Identifying active ingredients in cognitive-behavioral therapies: What if we didn't?

Self-Guided Behavioral Activation Using an Online Single-Session Intervention: Content and Lexical Analyses of Activity Scheduling

The Common Elements Toolbox (COMET) is a self-guided online single-session intervention (SSI) containing cognitive-behavioral elements, including behavioral activation (BA). Little is known about the process of activity scheduling in BA. Using data from an 8-week randomized controlled trial of COMET with 409 online workers with a history of psychopathology, two raters coded the types of activities individuals scheduled during the intervention. Additionally, we compared the activities to a BA dictionary developed from therapist-led psychotherapy. We explored baseline clinical and demographic variables that were predictive of the activity category scheduled and explored the scheduled activity category as a predictor of depression, anxiety, and well-being post-intervention. Results yielded 9 different activity types, most commonly sedentary hobbies (41%), physical activity (29%), and active hobbies (18%). We found a small overlap (17%) between the self-guided BA activities in our COMET sample and those in the existing BA dictionary. Demographic variables were predictive of activity category, but clinical variables were not. The type of activity scheduled was not predictive of post-intervention outcomes. In self-guided BA, individuals, particularly men, less educated participants, and racial-ethnic minorities, tend to pick sedentary activities. Findings underscore the need for adaptive and personalized interventions.

Learning training as a cognitive restructuring intervention

BACKGROUND

A core part of cognitive therapy for low mood is learning to identify and challenge negative beliefs. However, it is currently unclear whether improved ability to recognise such beliefs, and the biased interpretations of events which may maintain them, is a mechanism of symptom change during treatment.

METHODS

We investigated the effects of completing a learning task (training to identify and select self-enhancing interpretations of events) and a brief cognitive restructuring intervention (how exploring alternative explanations of events may result in improved mood) on causal attribution tendencies. Studies were conducted online using randomized-controlled experimental designs (N=200 &N=164), and data were analysed using hierarchical Bayesian models.

RESULTS

We found that both learning training and the restructuring intervention decreased tendencies to make unhelpful attributions and increased tendencies to make self-enhancing attributions. Across two studies, changes in attribution tendencies were associated with higher learning rates during learning training, an effect specific to learning about different kinds of event attribution. Contrary to expectation, we found no evidence that faster learning was associated specifically to changes in attribution tendencies following cognitive restructuring. Since participants with higher learning rate estimates also provided explicit ratings and free-text descriptions of event causes which were closer to the ground truth, we interpret this as representing a greater benefit of learning training in individuals who were better able to understand the task state space.

CONCLUSIONS

We suggest that personalized training, in conjunction with feedback based on interpretable computational model output, may provide a useful form of augmentation or learning support tool during therapy.

The use of process measures in studies investigating effects of psychotherapy for depressive symptoms following acquired brain injury: A scoping review

Persons with acquired brain injury (ABI) often experience mood problems like depression. While psychotherapy is widely accepted for managing depression in populations without ABI, its effectiveness for post-ABI depression is uncertain. The working mechanisms of psychotherapy in persons with ABI may differ from idiopathic depression. This scoping review aimed to identify studies on psychotherapeutic interventions for post-ABI depression, assess the use of process measures (instruments measuring the mechanisms of psychotherapy), and report effects on both process and primary outcome measures. In the 47 included studies, Cognitive Behavioural Therapy, Problem Solving Therapy, and Third-Wave Therapies were most frequently investigated. Results indicated that less than half of the studies implemented a process measure. Studies into Third-Wave Therapies most frequently implemented process measures. Around half of the studies found significant time or interaction effects on the process measure, while not necessarily finding effects on outcome measures for depression. Moreover, the review could not identify a specific type of intervention effective in improving depressive symptoms and the underlying process. Our findings emphasize that it is still unclear which psychotherapy works for whom, and how. To enhance understanding of effective interventions for post-ABI depression, it is crucial to incorporate process measures in future intervention studies.

Processes of change in digital interventions for depression: A meta-analytic review of cognitive and behavioral mediators

The efficacy of digital interventions for depression has been established. In contrast, only limited knowledge on their change processes is currently available, and precise effect size estimates for mediators are pending. This study aimed to systematically review mediation studies and meta-analytically evaluate indirect effects of cognitive and behavioral mediators in digital interventions for adults with depression. The databases CENTRAL, Embase, MEDLINE, and PsycINFO were systematically searched for eligible randomized controlled trials. Two independent reviewers extracted the data, assigned mediators to eight categories and evaluated the methodological quality of included studies. Two-stage structural equation modeling was applied to synthesize indirect effects for cognitive and behavioral mediators. Overall, 25 studies (8110 participants) were eligible, which investigated 31 cognitive, 29 behavioral and 24 other mediators. Meta-analyses yielded significant indirect effects for combined cognitive mediators (ab = -0.068; 95 %-CI: [-0.093, -0.047]; k = 14 studies) and combined behavioral mediators (ab = -0.037; 95 %-CI: [-0.048, -0.028]; k = 13), but not for the specific cognitive mediators interpretation bias and dysfunctional attitudes. The systematic review revealed that all studies fulfilled at least five out of nine methodological quality criteria for psychotherapy process research, but the risk of bias assessment raised some concerns, particularly in regard to potential deviations from intended interventions. Overall, the findings of this meta-analytic review contribute to the understanding of the mechanisms of change in digital interventions for depression, and can inform the evidence-based advancement of future interventions.

Improving treatments for mental disorders using computational models

Progress in the treatment of psychopathology has slowed and much remains unknown about how treatments achieve their beneficial effects. We propose that computational models can be used to provide new insights into how treatments may work and how they may be improved. We argue that treatments can be understood as interventions on systems of interacting components, and that computational models are needed if we are to accurately and precisely determine the effect an intervention will have on this system. We demonstrate this approach by using a computational model of panic disorder to conduct an in silico dismantling study of cognitive behavioral therapy. This simulated trial allows us to: identify a common source of treatment failure; propose a revised treatment protocol that mitigates this source of failure; and demonstrate that, if the model is accurate, this revised protocol will lead to improved treatment outcomes for 10% of patients. We conclude with a discussion of the promise and challenges of using computational models for treatment research.

Next-Generation Cognitive-Behavioral Therapy for Depression: Integrating Digital Tools, Teletherapy, and Personalization for Enhanced Mental Health Outcomes

Background and Objectives: This systematic review aims to present the latest developments in next-generation CBT interventions of digital support tools, teletherapies, and personalized treatment modules in enhancing accessibility, improving treatment adherence, and optimizing therapeutic outcomes for depression. Materials and Methods: This review analyzed 81 PRISMA-guided studies on the efficacy, feasibility, and applicability of NG-CBT approaches. Other important innovations include web-based interventions, AI-operated chatbots, and teletherapy platforms, each of which serves as a critical challenge in delivering mental health care. Key messages have emerged regarding technological readiness, patient engagement, and the changing role of therapists within the digital context of care. Results: Findings indicate that NG-CBT interventions improve treatment accessibility and engagement while maintaining clinical effectiveness. Personalized digital tools enhance adherence, and teletherapy platforms provide scalable and cost-effective alternatives to traditional therapy. Conclusions: Such developments promise great avenues for decreasing the global burden of depression and enhancing the quality of life through novel, accessible, and high-quality therapeutic approaches.

State of the Science: Using Digital Mental Health Interventions to Extend the Impact of Psychological Services

In recent years, digital mental health interventions (DMHIs) have emerged as a paradigm shift in care delivery that could expand the scale, efficiency, and effectiveness of psychological services. However, DMHI impact is constrained by issues related to limited reach, poor adoption, implementation barriers, and insufficient long-term maintenance. Organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance(RE-AIM) framework, this paper surveys the current state of DMHIs, highlighting research and practice gaps as well as potential strategies to move the field forward. Similarly, we discuss the role that emerging technologies and changes in the profession will play in shaping DMHIs in years to come. Finally, concrete and actionable steps to advance equity in the DMHI field are provided, with an emphasis on strategies to increase the representativeness of marginalized populations in DMHI research, the inclusion of these groups in the design and testing of DMHIs, and how to improve the contextual and cultural fit of DMHIs.

Change in negative mental filter is associated with depression reduction in metacognitive training for depression in older adults (MCT-Silver)

Identifying components of modularized psychological interventions that contribute to symptom reduction is essential to improving depression treatment. In a secondary analysis of a randomized controlled trial (RCT), session-specific effects of Metacognitive Training-Silver, a group intervention for older adults with depression, were investigated. Thirty-eight older adults with major depressive disorder or dysthymia participated in up to eight sessions of MCT-Silver. A clinical assessment of depressive symptoms (Hamilton Depression Rating Scale) as well as additional interviews and questionnaires administered as part of the RCT were completed at pre- and post-intervention. Depressive symptoms, negative (meta)cognitive beliefs, emotion regulation strategies and attitudes toward aging were assessed pre- and post-session. The rate of change in each variable per module, elevation following the module in which the variable was addressed, and the rate of change post module were examined via linear mixed models. Clinician-rated depressive symptoms were significantly reduced from pre- to post-intervention (Cohens d = 1.31). Self-reported depression and negative mental filter measured within sessions improved significantly over treatment, whereas black-and-white thinking improved after module #3 (Should Statements, All or Nothing Thinking and Acceptance). Module-specific within-session effects were found for overgeneralization (module #1: Mental Filter) and rumination (module #6: Rumination and Social Withdrawal). Improvement in mental filter in module #1 was significantly associated with depression reduction. This study provides initial evidence that MCT-Silver partially meets its aims of reducing depression and specific cognitive variables within and across sessions. Improvement of the instrument used to measure change may improve detection of module-specific effects.Trial registration: NCT03691402.

A network analysis of mechanisms of change during exposures over the course of intensive OCD treatment

Exposure and response prevention (ERP) is an evidence-based treatment for obsessive-compulsive disorder (OCD). Theories for how it works vary in their emphasis on active mechanisms of change. The current study aimed to clarify mechanisms of change in ERP for OCD using network analysis, comparing ERP networks at the start and end of intensive treatment (partial hospital and residential). In our sample of 182 patients, the most central node in both networks was engagement with exposure, which was consistently related to greater understanding of ERP rationale, higher willingness, and less ritualization, accounting for all other variables in the network. There were no significant differences in networks between the start and end of treatment. These results suggest that nonspecific parameters like facilitating engagement in exposures without ritualizing and providing a clear rationale to clients may be key to effective treatment. As such, it may be useful for clinicians to spend adequate time underscoring the need to eliminate rituals to fully engage in exposure tasks and explaining the rationale for ERP prior to doing exposures, regardless of theoretical orientation. Nonetheless, findings represent group-level statistics and more fine-grained idiographic analyses may reveal individual-level differences with respect to central mechanisms of change. Other limitations include demographic homogeneity of our sample.

Aphasia Depression and Psychological Therapy (ADaPT): Perspectives of People with Post-Stroke Aphasia on Participating in a Modified Cognitive Behavioral Therapy

Aphasia, a communication disability commonly caused by stroke, can profoundly affect a person's mood and identity. We explored the experiences of stroke survivors with aphasia and depression who received a modified cognitive behavioral therapy (CBT)-based psychological intervention. The therapy is manualized with a flexible treatment protocol, including 10 individually based therapy sessions (+2 booster sessions) either via telehealth or in person. Six participants with chronic aphasia (60% of the total sample) participated in in-depth interviews that were analyzed using reflexive thematic analysis. Two core themes were derived from the data: the first theme, helpful elements of therapy-doing enjoyable activities, new ways of thinking, problem solving, working with the experienced therapist, and using telehealth; and the second theme, making progress-mood, communication, acceptance of the 'new me', and improving relationships. All participants found the therapy to be helpful in managing mood problems with various elements being beneficial depending on the individual, highlighting the importance of tailoring the intervention. Therefore, delivering modified CBT to individuals with aphasia is likely to be acceptable both in person and through telehealth. Further evaluation of the intervention and its impact on mood would be beneficial.

Commentary: Holy grails, personalized medicine, and the public health burden of psychopathology - a reflection on Ahuvia et al. (2023)

Clinical psychology and psychiatry have many 'holy grails' or research findings that are widely sought after but remain elusive. The use of machine learning (ML) models for treatment selection is one of these holy grails. Ahuvia et al. (Journal of Child Psychology and Psychiatry, 2023) recently analyzed a large trial (n = 996) of two distinct single-session interventions (SSIs) for internalizing distress and found little evidence that an ML model could predict differential treatment response. I discuss potential avenues for advancing SSI research. One avenue is the dissemination and implementation of SSIs, including how they interact with other treatments in routine care. Quantifying and critically questioning the promises of holy grails like ML models is sorely needed. Using simulation modeling to evaluate the relative merits of using ML models for treatment selection or using SSIs versus other treatment strategies may be another path forward.

Beyond mediators: A critical review and methodological path forward for studying mechanisms in alcohol use treatment research

Understanding how treatments for alcohol use disorder (AUD) facilitate behavior change has long been recognized as an important area of research for advancing clinical care. However, despite decades of research, the specific mechanisms of change for most AUD treatments remain largely unknown because most prior work in the field has focused only on statistical mediation. Statistical mediation is a necessary but not sufficient condition to establish evidence for a mechanism of change. Mediators are intermediate variables that account statistically for the relationship between independent and dependent variables, whereas mechanisms provide more detailed explanations of how an intervention leads to a desired outcome. Thus, mediators and mechanisms are not equivalent. To advance mechanisms of behavior change research, in this critical review we provide an overview of methodological shortfalls of existing AUD treatment mechanism research and introduce an etiologically informed precision medicine approach that facilitates the testing of mechanisms of behavior change rather than treatment mediators. We propose a framework for studying mechanisms in alcohol treatment research that promises to facilitate our understanding of behavior change and precision medicine (i.e., for whom a given mechanism of behavior change operates and under what conditions). The framework presented in this review has several overarching goals, one of which is to provide a methodological roadmap for testing AUD recovery mechanisms. We provide two examples of our framework, one pharmacological and one behavioral, to facilitate future efforts to implement this methodological approach to mechanism research. The framework proposed in this critical review facilitates the alignment of AUD treatment mechanism research with current theories of etiologic mechanisms, precision medicine efforts, and cross-disciplinary approaches to testing mechanisms. Although no framework can address all the challenges related to mechanisms research, our goal is to help facilitate a shift toward more rigorous and falsifiable behavior change research.

How effective psychological treatments work: mechanisms of change in cognitive behavioural therapy and beyond

BACKGROUND

Cognitive behavioural therapy (CBT) has, in the space of 50 years, evolved into the dominant modality in psychological therapy. Mechanism/s of change remain unclear, however.

AIMS

In this paper, we will describe key features of CBT that account for the pace of past and future developments, with a view to identifying candidates for mechanism of change. We also highlight the distinction between 'common elements' and 'mechanisms of change' in psychological treatment.

METHOD

The history of how behaviour therapy and cognitive therapy developed are considered, culminating in the wide range of strategies which now fall under the heading of cognitive behavioural therapy (CBT). We consider how the empirical grounding of CBT has led to the massive proliferation of effective treatment strategies. We then consider the relationship between 'common factors' and 'mechanisms of change', and propose that a particular type of psychological flexibility is the mechanism of change not only in CBT but also effective psychological therapies in general.

CONCLUSION

Good psychological therapies should ultimately involve supporting people experiencing psychological difficulties to understand where and how they have become 'stuck' in terms of factors involved in maintaining distress and impairment. A shared understanding is then evaluated and tested with the intention of empowering and enabling them to respond more flexibly and thereby reclaim their life.

Cognitive Therapy-as-Usual versus Cognitive Therapy plus the Memory Support Intervention for adults with depression: 12-month outcomes and opportunities for improved efficacy in a secondary analysis of a randomized controlled trial

OBJECTIVE

Patient memory for treatment is emerging as an important transdiagnostic mechanism of treatment outcomes. However, patient memory for treatment is limited. The Memory Support Intervention was developed to improve patient memory for treatment and thereby strengthen treatment outcomes. In this secondary analysis, the primary, preregistered aim was to test the 12-month follow-up outcomes of the Memory Support Intervention when used with cognitive therapy (CT + MS) for major depressive disorder, relative to CT-as-usual. The secondary, exploratory aim was to investigate opportunities to improve efficacy of the Memory Support Intervention.

METHOD

Adults (N = 178) with major depressive disorder were randomized to CT-as-usual or CT + MS. Therapist use of memory support and patient memory for treatment, depression symptoms, and overall functioning were measured in blind assessments.

RESULTS

Findings did not support differences between treatment conditions at 12-month follow-up. Therapists used memory support strategies with a narrow subset of treatment contents, and similarly, patients recalled a narrow subset of treatment contents.

CONCLUSIONS

The findings highlight ways to strengthen the efficacy of the Memory Support Intervention, such as applying memory support strategies across a wider variety of treatment contents, which in turn, may boost patient recall and outcomes.