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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
F(CBT), the most established evidence-based psychother-
1
apeutic treatment. Efforts are being made to increase access
2
to CBT, 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
3
workers © 2010 PHOTOS.COM
• Internet-based CBT and telemedicine (telephone and
2 Heather A. Flynn, PhD
video conferencing)
• mobile phone applications that use text messaging, Associate Professor and Vice Chair for Research
social support, and physiological monitoring as adjuncts Department of Behavioral Sciences and Social Medicine
Florida State University College of Medicine
4
to clinical practice or stand-alone interventions. 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
therapy), and several new foci for exposure therapy. Department of Psychiatry
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 ( 5
Box, 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-
How does CBT work, and ful response to CBT in the acute phase may
for whom? have a protective effect against depression
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-
therapy disorders, unaddressed clinical questions pared with antidepr essant therapy that
remain:
• How does CBT work (mechanisms)? 7
continued beyond the acute phase.
• For whom does CBT work (particular
patients with particular characteristics)? Anxiety. Among psychotherapies, CBT’s
Because CBT encompasses diverse
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 disorder adaptations are considered first-
factors that affect response to CBT have not
been well studied or elucidated. Depression line treatment.8
Clinical Point severity, for example, may be an important
For mild to moderate moderator of depression treatment outcome;
behavioral activation has been found in recent CBT’s essential elements
depression, CBT studies to be particularly useful for more
5
severely depressed outpatients. Recent CBT focuses on distorted cognitions
is equivalent to CBT adaptations, including metacognitive about the self, the world, and the future,
antidepressant approaches, have not been rigorously and on behaviors that lead to or maintain
compared with traditional CBT or to other
medication in terms psychotherapeutic approaches. symptoms.
of response and For any treatment, identifying patient
variables and characteristics that moderate Cognitive interventions seek to identify
remission rates response is key to matching individuals thoughts and beliefs that trigger emotional
with effective therapies. Therefore, research
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-
Current Psychiatry • Combining antidepressant therapy viduals with depression characterized by
June 2014 6 lack of engagement or capacity for plea-
46 with CBT increases treatment adherence.
Figure 1
Sample collaborative case conceptualization worksheet
Events Actions
Changing jobs Spending more time alone
Financial stress Exercising less
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
( 9 activities and be useful with targeting
Figure 1), and collaborative empiricism.
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
17
Elements of CBT have been adapted for a CBT, particularly for severe worriers. MI
variety of anxiety disorders, based on specific attempts to help individuals with GAD rec-
symptoms and features ( 10-15 ognize their ambivalence about giving up
Table, page 52).
worry. This technique acknowledges and
Panic disorder. Panic control treatment validates perceived benefits of worry (eg, “It
Cognitive-behavioral is considered the first-line intervention helps me prepare for the worst, so I won’t be
therapy for panic disorder’s defining features: emotionally devastated if it happens”), but
spontaneous panic attacks, worry about also explores how worry is destructive.
future occurrence of attacks, and perceived
catastrophic consequences (such as heart
attack, fainting).10
This CBT adaptation Emerging CBT models for anxiety
includes: disorders
• patient education about the nature of Metacognitive treatment. Evidence, such
panic as presented by Dobson,18 suggests that
Clinical Point • breathing retraining to foster exposure the field of CBT is shifting towards a meta-
Motivational to feared bodily sensations and avoided cognitive model of change and treatment.
interviewing activities and places A metacognitive approach goes beyond
• cognitive restructuring of danger- changing thinking and emphasizes thoughts
appears to be a related thoughts (such as “I’m going about thoughts and experiences. Examples
useful adjunct to to faint,” or “It would be catastrophic if include mindfulness-based cognitive ther-
precede traditional I did”). apy (MBCT) and acceptance and commit-
CBT, particularly for ment therapy (ACT).
severe worriers Obsessive-compulsive disorder. Exposure MBCT typically consists of an 8-week
and response prevention (ERP) is the first- program of 2-hour sessions each week and
line treatment for obsessive-compulsive 1 full-day retreat. MBCT is modeled after
disorder (OCD).11 In traditional therapist- Kabat-Zinn’s widely disseminated and
guided ERP, patients expose themselves to empirically supported mindfulness based
perceived contaminants while refraining stress reduction course.19
MBCT was devel-
from inappropriate compulsive behaviors oped as a relapse prevention program for
(such as hand washing). patients who had recovered from depres-
Cognitive interventions also can be an sion. Unlike traditional cognitive therapy for
effective treatment of obsessions, with- depression that targets changing the content
out patients having to engage in exposure of automatic thoughts and core beliefs, in
16
to their horrific thoughts and images. MBCT patients are aware of negative auto-
Consider, for example, a new mother who matic thoughts and find ways to change
upon seeing the kitchen knife has the their relationship with these thoughts, learn-
intrusive thought, “What if I stabbed my ing that thoughts are not facts. This process
baby?” Instead of the traditional exposure mainly is carried out by practicing mind-
approach for OCD (ie, having her vividly fulness meditation exercises. Importantly,
imagine stabbing her baby until her anxiety MBCT goes beyond mindful acceptance of
level subsided), the cognitive intervention negative thoughts and teaches patients mind-
would be to educate her about the nor- ful acceptance of all internal experiences.
malcy of intrusive thoughts, particularly in A fundamental difference between
the postpartum period. ACT and traditional CBT is the approach
20
to cognitions. Although CBT focuses
Generalized anxiety disorder. CBT for on changing the content of maladaptive
generalized anxiety disorder (GAD) targets thoughts, such as “I am a worthless per-
patients’ overestimation of the likelihood son,” ACT focuses on changing the function
of negative events and the belief that these of thoughts. ACT strives to help patients to
Current Psychiatry events, should they occur, would be cata- accept their internal experiences—whether
12
50 June 2014 strophic and render them unable to cope. unwanted thoughts, feelings, bodily sen-
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