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CBT for Depression: How It Works, Examples, & Effectiveness

Author: Renee Skedel, LPC

Renee Skedel LPCC

Renee Skedel, LPCC, has extensive experience in crisis resolution, suicide risk assessment, and severe mental illness, utilizing CBT and DBT approaches. She’s worked in diverse settings, including hospitals and jails.

Cognitive behavioral therapy (CBT) for depression effectively targets negative thought patterns. It’s a short-term therapy for clinical depression that reduces symptoms by helping people recognize unhelpful thoughts and behaviors and replace them with healthier thinking and reacting.

How Does CBT Help Depression?

Cognitive behavioral therapy (CBT) is a type of psychotherapy that uses a combination of cognitive and behavioral approaches to reduce depression . 1 CBT therapy for depression focuses on changing a person’s feelings to help improve their thoughts and behaviors. CBT therapists may challenge depressive thinking patterns that lead to inaction or self-harming behaviors.

Cognitive Methods to Change Depressive Thinking Patterns

Cognitive methods teach you to challenge negative or irrational thoughts, eventually reducing their power over you. Techniques like cognitive restructuring can help you understand your thought patterns, the emotion behind them, and the actual reality of the situation. A therapist can help present a more realistic perspective to help reduce cognitive distortions . You can also use the free CBT for depression worksheet below to practice cognitive restructuring.

A common cognitive distortion among those with depression is “mind reading,” where you believe you know what others are thinking. By challenging this and other depressive thoughts, you can build a healthier pattern of thinking and self-talk. 1, 2

Cognitive Restructuring for Depression Worksheet

You can recognize unhealthy thought patterns that are making your depression symptoms worse by practicing cognitive restructuring with this worksheet.

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Types of CBT for Depression

Cognitive behavioral therapy is not only a treatment type, but it is also the main branch for a number of different therapy styles. There are three common types of CBT used for depression symptoms and episodes.

Along with standard CBT, here are three other common types of CBT used for depression:

Acceptance & Commitment Therapy (ACT)

ACT engages a number of techniques to increase someone’s mental flexibility. ACT for depression can help with reducing the difficulties of negative thoughts and self-talk, anxiety, and judgment, and increase the individual’s ability to focus.

ACT techniques include strategies for each of these pillars: 9

• Acceptance : allowing a thought or feeling to exist without judging it or pushing it away
• Mindfulness: encouraging the individual to be able to focus on the present
• Commitment to behavioral change: if something is not in line with the meaning or values the individual holds, then change this behavior to meet that value

Dialectical Behavioral Therapy (DBT)

Similar to ACT, DBT helps people learn how to accept difficult feelings and thoughts. In addition, DBT for depression teaches how to balance between the ability to accept and address irrational thoughts and behaviors to be able to make healthy and maintainable changes in their ability to cope with life’s stressors. 9

DBT is most frequently used to treat those with borderline personality disorder (BPD). However, it was initially developed to treat people who had frequent suicidal thoughts . In addition, those with BPD or bipolar disorder engage in significant amounts of self-harm—regardless of suicidal intent—that can be seen in depressive episodes across disorders.

Rational Emotive Behavior Therapy (REBT)

In treating depression, rational emotive behavioral therapy (REBT) uses the approach of utilizing the desire to feel happy or fulfilled to reduce depressive symptoms. The REBT approach uses many CBT techniques for depression to help people change their thought processes, helping to create healthier behavior patterns, and eventually helping someone move out of their depressive thoughts and behaviors. 10

REBT was created with the idea that individuals make choices in their lives to meet needs that allow them to survive and feel fulfilled. In turn, REBT teaches individuals how to address irrational and unhealthy behaviors and thoughts so that they can change them for a more functional and fulfilling life.

Behavioral Methods

Behavioral methods are highly effective in treating depression. They typically involve rewarding yourself for small behavioral changes. For example, depression can cause a lack of motivation or low energy. By rewarding yourself for engaging in a task like putting away a dish or two, you change the chemical outputs in your brain. Adding a reward makes you more likely to repeat the behavior in the future. 1

CBT employs several methods to reduce the power of not engaging in behaviors as well, like reducing self-harming or self-sabotaging behaviors that often accompany depression.

What Types of Depression Can CBT Treat?

Cognitive behavioral therapy for depression can be an effective treatment for various depressive disorders and episodes that may be impacting your life, especially in the mild to moderate range of symptoms. 3

CBT can be effective in treating these types of depression: 3

• Major depressive disorder (clinical depression)
• Persistent depressive disorder (PDD)
• Seasonal affective disorder
• Postpartum depression
• The depressive episodes of bipolar disorder
• Situational depression
• Schizoaffective disorder, depressive type

9 Common CBT Techniques for Depression

Common CBT techniques used for depression include cognitive restructuring, thought journaling, and mindful meditation. Many of these techniques are used together to show the connections between thoughts, emotions, and behaviors.

Here are nine common CBT techniques for depression: 2

1. Cognitive Restructuring

In challenging your thought patterns, tone, and self-talk, you learn about potential cognitive distortions and unhealthy thought patterns that could be increasing depressive emotions or suicidal thoughts. Cognitive restructuring , sometimes called reframing, forms healthier thought patterns, reduces cognitive errors, and helps you practice ways to rationalize distortions and untrue beliefs.

Here’s how to try the five steps to cognitive restructuring:

• Set up your list: draw a line down the middle of a piece of paper. Title the left-hand column “Unproductive Thoughts” and title the right-hand column “Replacement Thoughts.”
• Write down your unproductive thoughts: on the left-hand side of your paper, list your negative and self-critical thoughts, or any automatic thoughts you have regularly that make you unhappy, something like “I can’t do anything right.”
• Identify your replacement thoughts: for each of your unproductive thoughts, create a replacement thought and write it down on the right side of your paper, such as “Here’s a project I did well.”
• Review your list regularly: so you begin to memorize the unproductive thoughts and their replacement thoughts.
• Notice your thoughts in real time: pay attention to your thoughts throughout each day. When you think of one of your unproductive thoughts, stop yourself and remind yourself of the replacement thought. With practice, you’ll begin to challenge your unproductive thoughts and naturally start to replace them with rational ones.

2. Activity Scheduling

Activity scheduling involves rewarding yourself for scheduling activities that encourage positive experiences and self-care. By scheduling these activities and rewards, you learn to motivate yourself to complete necessary tasks even when you are feeling low. It also increases the chances of continuing to complete these tasks after you end your formal therapy sessions.

3. Thought Journaling

By journaling for mental health , exploring things like your emotions, thoughts, and behaviors, you create a space to process and identify any potential triggers, as well as how your thoughts have been influencing your behavior. This can increase self-awareness and help you learn coping techniques to use in the future. 4 You can also use specific journal prompts for depression to understand more where your beliefs and moods have been coming from.

4. ABC Analysis

Similar to journaling, the ABC model is solely focused on breaking down the behaviors that are related to depression, like snapping at people or sleeping all day. In analyzing your triggers and consequences, you can explore the “consequential” behaviors and look to find common causes in your depressive triggers.

The ABC model works by using the following structure:

• The “Activating” event
• Your “Beliefs” about that event
• The “Consequences” of the event, including your feelings and behaviors surrounding the event

5. Fact-checking

Fact-checking encourages you to review your thoughts and understand that, while you may be stuck in a depressive or harmful thought pattern, these thoughts are not facts but opinions based on your emotions (e.g., “I am a failure”). Fact-checking can also help you identify what behaviors you engage in due to your opinions or emotions instead of the actual facts.

6. Successive Approximation or “Breaking It Down”

Breaking down large tasks into smaller goals will help you feel less overwhelmed. By practicing successive approximation, you will be more likely to complete your goals and be better able to cope with large tasks in the future, even during times when your depression is heightened.

7. Mindful Meditation

By engaging in meditation for depression , you will learn to reduce focus on negative thoughts and increase your ability to remain in the present. Meditation can help you recognize and learn to accept your negative thought patterns and detach from them instead of letting them take over.

8. Behavioral Experiments

Therapists use behavioral experiments as a tool for challenging irrational thought patterns that may be contributing to your depression. You’ll learn how to replace these thoughts with healthier thoughts. By engaging in these experiments, you can spot and learn to stop catastrophic thinking and develop a more realistic view of the world.

9. Role Play

Your therapist may have you role play a specific situation you find challenging. You will act out the situation alongside the therapist, while learning to practice healthier responses and depression coping mechanisms . Role playing helps you gain a better understanding of your emotional responses and how to manage your reactions in a real-life situation.

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Examples of CBT for Depression

CBT uses cognitive and behavioral techniques to improve depression symptoms , but the exact CBT treatment plan for depression might depend on the type of depression someone is experiencing.

CBT For Major Depressive Disorder (MDD) Example

Jody, a 35-year-old female, has recently started to feel tired all the time. This began about two and a half weeks ago. Along with “sleeping all the time,” she reports these other symptoms that all started around the same time.

Those symptoms include:

• Experiencing negative thoughts
• Constantly worrying about different aspects of her life
• Finding it difficult to stay still
• Does not have an appetite
• Has generally been feeling sad, hopeless, irritable, and numb

She reports that she had also felt this way in her teens and mid-20’s; and she also experienced brief suicidal thoughts in her 20’s.

Jody began meeting with her therapist and the therapist diagnosed major depressive disorder after they finished their assessment. During sessions, her therapist began asking her to think about what thoughts are making her feel sad and to change her thought process. She also recommended journaling every day.

Part of the journaling homework includes documenting something that she chose to do to make her feel happy or productive daily, a CBT technique called behavioral activation. When Jody started reporting an increase in her worry and rumination , the therapist encouraged her to add meditation to her daily work, to help reduce the incessant worrying and increase calm in Jody’s mind. 1, 5

CBT For Persistent Depressive Disorder (PDD) Example

Matt, a 28-year-old male, has been experiencing a low and depressed mood, difficulty sleeping, low self-esteem , and difficulty with concentration for the last two and a half years. He works a difficult job and felt it was related, but was informed by family that they noticed this low-grade depression even when he was in less stressful positions.

Matt reached out to a therapist, who diagnosed him with persistent depressive disorder (dysthymia) . 1, 5, 6, 7 His therapist began working with him on journaling about his day on a regular basis, especially if something made him happy. The therapist encouraged him to write down and challenge his negative and irrational thoughts.

Matt and his therapist also worked on noting triggers for aggressive thoughts towards himself to increase his awareness. Matt’s therapist began encouraging him to engage in problem-solving tasks to help him function and build resilience when his depressive symptoms flared up. 1

CBT For Seasonal Affective Disorder (SAD) & Situational Depression Example

Jamie, a 37-year-old male, began experiencing depressive moods, difficulty concentrating, increased fatigue, lowered energy, feeling tense, and negative thoughts in his early 20’s. He reports that he never reached out for help because even if the symptoms tended to start in October to November almost every year, they always stopped around March.

This year, Jamie’s symptoms began around the same time, although he noticed that his negative thoughts were worse than normal and that his sleep schedule was off. As a result, he reached out to a local therapist, who diagnosed Jamie with “unspecified depressive disorder with seasonal pattern,” which is more commonly known as seasonal affective disorder (SAD) . 7

Jamie’s therapist began working with him to reduce the impact of his symptoms by having him engage in regular meditation to reduce his anxiety and challenge his thoughts outside of session to reduce the negative thought patterns impacting his perspective.

They also worked together to create a daily schedule of activities to help increase self-fulfillment and self-care , and journaling to increase acknowledgement of positive things during the difficult season, as well as to track Jamie’s mood. 1, 5, 7

CBT For Postpartum Depression Example

Julia, a 32-year-old female, had her baby about three weeks ago. About two weeks ago, Julia began experiencing significant levels of anxiety, panic attacks, low mood, feelings of depression and worthlessness, and loneliness . This was Julia’s first child and she had never experienced these feelings before, nor had anyone else in her family. 1, 7

Julia sought out a therapist to figure out her feelings and was diagnosed with “unspecified depressive disorder with peripartum onset,” more commonly known as postpartum depression . Her therapist knew that research indicated that CBT had improved long- and short-term symptoms of depression and had some impact on anxiety in postnatal depression. 8

Julia’s therapist encouraged her to journal her feelings each day to increase awareness as well as acknowledge the positive things she was doing.

She also had her engage in a daily short meditation and breathing regulation technique to lower anxiety and panic attacks, engage in gratitude practices with her journaling to increase her mood and lower depressive symptoms, and to discuss her emotional concerns with her support system and partner to allow herself time to meet her own needs.

Julia was encouraged to explore her thought patterns influencing the anxious thoughts, especially leading up to panic attacks, to help reduce anxiety and become more aware of her triggers to be able to feel comfortable with her baby. 4, 9

How Effective Is CBT for Depression?

Cognitive therapy can be as effective as depression medication in initially treating moderate to severe depression, although its success often relies on the therapist’s level of experience. Studies show that when CBT is delivered by skilled therapists, it can lead to substantial improvements in depressive symptoms. 11

Other research studies have proven the effectiveness of CBT for depression:

• Studies show that the behavioral activation techniques used in CBT are useful in the treatment of those with severe depression. 5
• When compared to antidepressant medication, CBT alone may be effective in continued recovery for depression. 5
• Cognitive therapy shares efficacy with medication in treating moderate to severe major depressive disorder, although this can be impacted by the level of the therapist’s experience with CT/CBT. 11
• CBT was found to be an effective intervention in lowering depressive symptoms and depression relapse rates, especially in comparison with a control group. 12
• A study on bipolar disorder, including depressive episodes and symptoms, found that the group with CBT treatment had fewer bipolar episodes, shorter bipolar episodes, and less hospitalization admissions. In addition, this group’s depressed mood and mania symptoms were noted to be significantly lower. 13

Would You Like to Try CBT Therapy?

What to Expect During CBT Treatment

Those seeking CBT for depression will typically attend 12-20 weekly sessions, although many will experience improvements after just a few sessions. CBT treatments can be done in-person or with a CBT therapist online. 14 Most insurance companies cover CBT to help reduce the cost, but if paying out of pocket, you can expect to pay between $100 and $200 per session.

While CBT may involve some rigor and homework, CBT treatment was intended to be short-term to allow people to thrive with the help of their therapist, but then on their own. Each CBT session will generally last about 50 to 55 minutes, and happen once a week. The format of each session is usually quite structured.

Each CBT session consists of: 13

• Setting a goal or a problem to process for that day
• Working on the problem reported (this might include processing barriers in the problem as well as the person’s thoughts on these)
• Creating an action plan to address the problem in and out of session
• Measuring the person’s movement on the problem (like discussing homework, a reported issue, communication, etc.)

While this may not always be the case in a CBT treatment plan or the model of every single session, this is the expectation for treatment. Your therapist may take some different approaches, but CBT treatment tends to be short-term and active in attempting to reduce the impact of your mental health symptoms on your life.

How to Find a CBT Therapist

If you’re wondering how to choose a therapist , ask your primary care provider or a trusted loved one for a list of recommendations. You can also search a local therapist directory to find a licensed CBT provider in your state who specializes in CBT for depression. Many therapists now offer video-based therapy that has enabled many people to get CBT online .

If you’re ready to begin online CBT, Online-Therapy.com is an excellent choice for those without insurance. There are also several online therapy options that take insurance .

At-Home Cognitive Behavioral Therapy Exercises For Depression

While you should always seek help from a professional if you think you may have depression, there are CBT exercises you can try on your own or through the use of CBT apps to help relieve mild symptoms, like journaling, scheduling out activities you enjoy, and starting a gratitude practice. A therapist can also help you develop these techniques so you’ll be prepared when depressive symptoms arise.

Here are some at-home CBT exercises for depression: 3

Even if you aren’t seeing a therapist, keeping a journal of your thoughts, feelings, and behaviors can be helpful. Through writing in a notebook or through a journaling app like the Sensa app , you may begin to learn more about yourself and identify difficulties that regularly impact you. This way, you can prepare for them in the future. 4

Schedule Enjoyable Activities

Have events scheduled that improve your mood, like concerts, lunch dates with friends, or road trips. Even on a smaller scale like making a general to-do list, scheduling can inspire you to keep moving forward.

Try Meditation

Meditation can be helpful in managing your emotions, decompressing, and even falling asleep. It has been proven to help with addiction, depressive disorders, anxiety disorders, and more. If you’re not sure where to start, using  meditation apps and free videos available online can help you clear your mind and connect to the present.

Practice Challenging Your Thoughts

You might want to start this practice in a journal, but it is also helpful to challenge or reframe your thinking in the moment. By reframing thoughts or saying affirmations in your head, you may be able to learn to stop negative thoughts in their tracks.

Start a Gratitude Practice

It might feel difficult at times, but it’s helpful to identify the positives in your life. One study showed that the use of gratitude helped to significantly reduce continuous negative thought processes (and reduced the risk of negative thoughts in individuals experiencing anxiety and depression ). 14 It can help to try writing three things you’re grateful for every day.

In My Experience

“In my experience, CBT can help with depression symptoms in many ways. In accessing CBT services, whether through a therapist or by practicing at-home skills, you can start feeling a bit better and getting back to the things that are most important to you.”

Choosing Therapy strives to provide our readers with mental health content that is accurate and actionable. We have high standards for what can be cited within our articles. Acceptable sources include government agencies, universities and colleges, scholarly journals, industry and professional associations, and other high-integrity sources of mental health journalism. Learn more by reviewing our full editorial policy .

Cognitive behavioral therapy EXERCISES Los ANGELES: CBT INTERVENTIONS. (2020). Retrieved from https://cogbtherapy.com/cognitive-behavioral-therapy-exercises

Fenn, K., & Byrne, M. (2013). The key principles of cognitive behavioural therapy. InnovAiT, 6(9), 579–585. https://doi.org/10.1177/1755738012471029

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive Behavioral Therapy for Depression. Indian Journal of Psychiatry, 62(8), 223. https://doi.org/10.4103/psychiatry.indianjpsychiatry_772_19

Utley, A., & Garza, Y. (2011). The therapeutic use of journaling with adolescents. Journal of Creativity in Mental Health, 6(1), 29-41.

Chand, S. P., & Maerov, P. J. (2019, March 28). Using CBT effectively for treating depression and anxiety. Retrieved from https://www.mdedge.com/psychiatry/article/82695/anxiety-disorders/using-cbt-effectively-treating-depression-and-anxiety/page/0/2

Publishing, H. (2014, March). Dysthymia. Retrieved from https://www.health.harvard.edu/newsletter_article/dysthymia

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (5th ed.). American Psychiatric Publishing.

Huang, L., Zhao, Y., Qiang, C., & Fan, B. (2018). Is cognitive behavioral therapy a better choice for women with postnatal depression? A systematic review and meta-analysis. PLOS ONE, 13(10), e0205243. https://doi.org/10.1371/journal.pone.0205243

Mike, D. (2016, February 8). Know the 3 Major Types of Therapy – CBT, ACT, DBT. Boca Raton Psychiatrist | Florida Psychologists. Retrieved November 13, 2021, from https://drmikemd.com/understanding-the-3-major-types-of-therapy-cbt-act-dbt

Ellis, A., & Joffe Ellis, D. (2019). Introduction. Rational Emotive Behavior Therapy (2nd Ed.)., 3–7. https://doi.org/10.1037/0000134-001

DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., O’Reardon, J. P., Lovett, M. L., Gladis, M. M., Brown, L. L., & Gallop, R. (2005). Cognitive Therapy vs Medications in the Treatment of Moderate to Severe Depression. Archives of General Psychiatry, 62(4), 409. https://doi.org/10.1001/archpsyc.62.4.409

Li, J. M., Zhang, Y., Su, W. J., Liu, L. L., Gong, H., Peng, W., & Jiang, C. L. (2018). Cognitive behavioral therapy for treatment-resistant depression: A systematic review and meta-analysis. Psychiatry Research, 268, 243–250. https://doi.org/10.1016/j.psychres.2018.07.020

Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, N., Parr-Davis, G., & Sham, P. (2003). A Randomized Controlled Study of Cognitive Therapy for Relapse Prevention for Bipolar Affective Disorder. Archives of General Psychiatry, 60(2), 145. https://doi.org/10.1001/archpsyc.60.2.145

What is a CBT Session Like? (2021, August 3). Beck Institute Cares. Retrieved November 16, 2021, from https://cares.beckinstitute.org/about-cbt/what-are-sessions-like/

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Frequently Asked Questions

How much does cbt cost.

CBT sessions generally cost about $100 to $200 out of pocket. Your insurance may cover it depending on their coverage for mental health treatments. If covered, insurance can reduce CBT sessions to around $25 to $75 each. If you’re considering CBT group therapy , the cost can be significantly lower. Group sessions tend to range from $25 to $50 per person, depending on the provider.

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What Is Therapy Homework?

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Types of Therapy That Involve Homework

If you’ve recently started going to therapy , you may find yourself being assigned therapy homework. You may wonder what exactly it entails and what purpose it serves. Therapy homework comprises tasks or assignments that your therapist asks you to complete between sessions, says Nicole Erkfitz , DSW, LCSW, a licensed clinical social worker and executive director at AMFM Healthcare, Virginia.

Homework can be given in any form of therapy, and it may come as a worksheet, a task to complete, or a thought/piece of knowledge you are requested to keep with you throughout the week, Dr. Erkfitz explains.

This article explores the role of homework in certain forms of therapy, the benefits therapy homework can offer, and some tips to help you comply with your homework assignments.

Therapy homework can be assigned as part of any type of therapy. However, some therapists and forms of therapy may utilize it more than others.

For instance, a 2019-study notes that therapy homework is an integral part of cognitive-behavioral therapy (CBT) . According to Dr. Erkfitz, therapy homework is built into the protocol and framework of CBT, as well as dialectical behavior therapy (DBT) , which is a sub-type of CBT.

Therefore, if you’re seeing a therapist who practices CBT or DBT, chances are you’ll regularly have homework to do.

On the other hand, an example of a type of therapy that doesn’t generally involve homework is eye movement desensitization and reprocessing (EMDR) therapy. EMDR is a type of therapy that generally relies on the relationship between the therapist and client during sessions and is a modality that specifically doesn’t rely on homework, says Dr. Erkfitz.

However, she explains that if the client is feeling rejuvenated and well after their processing session, for instance, their therapist may ask them to write down a list of times that their positive cognition came up for them over the next week.

"Regardless of the type of therapy, the best kind of homework is when you don’t even realize you were assigned homework," says Erkfitz.

Benefits of Therapy Homework

Below, Dr. Erkfitz explains the benefits of therapy homework.

It Helps Your Therapist Review Your Progress

The most important part of therapy homework is the follow-up discussion at the next session. The time you spend reviewing with your therapist how the past week went, if you completed your homework, or if you didn’t and why, gives your therapist valuable feedback on your progress and insight on how they can better support you.

It Gives Your Therapist More Insight

Therapy can be tricky because by the time you are committed to showing up and putting in the work, you are already bringing a better and stronger version of yourself than what you have been experiencing in your day-to-day life that led you to seek therapy.

Homework gives your therapist an inside look into your day-to-day life, which can sometimes be hard to recap in a session. Certain homework assignments keep you thinking throughout the week about what you want to share during your sessions, giving your therapist historical data to review and address.

It Helps Empower You

The sense of empowerment you can gain from utilizing your new skills, setting new boundaries , and redirecting your own cognitive distortions is something a therapist can’t give you in the therapy session. This is something you give yourself. Therapy homework is how you come to the realization that you got this and that you can do it.

"The main benefit of therapy homework is that it builds your skills as well as the understanding that you can do this on your own," says Erkfitz.

Tips for Your Therapy Homework

Below, Dr. Erkfitz shares some tips that can help with therapy homework:

• Set aside time for your homework: Create a designated time to complete your therapy homework. The aim of therapy homework is to keep you thinking and working on your goals between sessions. Use your designated time as a sacred space to invest in yourself and pour your thoughts and emotions into your homework, just as you would in a therapy session .
• Be honest: As therapists, we are not looking for you to write down what you think we want to read or what you think you should write down. It’s important to be honest with us, and yourself, about what you are truly feeling and thinking.
• Practice your skills: Completing the worksheet or log are important, but you also have to be willing to put your skills and learnings into practice. Allow yourself to be vulnerable and open to trying new things so that you can report back to your therapist about whether what you’re trying is working for you or not.
• Remember that it’s intended to help you: Therapy homework helps you maximize the benefits of therapy and get the most value out of the process. A 2013-study notes that better homework compliance is linked to better treatment outcomes.
• Talk to your therapist if you’re struggling: Therapy homework shouldn’t feel like work. If you find that you’re doing homework as a monotonous task, talk to your therapist and let them know that your heart isn’t in it and that you’re not finding it beneficial. They can explain the importance of the tasks to you, tailor your assignments to your preferences, or change their course of treatment if need be.

"When the therapy homework starts 'hitting home' for you, that’s when you know you’re on the right track and doing the work you need to be doing," says Erkfitz.

A Word From Verywell

Similar to how school involves classwork and homework, therapy can also involve in-person sessions and homework assignments.

If your therapist has assigned you homework, try to make time to do it. Completing it honestly can help you and your therapist gain insights into your emotional processes and overall progress. Most importantly, it can help you develop coping skills and practice them, which can boost your confidence, empower you, and make your therapeutic process more effective.

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Conklin LR, Strunk DR, Cooper AA. Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression . Cognit Ther Res . 2018;42(1):16-23. doi:10.1007/s10608-017-9873-6

Lebeau RT, Davies CD, Culver NC, Craske MG. Homework compliance counts in cognitive-behavioral therapy . Cogn Behav Ther . 2013;42(3):171-179. doi:10.1080/16506073.2013.763286

By Sanjana Gupta Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

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• Valued Living Questionnaire (Version 2) | Wilson, Groom | 2002 Download Archived Link
• Scale Download Primary Link Archived Link
• Scale Download Archived Link
• Zimmerman, M., Chelminski, I., McGlinchey, J. B., & Posternak, M. A. (2008). A clinically useful depression outcome scale. Comprehensive psychiatry, 49(2), 131-140.
• Reference Zung, W. W. (1965). A self-rating depression scale. Archives of General Psychiatry, 12(1), 63-70.
• Scale – Adult Download Primary Link Archived Link
• Scale – Child Age 11-17 Download Primary Link Archived Link
• Scale phqscreeners.com Download Primary Link
• Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: a new depression diagnostic and severity measure. Psychiatric annals, 32(9), 509-515.
• MADRS Score Card Download Archived Link
• Montgomery, S.A., Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134 (4): 382–89.
• Hamilton M. (1960). A rating scale for depression. J Neurol Neurosurg Psychiatry, 23, 56–62.
• Scale Download Primary Link
• Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. The British Journal of Psychiatry, 150(6), 782-786.

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• Depression In Adults: Treatment And Management (NICE Guideline) | NICE | 2022 Download Primary Link
• Behavioural activation treatment for depression (BATD) manual | Lejuez, Hopko & Hopko | 2001 Download Archived Link
• Suicide and self injury: a practitioners guide | Forensic Psychology Practice Ltd | 1999 Download Archived Link
• Behavioural activation treatment for depression – revised (BATD-R) manual | Lejuez, Hopko, Acierno, Daughters, Pagoto | 2011 Download Archived Link
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• Cognitive-behavioral therapy for depression in young people: a modular treatment manual | Orygen | 2015 Download Primary Link Archived Link
• Group therapy manual for cognitive behavioral treatment of depression | Muñoz, Miranda | 1993 Download Archived Link
• CBT For Depression In Veterans And Military Service Members – Therapist Manual | Wenzel, Brown, Carlin | 2011 Download Primary Link Archived Link
• Cognitive behaviour therapy for depression in young people: manual for therapists | Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT) Study CBT Sub-Group | 2010 Download Primary Link Archived Link
• Cognitive-Behavioural Therapy (CBT) Group Program For Depression | Milner, Tischler, DeSena, Rimer Download Primary Link Archived Link
• Manual for group cognitive-behavioral therapy of major depression: a reality management approach (Instructor’s manual) | Muñoz, Ippen, Rao, Le, Dwyer | 2000 Download Primary Link
• Individual therapy manual for cognitive-behavioural treatment of depression | Ricardo Muñoz, Jeanne Miranda | 1996 Download Primary Link Archived Link
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Recommended Reading

• Behavioural activation treatment for depression: returning to contextual roots | Jacobson, Martell, Dimidjian | 2001 Download Primary Link Archived Link

What Is Depression?

Signs and symptoms of depression.

To meet DSM-5 diagnostic criteria for major depressive disorder an individual must have experienced five of the following symptoms for at least two weeks:

• a depressed mood that is present most of the day, nearly every day
• diminished interest in activities which were previously experienced as pleasurable
• fatigue or a loss of energy
• sleep disturbance (insomnia or hypersomnia)
• feelings of worthlessness, self-reproach, or excessive guilt
• a diminished ability to think or concentrate, or indecisiveness
• recurrent thoughts of death or suicide, or suicidal behavior
• changes in appetite marked by a corresponding weight change
• psychomotor agitation or retardation to a degree which is observable by others

Psychological Models and Theory of Depression

Beck’s cognitive theory of depression (Beck, Rush, Shaw, & Emery, 1979) forms the basis for cognitive behavioral approaches for the treatment of depression. Beck’s theory proposes that there are different levels of cognition that can be dysfunctional in depression: core beliefs, rules and assumptions, and negative automatic thoughts. CBT aims to balance negatively biased cognition with more rational and accurate thoughts, beliefs, and assumptions. CBT also systematically aims to increase levels of rewarding activity.

Acceptance and commitment therapy (ACT) proposes that distress, including symptoms of depression, are the result of psychological inflexibility (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Indicators of psychological inflexibility include:

• ‘buying in’ to negative thoughts and narratives;
• engaging in worry or rumination that takes us away from the present moment;
• losing contact with our values—what is important to us.

Evidence-Based Psychological Approaches for Working with Depression

Many psychological therapies have an evidence base for working with depression:

• Cognitive behavioral therapy (CBT)
• Behavioral activation (BA)
• Acceptance and commitment therapy (ACT)
• Mindfulness-based cognitive therapy (MBCT) for preventing relapse
• Interpersonal therapy (IPT)

Resources for Working with Depression

Psychology Tools resources available for working therapeutically with depression may include:

• psychological models of depression
• information handouts for depression
• exercises for depression
• CBT worksheets for depression
• self-help programs for depression
• Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression . New York: Guilford Press.
• Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy , 44 (1), 1–25.
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9 CBT Worksheets and Tools for Anxiety and Depression

CBT is one of the most effective psychological treatments when it comes to managing anxiety and depression, and can be a highly useful approach to apply in online therapy.

If you help clients tackle cognitive distortions and unhelpful thinking styles, we’ve compiled a list of essential worksheets that should be part of your therapy toolbox.

How To Use CBT Worksheets in Therapy

Cognitive-behavioral therapy (CBT) is based on the idea that thoughts, feelings, physical sensations and behaviors are interlinked, and that changing negative thought patterns can enhance the way we act and feel.

It encompasses a variety of techniques and interventions that have been proven effective in the treatment of many mental disorders.

Besides anxiety and depression, a few examples include: [1]

• Panic disorder
• Bipolar disorder
• Borderline personality disorder, and
• Obsessive-compulsive disorder.

With the advent of online therapy, guided online CBT has become an increasingly popular way for mental health professionals to help clients manage behavioral health conditions without the need to meet in person as often.

CBT worksheets, exercises, and activities play a large role in these treatments to encourage further progress between sessions, in the same way that face-to-face CBT involves between-session practice. [2]

The Importance of Tailoring CBT Worksheets to Individual Needs

While CBT worksheets are effective tools, it is crucial to tailor these resources to the unique needs of each client.

Every individual’s experience with anxiety and depression is different, and a one-size-fits-all approach may not be as effective. Personalization involves understanding the specific triggers, thought patterns, and behaviors of a client.

For instance, a client struggling with social anxiety may benefit more from worksheets focusing on exposure and social skills training, while someone with generalized anxiety disorder might need tools aimed at managing worry and improving relaxation techniques.

Customizing worksheets also means considering the client’s cultural background, personal preferences, and level of cognitive functioning.

This tailored approach not only enhances the therapeutic alliance but also ensures that the interventions are more impactful, leading to better outcomes.

Therapists should regularly review and adjust the worksheets to keep them relevant and aligned with the client’s progress and evolving needs.

5 Example Tools For Treating Anxiety

So what types of online CBT worksheets can be used to help clients cope better with symptoms of anxiety ?

There is a wide spectrum of therapeutic approaches that range from self-help activities to guided interventions, and all of them focus on identifying and changing unhelpful thoughts, feelings, and behaviors.

Here are a few of the best-known techniques that can be applied with the right tools.

Identifying cognitive distortions

Recognizing and identifying maladaptive automatic thoughts is a main goal of CBT.

Recognizing and identifying maladaptive automatic thoughts is a main goal of CBT. Cognitive distortions describe inaccurate or exaggerated perceptions, beliefs, and thoughts that can contribute to or increase anxiety, so increasing a client’s awareness of these is the first step to unraveling them and feeling better.

Quenza’s  Unhelpful Thinking Styles – “Shoulding” and “Musting” worksheet, shown below, is an example exercise that can help clients recognize the damaging impacts of using “should” and “must” statements to place unreasonable demands or unnecessary pressure on themselves.

Cognitive restructuring

Cognitive restructuring involves disputing the distortions that underpin a client’s challenges. Various techniques that can be helpful here include Socratic questioning, decatastrophizing, and disputing troublesome thoughts with facts.

One example CBT exercise is the Cognitive Restructuring Expansion shown below, which can help clients identify automatic thoughts and substitute them with more fair, rational ways of thinking.

Journaling and thought records

Journaling is a form of self-monitoring that helps clients identify their thought patterns and emotional tendencies, as shown by the Stress Diary Expansion below.

Journals can involve logging negative thoughts or feelings as homework, with the aim of positioning clients to manage them successfully.

Stress Reduction Techniques

Stress reduction exercises such as deep breathing, meditation, and progressive muscle relaxation can all be effective CBT tools for managing anxiety.

The example below is Quenza’s Progressive Muscle Relaxation exercise, which clients can practice to increase their sense of control and calm when stressed or anxious.

Breathing Exercises

Diaphragmatic breathing is another useful relaxation exercise often used in CBT for anxiety.

With this mindfulness practice, clients learn to regulate their breath and activate their body’s relaxation response, as shown in Quenza’s audio  Diaphragmatic Breathing  exercise below.

CBT Worksheets for Depression (PDF)

CBT worksheets are useful resources for therapists helping clients manage depression, because they can be used to encourage your clients’ progress between sessions.

If you are a mental health professional, the following worksheets can be shared as homework. Each is available as a customizable Quenza Expansion for easy sharing with clients with a $1, 30-day Quenza trial .

The ABC Model of Helpful Behavior

ABC is an acronym for Antecedents, Behavior, and Consequences, and the ABC model proposes that behavior can be learned and unlearned based on association, reward, and punishment.

This CBT worksheet allows clients to reflect on adaptive behavior, thus building their awareness of the triggers for and consequences of this behavior.

After introducing the ABC Model of Behavior and the ABC Model of Helpful Behavior, the exercise asks clients to try it out themselves by:

• Describing a recent personal problem
• Recalling a helpful behavior that they carried out that contributed to the problem in a positive way.
• Recalling the Antecedents of the helpful Behavior – where they were, who they were with, and what they were doing, thinking, and feeling
• Considering the short- and long-term Consequences of that behavior – how they felt, what happened, and what others said or did.

Unhelpful Thinking Styles – Emotional Reasoning

This worksheet invites clients to identify and decrease the negative impact of a specific cognitive bias known as “Emotional Reasoning,” which can be common in clients with depression.

As an introduction, clients learn about the negative impacts of regarding emotions as evidence of the truth, or basing one’s view of situations, yourself, or others on how they feel at a certain moment.

They are then invited to reflect on a time when they used emotional reasoning and describe the situation as well as their thoughts and emotions at the time.

Through self-reflection, this therapy exercise aims to help the user separate their feelings from their thoughts so that they can reduce the negative effect of emotional reasoning on their wellbeing.

De-Catastrophizing

As we’ve seen, patients with symptoms of depression often experience negative thoughts that result from faulty thinking rather than accurate experiences of reality.

Catastrophizing is amplifying the importance of adverse events and situations while minimizing their positive aspects or outcomes. The Decatastrophizing Expansion can be an impactful cognitive restructuring technique to help with this cognitive distortion when it is practiced over time.

Clients are asked to describe the situation that they are currently catastrophizing about before answering a series of questions to challenge their thinking:

• What is the worst that can happen?
• What three events would have to take place for the worst to happen?
• How likely is it that  all three  of these events will take place?
• What is a more likely outcome, given what you know about the situation?

Here’s an example of the PDF copy that you or your clients can download of these exercises:  Decatastrophizing CBT worksheet

To customize these CBT worksheets for depression and browse more, take a look at the $1, 30-day Quenza trial .

Can CBT Help Build Self Esteem?

Studies have shown CBT to be useful in developing a client’s self-esteem so that they start to perceive themselves as more worthy and deserving. [3]

Cognitive restructuring is particularly can equip them with the skills to challenge or refute negative self-talk. This involves:

• Helping clients explore repetitive negative self-talk can be damaging to their sense of self-worth
• Challenging harmful cognitive distortions
• Supporting in the development of a more balanced, positive self-perspective.

Quenza’s Challenging Unhelpful Thoughts , pictured above, is an example CBT worksheet for self-esteem with the following prompts and questions:

• Describe a negative thought that keeps coming back.
• On a scale of 1 to 10, how strongly do you believe this thought to be true?
• What evidence supports this thought?
• What evidence do you have against the thought?
• What would you tell a friend (to help them) who would have the same thought?

Integrating Technology with CBT Worksheets for Enhanced Engagement

The advent of technology has significantly transformed the landscape of psychological treatments, including CBT.

Digital tools and applications can greatly enhance the engagement and effectiveness of CBT worksheets.

Interactive platforms allow clients to complete worksheets on their devices, providing instant feedback and progress tracking.

Additionally, gamification elements, such as rewards for completing tasks or interactive scenarios, can make the therapy process more engaging and motivating for clients.

Teletherapy platforms can integrate these digital worksheets, allowing therapists to monitor their clients’ progress in real time and make adjustments as needed.

Moreover, digital tools often include additional resources like videos, guided meditations, and forums for peer support, which can complement the worksheets and provide a more holistic approach to treatment.

By leveraging technology, therapists can ensure that CBT remains a dynamic and accessible option for clients, regardless of their location or schedule.

CBT Toolbox for Online Therapists

Once you’ve found the most useful tools for your programs and are ready to start treating clients, it’s time to organize them for easy, convenient delivery.

Without a centralized library of digital materials – and the ability to quickly personalize and share them – it’s easy to spend more time than is necessary on the admin side of helping others.

With the right CBT app , you should have an entire toolbox of CBT worksheets plus the tools you need to deliver them:

• Activity design tools: for efficiently creating online CBT interventions
• Customizable templates: e.g., Quenza Expansions that include personalizable science-based exercises and activities
• Documentation tools: e.g., Quenza Notes – A secure, convenient way to create and store session notes and collaborate with clients
• Pathway builder tools: which help you assemble separate worksheets and tools into programs and mental health treatment plans
• Real-time results tracking:  to securely collect and store client responses and results
• A free client app:  so that clients can easily receive, complete, and return your CBT resources and assemble a library of their finished activities.

Whether you’re new to the world of online therapy or coaching or simply looking to increase your impact, our free 30-page guide is a great place to start.

This PDF will give you an easy-to-understand introduction to the essentials of digital practice: how to create and share your own CBT interventions, keep clients engaged in their treatment, and improve your clients’ results while growing and scaling your business.

Click here to download your copy of  Coach, This Changes Everything .

Final Thoughts

Practicing CBT online for the first time may take some adapting, but the ability to help more clients with less work is always worth the payoff.

Hopefully, these worksheets and resources give you a solid starting point for building your CBT toolkit. Let your fellow practitioners know how you use them – leave a comment and join in the conversation below!

• ^ NHS. (2022). Overview - Cognitive behavioural therapy (CBT). Retrieved from https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/cognitive-behavioural-therapy-cbt/overview/
• ^ Harvard Health Publishing. (2015). Online cognitive-behavioral therapy: The latest trend in mental health care. Retrieved from https://www.health.harvard.edu/blog/online-cognitive-behavioral-therapy-the-latest-trend-in-mental-health-care-201511048551
• ^ McKay, M., & Fanning, P. (2016). Self-esteem. New Harbinger.

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Assigning Homework in Cognitive Behavioral Therapy

It’s certainly true that therapy outcomes depend in part on the work taking place in each session. But for this progress to reach its full impact, clients need to use what they learn in therapy during their daily lives. 

Assigning therapy “homework” can help your clients practice new skills during the week. While many types of therapy may involve some form of weekly assignment, homework is a key component of cognitive behavior therapy. 

Types of Homework

Some clients may respond well to any type of homework, while others may struggle to complete or find benefit in certain assignments. It’s important for clients to step outside of their comfort zone in some ways. For example, it’s essential to learn to challenge unwanted thoughts and increase understanding of feelings and emotions, especially for people who struggle with emotional expression. 

But there isn’t just one way to achieve these goals. Finding the right type of homework for each client can make success more likely. 

There are many different types of therapy homework. Asking your client to practice breathing exercises when they feel anxious or stressed? That’s homework. Journaling about distressing thoughts and ways to challenge them, or keeping track of cognitive distortions ? Also homework.

Some clients may do well with different assignments each week, while others may have harder times with certain types of homework. For example:

• An artistic client may not get much from written exercises. They might, however, prefer to sketch or otherwise illustrate their mood, feelings, or reactions during the week. 
• Clients who struggle with or dislike reading may feel challenged by even plain-language articles. If you plan to assign educational materials, ask in your first session whether your client prefers audio or written media. 

When you give the assignment, take a few minutes to go over it with your client. Give an example of how to complete it and make sure they understand the process. You’ll also want to explain the purpose of the assignment. Someone who doesn’t see the point of a task may be less likely to put real effort into it. If you give a self-assessment worksheet early in the therapy process, you might say, “It can help to have a clear picture of where you believe you’re at right now. Later in therapy I’ll ask you to complete another assessment and we can compare the two to review what’s changed.” 

Mental Health Apps

Some people may also find apps a useful way to develop and practice emotional wellness coping skills outside of therapy. Therapy apps can help people track their moods, emotions, or other mental health symptoms. They can provide a platform to practice CBT or other therapy skills. They can also offer structured mindfulness meditations or help clients practice other grounding techniques. 

If you’re working with a client who’s interested in therapy apps, you might try using them in treatment. Just keep in mind that not all apps offer the same benefits. Some may have limitations, such as clunky or confusing interfaces and potential privacy concerns. It’s usually a good idea to check whether there’s any research providing support for—or against—a specific app before recommending it to a client. 

Trusted mental health sources, such as the American Psychological Association or Anxiety and Depression Association of America websites, may list some popular mental health apps, though they may not specifically endorse them. These resources can be a good starting place. Other organizations, including Northwestern University’s Center for Behavioral Intervention Technologies and the Defense Department of the United States, have developed their own research-backed mental health apps. 

You can also review apps yourself. Try out scenarios or options within the app to get to know how the app works and whether it might meet your client’s needs. This will put you in a position to answer their questions and help give them tips on getting the most out of the app. 

Benefits of Homework

Some of your clients may wonder why you’re assigning homework. After all, they signed up for therapy, not school. 

When clients ask about the benefits of therapy homework, you can point out how it provides an opportunity to put things learned in session into practice outside the therapy session. This helps people get used to using the new skills in their toolbox to work through issues that come up for them in their daily lives. More importantly, it teaches them they can use these skills on their own, when a therapist or other support person isn’t actively providing coaching or encouragement. This knowledge is an important aspect of therapy success. 

A 2010 review of 23 studies on homework in therapy found evidence to suggest that clients who completed therapy homework generally had better treatment outcomes. This review did have some limitations, such as not considering the therapeutic relationship or how clients felt about homework. But other research supports these findings, leading many mental health experts to support the use of therapy homework, particularly in CBT. Homework can be one of many effective tools in making therapy more successful. 

Improving Homework Compliance

You may eventually work with a client who shows little interest in homework and doesn’t complete the assignments. You know this could impede their progress in therapy, so you’ll probably want to bring this up in session and ask why they’re having difficulty with the homework. You can also try varying the types of homework you assign or asking if your client is interested in trying out a mental health app that can offer similar benefits outside your weekly sessions. 

When you ask a client about homework non-compliance, it’s important to do it in a way that doesn’t anger them, make them feel defensive, or otherwise damage the relationship you’re working to develop. Here are some tips for having this conversation:

• Let them know homework helps them practice their skills outside of therapy. In short, it’s helping them get more out of therapy (more value for their money) and may lead to more improvement, sometimes in a shorter period of time than one weekly session would alone. 
• Bring up the possibility of other types of homework. “If you don’t want to write anything down, would you want to try listening to a guided meditation or tips to help manage upsetting emotions?” 
• Ask about it, in a non-confrontational way. You might say something like, “Is something making it difficult for you to complete the homework assignments? How can I help make the process easier for you?” 

The prospect of homework in therapy may surprise some clients, but for many people, it’s an essential element of success. Those put off by the term “homework” may view “skills practice” or similar phrasing more favorably, so don’t feel afraid to call it something else. The important part is the work itself, not what you call it.    References:

• Ackerman, C. (2017, March 20). 25 CBT techniques and worksheets for cognitive behavioral therapy. Retrieved from https://positivepsychology.com/cbt-cognitive-behavioral-therapy-techniques-worksheets
• ADAA reviewed mental health apps. (n.d.). Anxiety and Depression Association of America. Retrieved from https://adaa.org/finding-help/mobile-apps
• Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy and Research, 34 (5), 429-438. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939342
• Mental health apps. (n.d.). The American Institute of Stress. Retrieved from https://www.stress.org/mental-health-apps
• Novotney, A. (2016). Should you use an app to help that client? Monitor on Psychology, 47 (10), 64. Retrieved from https://www.apa.org/monitor/2016/11/client-app
• Tang, W, & Kreindler, D. (2017). Supporting homework compliance in cognitive behavioural therapy: Essential features of mobile apps. JMIR Mental Health, 4(2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481663

Professional Resources

• Starting a Private Practice
• Setting Sliding Scale Fees
• Tips for Intake Sessions
• How Salaries Vary Across Industries
• 10 Ways to Strengthen Therapeutic Relationships

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Depression Treatments for Adults

APA's Clinical Practice Guideline recommends seven psychotherapy interventions as well as a second-generation antidepressant (selective serotonin reuptake inhibitors — SSRIs — serotonin-norepinephrine reuptake inhibitors — SNRIs — or norepinephrine/dopamine reuptake inhibitors — NDRIs) for the treatment of depression in adults.

The information below about the recommended interventions is intended to provide clinicians with a basic understanding of the specific treatment approach. Clinicians are encouraged to become familiar with each of the different interventions to determine which of these might be consistent with their practice, to develop a plan for additional training and professional development, and to become informed about the range of evidence-based treatment options in order to help patients with decision-making and any necessary referrals. The information contained herein is not sufficient to enable one to become proficient in delivering these treatments. Clinicians are encouraged to pursue training opportunities and, to become fully competent in new interventions, to receive consultation or supervision while first delivering the intervention. Clinicians and patients should engage in shared decision-making to determine which intervention is right for each clinical situation.

Behavioral Therapy

Behavioral therapy focuses on the relationship between behavior and mood to target current problems and symptoms and focus on changing patterns of behavior that lead to difficulties in functioning.

Introduction to behavioral therapy

Behavioral therapy focuses on having the person re-engage more frequently in activities they once found pleasurable. The person and therapist work together to identify short-term and long-term goals specific to the individual. During the course of behavioral therapy, the person identifies their behaviors and reactions to difficult situations that might be unhelpful in moving forward in life. Instead, the person learns to engage in behaviors that are more likely to reverse the negative patterns. As the individual increases participation in pleasurable activities and changes those behavioral patterns, their mood is expected to improve. On average, adults receive 20-24 weekly sessions of behavioral therapy.

Behavioral therapy is recommended for the treatment of depression in adults.

How behavioral therapy can help treat depression in adults

Individuals with depression often disengage from their relationships and usual activities, perhaps because they perceive themselves as incompetent or as a burden to others. This self-perception and subsequent behavioral withdrawal can negatively influence their mood and lead to a confirmation bias (e.g., an individual feels incompetent and withdraws from task, and by not completing or fully engaging in the task, confirms their prior feeling of incompetence). Behavioral therapy can help address the negative perception of one’s ability to engage in activities of daily living by having the person reverse current patterns and actively participate in pleasurable activities, despite their current depressed mood. The active participation is presumed to increase their mood over time and improve functioning.

Using behavioral therapy to treat depression in adults

Treatment usually begins with the therapist providing an overview of the behavioral theory of depression and explaining how actively engaging in pleasant activities and reducing avoidance/withdrawal in difficult situations can improve one’s mood over time. The therapist and patient work collaboratively to define treatment success and goals. They identify problematic behaviors that impede the patient from experiencing the quality of life they desire (e.g., patient avoids going to work due to feeling guilty or ashamed after receiving a critique of a work assignment) and develop alternatives for coping with such situations.

The patient completes behavior monitoring logs outside of session, where the patient identifies their reaction and coping mechanisms used in difficult situations. This helps the patient and therapist work together to identify behaviors and activities that they will begin to re-engage in to enhance positive, adaptive behavior and reverse patterns of problematic behaviors that have likely contributed to the ongoing depression.

References and resources

American Psychological Association, Div. 12: Society of Clinical Psychology. (n.d.). Treatment: Behavioral activation for depression.  https://www.div12.org/treatment/behavioral-activation-for-depression/

Dimidjian, S., Martell, C.R., Addis, M.E., & Herman-Dunn, R. (2008). Behavioral activation for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 328-364). Guilford Press. https://psycnet.apa.org/record/2008-00599-000

Hopko, D.R., Ryba, M.M., McIndoo, C., & File, A. (2015) Behavioral activation. In A.M. Nezu and C.M. Nezu (Eds.), The Oxford Handbook of Cognitive and Behavioral Therapies (pp. 229-263). Oxford University Press. https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780199733255.001.0001/oxfordhb-9780199733255

Kanter, J.W., Busch, A.M, & Rusch, L.C. (2009). Behavioral activation: Distinctive features . Routledge. https://www.crcpress.com/Behavioral-Activation-Distinctive-Features/Kanter-Busch-Rusch/p/book/9780415446549

Kanter, J.W., Santiago-Rivera, A.L., Santos, M.M., Hurtado, G.D., West, P., Nagy, G., & Lopez, M. Behavioral activation for Latinos: Treatment manual [Unpublished manuscript]. University of Washington. https://www.div12.org/wp-content/uploads/2014/11/Behavioral_Activation_for_Latinos_Manual.pdf (PDF, 765KB)

Lejuez, C.W., & Hopko, D.R. (2013). Behavioral activation (BA) program treatment manual [Unpublished manuscript].  https://www.div12.org/treatment/behavioral-activation-for-depression/

Martell, C.R., Addis, M.E., & Jacobson, N.S. (2001). Depression in context: Strategies for guided action . W.W. Norton. https://psycnet.apa.org/record/2001-06573-000

Martell, C.R., Dimidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for depression: A clinician's guide . Guilford Press. https://www.guilford.com/books/Behavioral-Activation-for-Depression/Martell-Dimidjian-Herman-Dunn/9781462510177/authors

Cognitive Therapy

Cognitive therapy entails modifying pessimistic evaluations and unhelpful thinking patterns with the goal of disrupting these and reducing their interference with daily life.

Introduction to cognitive therapy

The cognitive therapy model proposes that holding negative views (also known as “schemas”) of the self, the world, others and the future are likely to lead to the development of unhelpful thinking patterns that play a role in the biological and emotional symptoms of depression. Cognitive therapy for depression emphasizes modifying these unhelpful thinking patterns. On average, adults receive eight to 28 weekly sessions of cognitive therapy.

Cognitive therapy is recommended for the treatment of depression in adults.

How cognitive therapy can help treat depression in adults

People with depression often look for evidence that confirms their negative perceptions of themselves. These perceptions are often learned earlier in life from their family members, friends and school. People may develop beliefs such as “the environment is dysfunctional or unsafe” or “receiving criticism means one is not worthy of love.” Those beliefs can be triggered when encountering a stressful situation. Cognitive therapy seeks to identify and alter negative schemas that have undue influence in how one feels and behaves in a situation.

Using cognitive therapy to treat depression in adults

Treatment usually begins with the therapist presenting a cognitive model of depression. This involves describing how early thinking patterns can shape the way we view and interpret the present. When those patterns are negative and unquestioned, they can lead to the development of depressive symptoms. A cognitive therapist works with the patient to identify those schemas and unhelpful thinking patterns that drive their own experience of depression. The therapist uses a strategy of Socratic questioning along with other approaches to help the patient arrive at different understandings of situations and events that are personally compelling.

An important component of treatment is completing homework assignments outside of session. The patient learns to identify and record the unhelpful thoughts that trigger negative emotions and then utilizes the Socratic method to analyze and refute those thoughts. These thought records are used in sessions to work together to identify and address root beliefs. By addressing the underlying negative beliefs about the self, the world, others and the future, depressive symptoms are then presumed to subside.

American Psychological Association, Div. 12: Society of Clinical Psychology. (n.d.). Treatment: Cognitive therapy for depression.  https://www.div12.org/treatment/cognitive-therapy-for-depression/

Gilson, M., Freeman, A., Yates, M.J., & Freeman, S.M. (2009). Overcoming depression: A cognitive therapy approach (2nd ed.). Oxford University Press. https://global.oup.com/academic/product/overcoming-depression-9780195371024?cc=us&lang=en&

Young, J.E., Rygh, J.L., Weinberger, A.D., & Beck, A.T. (2008). Cognitive therapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 250-305). Guilford Press. https://psycnet.apa.org/record/2008-00599-000

Cognitive-Behavioral Therapy (CBT)

Cognitive-behavioral therapy targets current problems and symptoms and focuses on recognizing the relationship between behaviors, thoughts, and feelings and changing patterns that reduce pleasure and interfere with a person’s ability to function at their best.

Introduction to CBT

CBT focuses on how thoughts, feelings and behaviors are intertwined in everyday functioning and how changes in any one domain can lead to improvement in the others. The way we view ourselves, the world around us (including other people), and our futures plays a role in how we feel and act in any given situation. CBT aims to modify the unhelpful thinking and behavioral patterns that impair one’s functioning. These changes can lead to healthier behaviors and improved emotion regulation. CBT targets current problems and symptoms and is typically delivered in six to 20 weekly sessions.

CBT is recommended for the treatment of depression in adults.

How CBT can help treat depression in adults

CBT can teach people how to differentiate between their thoughts and feelings and regulate their feelings by questioning their assumptions and beliefs. This is done through identifying and labeling the types of negative thinking patterns described in sessions and in the various exercises the individual completes (e.g., mood log). CBT might also address behavior patterns that contribute to withdrawal and lack of enjoyment with strategies such as helping people identify activities they have enjoyed in the past and planning to engage in them regularly.

Using CBT to treat depression in adults

Treatment begins with the therapist educating the patient about how thoughts, feelings and behaviors interact with each other to influence mood and well-being. The therapist introduces the idea that there are ways to modify thinking and behavioral patterns that could have a positive benefit on emotions and behaviors. Therapists teach patients how to use a variety of techniques to reduce symptoms and improve functioning.

The patient might be encouraged to complete a “mood diary” outside of sessions, noting the situations that triggered the thoughts that then influenced feelings and behaviors in the moment. The patient and therapist then work together to identify common themes that influence the unhelpful thinking and behavior patterns in a particular situation.

The therapist might have the patient challenge their beliefs about themselves (or others), the world, and the future by exposing the patient to a fearful situation (for example, talking to their boss about whether the feedback he/she received was intended as a criticism).

Patients are often encouraged to complete homework assignments to fully develop new skills and build confidence to work through stressful situations.

American Psychological Association, Div. 12: Society of Clinical Psychology. (n.d.). What is cognitive behavioral therapy?  https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral.pdf (PDF, 244KB)

Beck, J.S. (2011). Cognitive behavior therapy: Basics and beyond . Guilford Press. https://beckinstitute.org/product/basics-and-beyond/

Craske, M.G. (2017). Cognitive-behavioral therapy (2nd ed.). American Psychological Association. https://www.apa.org/pubs/books/4317445

Muñoz, R.F., & Miranda, J. (1996). Individual therapy manual for cognitive-behavioral treatment of depression.   https://www.rand.org/content/dam/rand/pubs/monograph_reports/2005/MR1198.6.pdf (PDF, 2.29MB)

Persons, J.B., Davidson, J., & Tompkins, M.A. (2001). Essential components of cognitive-behavior therapy for depression . American Psychological Association. https://www.apa.org/pubs/books/431758A?tab=2

Interpersonal Psychotherapy (IPT)

Interpersonal psychotherapy focuses on improving problematic relationships and circumstances that are most closely linked to the current depressive episode.

Introduction to IPT

IPT aims to improve the person’s relationships with others by learning strategies to effectively communicate emotions and needs as well as problem-solve within a significant relationship. Therapists using IPT emphasize a biopsychosocial explanation of depression, in that negative or distressing events people experience within their lives can exacerbate feelings of sadness and worthlessness. As relationships with others improve, the depressive symptoms may subside, and the person will hopefully experience improved functioning in multiple areas of their life. On average, adults receive 16 to 20 weekly sessions of IPT. If medication is being considered, the panel recommends augmenting IPT with a second-generation antidepressant.

Interpersonal psychotherapy is recommended for the treatment of depression in adults.

How IPT can help treat depression in adults

IPT conceptualizes depression as consisting of three components:

• Depression symptoms: Symptoms are seen as having both biological (e.g., sleep/wake functioning, eating patterns) and psychological (e.g., sadness; feelings of guilt) underpinnings.
• Social functioning: The way one interacts with significant others and responds to social situations. Difficulties in social interactions can lead to or exacerbate depression symptoms.
• Personality difficulties:  Individual characteristics that may be consistent across situations such as difficulty with anger expression, self-esteem and communication. These characteristics can play a role in a person’s response to a social situation which in turn can increase vulnerability to developing symptoms of depression.

While IPT is not expected to have an impact on personality due to the short treatment duration, the interpersonal communication skills attained in treatment may mitigate the impact of one’s personality difficulties on their relationships. In addition, the new social skills can hopefully prevent the development of future episodes of depression by improving coping skills.

Using IPT to treat depression in adults

Treatment begins with a comprehensive evaluation of the person’s social and emotional functioning along with educating the patient about the biopsychosocial model of depression, emphasizing that the illness does not define the person. Next, the therapist will ask questions about their relationships and how he/she interacts within those relationships. This comprehensive review allows the therapist to identify and work with one of the four problems areas that are commonly noted in adults with depression: grief (e.g., long periods of sadness after losing a loved one), role disputes (e.g., not feeling understood), role transitions (e.g., recent move to a new city) and interpersonal deficits (e.g., socially withdrawn).

In the middle stages of treatment, the therapist and patient identify strategies to ameliorate the chosen problem area and improve the patient’s relationships, with the goal of reducing depressive symptoms. The therapist then reviews the interpersonal skills (specifically, perspective-taking and effective communication) that the patient has learned and emphasizes use of these skills outside the office. The therapist might also offer “booster sessions” for the patient to help solidify the skills and possibly prevent future episodes.

American Psychological Association, Div. 12: Society of Clinical Psychology. (n.d.). Treatment: Interpersonal psychotherapy for depression.  https://www.div12.org/treatment/interpersonal-psychotherapy-for-depression/

Bleiberg, K.L., & Markowitz, J.C. (2008). Interpersonal psychotherapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders (4th ed., pp. 306-327). Guilford Press. https://psycnet.apa.org/record/2008-00599-000

Frank, E., & Levenson, J.C. (2011). Interpersonal psychotherapy . American Psychological Association. https://www.apa.org/pubs/books/4317234

Pettit, J.W., & Joiner, T.E. (2006). Chronic depression: Interpersonal sources, therapeutic solutions . American Psychological Association.

Ravitz, P., Watson, P., & Grigoriadis, S. (2013). Psychotherapy essentials to go: Interpersonal psychotherapy for depression (P. Ravitz, & R. Maunder, (Eds.)) W.W. Norton https://books.wwnorton.com/books/978-0-393-70829-5/

Weissman, M.M. (1995). Mastering depression through interpersonal psychotherapy: Patient workbook . Oxford University Press. https://global.oup.com/academic/product/mastering-depression-through-interpersonal-psychotherapy-9780195188479?cc=us&lang=en&

Weissman, M.M., Markowitz, J.C., & Klerman, G. L. (2017). The guide to interpersonal psychotherapy: Updated and expanded edition . Oxford University Press. https://www.oxfordclinicalpsych.com/view/10.1093/med-psych/9780190662592.001.0001/med-9780190662592

Mindfulness-Based Cognitive Therapy (MBCT)

Mindfulness-based cognitive therapy combines strategies of cognitive therapy with mindfulness meditation to modify unhelpful thoughts and develop a kinder, more loving self-view.

Introduction to MBCT

MBCT for depression uses methods from cognitive therapy (CT) with strategies such as mindfulness meditation. MBCT’s aim is to teach people how to recognize intrusive/unhelpful thoughts as mere mental events and view them objectively in a way that is loving and kind to oneself. On average, adults receive eight weekly two-hour sessions of MBCT in a group format. A full-day retreat between the sixth and seventh sessions and post-intervention booster sessions may also be included.

MBCT is recommended for the treatment of depression in adults.

How MBCT can help treat depression in adults

Several theories suggest how depression develops and recurs in adults. People with depression often hold rigidly negative views of themselves, the larger world (including other people), and their futures. They may also form comparisons about how things “should be,” versus how things are. People are also likely to confirm their negative perceptions by focusing on negative aspects instead of viewing events from a more positive perspective. Mindfulness training teaches people how to pay attention to and refocus their thoughts despite the inevitable ways their minds will wander. Through practice, people can develop the ability to alter thoughts, keep themselves in the present moment, and not become stuck in negative thoughts.

Using MBCT to treat depression in adults

MBCT is typically conducted in a small-group format that meets once a week for two hours for eight weeks. The first two sessions consist of educating the group on the theory of mindfulness and how ruminating on stressful situations contributes to the development of depression. Exercises that teach people how to attend to and be “in the moment” include body scanning, mindful eating, breathing and sitting practice. Cognitive exercises such as “affect labeling” are integrated with the mindfulness exercises.

In sessions three and four, group members are taught to remain in the present moment through the practice of “sitting” (focusing on the breath and body) and, at the same time, to identify alternative ways of responding to a stressful situation. Group members continue in sessions five and six with the practice of mindful breathing as well as learning that “thoughts are not facts” and that people have choices in how to respond to a situation.

Homework is assigned after each session and consists of practicing various mindfulness meditation exercises as well as completing brief worksheets on how to accept and acknowledge negative emotions. The group typically participates in a retreat or day-long session that goes over all of the mindfulness and cognitive skills they acquired throughout the course of treatment.

American Psychological Association, Div. 12: Society of Clinical Psychology. (n.d.). Treatment: Mindfulness-based cognitive therapy.  https://www.div12.org/treatment/mindfulness-based-cognitive-therapy/

Kuyken, W., & Evans, A. (2014). Mindfulness-based cognitive therapy for recurrent depression. In R.A. Baer (Ed.) Mindfulness-based treatment approaches (2nd ed.). Academic Press. https://www.elsevier.com/books/mindfulness-based-treatment-approaches/baer/978-0-12-416031-6

Segal, Z.V., Williams, M., & Teasdale, J. (2012). Mindfulness-based cognitive therapy for depression (2nd ed.). Guilford Press. https://www.guilford.com/books/Mindfulness-Based-Cognitive-Therapy-for-Depression/Segal-Williams-Teasdale/9781462537037

Teasdale, J., Williams, M., & Segal, Z.V. (2014). The mindful way workbook: An 8-week program to free yourself from depression and emotional distress . Guilford Press. https://www.guilford.com/books/The-Mindful-Way-Workbook/Teasdale-Williams-Segal/9781462508143

Williams, M., Teasdale, J., Segal, Z.V., & Kabat-Zinn, J. (2007). The mindful way through depression: Freeing yourself from chronic unhappiness . Guilford Press. https://www.guilford.com/books/The-Mindful-Way-through-Depression/Williams-Teasdale-Segal-Kabat-Zinn/9781593851286

Psychodynamic Therapy

Psychodynamic therapy focuses on unconscious thoughts, early experiences and the therapeutic relationship to understand current challenges, improve self-awareness and support the patient in developing more adaptive patterns of functioning.

Introduction to psychodynamic therapy

Psychodynamic therapists encourage the individual to freely explore their current mood and thinking to begin to recognize patterns of behavior and unexpressed feelings. The therapeutic relationship is often used to identify the individual’s common verbal and nonverbal patterns and nuances that negatively impact their other important relationships as well as view of self. The individual can apply lessons learned in the therapeutic relationship to issues he/she is currently experiencing in their personal relationships. Adults generally receive three to 80 weekly sessions of psychodynamic therapy, although the studies the APA guideline development panel reviewed consisted of short-term psychodynamic therapies.

Psychodynamic therapy is recommended for the treatment of depression in adults.

How psychodynamic therapy can help treat depression in adults

A psychodynamic therapy approach to depression treatment frequently emphasizes the role that early experiences, especially experiences of loss, play in the development of vulnerability to abandonment, self-criticism, hopelessness and other interpersonal challenges that can lead to depressive symptoms. Consequent goals of psychotherapy are to develop greater tolerance for uncomfortable feelings and greater reliance on the self, rather than looking to others, to feel good and to handle inevitable disappointments. Psychodynamic therapy, overall, may provide not only relief from suffering but may also help increase people’s self-awareness and appreciation of who they are.

Using psychodynamic therapy to treat depression in adults

There are very different models of psychodynamic therapy. Variations (often integrated in treatment) are based on drive/conflict, interpersonal/relational, or attachment theories. Depending on the patient’s preference, psychodynamic therapy can be either short-term or long-term.

Short-term psychodynamic therapy is time-limited and focuses on one major problem area contributing to the current depression (or other presenting concern). The initial phase of therapy typically involves promoting a supportive environment and providing education about depression. People with depression are often preoccupied with negative, hopeless thoughts, and experience neurovegetative signs and symptoms that are understood as stemming from earlier traumatic events and unresolved feelings.

Although patients are encouraged to engage in external activities that they identify as important and rewarding, the therapy focuses on in-session work to identify core conflicts or maladaptive patterns in the patient’s life. These often involve themes of abandonment and loss and subsequent negative feelings about the experiences. Facilitating increased self-awareness and self-expression, as well as encouraging new behaviors, are essential aims of treatment.

The therapeutic relationship is often used as ground to explore feelings and to provide a corrective experience. The therapist helps patients consolidate their new understandings to better distinguish older conflicts and feelings from current situations. Ending therapy carefully is important, as those patients with core themes of loss may re-experience those emotions as they say goodbye to the therapist. Still, this can be a valuable process for realizing new perspectives and strengths as a result of therapy.

American Psychological Association, Div. 12: Society of Clinical Psychology. (n.d.). Short-term psychodynamic therapy for depression.  https://www.div12.org/treatment/short-term-psychodynamic-therapy-for-depression/

Barber, J. P., Muran, J. C., McCarthy, K. S., Keefe, J. R., & Zilcha-Mano, S. (2021). Research on dynamic therapies. In M. Barkham, W. Lutz, & L. G. Castonguay (Eds.), Bergin and Garfield’s handbook of psychotherapy and behavior change (7th ed., pp. 387-420). Wiley. https://www.wiley.com/en-af/Bergin+and+Garfield's+Handbook+of+Psychotherapy+and+Behavior+Change,+6th+Edition-p-9781118415924

Busch, F.N., Rudden, M., & Shapiro, T. (2016). Psychodynamic treatment of depression (2nd ed.). American Psychiatric Publishing. https://www.appi.org/Psychodynamic_Treatment_of_Depression_Second_Edition

Driessen, E., Hegelmaier, L.M., Abbass, A.A., Barber, J.P., Dekker, J.J.M., Van, H. L.,…Jansma, E. P. & Cuijpers, P. (2015). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update. Clinical Psychology Review, 42 , 1–15. http://dx.doi.org/10.1016/j.cpr.2015.07.004   

Eppel, A. (2018). A manual for short-term psychodynamic psychotherapy. In Short-term psychodynamic psychotherapy (pp. 133-168). Springer. https://www.springer.com/us/book/9783319749945

Gabbard, G.O. (2017). Long-term psychodynamic psychotherapy: A basic text (3rd ed.). American Psychiatric Publishing. https://www.appi.org/Long-Term_Psychodynamic_Psychotherapy_Third_Edition

Haggerty, J. (2018). Psychodynamic psychotherapy. https://psychcentral.com/lib/psychodynamic-therapy/

Messer, S.B., & Warren, C.S. (1998). Models of brief psychodynamic therapy: A comparative approach . Guilford Press. https://psycnet.apa.org/record/1995-98730-000

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist 65 (2), 98-109. https://psycnet.apa.org/fulltext/2010-02208-012.pdf

Summers, R.J. & Barber, J.P. (2009). Psychodynamic psychotherapy: A guide to evidence-based practice . Guilford Press. https://www.guilford.com/books/Psychodynamic-Therapy/Summers-Barber/9781462509706/reviews

Supportive Therapy

Supportive therapy offers a supportive relationship that focuses on helping people explore and understand their experience in their current situation. The focus is on strengthening a person’s ability to make choices that help them cope effectively with various life stressors, from a stance of genuine empathy and supportive listening.

Introduction to supportive therapy

Supportive therapy emphasizes the therapeutic relationship between the person and therapist as the foundation of the treatment of depression in adults. The therapist shows genuine care for the well-being of the person by listening with empathy as well as being flexible in having the person define what successful treatment looks like. Therapists focus on the individual’s current stressors and provide affirmation and support for what the person is currently experiencing to facilitate effective coping. In an environment free of judgment and interpretation, the person shares difficult situations and how they felt about them. On average, adults receive four to 20 weekly or bi-weekly sessions of supportive therapy.

Supportive therapy is recommended for the treatment of depression in adults.

How supportive therapy can help treat depression in adults

Supportive therapy can be helpful for people who are, for example, currently struggling to find meaning in their life or cope with events and situations effectively. People with depression may interpret certain situations with more negativity but can learn to adapt and hold more positive views of themselves. Supportive therapy strives to achieve this via the unconditional support and regard the therapist provides the individual and the flexibility to explore different perspectives. Over time, the individual incorporates the therapist’s empathic perspective of the self into their self-concept. Supportive therapy also helps people better understand their current situations and strengthen their ability to face challenges despite difficulties.

Using supportive therapy to treat depression in adults

Techniques that are foundational to supportive therapy include showing empathy and unconditional positive regard toward the individual’s current struggle by normalizing their feelings, as well as providing suggestions for how to deal with whatever difficult situations the individual might be experiencing. Supportive therapists might also include exercises from a range of therapeutic orientations, such as diaphragmatic breathing or problem-solving. In experiencing the therapist’s empathic listening and unconditional positive regard, the individual will generally feel “heard” and understood and learn to internalize the therapist’s accepting view of the individual, ideally leading to improved self-esteem. The flexibility to explore different perspectives strengthens an individual’s inner resilience and capacity to cope.

Cain, D.J. (2010). Person-centered psychotherapies . American Psychological Association. https://psycnet.apa.org/record/2009-18997-000

Misch, D.A. (2000). Basic strategies of dynamic supportive therapy. The Journal of Psychotherapy Practice and Research, 9 (4), 173-189. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3330607/

Pinsker, H. (2013). A primer of supportive psychotherapy . Routledge. https://www.routledge.com/A-Primer-of-Supportive-Psychotherapy-1st-Edition/Pinsker/p/book/9781315803296

Werman, D.S. (1984). The practice of supportive psychotherapy . Brunner/Mazel. https://www.crcpress.com/Practice-Of-Supportive-Psychotherapy/Werman/p/book/9781138869004#googlePreviewContainer

Medications

Medication is often prescribed for the treatment of depression in adults. As each patient varies in their response and ability to tolerate a specific medication and dosage, medications must be tailored to the individual.

Introduction 

Second-generation antidepressants (selective serotonin reuptake inhibitors — SSRIs, serotonin-norepinephrine reuptake inhibitors — SNRIs or norepinephrine/dopamine reuptake inhibitors — NDRIs) are recommended but the evidence base is insufficient for recommending any specific medication over another.

Please see Table 3 in the full guideline document (PDF. 1.15MB) as well as the evidence grid located in the supplement for more information.

What are second-generation antidepressants?

Second-generation antidepressants include SSRIs, SNRIs and NDRIs. These drugs regulate the neurotransmitters serotonin, norepinephrine and dopamine, which are involved in brain functions related to mood and behavior.

SSRIs help regulate the amount of serotonin that is active in the synapses between neurons. SNRIs address levels of both serotonin and norepinephrine. NDRIs help regulate both norepinephrine and dopamine levels.

The following are common dosage ranges of SSRIs, SNRIs and NDRIs for adults with depression. Shared decision-making between the provider and patient is recommended as individual patients may have different responses to the medications or be concerned about different side effect profiles.

• bupropion (Wellbutrin): 150-450 mg once daily
• citalopram (Celexa): 20-40 mg daily
• desvenlafaxine (Pristiq): 50 mg daily
• duloxetine (Cymbalta): 40-60 mg 1-2 times daily
• escitalopram (Lexapro): 10-20 mg daily
• fluoxetine (Prozac): 10-80 mg daily
• fluvoxamine (Luvox): 50-300 mg daily
• levomilnacipran (Fetzima): 40-120 mg daily
• mirtazapine (Remeron): 15-45 mg daily
• paroxetine (Paxil): 20-40 mg daily
• sertraline (Zoloft): 50-200 mg daily
• trazodone (Desyrel): 150-400 mg once daily
• venlafaxine (Effexor): 75-300 mg once daily
• vilazodone (Viibryd): 20-40 mg daily
• vortioxetine (Brintellix): 10-20 mg daily

Side effects and frequency of prescriber visits

Side effects of second-generation antidepressants are generally mild to moderate side effects that can be tolerated or managed with over-the-counter remedies (e.g., headaches, nausea, drowsiness). Upon initially being prescribed medication, the patient will likely see the prescriber at least a few times within the first eight weeks to check whether he/she is taking the medication as prescribed, as well as to determine whether the dose is optimal and whether the patient is experiencing any adverse side effects.

Once the patient has a stable medication dosage and reports a decrease of symptoms, visits to the prescriber will likely be less frequent. It is generally recommended that medication be continued at the same dose after remission of symptoms, in order to facilitate recovery and to prevent relapse.

Gartlehner, G., Gaynes, B.N., Amick, H.R., Asher, G., Morgan, L.C., Coker-Schwimmer, E., Forneris, C., Boland, E., Lux, L. J., Gaylord, S., Bann, C., Pierl, C. B. & Lohr, K.N. (2015). Nonpharmacological versus pharmacological treatments for adult patients with major depressive disorder (RTI International-University of North Carolina Evidence-based Practice Center Contract No. 290-2012-00008-I). U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality.  https://www.ncbi.nlm.nih.gov/pubmed/26764438  

Kaiser Permanente. (2018). Adult & adolescent depression screening, diagnosis, and treatment guideline . https://wa.kaiserpermanente.org/static/pdf/public/

Before taking any medications, over-the-counter drugs, supplements or herbs, consult a health care provider for a thorough evaluation. American Psychological Association (APA) does not endorse any medications, vitamins or herbs. A qualified health care provider should make a decision based on each person's medical history and current prescriptions. The medication summaries provided do not include all of the information important for patient use and should not be used as a substitute for professional health care advice. The prescribing professional should be consulted concerning any questions that you have.

This website is for informational and educational purposes only. The content is not intended to be a substitute for professional medical or psychological advice, diagnosis or treatment. APA recommends that individuals consult with a mental health professional in order to obtain an accurate diagnosis and to discuss various treatment options. When you meet with a professional, be sure to work together to establish clear treatment goals and to monitor progress toward those goals. Even treatments that have scientific support will not work for everyone, and carefully monitoring your progress will help you and your mental health professional decide if a different approach should be tried.

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Supporting Homework Compliance in Cognitive Behavioural Therapy: Essential Features of Mobile Apps

1 Discipline of Psychiatry, Department of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada

David Kreindler

2 Division of Youth Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

3 Centre for Mobile Computing in Mental Health, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

4 Department of Psychiatry, University of Toronto, Toronto, ON, Canada

Cognitive behavioral therapy (CBT) is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Homework is an integral component of CBT, but homework compliance in CBT remains problematic in real-life practice. The popularization of the mobile phone with app capabilities (smartphone) presents a unique opportunity to enhance CBT homework compliance; however, there are no guidelines for designing mobile phone apps created for this purpose. Existing literature suggests 6 essential features of an optimal mobile app for maximizing CBT homework compliance: (1) therapy congruency, (2) fostering learning, (3) guiding therapy, (4) connection building, (5) emphasis on completion, and (6) population specificity. We expect that a well-designed mobile app incorporating these features should result in improved homework compliance and better outcomes for its users.

Homework Non-Compliance in CBT

Cognitive behavioral therapy (CBT) is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [ 1 , 2 ]. It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [ 3 - 6 ]. Homework is an important component of CBT; in the context of CBT, homework can be defined as “specific, structured, therapeutic activities that are routinely discussed in session, to be completed between sessions” [ 7 ]. Completion of homework assignments was emphasized in the conception of CBT by its creator, Aaron Beck [ 8 ]. Many types of homework are prescribed by CBT practitioners, including symptom logs, self-reflective journals, and specific structured activities like exposure and response prevention for obsessions and compulsions. These can be divided into the following 3 main categories: (1) psychoeducational homework, (2) self-assessment homework, and (3) modality-specific homework. Psychoeducation is an important component in the early stage of therapy. Reading materials are usually provided to educate the client on the symptomatology of the diagnosed illness, its etiology, as well as other treatment-relevant information. Self-assessment strategies, including monitoring one’s mood using thought records, teach the patients to recognize the interconnection between one’s feelings, thoughts, and behaviors [ 8 ]. For example, depressed patients may be asked to identify thinking errors in daily life and document the negative influences these maladaptive thinking patterns can produce on their behaviors. Various psychiatric disorders may require different types of modality-specific homework. For example, exposure to images of spiders is a treatment method specific to arachnophobia, an example of a “specific phobia” in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [ 9 ]. Homework is strategically created by the therapist to correct and lessen the patient’s psychopathology. The purpose of these exercises is to allow the patients to practice and reinforce the skills learned in therapy sessions in real life.

Homework non-compliance is one of the top cited reasons for therapy failure in CBT [ 10 ] and has remained a persistent problem in the clinical practice. Surveys of practitioners have suggested rates of non-adherence in adult clients of approximately 20% to 50% [ 10 , 11 ] while adherence rates in adolescents have been reported to be approximately 50% [ 12 ]. Many barriers to homework compliance have been identified in the literature; to facilitate discussions, they can be divided into internal and external factors. Internal factors originate from a client’s own psychological environment while external ones are created by external influences. Internal factors that have been identified include lack of motivation to change the situation when experiencing negative feelings, the inability to identify automatic thoughts, disregard for the importance or relevance of the homework, and the need to see immediate results [ 12 - 14 ]. Various external factors have also been identified, including the effort associated with pen-and-paper homework formats, the inconvenience of completing homework because of the amount of time consumed, not understanding of the purpose of the homework, lack of instruction, and failure to anticipate potential difficulties in completing the homework [ 14 - 16 ]. There is strong evidence suggesting that homework compliance is integral to the efficacy of CBT in a variety of psychiatric illnesses. In the treatment of depression with CBT, homework compliance has been correlated with significant clinical improvement and shown to predict decreases in both subjective and objective measures of depressive symptoms [ 17 - 23 ]. Similarly, homework compliance is correlated with short-term and long-term improvement of symptoms in anxiety disorders, including generalized anxiety disorder (GAD), social anxiety disorder (SAD), hoarding, panic disorder, and post-traumatic stress disorder (PTSD) [ 17 , 24 - 32 ]. Fewer studies have been done on homework compliance in other psychiatric conditions, but better homework compliance has been correlated with significant reductions in pathological behaviors in psychotic disorders [ 33 , 34 ], cocaine dependence [ 35 , 36 ], and smoking [ 37 ]. Two meta-analyses further support the notion that greater homework adherence is associated with better treatment outcomes in depression, anxiety-related disorders, and substance use [ 38 , 39 ].

The Utility of Technology in Enhancing CBT Homework

Despite its demonstrated efficacy, access to CBT (as well as other forms of psychotherapy) remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ]. With the rise of mass-market mobile communication devices such as the iPhone or other kinds of mobile devices with app capabilities (smartphones), new solutions are being sought that will use these devices to provide therapy to patients in a more cost-effective manner. Mobile phones with app capabilities are portable devices that combine features of a cellphone and a hand-held computer with the ability to wirelessly access the Internet. Over time, ownership of mobile phones in North America has grown [ 41 , 42 ] and progressively lower prices have further reduced barriers to their use and ownership [ 43 , 44 ]. As more and more people acquire mobile phones, the acceptance of and the demand for mobile health solutions have been on the rise [ 45 ]. Boschen (2008), in a review predating the popularization of the modern mobile phone, identified the unique features of the mobile telephone that made it a potentially suitable vehicle for adjunctive therapeutic applications: portability, acceptability, low initial cost, low maintenance cost, social penetration and ubiquity, “always on,” “always connected,” programmability, audio and video output, keypad and audio input, user-friendliness, and ease of use [ 46 ]. Over the last decade, modern mobile phones have supplanted the previous generation of mobile telephones; progressive increases in their computing power, ongoing advances in the software that they run and interact with (eg, JAVA, HTML5, etc.), common feature sets across different operating systems such as Google Inc.'s Android or Apple Inc.'s iOS, and adoption of common hardware elements across manufacturers (eg, touch screens, high-resolution cameras, etc) have enabled the development of platform-independent apps for mobile phones, or at least apps on different platforms with comparable functionality (eg, apps written for Apple's HealthKit or the apps written for Microsoft's HealthVault).

The popularization of the smartphone presents a unique opportunity to enhance CBT homework compliance using adjunctive therapeutic applications such that well-designed mobile software may be able to diminish barriers to CBT [ 40 ] by making CBT therapists' work more cost-effective. However, there are no guidelines and no existing research that directly address the design of mobile phone apps for this purpose. Given this gap in the literature, we searched MEDLINE (1946 to April 2015) and PsycINFO (1806 to April 2015) for all articles related to “cognitive behavioral therapy”, “homework”, “mobile applications” and “treatment compliance or adherence”, and reviewed articles related to (1) mobile technologies that address homework completion, (2) essential features of therapy, or (3) barriers to homework completion in CBT. In this article, we propose a collection of essential features for mobile phone-based apps that will optimally support homework compliance in CBT.

A Proposed List of Essential Features for Mobile Apps That Optimally Support CBT Homework Compliance

In order to be effective for patients and acceptable to therapists, an optimal mobile phone app to support CBT homework compliance should conform to the CBT model of homework while addressing barriers to homework compliance. Tompkins (2002) provides a comprehensive guideline on the appropriate ways to provide CBT homework such that homework should be meaningful, relevant to the central goals of therapy, salient to focus of the session, agreeable to both therapist and client, appropriate to sociocultural context, practiced in session to improve skill, doable, begin small, have a clear rationale, include written instructions, and include a backup plan with homework obstacles [ 47 ]. In addition, the therapist providing the homework needs to be curious, collaborative, reinforce all pro-homework behavior and successful homework completion, and emphasize completion over outcome [ 47 ]. By combining Tompkins' guidelines with the need to reduce barriers to homework compliance (as described above), we obtained the following list of 6 essential features that should be incorporated into mobile apps to maximize homework compliance: (1) congruency to therapy, (2) fostering learning, (3) guiding therapy, (4) building connections, (5) emphasizing completion, and (6) population specificity.

Congruency to Therapy

Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session. A mobile app is no exception; apps have to deliver useful content and be congruent to the therapy being delivered. There are different types of homework in CBT, including (1) psychoeducational homework; (2) self-assessment homework; and (3) modality-specific homework. Which types are assigned will depend on the nature of the illness being treated, the stage of treatment, and the specific target [ 48 ]. An effective app supporting homework compliance will need to be able to adjust its focus as the therapy progresses. Self-monitoring and psychoeducation are major components in the early stage of therapy. Thought records can be used in depression and anxiety while other disorders may require more specific tasks, such as initiating conversation with strangers in the treatment of SAD. Therefore, the treatment modules delivered via mobile phones should meet the specific needs of therapy at each stage of therapy, while also providing psychoeducation resources and self-monitoring capabilities.

Psychoeducational Homework

While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ]. Mobile apps can enhance psychoeducation by delivering clear and concise psychoeducational information linked to the topics being covered in therapy. As psychoeducation is seen as a major component of mobile intervention [ 50 ], it has been incorporated into several mobile apps, some of which have been shown to be efficacious in treating various psychiatric conditions, including stress [ 51 ], anxiety and depression [ 52 ], eating disorders [ 53 ], PTSD [ 54 ], and obsessive compulsive disorder (OCD) [ 55 ]. For example, Mayo Clinic Anxiety Coach is a mobile phone app “designed to deliver CBT for anxiety disorders, including OCD” [ 55 ]. The app contains a psychoeducational module that teaches the user on “the use of the application, the cognitive-behavioral conceptualization of anxiety, descriptions of each anxiety disorder, explanations of CBT, and guidance for assessing other forms of treatment” [ 55 ]. The benefits of delivering psychoeducation via a mobile phone app are obvious: the psychoeducational information becomes portable and is easily accessed by the patient. Furthermore, the information is also curated and validated by proper healthcare authorities, which builds trust and reduces the potential for misinformation that can result from patient-directed Internet searches. However, psychoeducation on its own is not optimal. Mobile interventions that also incorporate symptom-tracking and self-help interventions have resulted in greater improvement when used for depression and anxiety symptoms than those that deliver only online psychoeducation [ 50 ].

Self-Assessment Homework

In contrast to conventional, paper-based homework, mobile apps can support in-the-moment self-assessments by prompting the user to record self-report data about the user’s current state [ 56 ]. While information collected retrospectively using paper records can be adversely affected by recall biases [ 57 ], mobile apps enable the patient to document his or her thoughts and feelings as they occur, resulting in increased accuracy of the data [ 58 ]. Such self-assessment features are found in many mobile apps that have been shown to significantly improve symptoms in chronic pain [ 59 , 60 ], eating disorders [ 61 ], GAD [ 62 ], and OCD [ 55 ]. Continuing with the previous example, the Mayo Clinic Anxiety Coach offers a self-assessment module that “measures the frequency of anxiety symptoms” with a self-report Likert-type scale [ 55 ]. The app tracks users’ progress over time based on the self-assessment data; users reported liking the record of daily symptom severity scores that the application provides.

Modality-Specific Homework

Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages (short message service, SMS) to therapists in bulimia nervosa [ 61 ]. Mayo Clinic Anxiety Coach, for example, has a treatment module for OCD that “guides patients through the use of exposure therapy” [ 55 ]; patients can use this to build their own fear hierarchies according to their unique diagnoses. Users reported liking the app because it contains modality-specific homework that can be tailored to their own needs. Novel formats, such as virtual reality apps to create immersive environments, have been experimented with as a tool for facilitating exposure in the treatment of anxiety disorders with mostly positive feedback [ 64 - 66 ]. Apps that provide elements of biofeedback (such as heart rate monitoring via colorimetry of users' faces using the mobile phone's camera), have recently begun to be deployed. So-called ”serious games,“ (ie, games developed for treatment purposes), are also showing promise in symptom improvement in certain cases [ 51 , 67 , 68 ].

Fostering Learning

Doing CBT homework properly requires time and effort. As noted above, any sense of inconvenience while doing the homework may hamper a patient’s motivation to complete the homework. While patients may appreciate the importance of doing homework, they often find the length of time spent and the lack of clear instructions discouraging, resulting in poor engagement rates [ 49 , 52 ]. Therefore, it makes sense that the tasks should be simple, short in duration to begin with, and include detailed instructions [ 47 ], since homework completion rates have been shown to be correlated with patients’ knowing exactly what to do [ 33 , 69 ]. Many apps incorporate text messaging-based services or personalized feedback to encourage dynamic interactions between the therapist and the client [ 59 ]. However, the types of homework delivered by these apps are fixed. An app that adapts the contents to the user’s progress in learning homework tasks would be more engaging and effective since therapy should be a flexible process by nature. Ideally, the app would monitor and analyze the user’s progress and adjust the homework's content and difficulty level accordingly. While the effectiveness of this type of app has not been studied, a similar app has been described in the literature for treating GAD [ 62 ]. This app, used in conjunction with group CBT, collected regular symptom rating self-reports from patients to track anxiety. Based on patients’ ratings, the app would respond with encouraging comments and invite patients to practice relaxation techniques or prompt the patient to complete specific built-in cognitive therapy modules if their anxiety exceeded a threshold rating. Despite the simple algorithm used to trigger interventions, use of the app with group CBT was found to be superior to group CBT alone.

Guiding Therapy

Therapists have a number of important roles to play in guiding and motivating clients to complete homework. First, the therapist needs to address the rationale of the prescribed homework and work with the client in the development of the treatment plan [ 47 ]. Failure to do this has been identified as a barrier to homework compliance. Second, the therapist should allow the patient to practice the homework tasks during the therapy sessions [ 47 ] in order to build confidence and minimize internal barriers, such as the failing to identify automatic thoughts. Lastly, the therapist has to be collaborative, regularly reviewing homework progress and troubleshooting with the patients [ 47 , 70 ]; this can be done during or in between homework assignments, either in-person or remotely (ie, via voice or text messaging) [ 60 , 71 ].

Reviewing and troubleshooting homework has been seen as a natural opportunity for apps to augment the role of therapists. Individualized guidance and feedback on homework is found in many Internet-based or mobile apps that have been shown to be effective in treating conditions such as PTSD [ 72 ], OCD [ 55 ], chronic pain [ 59 , 60 ], depression and suicide ideation [ 71 ], and situational stress [ 73 ]. Moreover, providing a rationale for homework, ensuring understanding of homework tasks, reviewing homework, and troubleshooting with a therapist have each individually been identified as predictors of homework compliance in CBT [ 74 , 75 ]. However, despite incorporating a variety of features including self-monitoring, psychoeducation, scheduled reminders, and graphical feedback [ 52 ], automated apps with minimal therapist guidance have demonstrated elevated homework non-completion rates of up to 40%, which is less than ideal.

Building Connections

The effects of technology should not interfere with but rather encourage a patient’s ability to build meaningful connections with others [ 76 ]. The therapeutic alliance between the therapist and the client is the strongest predictor of therapeutic outcome [ 77 ] and has been suggested to predict level of homework compliance as well [ 78 ]. While there is no evidence so far to suggest that technology-based interventions have an adverse effect on the therapeutic alliance [ 79 , 80 ], this conclusion should not be generalized to novel technologies as their impact on therapeutic alliance has not been well studied [ 81 ].

An arguably more significant innovation attributable to technology has been its potential to allow patients to form online communities, which have been identified as useful for stigma reduction and constructive peer support systems [ 82 ]. Online or virtual communities provide patients with a greater ability to connect with others in similar situations or with similar conditions than would be possible physically. Internet-delivered CBT that includes a moderated discussion forum has been shown to significantly improve depression symptoms [ 83 ]. Furthermore, professional moderation of online communities increases users’ trust of the service [ 84 ]. Therefore, including social platforms and online forums in a mobile app may provide additional advantages over conventional approaches by allowing easier access to social support, fostering collaboration when completing homework, and enabling communication with therapists.

Emphasizing Completion

A patient’s need to see immediate symptomatic improvement is an impediment to homework compliance since the perception of slow progress can be discouraging to the user [ 35 ]. To address this issue, it is important for both therapists and mobile apps to emphasize homework completion over outcome [ 47 ]. While a therapist can urge the client to finish uncompleted homework during the therapy session to reinforce its importance [ 47 , 85 ], there is little a therapist can do in between therapy sessions to remind clients to complete homework. In contrast, a mobile app can, for example, provide ongoing graphical feedback on progress between sessions to motivate users [ 52 , 86 ], or employ automatic text message reminders, which have been demonstrated to significantly improve treatment adherence in medical illnesses [ 87 ]. These features have previously been incorporated into some technology-based apps for homework adherence when treating stress, depression, anxiety, and PTSD [ 52 , 54 , 88 ] with significant symptom improvement reported in one paper [ 71 ].

Population Specificity

Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels (including learning or cognitive disabilities). One example of how culture-specific design features can be incorporated can be found in Journal to the West, a mobile app for stress management designed for the Chinese international students in the United States, which incorporates cultural features into its game design [ 89 ]. In this game, breathing activity is associated with the concept of “Qi” (natural energy) in accordance with Chinese traditions; the name of the game itself references to a famous Chinese novel and the gaming environment features inkwash and watercolor schemes of the East Asian style, making the experience feel more “natural” as reported by the users. A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ 68 ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders. In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration. Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated.

Other Considerations

There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone [ 47 ]. The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ 90 ]. One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ 52 , 61 , 91 , 92 ]. Privacy and security issues are also real concerns for the users of technology [ 93 ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ 88 , 94 - 98 ]. Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server.

Finally, while this paper focused on “essential” features of apps, this should not be misunderstood as an attempt to itemize all elements necessary for designing a successful piece of software. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface [ 99 ] that is cognitively efficient relative to its intended purpose [ 100 ] and which makes effective use of underlying hardware.

The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. A variety of barriers exist in traditional, paper-based CBT homework that can significantly hamper clients’ motivation to complete homework as directed. The 6 essential features identified in this paper can each potentially enhance homework compliance. Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers. Apps should help the therapist guide the client through therapy and not hinder the therapeutic process or interfere with patient’s building connections with others. It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users.

As an example of how this applies in practice, “Mental Health Telemetry-Anxiety Disorders” (MHT-ANX) is a new mobile app developed by the Centre for Mobile Computing in Mental Health at Sunnybrook Health Sciences Centre in Toronto that helps patients monitor their anxiety symptoms using longitudinal self-report. The symptom log is therapy congruent to the practice of CBT since it promotes patients' awareness of their anxiety symptoms and the symptoms’ intensity. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance. The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship. Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done. While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use. While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance.

Limitations and Future Challenges

The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. For example, as artificial intelligence [ 101 ] or emotional sensing [ 102 ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states.

This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review. The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done. We would anticipate synergistic effects when homework-compliance apps are used in CBT (eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work), but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation.

Abbreviations

Conflicts of Interest: None declared.

How to Design Homework in CBT That Will Engage Your Clients

Take-home assignments provide the opportunity to transfer different skills and lessons learned in the therapeutic context to situations in which problems arise.

These opportunities to translate learned principles into everyday practice are fundamental for ensuring that therapeutic interventions have their intended effects.

In this article, we’ll explore why homework is so essential to CBT interventions and show you how to design CBT homework using modern technologies that will keep your clients engaged and on track to achieving their therapeutic goals.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with a detailed insight into positive CBT and give you the tools to apply it in your therapy or coaching.

This Article Contains:

Why is homework important in cbt, how to deliver engaging cbt homework, using quenza for cbt: 3 homework examples, 3 assignment ideas & worksheets in quenza, a take-home message.

Many psychotherapists and researchers agree that homework is the chief process by which clients experience behavioral and cognitive improvements from CBT (Beutler et al., 2004; Kazantzis, Deane, & Ronan, 2000).

We can find explanations as to why CBT  homework is so crucial in both behaviorist and social learning/cognitive theories of psychology.

Behaviorist theory

Behaviorist models of psychology, such as classical and operant conditioning , would argue that CBT homework delivers therapeutic outcomes by helping clients to unlearn (or relearn) associations between stimuli and particular behavioral responses (Huppert, Roth Ledley, & Foa, 2006).

For instance, imagine a woman who reacts with severe fright upon hearing a car’s wheels skidding on the road because of her experience being in a car accident. This woman’s therapist might work with her to learn a new, more adaptive response to this stimulus, such as training her to apply new relaxation or breathing techniques in response to the sound of a skidding car.

Another example, drawn from the principles of operant conditioning theory (Staddon & Cerutti, 2003), would be a therapist’s invitation to a client to ‘test’ the utility of different behaviors as avenues for attaining reward or pleasure.

For instance, imagine a client who displays resistance to drawing on their support networks due to a false belief that they should handle everything independently. As homework, this client’s therapist might encourage them to ‘test’ what happens when they ask their partner to help them with a small task around the house.

In sum, CBT homework provides opportunities for clients to experiment with stimuli and responses and the utility of different behaviors in their everyday lives.

Social learning and cognitive theories

Scholars have also drawn on social learning and cognitive theories to understand how clients form expectations about the likely difficulty or discomfort involved in completing CBT homework assignments (Kazantzis & L’Abate, 2005).

A client’s expectations can be based on a range of factors, including past experience, modeling by others, present physiological and emotional states, and encouragement expressed by others (Bandura, 1989). This means it’s important for practitioners to design homework activities that clients perceive as having clear advantages by evidencing these benefits of CBT in advance.

For instance, imagine a client whose therapist tells them about another client’s myriad psychological improvements following their completion of a daily thought record . Identifying with this person, who is of similar age and presents similar psychological challenges, the focal client may subsequently exhibit an increased commitment to completing their own daily thought record as a consequence of vicarious modeling.

This is just one example of how social learning and cognitive theories may explain a client’s commitment to completing CBT homework.

Let’s now consider how we might apply these theoretical principles to design homework that is especially motivating for your clients.

In particular, we’ll be highlighting the advantages of using modern digital technologies to deliver engaging CBT homework.

Designing and delivering CBT homework in Quenza

Gone are the days of grainy printouts and crumpled paper tests.

Even before the global pandemic, new technologies have been making designing and assigning homework increasingly simple and intuitive.

In what follows, we will explore the applications of the blended care platform Quenza (pictured here) as a new and emerging way to engage your CBT clients.

Its users have noted the tool is a “game-changer” that allows practitioners to automate and scale their practice while encouraging full-fledged client engagement using the technologies already in their pocket.

To summarize its functions, Quenza serves as an all-in-one platform that allows psychology practitioners to design and administer a range of ‘activities’ relevant to their clients. Besides homework exercises, this can include self-paced psychoeducational work, assessments, and dynamic visual feedback in the form of charts.

Practitioners who sign onto the platform can enjoy the flexibility of either designing their own activities from scratch or drawing from an ever-growing library of preprogrammed activities commonly used by CBT practitioners worldwide.

Any activity drawn from the library is 100% customizable, allowing the practitioner to tailor it to clients’ specific needs and goals. Likewise, practitioners have complete flexibility to decide the sequencing and scheduling of activities by combining them into psychoeducational pathways that span several days, weeks, or even months.

Importantly, reviews of the platform show that users have seen a marked increase in client engagement since digitizing homework delivery using the platform. If we look to our aforementioned drivers of engagement with CBT homework, we might speculate several reasons why.

• Implicit awareness that others are completing the same or similar activities using the platform (and have benefitted from doing so) increases clients’ belief in the efficacy of homework.
• Practitioners and clients can track responses to sequences of activities and visually evidence progress and improvements using charts and reporting features.
• Using their own familiar devices to engage with homework increases clients’ self-belief that they can successfully complete assigned activities.
• Therapists can initiate message conversations with clients in the Quenza app to provide encouragement and positive reinforcement as needed.

The rest of this article will explore examples of engaging homework, assignments, and worksheets designed in Quenza that you might assign to your CBT clients.

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Let’s now look at three examples of predesigned homework activities available through Quenza’s Expansion Library.

Urge Surfing

Many of the problems CBT seeks to address involve changing associations between stimulus and response (Bouton, 1988). In this sense, stimuli in the environment can drive us to experience urges that we have learned to automatically act upon, even when doing so may be undesirable.

For example, a client may have developed the tendency to reach for a glass of wine or engage in risky behaviors, hoping to distract themselves from negative emotions following stressful events.

Using the Urge Surfing homework activity, you can help your clients unlearn this tendency to automatically act upon their urges. Instead, they will discover how to recognize their urges as mere physical sensations in their body that they can ‘ride out’ using a six-minute guided meditation, visual diagram, and reflection exercise.

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Moving From Cognitive Fusion to Defusion

Central to CBT is the understanding that how we choose to think stands to improve or worsen our present emotional states. When we get entangled with our negative thoughts about a situation, they can seem like the absolute truth and make coping and problem solving more challenging.

The Moving From Cognitive Fusion to Defusion homework activity invites your client to recognize when they experience a negative thought and explore it in a sequence of steps that help them gain psychological distance from the thought.

Finding Silver Linings

Many clients commencing CBT admit feeling confused or regretful about past events or struggle with self-criticism and blame. In these situations, the focus of CBT may be to work with the client to reappraise an event and have them look at themselves through a kinder lens.

The Finding Silver Linings homework activity is designed to help your clients find the bright side of an otherwise grim situation. It does so by helping the user to step into a positive mindset and reflect on things they feel positively about in their life. Consequently, the activity can help your client build newfound optimism and resilience .

As noted, when you’re preparing homework activities in Quenza, you are not limited to those in the platform’s library.

Instead, you can design your own or adapt existing assignments or worksheets to meet your clients’ needs.

You can also be strategic in how you sequence and schedule activities when combining them into psychoeducational pathways.

Next, we’ll look at three examples of how a practitioner might design or adapt assignments and worksheets in Quenza to help keep them engaged and progressing toward their therapy goals.

In doing so, we’ll look at Quenza’s applications for treating three common foci of treatment: anxiety, depression, and obsessions/compulsions.

When clients present with symptoms of generalized anxiety, panic, or other anxiety-related disorders, a range of useful CBT homework assignments can help.

These activities can include the practice of anxiety management techniques, such as deep breathing, muscle relaxation, and mindfulness training. They can also involve regular monitoring of anxiety levels, challenging automatic thoughts about arousal and panic, and modifying beliefs about the control they have over their symptoms (Leahy, 2005).

Practitioners looking to support these clients using homework might start by sending their clients one or two audio meditations via Quenza, such as the Body Scan Meditation or S.O.B.E.R. Stress Interruption Mediation . That way, the client will have tools on hand to help manage their anxiety in stressful situations.

As a focal assignment, the practitioner might also design and assign the client daily reflection exercises to be completed each evening. These can invite the client to reflect on their anxiety levels during the day by responding to a series of rating scales and open-ended response questions. Patterns in these responses can then be graphed, reviewed, and used to facilitate discussion during the client’s next in-person session.

As with anxiety, there is a range of practical CBT homework activities that aid in treating depression.

It should be noted that it is common for clients experiencing symptoms of depression to report concentration and memory deficits as reasons for not completing homework assignments (Garland & Scott, 2005). It is, therefore, essential to keep this in mind when designing engaging assignments.

CBT assignments targeted at the treatment of depressive symptoms typically center around breaking cycles of negative events, thinking, emotions, and behaviors, such as through the practice of reappraisal (Garland & Scott, 2005).

Examples of assignments that facilitate this may include thought diaries , reflections that prompt cognitive reappraisal, and meditations to create distance between the individual and their negative thoughts and emotions.

To this end, a practitioner looking to support their client might design a sequence of activities that invite clients to explore their negative cognitions once per day. This exploration can center on responses to negative feedback, faced challenges, or general low mood.

A good template to base this on is the Personal Coping Mantra worksheet in Quenza’s Expansion Library, which guides clients through the process of replacing automatic negative thoughts with more adaptive coping thoughts.

The practitioner can also schedule automatic push notification reminders to pop up on the client’s device if an activity in the sequence is not completed by a particular time each day. This function of Quenza may be particularly useful for supporting clients with concentration and memory deficits, helping keep them engaged with CBT homework.

Obsessions/compulsions

Homework assignments pertaining to the treatment of obsessive-compulsive disorder typically differ depending on the stage of the therapy.

In the early stages of therapy, practitioners assigning homework will often invite clients to self-monitor their experience of compulsions, rituals, or responses (Franklin, Huppert, & Roth Ledley, 2005).

This serves two purposes. First, the information gathered through self-monitoring, such as by completing a journal entry each time compulsive thoughts arise, will help the practitioner get clearer about the nature of the client’s problem.

Second, self-monitoring allows clients to become more aware of the thoughts that drive their ritualized responses, which is important if rituals have become mostly automatic for the client (Franklin et al., 2005).

Therefore, as a focal assignment, the practitioner might assign a digital worksheet via Quenza that helps the client explore phenomena throughout their day that prompt ritualized responses. The client might then rate the intensity of their arousal in these different situations on a series of Likert scales and enter the specific thoughts that arise following exposure to their fear.

The therapist can then invite the client to complete this worksheet each day for one week by assigning it as part of a pathway of activities. A good starting point for users of Quenza may be to adapt the platform’s pre-designed Stress Diary for this purpose.

At the end of the week, the therapist and client can then reflect on the client’s responses together and begin constructing an exposure hierarchy.

This leads us to the second type of assignment, which involves exposure and response prevention. In this phase, the client will begin exploring strategies to reduce the frequency with which they practice ritualized responses (Franklin et al., 2005).

To this end, practitioners may collaboratively set a goal with their client to take a ‘first step’ toward unlearning the ritualized response. This can then be built into a customized activity in Quenza that invites the client to complete a reflection.

For instance, a client who compulsively hoards may be invited to clear one box of old belongings from their bedroom and resist the temptation to engage in ritualized responses while doing so.

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Developing and administering engaging CBT homework that caters to your client’s specific needs or concerns is becoming so much easier with online apps.

Further, best practice is becoming more accessible to more practitioners thanks to the emergence of new digital technologies.

We hope this article has inspired you to consider how you might leverage the digital tools at your disposal to create better homework that your clients want to engage with.

Likewise, let us know if you’ve found success using any of the activities we’ve explored with your own clients – we’d love to hear from you.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Bandura, A. (1989). Human agency in social cognitive theory. American Psychologist , 44 (9), 1175–1184.
• Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., & Wong, E. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed.) (pp. 227–306). Wiley.
• Bouton, M. E. (1988). Context and ambiguity in the extinction of emotional learning: Implications for exposure therapy. Behaviour Research and Therapy , 26 (2), 137–149.
• Franklin, M. E., Huppert, J. D., & Roth Ledley, D. (2005). Obsessions and compulsions. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 219–236). Routledge.
• Garland, A., & Scott, J. (2005). Depression. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 237–261). Routledge.
• Huppert, J. D., Roth Ledley, D., & Foa, E. B. (2006). The use of homework in behavior therapy for anxiety disorders. Journal of Psychotherapy Integration , 16 (2), 128–139.
• Kazantzis, N. (2005). Introduction and overview. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 1–6). Routledge.
• Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta‐analysis. Clinical Psychology: Science and Practice , 7 (2), 189–202.
• Kazantzis, N., & L’Abate, L. (2005). Theoretical foundations. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 9–34). Routledge.
• Leahy, R. L. (2005). Panic, agoraphobia, and generalized anxiety. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 193–218). Routledge.
• Staddon, J. E., & Cerutti, D. T. (2003). Operant conditioning. Annual Review of Psychology , 54 (1), 115–144.

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Ketamine therapy can help people with depression, but also poses risks: experts

Ketamine can be a "life-saving" treatment for depression but also a major risk to patients with a history of addiction, Canadian psychiatrists say after U.S. authorities charged several people in connection with actor Matthew Perry's overdose death.

Police and prosecutors in California allege that five people, including two doctors, supplied the former “Friends” star with dangerous amounts of ketamine before his death last October. The Ottawa-raised actor had been receiving legitimate ketamine infusion treatments for depression but turned to an illicit supply to obtain more doses, they said last week.

Dr. Rebecca Carriere, a psychiatrist who assesses patients for treatment at the Toronto Ketamine Clinic, said Perry should have never been offered the drug in the first place, given his struggles with alcohol and opioid abuse over the years.

“It highlights what we already know about ketamine – that there is a potential for addiction – that’s why it’s only administered in a clinical setting,” Carriere said in an interview.

At the Toronto Ketamine Clinic, "individuals like Matthew Perry typically would not be offered ketamine treatment because of his medical history with addiction," she said.

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“The other side of the conversation certainly has to be around benefits for individuals who have struggled very intensely for a long period of time with depression, trying multiple treatments and not getting any kind of benefit.”

Ketamine is an approved anesthetic for surgeries, but it's also known as a party drug with hallucinogenic effects.

Its use in treatments for depression and anxiety has increased in recent years as more doctors and researchers explore the drug's psychotherapeutic effects. While still an active area of research, ketamine appears to increase glutamate levels, which help regulate mood and cognition.

A ketamine-derived nasal spray called Spravato has been approved in both Canada and the U.S. for use in combination with an oral antidepressant to treat major depressive disorder in patients who did not respond well to other treatments.

However, Health Canada says on its website that it has not assessed the risks and benefits of off-label use of ketamine for the treatment of different mental health conditions.

Several clinical trials are currently underway to test ketamine therapy for depression and other disorders, according to Health Canada's database.

That includes a trial launched two years ago at the Centre for Addiction and Mental Health in Toronto, which admitted about 30 patients. Data on its success is still being analyzed, a spokesperson for the centre said.

There are also a handful of clinics in Canada where patients can pay out-of-pocket for ketamine treatments. At Toronto Ketamine Clinic, six treatments that last about two hours each, plus three sessions with a psychiatrist, cost $4,500 and one-hour blocks of ketamine-assisted psychotherapy cost $235.

The clinic has seen approximately 300 patients since it opened in 2021. Carriere said its anesthesiologists administer ketamine through an intravenous drip and the drug is kept behind two locked doors.

“I think it highlights the safety issue,” said Carriere.

However, the benefits can be life-changing, she said, noting an estimated 70 per cent response rate.

"For those responding (to the treatment), it can be dramatic. I have seen individuals returning to work after having been on disability for depression for some time," she said.

“People describe feeling a lifting up of their mood … they can experience joy again.”

A pilot that launched at Toronto's St. Michael’s Hospital in 2021 has evolved into a regular program where patients with treatment-resistant depression receive two intravenous doses of ketamine per week for two to three weeks, said Dr. Venkat Bhat, director of the hospital’s interventional psychiatry program.

The ketamine treatment program receives eight to 10 referrals per week, with 40 to 50 per cent of patients showing improvement by the end of the standard treatment course, according to the hospital. The program covers the cost of treatment.

While antidepressants can take weeks to have any impact, the effects of ketamine can be evident within a couple of hours to a couple of days, Bhat said.

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“That's what's made ketamine an important therapeutic modality. It can be life saving, but in strictly monitored and specific circumstances.”

C anadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

This report by The Canadian Press was first published Aug. 19, 2024.  

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An elderly woman says she’s lucky to be alive after surviving a stabbing attack while walking her dog near her east London home on Monday morning.

Six local manufacturers receive an economic boost from the federal government

London-based Edge Automation is one of six manufactures from Stratford to Leamington receiving a share of a $7.7 million interest-free loan from FedDev Ontario.

Londoner hits $100,000 jackpot on lottery ticket

A local 25 year old cashed in on his lucky horseshoe – scoring a $100,000 price on an Instant Bingo Doubler lottery ticket.

Young mother killed in head-on Innisfil crash crossed centre line, police say

A young mother who died in a crash in Innisfil in the spring caused the fatal collision, police say.

Boy, 14, hospitalized after alleged stabbing at Barrie park

Police officers are investigating reports a young teen was stabbed at a park in Barrie Tuesday evening.

Guilty plea expected in Barrie hit-and-run that claimed international student's life

A 20-year-old man charged in connection with the death of an international student in Barrie could soon be entering a guilty plea.

Heavy police presence in Chatham, public asked to avoid area

The Chatham-Kent Police Service has alerted the public of a heavy police presence in the area of McNaughton Avenue East between Taylor Trail and Spurgeon Drive.

No threats sent to Windsor Jewish Community

The Windsor Jewish Community did not receive any threats on Wednesday, despite reports of bomb threats that were sent to other Jewish organizations, synagogues and some hospitals across Canada.

$100,000 in damages following morning fire on Ellis Street

Windsor Fire and Rescue Services has reported damages more than $100,000 following an early morning fire on Wednesday.

Vancouver Island

Man charged with mischief for allegedly starting several fires Vernon, B.C.

A 33-year-old man is facing multiple charges for allegedly setting several fires in Vernon on Monday.

West Kelowna police seek help identifying break-and-enter suspect

Mounties in West Kelowna are looking for a suspect they say broke into a local home while a mother and her child were inside.

One year later: Hazards, progress, frustration in wake of West Kelowna wildfire

When the McDougall Creek fire sparked on Aug. 15, 2023, no one could’ve imagined it would mushroom in size, consuming homes, infrastructure and livelihoods in the West Kelowna area with damage that will take years to address.

Crown files notice, may appeal not-guilty verdicts in Coutts murder-conspiracy case

Crown prosecutors in Alberta have given notice they plan to appeal the not-guilty verdicts given to two men arrested at the 2022 blockade at Coutts, Alta.

Whoop-Up Days 2024 kicks off in Lethbridge

Whoop-Up Days are here and plenty of people have already made their way to the exhibition grounds to see what this year has in store.

2024 Whoop-Up Days parade brings out thousands of spectators

Thousands of people dusted off their cowboy hats and boots to take in the 2024 Whoop-Up Days parade on Tuesday.

Sault Ste. Marie

Hwy. 17 east of the Sault reopens after collision

Highway 17 is closed in Thessalon, Ontario Provincial Police said Wednesday afternoon.

Sault stabbing suspect wanted for second-degree murder arrested in Toronto

A year to the day after the fatal stabbing took place in Sault Ste. Marie, 25-year-old Tyler Abbot has been charged with second-degree murder.

Myrle Vokey, beloved educator who created the Newfoundland Screech-in, dead at 85

Myrle Vokey, an educator who created Newfoundland's famed Screech-in ceremony as a way to give people a sense of belonging, died on Saturday at the age of 85, after a road trip and a night out for his 58th wedding anniversary.

Trial begins for Newfoundland RCMP officer accused of assaulting unruly air passenger

A trial is underway for an RCMP officer accused of assaulting an unruly flight passenger after he was escorted off an international flight that had been diverted to the airport in Stephenville, N.L.

Hurricane Ernesto to swing south of Newfoundland, but it will bring heavy rain and high seas

Newfoundland has caught a lucky break with Hurricane Ernesto expected to pass south of the island, but the fast-moving storm will still bring a lot of rain in a short time overnight on Monday, Environment Canada says.

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Matthew Perry’s Death Shines a Harsh Light on Ketamine Treatment

Was Mr. Perry, whose struggles with substance abuse were widely known, a good candidate for a drug used to relieve depression? Doctors say his case raises thorny questions.

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By Matt Stevens and Chris Hamby

The actor Matthew Perry, who had long struggled with addiction, grew intrigued by ketamine a few years ago during a stay at a rehab facility in Switzerland where he received daily infusions of the powerful anesthetic “to ease pain and help with depression.”

“Has my name written all over it — they might as well have called it ‘Matty,’” he later wrote of ketamine, which is known for its dissociative properties, in his 2022 memoir, “ Friends, Lovers and the Big Terrible Thing .” It felt, he said, “like a giant exhale.”

“As the music played and the K ran through me, it all became about the ego, and the death of the ego,” he wrote. “And I often thought that I was dying during that hour. Oh, I thought, this is what happens when you die.” As much as he was drawn to it, he wrote, he found the hangover unpleasant and ultimately decided that “ketamine was not for me.”

But he eventually returned to the drug, getting ketamine treatments from doctors at clinics and then, as he grew addicted to it, buying it from illicit sources and getting multiple injections each day at his Los Angeles home, the authorities have said. On Oct. 28, after he received several shots from his personal assistant, he did die — face down in his hot tub. An autopsy determined that Mr. Perry had died from “the acute effects of ketamine,” with drowning one of several contributing factors.

“ Matthew Perry sought treatment for depression and anxiety and went to a local clinic where he became addicted to intravenous ketamine,” Anne Milgram, the head of the federal Drug Enforcement Administration, said at a news conference last week. “When clinic doctors refused to increase his dosage, he turned to unscrupulous doctors who saw Perry as a way to make quick money.”

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