Using CBT effectively for treating depression and anxiety

Fewer than 20% of people seeking help for depression and anxiety disorders receive cognitive-behavioral therapy (CBT), the most established evidence-based psychother­apeutic treatment.¹ 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
• Internet-based CBT and telemedicine (telephone and video conferencing)²
• mobile phone applications that use text messaging, social support, and physiological monitoring as adjuncts to clinical practice or stand-alone interventions.⁴

New models of CBT also are emerging, including transdi­agnostic CBT and metacognitive approaches (mindfulness-based cognitive therapy and acceptance and commitment therapy), and several new foci for exposure therapy.

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 (Box⁵ ). We review the evidence of CBT’s efficacy for acute-phase treatment and relapse pre­vention; explain the common elements considered essential to CBT practice; describe CBT adaptations for specific anxiety disorders; and provide an overview of recent advances in conceptual­izing and adapting CBT.

Efficacy for mood and anxiety disorders
Depression. Dozens of randomized con­trolled trials (RCT) and other studies support CBT’s efficacy in treating major depressive disorder (MDD). For acute treatment:
• CBT is more effective in producing remission when compared with no treat­ment, treatment as usual, or nonspecific psychotherapy.
• For mild to moderate depression, CBT is equivalent to antidepressant medi­cation in terms of response and remission rates.
• Combining antidepressant therapy with CBT increases treatment adherence.⁶

Less well known may be that a success­ful response to CBT in the acute phase may have a protective effect against depression recurrences. A 2013 meta-analysis that totaled 506 individuals with depressive disorders found a trend toward signifi­cantly lower relapse rates when CBT was discontinued after acute therapy, com­pared with antidepressant therapy that continued beyond the acute phase.⁷

Anxiety. Among psychotherapies, CBT’s superior efficacy for anxiety disorders is well-established. CBT and its specific-disorder adaptations are considered first-line treatment.⁸

CBT’s essential elements
CBT focuses on distorted cognitions about the self, the world, and the future, and on behaviors that lead to or maintain symptoms.

Cognitive interventions seek to identify thoughts and beliefs that trigger emotional and behavioral reactions. A person with social anxiety disorder, for example, might believe that people will notice if he makes even a minor social mistake and then reject him, which will make him feel worthless. CBT can help him subject these beliefs to rational analysis and develop more adap­tive beliefs, such as: “It is not certain that I will behave so badly that people would notice, but if that happened, the likeli­hood of being outright rejected is probably low. If—in the worst-case scenario—I was rejected, I am not worthless; I’m just a fal­lible human being.”

CBT’s behavioral component can be con­ceptualized as behavioral activation (BA), a structured approach to help the patient:
• increase behaviors and experiences that are rewarding
• overcome barriers to engaging in these new behaviors
• and decrease behaviors that maintain symptoms.

BA can be a useful intervention for indi­viduals with depression characterized by lack of engagement or capacity for pleasurable experiences. During pregnancy and the postpartum period, for example, a woman undergoes physical, social, and environmental changes that might gradu­ally deprive her of sources of pleasure and other reinforcing activities. BA would focus on developing creative solutions to regain access to or create new opportuni­ties for rewarding experiences and to avoid behaviors (such as social withdrawal or physical activity restriction) that perpetuate depressed mood.

Common elements. Cognitive and behav­ioral interventions focus on problem solv­ing, individualized case conceptualization (Figure 1), and collaborative empiricism.⁹

Individualized case conceptualization lays the foundation for the course of CBT, and may be thought of as a map for therapy. Case conceptualization brings in several domains of assessment including symp­toms and diagnosis, the patient’s strengths, formative experiences (including biopsy­chosocial aspects), contextual factors, and cognitive factors that influence diagnosis and treatment, such as automatic thoughts or schemas. The case formulation leads to a working hypothesis about the optimal course and focus of CBT.

Collaborative empiricism is the way in which the patient and therapist work together to continually refine this work­ing hypothesis. The pair works together to investigate the hypotheses and all aspects of the therapeutic relationship.