Cognitive Behavioral Therapy (CBT) for Adult Depression

Scientific Rating:
1
Well-Supported by Research Evidence
See scale of 1-5
Child Welfare System Relevance Level:
Medium
See descriptions of 3 levels

About This Program

The information in this program outline is provided by the program representative and edited by the CEBC staff. Cognitive Behavioral Therapy (CBT) for Adult Depression has been rated by the CEBC in the area of: Depression Treatment (Adult).

Target Population: Adults (18 and over) diagnosed with a mood disorder, including Unipolar Major Depressive Disorder (MDD), Depressive Disorder Not Otherwise Specified, and minor depression.

Brief Description

CBT is a skills-based, present-focused, and goal-oriented treatment approach that targets the thinking styles and behavioral patterns that cause and maintain depression-like behavior and mood. Depression in adults is commonly associated with thinking styles that are unrealistically negative, self-focused and critical, and hopeless in nature. Ruminative thinking processes are also typical. Cognitive skills are used to identify the typical “thinking traps” (cognitive distortions) that clients commit and challenge them to consider the evidence more fairly. Depressed adults also demonstrate increased isolation, withdrawal, simultaneous rejection of others and sensitivity to rejection, and decreased activity and enjoyment in activities. They typically experience a number of functional impairments including disrupted sleep cycles, eating and appetite issues, and increased thoughts of death and dying. Behavioral interventions can often help these interpersonal and functional impairments. Behavioral interventions include problem solving, behavioral activation, and graded activation or exposure. Treatment is generally time-limited and can be conducted in individual or group formats.


Program Goals:

The goals of CBT are to help clients:

  • Distinguish between thoughts and feelings.
  • Become aware of how their thoughts influence feelings in ways that are not helpful.
  • Evaluate critically the veracity of their automatic thoughts and assumptions.
  • Develop the skills to notice, interrupt, and intervene at the level of automatic thoughts.
  • Use behavioral techniques to identify situations that trigger distress and sadness.
  • Use behavioral activation to become more attuned with meaningful reinforcement in their lives.
  • Develop active problem-solving skills.

Essential Components

The essential elements of Cognitive-Behavioral Therapy (CBT) include:

  • Based on an integrated cognitive-behavioral model that emphasizes the role of thinking patterns and learned behaviors in maintaining depression.
  • Present-focused, goal-oriented, and time-limited.
  • Focused on developing cognitive skills such as identifying and changing unrealistic, distorted thinking.
  • Focused on developing behavioral skills such as behavioral activation, scheduling of pleasant activities, problem solving, addressing depression-like interpersonal interaction styles, and developing social skills.
  • Cognitive-Behavioral Therapy for Adult Depression can be delivered in individual or group sessions. If done in a group, the size of the group varies based on the setting.

Adult Services

Cognitive Behavioral Therapy (CBT) for Adult Depression directly provides services to adults (regardless of whether they are parents or caregivers) and addresses the following:

  • Major Depressive Disorder (MDD)
  • Depressive Disorder Not Otherwise Specified
  • Minor Depression
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: Some programs involve family members, others may not.

Delivery Settings

This program is typically conducted in a(n):

  • Community Agency
  • Hospital
  • Outpatient Clinic

Homework

Cognitive Behavioral Therapy (CBT) for Adult Depression includes a homework component:

Adult clients are assigned homework based on session material. This can include tracking depression-like thoughts and behavior patterns, practice in challenging negative thoughts as they arise, or graded behavioral activation exercises.

Languages

Cognitive Behavioral Therapy (CBT) for Adult Depression has materials available in a language other than English:

Spanish

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

Private room where therapy can occur.

Minimum Provider Qualifications

Master’s degree in a mental health, medical, or allied health profession.

Education and Training Resources

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contact:
  • David Teisler, CAE, Director of Communications
    Association for Behavioral and Cognitive Therapies
    www.abct.org

    phone: (212) 647-1890
Training is obtained:

The website for ABCT (www.abct.org) provides a number of resources to help clinicians obtain training locally or at a distance, including:

  • Disorder fact sheets
  • Recommendations for specific treatments for specific disorders
  • Videos and podcasts of experts in the field providing introductory and master workshops on specific treatments 
  • A listing of ABCT-approved Self Help guides to recommend to clients
  • “Find a Therapist” searchable database to find experts for training, consultation, or referrals
Number of days/hours:

Depends on the training venue

Implementation Information

Since Cognitive Behavioral Therapy (CBT) for Adult Depression is rated on the Scientific Rating Scale, information was requested from the program representative on available pre-implementation assessments, implementation tools, and/or fidelity measures.

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Pre-Implementation Materials

The program representative did not provide information about pre-implementation materials.

Formal Support for Implementation

The program representative did not provide information about formal support for implementation of Cognitive Behavioral Therapy (CBT) for Adult Depression.

Fidelity Measures

The program representative did not provide information about fidelity measures of Cognitive Behavioral Therapy (CBT) for Adult Depression.

Implementation Guides or Manuals

The program representative did not provide information about implementation guides or manuals for Cognitive Behavioral Therapy (CBT) for Adult Depression.

Research on How to Implement the Program

The program representative did not provide information about research conducted on how to implement Cognitive Behavioral Therapy (CBT) for Adult Depression.

Relevant Published, Peer-Reviewed Research

This program is rated a "1 - Well-Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The program must have at least two rigorous randomized controlled trials with one showing a sustained effect of at least 1 year. The article(s) below that reports outcomes from an RCT showing a sustained effect of at least 1 year has an asterisk (*) at the beginning of its entry. Please see the Scientific Rating Scale for more information.

Child Welfare Outcome: Child/Family Well-Being

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Several meta-analyses have been conducted on Cognitive Behavior Therapy (CBT) for Adult Depression:

  • Butler, A. C., Chapman, J. E., Forman, E. M. & Beck A. T., (2005). The emperical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26. 17-31.
  • Cuijpers, P., van Straten, A., & Warmerdam, L. (2007). Behavioral activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27, 318-326.
  • Cuijpers, P., van Straten, A., Andersson, G. & van Oppen, P. (2008). Psychotherapy for depression in adults: A meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology, 76, 909-922.
  • Ekers, D., Richards, D., & Gilbody, S. (2008). A meta-analysis of randomized trials of behavioural treatment of depression. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 38, 611-623.
  • Cristea, I. A., Huibers, M. J., David, D., Hollon, S. D., Andersson, G., & Cuijpers, P. (2015). The effects of cognitive behavior therapy for adult depression on dysfunctional thinking: A meta-analysis. Clinical Psychology Review, 42, 62-71.

Numerous research studies have been conducted of CBT. The 5 studies described in the section below are a selection of those most relevant to the topic area. For a complete listing of studies, please refer to:

  • Hollon, S. D., Stewart, M. O., & Strunk, D. (2006). Enduring effects for cognitive behavior therapy in the treatment of depression and anxiety. Annual Review of Psychology, 57, 285-315.
  • Wilson, P. H. (1989). Cognitive-behavior therapy. Behavior Change, 6(2), 85-95.

Elkin, I., Shea, T. M., Watkins, J. T., Imber, S. D., Sotsky, S M., Collins, J. F., ... Parloff, M. B. (1989). National Institute of Mental Health treatment of depression collaborative research program. Archive of General Psychiatry, 46, 971-982.

Type of Study: Randomized controlled trial
Number of Participants: 250

Population:

  • Age — Mean=35 years
  • Race/Ethnicity — 89% Caucasian
  • Gender — 70% Female
  • Status — Participants were adults with major depressive disorder.

Location/Institution: University of Pittsburgh (PA), George Washington University (Washington, DC) and the University of Oklahoma, (Oklahoma City)

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study investigated the effectiveness of Cognitive-Behavioral Therapy and Interpersonal Psychotherapy for the treatment of outpatients with major depressive disorder. Measures utilized were the Schedule for Affective Disorders and Schizophrenia Interview, the Hamilton Rating Scale for Depression and the Collaborative Study Psychotherapy Rating Scale. Patients in all treatments showed significant reduction in depressive symptoms and improvement in functioning over the course of treatment. Patients were referred from psychiatric outpatient services at each research site, self-referrals, and other mental health facilities Limitations include generalizablity due to gender and ethnicity.

Length of postintervention follow-up: Not specified.

Shapiro, D. A., Barkham, M., Rees, A., Gillian, H. E., Reynolds, S., & Startup, M. (1994). Effects of treatment duration and severityh of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy. Journal of Counseling and Clinical Psychology 62(3), 522-534.

Type of Study: Randomized controlled trial
Number of Participants: 117

Population:

  • Age — Mean=40 years
  • Race/Ethnicity — “Predominately White Anglo-Saxon"
  • Gender — 52% Female
  • Status — Participants were adults with depression.

Location/Institution: Sheffield, United Kingdom

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study compared Cognitive-Behavioral Therapy (CBT) and psychodynamic-interpersonal therapy on clients presenting with mild, moderate and severe depression. Forty clients in each of three ranges of depression severity were assigned at random to 8 or 16 weekly sessions of CBT or psychodynamic-interpersonal psychotherapy (PI). Measures utilized were the Beck Depression Inventory, the Present State Examination, and the Diagnostic Interview Schedule. Only on the BDI was there a significant treatment effect between CBT and PI. There was also clear evidence that the 16-session treatment was more effective than 8-session treatment for individuals with severe depression. Limitations include generalizablity due to ethnicity as well as to treatment in regards to range of depression severity, as well as therapist bias.

Length of postintervention follow-up: 3 months.

DeRubeis, R. J., Gelfand, L. A., Tang, T. Z., & Simons, A. D. (1999). Medications versus cognitive behavior therapy for severely depressed outpatients: Mega-analysis of four randomized comparisons. American Journal of Psychiatry, 156, 1007-1013.

Type of Study: Mega-analysis
Number of Participants: Not specified

Population:

  • Age — Not specified
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were adults with severe depression.

Location/Institution: University of Pennsylvania

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study compared the acute outcomes of antidepressant medication and Cognitive-Behavioral Therapy (CBT) in the severely depressed outpatient subgroups of four major randomized trials. Measures included the Hamilton Depression Scale and the Beck Depression Inventory. A secondary objective was to compare the results obtained in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Outcomes of antidepressant medication and CBT were compared; measures included the Hamilton Rating Scale for Depression and the Beck Depression Inventory. Comparing antidepressant medication to CBT favored CBT, but tests comparing the two modalities did not reveal a significant advantage for either modality overall. Limitations include the differences between the four studies examined.

Length of postintervention follow-up: Not specified.

*Blatt, S. J., Zuroff, D. C., Bondi, C.M., & Sanislow, C. A., (2000). Short and long-term effects of medication and psychotherapy in the brief treatment of depression: Further analyses of data from the NIMH TDCRP. Society for Psychotherapy Research, 10(2), 215-234.

Type of Study: Randomized controlled trial
Number of Participants: 239; 162 completed treatment

Population:

  • Age — Mean=35 years
  • Race/Ethnicity — Not specified
  • Gender — 70% Female
  • Status — Participants were adults who were severely depressed.

Location/Institution: Not specified

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study uses a subset of the sample from Elkin et al., 1989. This study analyses data from the NIMH-sponsored Treatment for Depression Collaborative Research Program (TDCRP) which examined depression treatment with Impramine, Cognitive-Behavioral Therapy (CBT), or Interpersonal Therapy (IPT). Measures utilized were the Social Adjustment Scale, Schedule for Affective Disorders and Schizophrenia-Change Version (SADS-C), the Hamilton Rating Scale for Depression, Global Adjustment Scale, the Hopkins Symptom Checklist, and the Beck Depression Inventory. There were no significant differences between the three treatments at the end of the study. Significant treatment differences emerged, however, at the 18-month follow-up time point. Patients in the IPT group reported greater satisfaction with treatment, and patients in both the IPT and CBT groups reported significantly greater effects of treatment on their capacity to establish and maintain interpersonal relationships and to recognize and understand sources of their depression.

Length of postintervention follow-up: 18 months.

Westbrook, D., & Kirk, J. (2005). The clinical effectiveness of Cognitive Behavior Therapy: Outcomes for a large sample of adults treated in routine practice. Behavior Research and Therapy, 43, 1243-1261.

Type of Study: Case series (uncontrolled longitudinal pre-post-test study)
Number of Participants: 1276

Population:

  • Age — 18-65 years
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were adults with depression.

Location/Institution: Oxford Adult Mental Health Psychology Department

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study is a meta-analysis compared outcome data from a clinical setting with similar date from research studies to see the effectiveness of each approach. This study also analyses outcome data to determine the improvement and deterioration rates of the participants in the studies in regards to cognitive behavioral therapy in routine clinical practice. Measures utilized were the Beck Depression Inventory and the Beck Anxiety Inventory. Results provide evidence that Cognitive-Behavioral Therapy (CBT) can be effective in ordinary clinical settings as well as in research trials. Limitations include lack of control group, measures which are subject to significant rates of missing data, possible therapist bias, and uncertainties about the exact nature of the therapy delivered and possible effects of pharmacotherapy.

Length of postintervention follow-up: None.

Vittengl, J. R., Jarrett, R. B., Weitz, E., Hollon, S. D., Twisk, J., Cristea, I., ... & Faramarzi, M. (2016). Divergent outcomes in Cognitive-Behavioral Therapy and pharmacotherapy for adult depression. American Journal of Psychiatry, 173(5), 481-490. doi:10.1176/appi.ajp.2015.15040492

Type of Study: Randomized controlled trial
Number of Participants: 1,700

Population:

  • Age — Mean=37.38 years
  • Race/Ethnicity — Not specified
  • Gender — 69.4% Female
  • Status — Participants were adults with depression.

Location/Institution: Not specified

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study is evaluated sixteen randomized clinical trials comparing Cognitive-Behavioral Therapy (CBT) for Adult Depression and pharmacotherapy for unipolar depression. Measures utilized include the Hamilton Depression Rating Scale (HAM-D) and the Beck Depression Inventory (BDI). Results at posttreatment indicated treatment with pharmacotherapy versus CBT increased patients’ odds of superior improvement from the clinician’s perspective. Also at posttreatment, deterioration and extreme nonresponse and, similarly, superior improvement and superior response, both occur infrequently in randomized clinical trials comparing CBT and pharmacotherapy for depression. Pretreatment symptom levels help forecast both negative and unusually positive outcomes but do not guide selection of CBT versus pharmacotherapy. Limitations include may not generalize fully to routine clinical practice; analyses focused on trials of CBT versus pharmacotherapy and do not address combinations, sequences, dissemination, or the quality of implementation of treatments; and lack of follow-up

Length of postintervention follow-up: None.

References

Barlow, D. H. (2007). Clinical handbook of psychological disorders (4th ed). New York: Guilford.

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

Leahy, R. L. & Holland, S. J. (2000). Treatment plans and interventions for depression and anxiety disorders. New York, NY: Guilford.

Contact Information

Name: David Teisler, CAE
Title: Director of Communications
Agency/Affiliation: Association for Behavioral and Cognitive Therapies
Website: www.abct.org/Information/?m=mInformation&fa=_WhatIsCBTpublic
Email:
Phone: (212) 647-1890

Date Research Evidence Last Reviewed by CEBC: June 2016

Date Program Content Last Reviewed by Program Staff: July 2014

Date Program Originally Loaded onto CEBC: September 2012