Using CBT effectively for treating depression and anxiety Modify the elements of CBT to address specific anxiety disorders, patient factors ewer than 20% of people seeking help for depression and anxiety disorders receive cognitive-behavioral therapy (CBT), the most established evidence-based psychother- F 1 apeutic treatment. Efforts are being made to increase access to CBT,2 but a substantial barrier remains: therapist training is a strong predictor of treatment outcome, and many therapists offering CBT services are not sufficiently trained to deliver multiple manual-based interventions with adequate fidelity to the model. Proposed solutions to this barrier include: • abbreviated versions of CBT training for practitioners in primary care and community settings • culturally adapted CBT training for community health workers3 © 2010 PHOTOS.COM • Internet-based CBT and telemedicine (telephone and video conferencing)2 Heather A. Flynn, PhD • mobile phone applications that use text messaging, Associate Professor and Vice Chair for Research Department of Behavioral Sciences and Social Medicine social support, and physiological monitoring as adjuncts Florida State University College of Medicine to clinical practice or stand-alone interventions.4 Tallahassee, Florida New models of CBT also are emerging, including transdi- Ricks Warren, PhD, ABPP agnostic CBT and metacognitive approaches (mindfulness- Clinical Assistant Professor based cognitive therapy and acceptance and commitment University of Michigan Medical School Department of Psychiatry therapy), and several new foci for exposure therapy. Ann Arbor, Michigan In light of these ongoing modulations, this article is intended to help clinicians make informed decisions about CBT when selecting treatment for patients with depressive and anxiety disorders (Box,5 page 46). We review the evidence of CBT’s efficacy for acute-phase treatment and relapse pre- vention; explain the common elements considered essential to Disclosures The authors report no financial relationships with any company whose products are Current Psychiatry mentioned in this article or with manufacturers of competing products. Vol. 13, No. 6 45 Box Less well known may be that a success- ful response to CBT in the acute phase may How does CBT work, and have a protective effect against depression for whom? recurrences. A 2013 meta-analysis that ven though cognitive-behavioral therapy totaled 506 individuals with depressive E(CBT) is supported by an impressive disorders found a trend toward signifi- evidence base and is recommended as cantly lower relapse rates when CBT was Cognitive-behavioral first-line treatment for depression and anxiety discontinued after acute therapy, com- disorders, unaddressed clinical questions therapy remain: pared with antidepr essant therapy that • How does CBT work (mechanisms)? continued beyond the acute phase.7 • For whom does CBT work (particular patients with particular characteristics)? Because CBT encompasses diverse Anxiety. Among psychotherapies, CBT’s approaches and techniques, little information superior efficacy for anxiety disorders exists about the “key ingredients” of CBT that is well-established. CBT and its specific- lead to improved clinical outcomes. Individual factors that affect response to CBT have not disorder adaptations are considered first- been well studied or elucidated. Depression line treatment.8 Clinical Point severity, for example, may be an important moderator of depression treatment outcome; For mild to moderate behavioral activation has been found in recent studies to be particularly useful for more CBT’s essential elements depression, CBT severely depressed outpatients.5 Recent CBT focuses on distorted cognitions is equivalent to CBT adaptations, including metacognitive about the self, the world, and the future, approaches, have not been rigorously antidepressant compared with traditional CBT or to other and on behaviors that lead to or maintain medication in terms psychotherapeutic approaches. symptoms. For any treatment, identifying patient of response and variables and characteristics that moderate response is key to matching individuals Cognitive interventions seek to identify remission rates with effective therapies. Therefore, research thoughts and beliefs that trigger emotional on CBT’s mechanisms and moderators is and behavioral reactions. A person with essential for efficient targeting of treatment social anxiety disorder, for example, might options and to improve CBT’s efficacy overall. believe that people will notice if he makes even a minor social mistake and then reject him, which will make him feel worthless. CBT practice; describe CBT adaptations for CBT can help him subject these beliefs to specific anxiety disorders; and provide an rational analysis and develop more adap- overview of recent advances in conceptual- tive beliefs, such as: “It is not certain that izing and adapting CBT. I will behave so badly that people would notice, but if that happened, the likeli- hood of being outright rejected is probably Efficacy for mood and anxiety low. If—in the worst-case scenario—I was disorders rejected, I am not worthless; I’m just a fal- Depression. Dozens of randomized con- lible human being.” trolled trials (RCT) and other studies support CBT’s efficacy in treating major depressive CBT’s behavioral component can be con- disorder (MDD). For acute treatment: ceptualized as behavioral activation (BA), • CBT is more effective in producing a structured approach to help the patient: remission when compared with no treat- • increase behaviors and experiences that Discuss this article at ment, treatment as usual, or nonspecific are rewarding www.facebook.com/ psychotherapy. • overcome barriers to engaging in these CurrentPsychiatry • For mild to moderate depression, new behaviors CBT is equivalent to antidepressant medi- • and decrease behaviors that maintain cation in terms of response and remission symptoms. rates. BA can be a useful intervention for indi- • Combining antidepressant therapy viduals with depression characterized by Current Psychiatry 46 June 2014 with CBT increases treatment adherence.6 lack of engagement or capacity for plea- Figure 1 Sample collaborative case conceptualization worksheet Actions Events Spending more time alone Changing jobs Exercising less Financial stress Missing work Mood Feeling stressed, sad, down, or overwhelmed Thoughts Communication Worrying more than usual with others Thinking that you are a Conflict with your partner disappointment or failure Losing touch with friends Physical reactions Clinical Point Feeling tense or exhausted Headaches A mood activity log Not getting enough sleep can illuminate links Using a graphical representation, such as this example, can be useful in developing an individual between moods and case conceptualization collaboratively with the patient. The therapist and patient develop the content activities and can be for each of the boxes together. This exercise serves as a way to collaboratively assess different influence on mood and to teach the patient about domains of influences on their mood and how useful with targeting they might change these influences. interventions surable experiences. During pregnancy and treatment, such as automatic thoughts and the postpartum period, for example, or schemas. The case formulation leads to a woman undergoes physical, social, and a working hypothesis about the optimal environmental changes that might gradu- course and focus of CBT. ally deprive her of sources of pleasure Collaborative empiricism is the way and other reinforcing activities. BA would in which the patient and therapist work focus on developing creative solutions to together to continually refine this work- regain access to or create new opportuni- ing hypothesis. The pair works together to ties for rewarding experiences and to avoid investigate the hypotheses and all aspects behaviors (such as social withdrawal or of the therapeutic relationship. physical activity restriction) that perpetuate Although no specific technique defines depressed mood. CBT, a common practice is to educate a person about interrelationships between Common elements. Cognitive and behav- behaviors/activities, thoughts, and mood. ioral interventions focus on problem solv- A mood activity log (Figure 2, page 51) ing, individualized case conceptualization can illuminate links between moods and (Figure 1), and collaborative empiricism.9 activities and be useful with targeting Individualized case conceptualization interventions. For a person with social lays the foundation for the course of CBT, anxiety, for example, a mood activity log and may be thought of as a map for therapy. could assist in developing a hierarchy of Case conceptualization brings in several feared social situations and avoidance domains of assessment including symp- intensity. Systematic exposure therapy toms and diagnosis, the patient’s strengths, would follow, beginning with the least formative experiences (including biopsy- frightening/intense situation, accompa- chosocial aspects), contextual factors, and nied by teaching new coping skills (such as Current Psychiatry cognitive factors that influence diagnosis relaxation strategies). Vol. 13, No. 6 47 continued on page 50 continued from page 47 CBT adaptations for anxiety Motivational interviewing (MI) appears disorders to be a useful adjunct to precede traditional Elements of CBT have been adapted for a CBT, particularly for severe worriers.17 MI variety of anxiety disorders,