Comparing skill enhanced and standard cognitive behavioral therapy for depression: a protocol for a randomized trial

Samuel T. Murphy, Brooklynn Bailey, Graham C. Bartels, Lisa N. Vittorio, Megan L. Whelen, Robert J. Zhou, Daniel R. Strunk


Background: Cognitive behavioral therapy (CBT) features prominently among the first-line treatments for depression. The development of CBT skills is associated with both symptom reductions and reduced risk for relapse, suggesting that improvements in CBT skills might be important to the benefits of CBT. Nonetheless, standard CBT places modest emphasis on the development of these skills.

Methods: In this paper, we describe a randomized clinical trial testing the benefits of a variation of CBT that places greater emphasis on teaching patients CBT skills and makes patients' independent use of these skills a central therapeutic goal. Patients in this study (75 per condition) are being randomized to 12 weeks of standard or skill enhanced CBT for depression. The primary outcomes are change in symptoms and change in CBT skills. We will also evaluate the process of change in the treatments.

Conclusions: This study has the potential to suggest an approach to enhancing CBT outcomes through greater focus on patients developing and independently using CBT skills. It will also provide an important context for understanding the role that CBT skills play in the therapeutic outcomes of CBT.

Trial registration: The trial has been registered in Registration number: NCT04673513; registered on 17 December 2020.


Cognitive behavioral therapy, CBT skills, Emotion regulation, Depression, Protocol

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Strunk DR, Adler AD, Hollon SD. Cognitive therapy of depression. DeRubeis RJ, Strunk DR, Editors. The Oxford handbook of mood disorders. Oxford University. 2017;411-22.

Cuijpers P, Karyotaki E, Weitz E, Andersson G, Hollon SD, van Straten A. The effects of psychotherapies for major depression in adults on remission, recovery and improvement: A meta-analysis. J Affect Disord. 2014;159:118-26

Cuijpers P, Hollon SD, van Straten A, Bockting C, Berking M, Andersson G. Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ Open. 2013;3.

Hollon SD, DeRubeis RJ, Shelton RC, Amsterdam JD, Salomon RM, O'Reardon JP, et al. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch Gen Psychiatry. 2005;62(4):417-22.

Bruijniks SJ, DeRubeis RJ, Hollon SD, Huibers MJ. The potential role of learning capacity in cognitive behavior therapy for depression: A systematic review of the evidence and future directions for improving therapeutic learning. Clin Psychol Sci. 2019;7:668-92.

Hundt NE, Mignogna J, Underhill C, Cully JA. The relationship between use of CBT skills and depression treatment outcome: a theoretical and methodological review of the literature. Behav Ther. 2013;44(1):12-26.

Schmidt ID, Pfeifer BJ, Strunk DR. Putting the “cognitive” back in cognitive therapy: Sustained cognitive change as a mediator of in-session insights and depressive symptom improvement. J Consult Clin Psychol. 2019;87:446-56.

Stone SJ, Strunk DR. Fostering Cognitive Change in Cognitive Therapy of Depression: An Investigation of Therapeutic Strategies. Cognitive Therap Res. 2020;44:21-7.

Strunk DR, DeRubeis RJ, Chiu AW, Alvarez J. Patients' competence in and performance of cognitive therapy skills: Relation to the reduction of relapse risk following treatment for depression. J Consult Clin Psychol. 2007;75:523-30.

Bruijniks SJ, Sijbrandij M, Schlinkert C, Huibers MJ. Isolating therapeutic procedures to investigate mechanisms of change in cognitive behavioral therapy for depression. J Exp Psychopathol. 2018;9:2043808718800893.

Bruijniks SJ, Los SA, Huibers MJ. Direct effects of cognitive therapy skill acquisition on cognitive therapy skill use, idiosyncratic dysfunctional beliefs and emotions in distressed individuals: An experimental study. J Behav Therap Exp Psychiatr. 2020;67:101460.

First MB, Williams JBW, Karg RS, Spitzer RL. Structured Clinical Interview for DSM-5 (research version). American Psychiatric Association. 2015.

Salama I, Ivanova A, Qaqish B. Efficient generation of constrained block allocation sequences. Stat Med. 2008;27:1421-8.

Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: Updated guidelines for reporting parallel group randomised trials. Int J Surg. 2012;10:28-55.

Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. Guilford Publications. 1979.

Beck AT, Davis DD, Freeman A. Cognitive therapy of personality disorders. Guilford Publications. 2015.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). 2013. Available at: psychiatrists/practice/dsm. Accessed on 14 June 2021.

Murphy ST, Cooper AA, Hollars SN, Strunk, DR. Who benefits from a cognitive vs. behavioral approach to treating depression? A pilot study of prescriptive predictors. Behav Therap. 2021;52(6):1433-48.

Rush AJ, Trivedi MH, Ibrahim HM, Carmody TJ, Arnow B, Klein DN, et al. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54(5):573-83.

Barber JP, DeRubeis RJ. The ways of responding: A scale to assess compensatory skills taught in cognitive therapy. Behavioral Assessment. 1992;14:93-115.

Mundt JC, Marks IM, Shear MK, Greist JH. The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry. 2002;180:461-4.

Strunk DR, Hollars SN, Adler AD, Goldstein LA, Braun JD. Assessing patients’ cognitive therapy skills: Initial evaluation of the competencies of cognitive therapy scale. Cognitiv Ther Res. 2014;38:559-69.

Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatr Ann. 2002;32:509515.

Hatcher RL, Gillaspy JA. Development and validation of a revised short version of the Working Alliance Inventory. Psychotherap Res. 2006;16:12-25

Harvey AG, Dong L, Lee JY, Gumport NB, Hollon SD, Rabe-Hesketh S, et al. Can integrating the Memory Support Intervention into cognitive therapy improve depression outcome? Study protocol for a randomized controlled trial. Trials. 2017;18(1):539.

Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Personal Social Psychol.1988;54:1063-70.

Spitzer RL, Kroenke K, Williams JB, Löwe, B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Int Med. 2006;166:1092-7.

Beck AT, Steer RA. Beck Hopelessness Scale manual. The Psychological Corporation. 1988.

Weissman AN. The Dysfunctional Attitude Scale: A validation study. Dissertation Abstracts International, 1979;40:1389-90.

Nolen-Hoeksema S, Morrow J. A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. J Personal Soc Psychol. 1991;61:115-21.

Whitmer A, Gotlib, IH. Brooding and reflection reconsidered: A factor analytic examination of rumination in currently depressed, formerly depressed, and never depressed individuals. Cognitiv Therap Res. 2011;35:99-107.

Krueger RF, Derringer J, Markon KE, Watson D, Skodol AE. Initial construction of a maladaptive personality trait model and inventory for DSM-5. Psychol Med. 2012;42(9):1879-90.

Costa PT, McCrae RR. NEO PI-R professional manual. Psychological Assessment Resources, Inc. 1992.

Pfeifer BJ, Strunk DR. Assessing the Disproportionality of Depressive Reactions to Life Stress. Clin Psychol Psychother. 2021.

Cohen S, Kamarck T, Mermelstein R. Perceived Stress Scale. Measuring Stress: A Guide for Health and Social Scientists. 1994;10:1-2.

Dohrenwend BS, Krasnoff L, Askenasy AR, Dohrenwend BP. Exemplification of a method for scaling life events: The PERI Life Events Scale. J Health Soc Behav. 1978;19:205-29.

Hofmann SG, Carpenter JK, Curtiss J. Interpersonal Emotion Regulation Questionnaire (IERQ): Scale Development and Psychometric Characteristics. Cognit Ther Res. 2016;40(3):341-56.

Barkham M, Hardy GE, Startup M. The IIP-32: A short version of the Inventory of Interpersonal Problems. Br J Clin Psychol. 1996;35:21-35.

DeRubeis RJ, Gelfand LA, German RE, Fournier JC, Forand NR. Understanding processes of change: How some patients reveal more than others—and some groups of therapists less—about what matters in psychotherapy. Psychother Res. 2014;24:419-28.

Devilly GJ, Borkovec TD. Psychometric properties of the credibility/expectancy questionnaire. J Behav Therap Exp Psychiatr. 2000;31:73-86.

Fitzpatrick OM, Whelen ML, Falkenström F, Strunk DR. Who benefits the most from cognitive change in cognitive therapy of depression? A study of interpersonal factors. J Consult Clin Psychol. 2020;88(2):128-36.

Sasso KE, Strunk DR, Braun JD, DeRubeis RJ, Brotman MA. Identifying moderators of the adherence-outcome relation in cognitive therapy for depression. J Consult Clin Psychol. 2015;83:976-84.

Huibers MJH, Lorenzo-Luaces L, Cuijpers P, Kazantzis N. On the Road to Personalized Psychotherapy: A Research Agenda Based on Cognitive Behavior Therapy for Depression. Front Psychiatry. 2021;11:607508.

Cohen ZD, DeRubeis RJ. Treatment selection in depression. Ann Rev Clin Psychol. 2018;14:209-36.