Which Components of CBT Actually Drive Outcomes?

“Cognitive behavioral therapy for X” is the backbone of many mental health startups and digital therapeutics, yet it’s unclear which individual components of CBT actually drive outcomes.

A recent study in JAMA Psychiatry attempted to tackle that question, randomizing 767 adults with depression into cohorts that received some, but not all, of the seven individual components of internet-delivered CBT.

  • Those include: activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, absorption training, and self-compassion training

While internet-delivered CBT resulted in reduced depression at six months (mean follow-up difference in PHQ-9 score: -8.63), the researchers were surprised to find that none of the factors appeared to drive an impact independent of the others.

  • The one exception? Absorption training.

The absorption training module taught individuals to become immersed in what they are doing in the present moment to “improve their direct connection with experience and enhance contact with positive reinforcers.”

  • Patients completed a behavioral experiment where they compared memories of being absorbed versus not absorbed in a task, learned about flow states, and identified activities that make them feel absorbed. 
  • Although statistically significant, the effect of adding this module was still only one-fifth of a PHQ-9 point.

The Takeaway

At least within this study, none of the components of CBT – with the exception of absorption training – significantly reduced depression symptoms relative to their absence, despite an overall average reduction in symptoms. The findings suggest that treatment benefit from CBT probably accrues from factors common to all CBT components (e.g. structure, making active plans), and non-specific therapy factors (e.g. positive expectancy).

Online CBT Improves Depression Symptoms

Amid a recent flurry of reports calling into question the effectiveness of virtual cognitive behavioral therapy, a new study published in JAMA Network Open found that computer-assisted CBT (CCBT) does in fact improve depressive symptoms in primary care patients.

  • Methodology – The study included 175 adult primary care patients at the University of Louisville who had scored 10 or higher on the Patient Health Questionnaire-9 (27 point scale), indicating at least a moderate case of clinical depression. Nearly 62% of participants made less than $30k/year, while 74% did not graduate from college.
  • Interventions – Participants were randomly assigned to CCBT or treatment-as-usual groups (TAU) for 12 weeks of active treatment, as well as 3- and 6-month follow ups. CCBT included 9 online CBT lessons and weekly 20-minute teletherapy visits, in addition to TAU, which included in-office treatment at the primary care practices. 
  • Results – CCBT led to significantly greater improvement in PHQ-9 scores than TAU (mean difference: -2.5), with the positive results maintained at 3-month (-2.3) and 6-month follow-ups (-3.2). CCBT remission rates were more than double TAU at all time points.

Conclusions and Relevance

This study was particularly interesting because of the treatment’s sustained results and because its participants largely came from groups that are often underrepresented in CCBT research. Although the study had some limitations (treatment-as-usual as a control can’t compare CCBT to regular CBT), the results suggest that CCBT has the potential to be particularly valuable for patients in diverse primary care settings.

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