Cognitive Behavioral Therapy For Depression



Cognitive-behavioral therapy (CBT) is a term that encompasses numerous specific treatment approaches for various psychiatric disorders. As the name suggests, cognitive-behavioral treatments incorporate both cognitive and behavioral strategies. With regard to depression, CBT refers to the use of both cognitive restructuring and the behavioral strategy of activity scheduling or behavioral activation.

Cognitive-behavioral approaches to the treatment of depression stem from early behavioral treatments that emerged in the 1960s and 1970s. Among the most prominent was Lewinsohn et al’s behavioral treatment for depression. [1Lewinsohn proposed that depression resulted from deficient response contingent positive reinforcement, which he reported was a function of the following 3 factors: [2]

  • Individual differences in what is experienced as reinforcing

  • The availability in the individual’s environment of potentially reinforcing events

  • The skill level needed to obtain reinforcement

For example, if someone found conversing with others to be reinforcing, had other individuals available with whom to converse, and possessed the social skills needed to engage one of those individuals in conversation, then he or she could experience positive reinforcement. Lewinsohn’s treatment, therefore, aimed to increase depressed individuals’ ability to obtain response-contingent positive reinforcement and therefore improve their mood; he did this by having them identify and engage in events they described as having been, or potentially being, pleasurable and addressing skills deficits that may preclude them from obtaining the desired reinforcement from identified pleasant events. Numerous depression treatments that included activity scheduling emerged during the 1970s and 1980s. [34156]

Although early versions of activity scheduling primarily focused on increasing mood-related pleasant events, Beck incorporated a form of activity scheduling into his cognitive therapy for depression, aimed at increasing both pleasant events and providing a sense of accomplishment or mastery (eg, working on a resume, completing a school assignment). [7Following a component analysis of cognitive therapy that found this activity scheduling component to be as effective as the full treatment package, [8interest in behavioral treatments for depression increased, leading to modern approaches called behavioral activation (BA) treatments.

Modern BA approaches are based on the same principles as early versions of activity scheduling but incorporate more sophisticated strategies for identifying activity assignments and addressing barriers to their completion. [910Several meta-analyses have examined studies of activity scheduling and BA approaches over the past several decades and have provided substantial empirical support for these approaches. [111213]

During the 1970s, cognitive treatments for depression began to gain in popularity and empirical support, with the most well-known being Beck et al’s cognitive therapy for depression. [7Cognitive therapy is based on the fundamental assumptions that (1) cognitive activity affects behavior, (2) cognitive activity can be monitored and changed, and (3) cognitive changes can lead to desired behavioral changes. [14Cognitive therapy emphasizes the need to change cognitions in order to achieve improvements in mood and behavior. As mentioned above, Beck’s cognitive therapy for depression includes activity scheduling treatment strategies adapted from earlier behavioral interventions but also includes cognitive strategies such as cognitive restructuring that were designed to directly challenge and change maladaptive thoughts.

Although behavioral approaches typically do not include any direct attempts to change cognitions (but attempt to indirectly do so through changes in behavior), cognitive therapy does directly attempt to change behavior but does so for the ultimate goal of changing cognitions in order to reduce depressive symptoms. Therefore, at times, such approaches may be called either cognitive therapy or CBT, with both incorporating behavioral and cognitive interventions.

Within the CBT model, individuals with depression are viewed as exhibiting the “cognitive triad” of depression, which includes a negative view of themselves, a negative view of their environment, and a negative view of their future. [15Related to the cognitive triad, depressed patients are believed to exhibit numerous cognitive distortions that maintain these negative beliefs. [7Examples of these distortions include all-or-nothing thinking (ie, viewing things in black and white categories), overgeneralization (ie, assuming one negative event constitutes a pattern of never-ending negative events), and fortune telling (ie, making negative predictions about the future that are often inaccurate or negatively biased). [16Within Beck’s model, negative automatic thoughts and distortions in thinking are hypothesized as stemming from problematic schemas, which are cognitive structures that influence how information is interpreted and recalled. [177Schemas are often targeted in the later phases of treatment, whereas behavioral strategies and efforts to elicit and test automatic thoughts are implemented earlier in treatment. [15Elaboration of specific treatment strategies is presented below.

Because CBT for depression is a broad category that includes numerous treatment strategies, different aspects of treatment may be emphasized to a greater or lesser extent in practice. In general, however, CBT for depression includes specific behavioral strategies (ie, activity scheduling) as well as cognitive restructuring aimed at changing negative automatic thoughts.

CBT for depression has been examined in numerous clinical trials and has received empirical support across various settings and populations. [18192021]

Beck’s cognitive therapy for depression has been listed as a well-established treatment by the American Psychological Association’s Task Force on Promotion and Dissemination of Psychological Procedures since its inception in 1993. Several meta-analyses have demonstrated the effectiveness of CBT for depression. [22232425]


Individual and group-based CBT is recognized in the most recent American Psychiatric Association Guidelines for The Treatment of Major Depressive Disorder as an effective and evidence based treatment for depression. [26When used, it should be integrated into the overall care that the patient is receiving (ie, communication is needed between the treating therapist and the prescribing psychiatrist or primary care physician).

The use of CBT for a particular patient is often based on patient preference, severity of depression, and ability of the patient to gain access to the treatment. The use of CBT as a stand-alone treatment is recommended for patients with mild-to-moderate major depressive disorder and should also be considered for women who are pregnant, wish to become pregnant, or are actively breast-feeding. It should also be made available for patients that express a preference to use CBT.

A combination of antidepressant medication and psychotherapy such as CBT is recommended for individuals with moderate-to-severe major depressive disorder or for teens with major depressive disorder [27in order to reduce the risk of relapse. [2628According to the American Psychiatric Association guidelines, CBT combined with pharmacotherapy is also considered first-line treatment in patients with more severe, chronic, or complex presentations of depression. [26]


CBT has been used clinically in almost every imaginable patient population. No evidence-based exclusion criteria for the use of CBT for depression has been established. Many studies of CBT typically exclude individuals with specific characteristics due to beliefs that these characteristics could lead to less improvement in symptoms over the course of treatment. Typical exclusion criteria include an alcohol or other substance disorder, a psychotic disorder, organic brain syndrome, and mental retardation, with many studies also specifying that participants have major depressive disorder in the absence of suicide risk. More research on this issue is needed; many believe that individuals with these characteristics may still benefit from CBT for depression.

Technical Considerations

Complication Prevention

The support of family members and friends can assist with treatment by helping remind and encourage patients to complete important aspects of treatment such as attending therapy sessions, taking psychiatric medications (if prescribed), and completing therapy assignments. They may also be active participants in some of the activity scheduling assignments. Further, family members may be asked to attend therapy sessions in order to gain information about depression and CBT and to learn specific ways in which they can support or assist the patient.

Cognitive Behavioral Therapy for Depression Technique

Approach Considerations

CBT for depression begins with a focus on symptom reduction through behavioral techniques and cognitive techniques designed to identify and challenge negative automatic thoughts. Once significant symptom reduction has occurred, individuals practicing Beck’s version of cognitive therapy may then shift to a schema-focused phase for the purpose of relapse prevention. During this phase of treatment, the goal is to identify and replace dysfunctional schemas that are thought to enhance vulnerability to depressive episodes.

Behavioral Strategies

Behavioral strategies are often used in the beginning of CBT for depression. Individuals with depression often engage in significant avoidance and a corresponding decrease in activity level. For instance, many individuals with depression find themselves spending more time in bed and less time engaging in social activities, household tasks, work or school-related activities, and, at times, important hygiene behaviors. Martell and colleagues conceptualize this process with their “3 circles” model (see the image below), which demonstrates how negative life events lead to depressed mood and other negative emotional responses, which then leads to avoidance behaviors, creating a negative cycle in which depressive symptoms may worsen. [9]

Behavioral Activation Model of Depression (AdaptedBehavioral Activation Model of Depression (Adapted by Dr Rachel Leonard from Martell CR, Addis, ME, Jacobson NS. Depression in Context: Strategies for Guided Action. New York: Norton; 2001.).

To counteract this, behavioral strategies are used in order to decrease avoidance and increase engagement in the types of activities demonstrated to help alleviate depressive symptoms (ie, activities associated with pleasure and mastery or accomplishment). Within the model presented in the image above, this involves replacing the avoidance patterns with activation behaviors, which then stops the negative cycle of depression and works to improve mood. These behavioral strategies are especially recommended for patients presenting to treatment who are passive, experiencing anhedonia, are socially withdrawn, and have difficulty concentrating for long periods of time.

Activities are often assigned using a graded approach in which initial assigned activities are less complex and difficult, with more difficult activities being assigned gradually over the course of treatment as the patient becomes more active. For example, a patient with mild-to-moderate depression may be given initial activity assignments of going to a party (pleasurable activity) and spending 20 minutes on a report for work (accomplishment/mastery activity). For patients with moderate-to-severe depression, initial assignments would be less difficult or complex, such as reading a book for 10 minutes (pleasurable activity) and making their bed (accomplishment/mastery activity). The important point is to meet the patient at their current level of functioning based on their depressive symptoms and gradually work to increase engagement in more complex activities.

To assist with activity scheduling, therapists often assign an activity rating form on which patients maintain a record of their activities over the course of each day and provide ratings on a 0-10 scale for how much pleasure and mastery they experienced with each completed activity. See the image below.

Completed Daily Activity Monitoring Sheet. Completed Daily Activity Monitoring Sheet.

This is often useful data that can serve to counteract patients’ beliefs that they are unable to experience joy or gain a sense of accomplishment from any activities, and can help determine specific types of activities to assign in the future that are likely to lead to feelings of pleasure and mastery. To assist with completion of assigned activities, patients may be asked to engage in imaginal rehearsal (sometimes termed cognitive rehearsal), in which they imagine themselves engaging in various activities in order to identify obstacles to experiencing a sense of pleasure or mastery from those events. [7This enables the therapist and patient to then problem-solve obstacles and increase the chances of assigned activities leading to desired outcomes.

Additional behavioral strategies may be incorporated to assist with other specific problems the patient may experience that influence their depressive symptoms. For instance, patients may be taught specific techniques for improving sleep if they experience significant sleep difficulties. In addition, patients with social skills deficits may require additional treatment focused on their specific skills deficits in order to improve their ability to successfully complete activity scheduling assignments and gain the desired sense of pleasure or mastery from these. Examples of techniques for skills deficits include social skills training, assertiveness training, and strategies targeting communication skills. Therapists may ask patients to engage in in-session role playing in order to practice more effective social skills.

Initial Cognitive Strategies

The primary cognitive techniques involve eliciting the patient’s automatic thoughts, testing these thoughts, and identifying core schemas that influence how the patient views the world. Automatic thoughts are defined as “thoughts that intervene between outside events and the individual’s emotional reactions to them.” [15Automatic thoughts tend to occur frequently and to not be noticed by the individual and are therefore often accepted as true without evaluation. For individuals with depression, these automatic thoughts tend to be negative thoughts in line with the cognitive triad and therefore maintain and worsen depressive symptoms. Examples of negative automatic thoughts related to depression may include thoughts such as “I am a worthless person,” “nobody likes me,” and “I will never get better.”

The initial focus is on eliciting automatic thoughts and teaching patients to recognize these thoughts when they occur. One method for doing this is for the therapist to question the patient regarding thoughts that occurred in response to various events. Role playing may also be used to recreate previous events and assess different thoughts the patient experiences throughout the interaction. When eliciting automatic thoughts, the patient is also taught to pay attention to changes in their mood that occur following automatic thoughts, in order to learn about the relationship between their automatic thoughts and their emotions. To assist with this process, patients are often asked to keep a thought record on which they list emotions and automatic thoughts that coincide with distressing situations that occur between therapy sessions. This thought record can then be reviewed during the next therapy session. [15]

When the therapist and patient are able to identify automatic thoughts as they occur, the next step is to challenge these negative automatic thoughts. To do this, the patient is taught to complete additional columns on the thought record. The full thought record often includes columns for describing distressing situations, describing the emotions and negative automatic thoughts that occur in response to these situations, rating their initial belief in the negative automatic thought, generating alternative rational responses to the situation, rating the extent to which they believe the rational alternatives, and, finally, indicating which emotions they felt in response to this modified belief.

The thorough record can be individualized to challenge cognitive distortions specific to the patient, with the primary goal being to examine evidence for and against their negative thoughts and determine alternative explanations that are more realistic and less likely to lead to depressed mood. See the image below for examples of cognitive distortions frequently endorsed by individuals with depression. [16]

Cognitive distortions. Cognitive distortions.

To challenge a negative automatic thought such as “nobody likes me,” the patient may be asked a question such as “what evidence do you have that nobody likes you?” Subsequent questions evaluate each piece of evidence provided to determine whether that piece of evidence directly supports the hypothesis that nobody likes the patient. Typically, individuals with depression do not have much evidence to support their negative beliefs but tend to misinterpret available cues in a manner that maintains or worsens their depressed mood.

Another method for evaluating negative automatic thoughts is to have the patient complete behavioral tests. In order to do this effectively, the patient must agree that the thought is indeed testable and could potentially be modified. If the patient is not yet at this point, further discussion regarding the patient’s maladaptive thoughts and symptoms of depression is needed. In addition to having the patient agree that a specific negative thought is testable, the behavior must completed is well defined and that the patient and therapist agree as to what the behavior entails.

Finally, following the behavioral test, the patient is to record conclusions regarding how the behavior went and how it related to their negative thought, and these conclusions are then reviewed by the therapist and patient together. [29These conclusions are often recorded on the thought record. An example of a behavioral test may involve having a patient with the negative thought, “nobody wants to spend time with me” agree to try calling 10 specific individuals to ask them to get together in the near future and record how many of the 10 agree. The therapist and patient discuss what the patient should say on the phone, when to try calling, and other aspects of the assignment in order to increase chances of success. During the next session, the patient and therapist review the results and discuss how the results relate to the hypothesis that nobody wants to spend time with the patient.

Changing Maladaptive Schemas

As mentioned above, once the patient has experienced benefit from the first phase of treatment and experienced significant reductions in their depressive symptoms, CBT may shift to a focus on changing core schemas in order to prevent relapse. This phase of treatment may not be used by CBT therapists not following Beck’s specific cognitive therapy protocol. [7]

Schemas are thought to be more difficult to change than negative automatic thoughts and are viewed as stemming from earlier events that occurred in the patient’s development. This schema-focused phase places more emphasis on developmental patterns, interpersonal relationships (including the patient-therapist relationship), and emotional/experiential exercises. [15]

The schema-focused phase begins with assessment of the patient’s history in order to identify potential schemas as well as provision of education about schemas and how they influence individuals. Once this initial assessment and education phase is completed, efforts to change maladaptive schemas are introduced. The strategies for doing this are often similar to those used in the first phase of treatment (eg, activity scheduling, cognitive restructuring), but they focus on longstanding patterns in which situations are repeatedly interpreted in a specific manner due to the maladaptive schemas.

Other Aspects

In addition to the specific treatment strategies reviewed above, CBT also has a specific style and organization. In addition, in contrast with earlier psychodynamic approaches to treatment that tended to involve several years of therapy, CBT approaches are time-limited in nature. For instance, many CBT treatments are designed to be implemented over the course of approximately 12-16 sessions, depending on the severity of symptoms and other specific characteristics of the patient.

CBT approaches emphasize the need for a collaborative therapist-patient relationship in which the therapist and patient work together and adapt a cooperative attitude. This is captured by the focus on jointly determining goals for therapy, such that both the patient and the therapist have input regarding which goals to focus on throughout treatment, the priority of those goals over the course of therapy, and even the goals for each specific session. This is done through the process of setting an agenda. Most CBT therapists begin each session by outlining the agenda for that session and ask for input from the patient regarding items they would like to add to the agenda. This collaborative relationship also includes regular feedback to the patient regarding how they are doing and a rationale for each treatment intervention, such that the patient feels fully informed regarding his or her treatment. [15]

A specific aspect of this collaborative relationship is termed collaborative empiricism. Collaborative empiricism involves having the patient and therapist act as a team set out to investigate and evaluate hypotheses regarding the patient’s automatic thoughts and maladaptive schemas in a scientific manner. [7]

Finally, assigning homework between sessions is an important aspect of CBT. Specific homework assignments depend on the phase of treatment and the patient’s specific symptoms but often include activity scheduling assignments as well as assignments to regularly complete the thought record and challenge automatic thoughts as they occur.

Long-term Monitoring

As mentioned above, CBT is a time-limited treatment. Following the termination of therapy, however, patients may seek additional follow-up if they notice symptoms returning. If this occurs, patients are encouraged to follow up with their psychiatrist or primary care physician, or they can directly refer themselves back to their CBT provider if symptoms worsen following treatment discontinuation. At times, therapists may provide “booster” sessions in which CBT strategies are reviewed and specific symptoms may be targeted without the need for resuming weekly therapy sessions.

Patient Education

Patients interested in receiving CBT for depression should be educated about depression treatment by clinicians involved in their care. Topics to be addressed include the following:

  • Basic strategies involved in CBT for depression

  • Data on the effectiveness of CBT (alone and in combination with medication)

  • Anticipated number of sessions or length of stay

  • Alternatives to CBT for the treatment of depression

  • Ways in which family members and friends can provide support

Useful websites to which to refer patients and families include the following:

Useful books for patients include the following:

  • The Feeling Good Handbook by David D. Burns (1999).

  • Overcoming Depression One Step at a Time: The New Behavioral Activation Approach to Getting Your Life Back by Michael Addis and Christopher Martell (2004).

Future Directions

Many researchers and clinicians are examining ways to make CBT more accessible and cost-effective. One method for doing this is through the use of computerized interventions. These computerized interventions typically present CBT principles in a series of lessons, often with assigned homework and supplementary information.

A meta-analysis by Andrews et al found that computerized CBT programs targeting 4 disorders, including major depressive disorder, led to significantly greater symptom improvement than a control group and comparable improvement to face-to-face CBT. [30Andrews et al also found that most participants completed all lessons and rated the program as being satisfactory. In addition, the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom has endorsed the use of a computerized CBT program titled “Beating the Blues” for individuals with depression and anxiety. [31Additional efficacy studies of internet-based CBT for depression have found that internet-based CBT produced greater improvement than a wait list control group [3233and an online discussion group. [34There is also indication that those who respond to internet-based CBT retain gains for up to 3.5 years after treatment. [35]

Many different computerized CBT programs have been developed for the treatment of depression, and additional research is needed to determine their efficacy. Further, additional research examining different aspects of computerized CBT programs that may improve outcomes is needed. For instance, there is some indication that internet-based CBT programs that are not open to the public, incorporate a diagnostic interview, and utilize careful screening measures lead to larger treatment effects and may improve patient retention. [36Further examination of factors affecting outcomes is needed.

In addition to full computerized CBT programs, individuals have started to create smartphone applications that include CBT principles and can be used in conjunction with CBT sessions. Many individuals, not just mental health professionals, can create CBT smartphone applications, thus consulting with treatment providers before using any of these programs is essential. Further, this is a fairly recent development, thus more research examining the efficacy of these applications is needed.

Cognitive Behavioral Therapy for Depression Medication

Medication Summary

As described above, CBT is often used in depression as standalone treatment in mild-to-moderate depression or in combination with other treatments such as medication in more severe depression. Several meta-analyses of studies of the combination of psychotherapy and pharmacotherapy for patients with depression have documented an advantage of the combination treatment compared with either treatment alone. [37383940This advantage may be particularly pronounced in patients with chronic depression or severe recurrent depression and hospitalized patients.

Combination treatment theoretically adds the unique advantages of both treatment modalities. Pharmacotherapy may provide earlier symptomatic relief and psychotherapy may provide longer lasting symptomatic improvement. [41CBT can be used to target anxiety and procrastination and can help the patient adhere to more of a schedule, all of which can enhance medication adherence. A Cochrane review showed that adding CBT to a medication regiment improved adherence to the medication and decrease the incidence of hospitalization. [42CBT can do this by eliciting and modifying maladaptive cognitions about pharmacotherapy such as “if I take a drug I’m weak” or “I’m always the one to get side effects.”

Behavioral methods such as reminder systems and pairing medications with routine activities can also enhance adherence. Medications can enhance the therapy by augmenting concentration, sleep, energy or other functions needed to obtain full benefits from psychotherapy.

Risks of combination therapy include medications that interfere with learning and memory, which may make CBT less effective. Medication may also lead to “premature” relief of symptoms, which might reduce motivation to continue in psychotherapy.

Evidence does not suggest whether particular antidepressants or classes of antidepressants “combine better” with CBT.

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