy is another form of CBT. This type of therapy, which is based on functional contextualism, can help patients accept and adjusting to persistent problems. It appears to be effective in reducing depressive symptoms and preventing relapses[ 77 , 84 ].

Another form of CBT is computerized CBT (CCBT), implemented via a computer with a CD-ROM, DVD, or online CCBT, allowing patients to benefit from this therapy under conditions of reduced mobility, remoteness, confinement, or quarantine[ 79 ] .

CCBT and guided bibliotherapy based on CBT could be considered for self-motivated patients with mild to moderate major depression or as a complementary treatment to pharmacotherapy[ 25 ]. CBT is also recommended for patients with resistant depression in combination with antidepressants[ 85 ].

Schema therapy is another CBT-derived therapy that can be used in patients who have failed classical CBT, like patients with personality disorder comorbidity. Schema therapy is about as effective as CBT for treating depression[ 86 ]. In adolescent patients with depression, CBT is also a recommended option with plenty of evidence from multiple trials. Meanwhile, it remains the first-line treatment in children despite mixed findings across trials[ 87 ] . CBT is also a promising option for elderly depressed patients, though substantial evidence is still lacking because of the limited data on the subject[ 88 ] .

IPT: The goal of IPT is to identify the triggers of depressive symptoms or episodes. These triggers may include losses, social isolation, or difficulties in social interactions. The role of the intervention is to facilitate mourning (in the case of bereavement), help the patient recognize their own affect, and resolve social interaction dysfunction by building their social skills and social supports[ 89 ]. IPT, like CBT, is a first-line treatment for mild to moderate major depressive episodes in adults; it is also a well-established intervention for adolescents with depression[ 25 ] .

Problem-solving therapy: The problem-solving therapy (PST) approach combines cognitive and interpersonal elements, focusing on negative assessments of situations and problem-solving strategies. PST has been used in different clinical situations, like preventing depression among the elderly and treating patients with mild depressive symptoms, especially in primary care. Despite its small effect sizes, PST is comparable to other psychotherapeutic methods used to treat depression[ 88 , 90 ].

Marital and family therapy: Marital and family therapy (MFT) is effective in treating some aspects of depression. Family therapy has also been used to treat severe forms of depression associated with medications and hospitalization[ 91 ]. Marital and family problems can make people more vulnerable to depression, and MFT addresses these issues[ 92 ]. Marital therapy includes both members of the couple, as depression is considered in an interpersonal context in such cases. Some of the goals of this therapy are to facilitate communication and resolve different types of marital conflict. Family therapy uses similar principles as other forms of therapy while involving all family members and considering depression within the context of pathological family dynamics[ 93 ].

ST: Although ST is not as well-structured or well-evaluated as CBT or IPT, it is still commonly used to support depressed patients. In addition to sympathetic listening and expressing concern for the patient’s problems, ST requires emotionally attuned listening, empathic paraphrasing, explaining the nature of the patient’s suffering, and reassuring and encouraging them. These practices allow the patient to ventilate and accept their feelings, increase their self-esteem, and enhance their adaptive coping skills[ 94 ].

Psychodynamic therapy: Psychodynamic therapy encompasses a range of brief to long-term psychological interventions derived from psychoanalytic theories. This type of therapy focuses on intrapsychic conflicts related to shame, repressed impulses, problems in early childhood with one’s emotional caretakers that lead to low self-esteem and poor emotional self-regulation[ 93 , 95 ]. Psychodynamic therapy’s efficacy in the acute phase of MDD is well-established compared to other forms of psychotherapy.

Group therapy: The application of group therapy (GT) to MDD remains limited. Some data support the efficacy of specific types of GT inspired by CBT and IPT[ 96 - 98 ]. Group CBT for patients with subthreshold depression is an effective post-depressive-symptomatology treatment but not during the follow-up period[ 99 ]. Supportive GT and group CBT reduce depressive symptoms[ 96 ], especially in patients with common comorbid conditions[ 100 ]. However, studies are still lacking in this domain.

MBCT: MBCT is a relatively recent technique that combines elements of CBT with mindfulness-based stress reduction[ 101 ]. Studies have shown that eight weeks of MBCT treatment during remission reduces relapse. Thus, it is a potential alternative to reduce, or even stop, antidepressant treatment without increasing the risk of depressive recurrence, especially for patients at a high risk of relapse ( i.e. , patients with more than two previous episodes and patients who have experienced childhood abuse or trauma)[ 102 ].

Other psycho-interventions

Psycho-education: This type of intervention educates depressed patients and (with their permission) family members involved in the patient’s life about depression symptoms and management. This education should be provided in a language that the patient understands. Issues such as misperceptions about medication, treatment duration, the risk of relapse, and prodromes of depression should be addressed. Moreover, patients should be encouraged to maintain healthy lifestyles and enhance their social skills to prevent depression and boost their overall mental health. Many studies have highlighted the role of psycho-education in improving the clinical course, treatment adherence, and psychosocial functioning in patients with depression[ 103 ].

Physical exercise: Most guidelines for treating depression, including the National Institute for Health and Care Excellence, the American Psychiatric Association, and the Royal Australian and New Zealand College of Psychiatrists, recommend that depressed patients perform regular physical activity to alleviate symptoms and prevent relapses[ 104 ] . Exercise also promotes improvements in one’s quality of life in general[ 105 ] . However, exercise is considered an adjunct to other anti-depressive treatments[ 25 ] .

Although psychotherapy is effective for treating depression and improving patients’ quality of life, its direct actions against depressive symptoms are not fully understood[ 106 ]. Identifying factors ( e.g. , interpersonal variables) linked to treatment responses can help therapists choose the right therapeutic strategy for each patient and guide research to modify existing therapies and develop new ones[ 107 ].

Since depression is a primary care problematic, simplifying psychotherapy procedures will increase the use of psychological interventions for depression, especially in general practice. Brief forms (six to eight sessions) of CBT and PST have already shown their effectiveness for treating depression[ 108 ]. Nevertheless, simpler solutions must be made available to practitioners to help them manage and prevent depression.

SOMATIC TREATMENTS

In many situations, depression can also be managed via somatic treatments. ECT is the most well-known treatment for resistant depression, and solid evidence supports its effectiveness and safety. In recent decades, various innovative techniques have been proposed, such as repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), and magnetic seizure therapy, with varying efficiency levels[ 109 ].

ECT is arguably the most effective treatment modality in psychiatry, and its superiority over pharmacotherapy for major unipolar depression is widely supported[ 110 ]. ECT reduces the number of hospital readmissions and lightens the burden of depression, leading to a better quality of life[ 111 , 112 ].

Moreover, ECT is considered safe[ 113 ]. Advances in anesthesia and ECT techniques have decreased complications related to ECT while also improving cognitive outcomes and patient satisfaction.

However, the stigma surrounding ECT limits its use. Most misconceptions date back to early ECT techniques (when it was performed without muscle relaxants or anesthesia). Nevertheless, some people still consider ECT as the last option for treating depression, even though most studies indicate that ECT is more beneficial in patients with fewer pharmacological treatments[ 114 - 116 ].

ECT is typically recommended for patients with severe and psychotic depression, a high risk of suicide, or Parkinson’s disease, as well as pregnant patients[ 117 - 119 ]. The maintenance ECT also appears to prevent relapses[ 120 ]. The current practice of ECT continues to improve as protocols become more advanced, mainly owing to bioinformatics, and as more research is carried out in this domain[ 121 - 125 ].

This method, which is a type of biological stimulation that affects brain metabolism and neuronal electrical activity, has been widely used in research on depression[ 126 ]. Recent literature shows a significant difference between rTMS and fictitious stimulation regarding its improvements in depressive symptoms[ 127 ]. Preliminary research has revealed synergistic ( e.g. , rTMS/quetiapine) and antagonizing ( e.g. , rTMS/cannabinoid receptor (CB1) antagonist) interactions between neuro-modulation and pharmacotherapy[ 128 ]. Treatments combining rTMS and antidepressants are significantly more effective than placebo conditions, with mild side effects and good acceptability[ 129 ]. Although these results are encouraging, they remain inconsistent due to differences in rTMS treatment frequencies, parameters, and stimulation sites[ 129 ]. Therefore, clinical trials with large sample sizes are needed to specify which factors promote favorable therapeutic responses. Also, additional preclinical research should investigate the synergistic effects of other pharmacological molecules and guide integrated approaches (rTMS plus pharmacotherapy).

This technique delivers weak currents to the brain via electrodes placed on the scalp[ 130 ]. It is easy to use, safe, and tolerable[ 131 ]. The tDCS technique significantly outperforms the simulator in terms of the rate of response and remission[ 132 ]. However, its effect remains lower than that of antidepressants[ 133 ] and rTMS[ 134 ]. It can be used as a complementary intervention or as monotherapy to reduce depressive symptoms in unipolar or bipolar depression patients[ 135 ]. The antidepressant effects of tDCS may involve long-term neuroplastic changes that continue to occur even after the acute phase of treatment, which explains its delayed efficacy[ 135 ].

Recently, neurophysiological studies have shown that the clinical effects of tDCS do not have a direct linear relationship with the dose of stimulation[ 136 ]. tDCS, as a relatively simple and portable technology, is well-suited for remote supervised treatment and assessment at home, thus facilitating long treatment durations[ 136 ].

Since the optimal clinical effects of tDCS are delayed, future clinical trials should use longer evaluation periods and aim to identify responsive patients using algorithms[ 137 ].

VNS is a therapeutic method that has been used for the last sixteen years to treat resistant unilateral or bipolar depression. However, despite several clinical studies attesting to its favorable benefit-risk ratio and its approval by the Food Drug Administration in 2005, it is not used very often[ 138 ].

VNS involves the implantation of a pacemaker under the collarbone that is connected to an electrode surrounding the left vagus nerve. The left vagus nerve is preferred because it exposes the patient to fewer potential adverse cardiac effects. Indeed, most cardiac afferent fibers originate from the right vagus nerve[ 139 ]. Since the turn of the century, numerous studies have demonstrated the efficacy of VNS in resistant depression[ 140 - 142 ].

However, only one randomized, double-blind, controlled trial comparing VNS with usual medical treatment has been conducted over a short period of 10 wk[ 141 ]. Moreover, the results of this study did not indicate that the combination of VNS with typical medical treatments was better than the typical medical treatment on its own.

However, VNS has demonstrated progressively increasing improvements in depressive symptoms, with significant positive outcomes observed after six to 12 mo; these benefits can last for up to two years[ 143 ].

More long-term studies are needed to fully determine the predictors of the correct response.

According to the literature, DBS of the subgenual cingulate white matter (Brodmann area = BA 25) elicited a clinical response in 60% of resistant depression patients after six months and clinical remission in 35% of patients, with benefits maintained for over 12 mo[ 144 ]. The stimulation of other targets, in particular the nucleus accumbens, to treat resistant depression has gained interest recently. Behavioral effects indicate the quick and favorable impact of stimulation on anhedonia, with significant effects on mood appearing as early as week one after treatment begins[ 145 ].

Magnetic seizure therapy

Magnetic seizure therapy involves inducing a therapeutic seizure by applying magnetic stimulation to the brain while the patient is under anesthesia. This technique is still being investigated as a viable alternative to ECT to treat many psychiatric disorders. Evidence supporting its effectiveness on depressive symptoms continues to grow, and it appears to induce fewer neurocognitive effects than ECT[ 146 , 147 ].

Luxtherapy (phototherapy)

The first description of reduced depression symptoms due to intense light exposure was presented in 1984[ 148 ]. Optimal improvements were obtained with bright light exposure of 2500 Lux for two hours per day, with morning exposure shown to be superior to evening exposure[ 149 ].

A review and meta-analysis[ 150 ] showed that more intense (but shorter) exposures (10000 Lux for half an hour per day or 6000 Lux for 1.5 h per day) have the same efficacy. Importantly, this treatment method is effective both for those with seasonal and non-seasonal depression. Benefits of phototherapy related to sleep deprivation and drug treatments have also been reported[ 151 ].

Neuro-modulation treatments offer a range of treatment options for patients with depression. ECT remains the most documented and effective method in this category[ 151 ]. rTMS is an interesting technique as well, as it offers a well-tolerated profile[ 85 ], while tDCS offers encouraging but varying results that depend on the study’s design and the techniques used[ 130 ].

More investigations are needed to specify which indications are the best for each method according to the clinical and biological profiles of patients. The uses of such methods are expanding, probably, with their efficiency increasing when they are tailored to the patient. Furthermore, somatic interventions for depression need to be regularly assessed and integrated into psychiatrists’ therapeutic arsenals.

Treating depression is still a significant challenge. Finding the best option for each patient is the best way to obtaining short- and long-term effectiveness. The three principal methods available to caregivers are antidepressants, specifically structured psychotherapies, and somatic approaches. Research on depression pharmacotherapy continues to examine new molecules implicated in gamma-aminobutyric acid regulation and glutamate transmission. Also, efforts to personalize and simplify psychotherapeutic interventions are ongoing. Protocols using somatic interventions need to be studied in more depth, and their indications must be specified. ECT is the only somatic treatment with confirmed indications for certain forms of depression. Combinations of medications, psychotherapy, and somatic therapies remain the most effective ways to manage resistant forms of depression.

Conflict-of-interest statement: All authors declare that they have no conflict of interest related to this article.

Manuscript source: Invited manuscript

Peer-review started: March 31, 2021

First decision: June 5, 2021

Article in press: October 11, 2021

Specialty type: Medicine, research and experimental

Country/Territory of origin: Morocco

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): 0

Grade D (Fair): D

Grade E (Poor): 0

P-Reviewer: Narumiya K S-Editor: Fan JR L-Editor: A P-Editor: Fan JR

Contributor Information

Rabie Karrouri, Department of Psychiatry, Moulay Ismaïl Military Hospital, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez 30070, Morocco.

Zakaria Hammani, Department of Psychiatry, Moulay Ismaïl Military Hospital, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez 30070, Morocco.

Roukaya Benjelloun, Department of Psychiatry, Faculty of Medicine, Mohammed VI University of Health Sciences, Casablanca 20000, Morocco.

Yassine Otheman, Department of Psychiatry, Moulay Ismaïl Military Hospital, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez 30070, Morocco. [email protected] .

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The Effectiveness of Cognitive-behavioural Therapy in Treating Depression

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Psychotherapy for depression in college students

A protocol for systematic review and network meta-analysis.

Zhang, Xiu MN a ; Niu, Ming-Ming MN b ; Ma, Pei-Fen MN c,d ; Du, Li MD e ; Wan, Lin MN a,∗

a Department of Orthopedics, Second Hospital of Lanzhou University

b Evidence-Based Nursing Center, School of Nursing, Lanzhou University

c Department of Nursing, Second Hospital of Lanzhou University

d School of Nursing, Lanzhou University

e The Third People's Hospital of Lanzhou city, Lanzhou, China.

∗Correspondence: Lin Wan, Department of Orthopedics, Second Hospital of Lanzhou University, No. 82, Cuiyingmen, Chengguan District, Lanzhou City, Gansu Province, China (e-mail: [email protected] ).

Abbreviations: ACT = acceptance and commitment therapy, BA = behavioral activation, BDI = beck depression inventory, CBT = cognitive-behavioral therapy, CESD-R = center for epidemiologic studies depression scale revised, CSCT = comprehensive self-control training, DSM = diagnostic and statistical manual of mental disorders, HRSD = Hamilton Rating Scale for depression, ICD = International Classification of Diseases, NMA = network meta-analysis, RCTs = randomized controlled trials, SASS = social adaptation self-evaluation scale, SMD = standard mean difference, SNRIs = serotonin norepinephrine reuptake inhibitors, SSRIs = selective serotonin reuptake inhibitors, SUCRA = surface under the cumulative ranking area, TAU = treatment as usual, TCAs = tricyclic antidepressants, WLC = waiting-list control.

How to cite this article: Zhang X, Niu MM, Ma PF, Du L, Wan L. Psychotherapy for depression in college students: a protocol for systematic review and network meta-analysis. Medicine . 2020;99:39(e22344).

XZ and M-MN contributed equally to this work.

This study is based on a network meta-analysis of published studies, so ethical approval and patient consent are not required. And this systematic review and network meta-analysis will be published in a peer-reviewed journal.

This study is supported by Gansu Province Health Industry Scientific Research Project (No. GSWSKY-2019-102), Lanzhou University Second Hospital Cuiying Technology Project (No. CY2018-HL18) and Development and promotion of mental health tracking and intervention database for pediatric medical staff in Gansu Province (No. 2018-RC-52).

There are no potential conflicts of interest to disclose.

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

Background: 

Depression is a disease with a high incidence and easy to relapse. It not only affects the work and life of patients, but also brings a heavy economic burden. University is the peak of depression, and the prevalence of depression among college students is much higher than that of ordinary people. The purpose of this research is to evaluate depression symptoms, life satisfaction, self-confidence, substance use, social adjustment, and dropout rates of the use of psychological intervention for college students.

Methods: 

We will identify relevant trials from systematic searches in the following electronic databases: PubMed, Embase, Web of Science and The Cochrane Library. We will also search Clinical Trials.gov, the WHO International Clinical Trials Registry Platform for unpublished data. Additional relevant studies will be searched through search engines (such as Google), and references included in the literature will be tracked. All relevant randomized controlled trials (RCTs) will be included. There are no date restrictions. Use Cochrane Collaboration's Risk of bias tool to conduct risk of bias analysis. Use the Grades of Recommendation, Assessment, Development, and Evaluation to assess the quality of evidence. All statistical analysis will be performed using Stata (V.15.0.) and Review Manager (V.5.2.0).

Results: 

A total of 6238 records were obtained by searching the database and 27 records were obtained by other sources. After removing duplicate records, there are 4225 records remaining. We excluded 3945 records through abstract and title, leaving 280 full-text articles.

Conclusion: 

This will be the first study to compare the effects of different psychological treatments on depression in college students. We hope that this study will guide clinical decision-making of psychotherapy to better treat depression in college students.

Protocol Registration: 

INPLASY202070134.

1 Introduction

Depression is a common mental health disorder, which is mainly manifested by significant and lasting depression, slow thinking, sleep disturbance, loss of appetite, etc. In severe cases, suicide attempts or behaviors may occur. [1] Each episode of depression lasts at least two weeks. In severe cases, it may last for several years. This has a serious impact on work and life, and has caused a heavy financial burden. According to the World Health Organization, more than 350 million people worldwide suffer from depression. [2] The current incidence of depression in China is 6.1%. [3] By 2020, depression may become the second largest disease after heart disease. [4] And depression has become the main reason for people's loss of social function and ranks third in the global burden of disease. [5] Studies have shown that in the United States alone, the annual cost exceeds $43.7 billion. [6,7] College students are faced with the pressure from interpersonal communication, arduous learning tasks and adaptation to the new environment and lifestyle, which makes them prone to produce strong psychological conflicts and lead to depression. [8] Therefore, compared with their peers, college students have a higher risk of depression. [9]

At present, the treatment of depression is mainly divided into medication and psychotherapy. Drug therapy mainly includes selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin norepinephrine reuptake inhibitors (SNRIs), etc. [10] Psychotherapy is to establish a relationship with the patient through a structured and purposeful connection and use a series of specific techniques to improve the patient's mental state. [11] It plays an important role in the treatment of depression. At present, the common psychotherapy in clinical treatment methods include cognitive behavior therapy, group psychotherapy, interpersonal behavior therapy, mindfulness therapy, etc. Previous studies showed that there are few systematic reviews and meta-analysis of depression in college students. However, the relevant evidence for the effectiveness of psychotherapy is still unclear, and there is no evidence to directly compare different psychological interventions. Therefore, this field urgently needs a Bayesian network meta-analysis (NMA) method that combines direct evidence with indirect evidence from multiple treatment comparisons to estimate the correlation between all treatments. [12] In this study, we will conduct a systematic review and NMA to evaluate depression symptoms, life satisfaction, self-confidence, substance use, social adjustment, and dropout rates of the use of psychotherapy for college students.

2.1 Eligibility criteria

2.1.1 type of study.

We will include all relevant randomized controlled trials (RCTs) including crossover trials. There are no language restrictions.

2.1.2 Type of patient

The patients we will include are college students diagnosed with depression according to any diagnostic criteria, such as Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, [13] DSM-IV, [14] and International Classification of Diseases, 10th Revision (ICD-10). [15] Studies in which participants have a diagnosis of bipolar disorder, psychotic depression will be excluded. In addition, studies where participants are not clearly diagnosed with depression will also be excluded.

2.1.3 Type of interventions

We will include RCTs comparing one psychological intervention with another control conditions for depression in college students. For psychotherapy, mindfulness therapy, cognitive-behavioral therapy (CBT), meditation therapy, comprehensive self-control training (CSCT), [16] acceptance and commitment therapy (ACT), [17] and behavioral activation (BA) will be included. There will be no limit to the treatment session. In terms of control conditions, waiting-list control (WLC), [18] non-treatment control, physical exercise, bibliotherapy, [19] treatment as usual (TAU) will be included.

2.1.4 Type of outcomes

Primary outcome

Depression symptoms that mean the change in severity of depression from baseline to end point which is measured by the depression scale, such as Beck Depression Inventory (BDI), [20] The Center for Epidemiologic Studies Depression Scale (CESD-R), [21] Hamilton Rating Scale for Depression (HRSD). [22]

Second outcomes

• 1. self-confidence, life satisfaction was assessed using visual rating scale
• 2. social adjustment was assessed using the Social Adaptation Self Evaluation Scale (SASS) [23] and the Social Adjustment Scale-Self Report for Youth. [24]
• 3. substance use was measured with 10 items to assess the use of eight substances, quantity per drinking and smoking day. [25]
• 4. Dropout rates from the beginning of the study to the end of the intervention.

2.2 Data source

We will identify relevant trials from systematic searches in the following electronic databases: PubMed, Embase, Web of Science and The Cochrane Library. We will also search Clinical Trials.gov, the WHO International Clinical Trials Registry Platform for unpublished data. The search terms will include “depression”, “depressive disorder”, “students”, “university student”, “college student”. Additional relevant studies will be searched through search engines (such as Google), and references included in the literature will be tracked. There is no date restriction. Detail of search strategy of PubMed is shown in Table 1 as well as detail of search strategy of Embase is shown in Table 2 .

2.3 Study selection

All records identified in the databases will be collected in the reference management software EndNote X8 for data screening. Two (MMN and PFM) reviewers will use data extraction tables to extract data from the original report independently, including research characteristics (such author information, publication year, journal and country), patient characteristics, intervention and outcome. Any disagreements will be resolved by the third member of our review team.

2.4 Risk of bias analysis

According to Cochrane Collaboration's Risk of bias tool, we will assess risk of bias as ‘low risk’, ‘unclear risk’ or ‘high risk’. [26] The following items will be evaluated: sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessors, incomplete outcome data and selective outcome reporting and other sources of bias. [27] The evaluation will be conducted by two independent raters (PFM and LD). Any disagreements will be resolved by a third review author.

2.5 Statistical analysis

2.5.1 pairwise meta-analysis.

We will use Review Manager (V.5.2.0) to perform traditional pairwise meta-analysis. Dichotomous data will be expressed as relative risk (RR) with 95% confidence interval (CI), and continuous outcomes will be expressed as standard mean difference (SMD) with 95% CI. [28]

2.5.2 Network meta-analysis

To simultaneously assess the comparative effects of more than 2 psychotherapy, an NMA will be performed. An NMA synthesizes direct and indirect comparisons over an entire network of psychotherapy, allowing for all available evidence to be considered in one analysis. Based on the network development process as outlined above, the outcome variable for the NMA is the standardized mean change in the DSST (measured using Hedge's G) from baseline to end of study. The standardization is based on the pooled (across treatment arms within study) estimate of the SDs. The NMA will be carried out using a frequentist's approach, and a 2-way ANOVA model is used. As the residual variances between treatment groups are known, it is possible for random effect estimates to be produced, which account for the between-trial heterogeneity. The model is used to perform ordinary pairwise meta-analysis comparing the different psychotherapy based on direct evidence from the clinical studies. Ranking probabilities will be calculated based on the joint distribution of the estimates of relative efficacy. [29]

Consistency will be addressed through the principle of node splitting by using a network meta-regression model. The purpose of node-splitting is to investigate if the relative effect of 2 psychotherapy based on direct comparisons is comparable with the same effect based on indirect comparisons. Statistically, the model is an extension of the NMA, which allows for a different relative effect between the 2 psychotherapy that are being split in head-to-head trials compared with all other trials. NMA will be implemented by the mvmeta software package in Stata (15.0; Stata Corporation, College Station, TX, USA Stata), [30] If P value <.1 and I 2 > 50%, it is considered that there is heterogeneity in the study, and sensitivity analysis or subgroup analysis will be performed to detect the source of heterogeneity. Funnel plot and Egger linear regression analysis will be used to assess publication bias. Using Review Manager (V.5.2.0) to analyze the risk of bias in the included studies, where the green, yellow, and red in the image represent low, unclear, and high risks, respectively. [31,32]

2.5.3 Subgroup analysis

If statistical heterogeneity is evident, we will analyze the causes of heterogeneity, if there is enough data (such as differences between sexes, comparison between different countries, studies sponsored versus not sponsored by companies).

2.5.4 Sensitivity analysis

We will use the exclusion method to conduct sensitivity analysis:

• (1) exclude low-quality studies;
• (2) exclude studies with comorbid physical or mental illnesses;
• (3) exclude trials with missing data.

2.6 Quality of evidence

We will use Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to assess the quality of evidence for the primary outcomes. [33,34] The quality of evidence is assessed as ‘high’, ‘moderate’, ‘low’ or ‘very low’. The following item will be evaluated: limitations, inconsistency, imprecision, indirectness, and publication bias. [35]

2.7 Summary of findings

A “summary of finding” table will be created for the major outcome. We will also add absolute and relative percentage changes to the “summary of finding”. For detailed information, see Table 3 ; we have listed partial summary of findings for the main comparison.

3.1 Results of the search

A total of 6238 records were obtained by searching the database and 27 records were obtained by other means. After removing duplicate records, there are 4225 records remaining. We excluded 3945 records through abstract and title, leaving 280 full-text articles. The document screening flowchart is shown in Figure 1 .

3.2 Characteristic of included studies

In a preliminary trial, we included 8 studies. The average age of patients was 18 to 26, with a maximum sample size of 181 and a minimum sample size of 32. The research period ranges from one month to 12 months. For more detailed information, see Table 4 .

4 Discussion

At present, although some studies have evaluated the intervention effects of psychotherapy, there is no NMA to compare the therapeutic effects of different psychological interventions for college students. Therefore, this systematic review and NMA will summarize the direct comparison and indirect comparison evidence to evaluate different psychological interventions. We hope that this study will help guide clinical decision-making for psychotherapy to better treat depression in college students.

Author contributions

Conceptualization: Xiu Zhang, Lin Wan.

Data curation: Xiu Zhang, Ming-Ming Niu, Pei-Fen Ma, Li Du, Lin Wan.

Methodology: Xiu Zhang, Lin Wan.

Software: Xiu Zhang, Ming-Ming Niu, Pei-Fen Ma, Li Du.

Writing – original draft: Xiu Zhang, Ming-Ming Niu, Lin Wan.

Writing – review & editing: Xiu Zhang, Lin Wan.

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