Individual Cognitive Behavioral Therapy Research Articles

Cognitive behavioral therapy for anxiety and opioid use disorder: Development and pilot testing

IntroductionAnxiety disorders are highly prevalent among people with opioid use disorder (OUD), and they have a negative impact on disorder course and treatment outcomes. The objective of this Stage 1 A/1B behavioral treatment development trial was to develop a novel cognitive-behavioral therapy (CBT) protocol for co-occurring anxiety disorders and OUD. MethodsFollowing a period of iterative manual development involving patient interviews and feedback from content experts, we tested a 12-session individual CBT protocol in a small, open pilot trial (N = 5). This was followed by a small, randomized controlled trial (N = 32), comparing the new protocol to 12 sessions of manualized Individual Drug Counseling. All participants also received medication for OUD. ResultsOverall, support for feasibility and acceptability was strong, based on recruitment and retention rates and patient satisfaction ratings. Within-subjects results identified 11-point reductions in anxiety symptom severity (on a 0–56 point scale); these gains were sustained through 3 months of follow-up. However, these changes did not differ between randomized conditions. With respect to opioid outcomes, 85 % of participants were abstinent in the prior month at the end of treatment. Opioid use outcomes also did not differ by treatment condition. ConclusionsThese results support the feasibility and acceptability of a CBT protocol for co-occurring anxiety and OUD. However, in this small pilot trial results do not show an initial benefit over an evidence-based psychosocial treatment targeted to OUD alone, in combination with medication for OUD.

Clinical characteristics, treatment course and outcome of adults treated for avoidant/restrictive food intake disorder (ARFID) at a tertiary care eating disorders program

BackgroundAvoidant/restrictive food intake disorder (ARFID) is now recognized as a feeding/eating disorder that affects individuals across the lifespan, but research on ARFID in general and particularly in adults remains limited. The purpose of this study was to describe the demographic and clinical characteristics of adults with ARFID seeking treatment at a tertiary care eating disorders program, and to describe the course and outcomes of treatment at three levels of care—inpatient, intensive outpatient, and outpatient individual therapy.MethodThis retrospective chart review study examined the charts of 42 patients who received treatment for ARFID between April 2020 and March 2023. Following diagnostic assessment, patients were referred to either inpatient treatment, intensive outpatient treatment, or outpatient individual therapy. All three levels of care involved individual cognitive behaviour therapy. Inpatients typically transitioned to one of the outpatient treatments as part of a continuous care plan. We examined demographic and clinical characteristics, treatment length and completion, and changes in key indicators during treatment.ResultsPatients were diverse with respect to demographics (e.g., 62% cisgender women; 21% cisgender men; 17% transgender, non-binary, or other gender) and comorbid concerns (e.g., 43% had neurodevelopmental disorders; > 50% had mood and anxiety disorders; 40% had posttraumatic stress disorder [PTSD]; 35% had medical conditions impacting eating/digestion). Most patients presented with more than one ARFID maintaining mechanism (i.e., lack of appetite/interest, sensory sensitivities, and/or fear of aversive consequences of eating). Treatment completion rates and outcomes were good. On average, patients showed significant improvement in impairment related to their eating disorder, and those who were underweight significantly improved on BMI and were not underweight at end of treatment.DiscussionThese findings add to the literature by indicating that ARFID patients are commonly male or have diverse gender identities, and have high rates of neurodevelopmental, mood, anxiety, and gastrointestinal disorders. We also found high rates of PTSD. The findings show promise for treatment outcomes across the continuum of care. Next steps in ARFID treatment and research include incorporating ARFID-specific assessments into routine care, and ongoing research investigating the efficacy and effectiveness of treatments such as CBT-AR.

Psychodynamic Group Therapy for Eating Disorders: A Narrative Review

Several psychotherapeutic interventions are recommended for Eating Disorders (EDs), chiefly individual cognitive-behavioral therapy and family-based treatments. Manualized individual psychodynamic treatments are recommended for adults with Anorexia Nervosa (AN). Evaluation of psychodynamic group treatments in treating EDs requires further assessment, and recent reviews focused only marginally on this topic. To fill this gap, a narrative review through APA PsychInfo, PubMed and Scopus was carried out. Psychodynamic group treatments appear to improve some ED symptoms at the end of the treatment; however, most of the studies cited were not manualized and lacked control groups and follow-ups. The differences in therapeutic methods and the criteria used to measure remission across the studies included, as well as the incorporation of diverse interventions (including psychodynamic group therapy and elements of BT/CBT or psychoeducation), create difficulties when it comes to forming conclusive judgments about the effectiveness of psychodynamic group therapies for Eating Disorders. The need for more rigorous research and Randomized Controlled Trials (RCTs) is evident.

A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review.

A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review.

Is cognitive behavioral therapy more effective than pharmacotherapy for binge spectrum disorders? A systematic review and meta-analysis.

Binge spectrum disorders are prevalent worldwide. Psychiatric and medical comorbidities are common, and societal costs are significant. Evidence-based treatment remains underutilized. Cognitive behavioral therapy is the recommended first-line treatment, but pharmacotherapy may be easier to access. Meta-analytic evidence directly comparing cognitive behavioral therapy with pharmacotherapy is lacking. We aimed to compare the effects of cognitive behavioral therapy interventions with any pharmacological treatment for binge spectrum disorders. We searched PubMed, Embase, CENTRAL, ClinicalTrials.gov and reference lists for randomized controlled trials comparing cognitive behavioral therapy with any pharmacotherapy for bulimia nervosa/binge eating disorder and performed pairwise meta-analytic evaluations. Primary outcomes are remission and frequency of binges. Secondary outcomes are frequency of purges, response, eating disorder psychopathology, weight/body mass index, depression, anxiety, quality of life and dropouts. Eleven randomized controlled trials comparing cognitive behavioral therapy with fluoxetine/imipramine/desipramine/methylphenidate/sibutramine were identified (N = 531). Cognitive behavioral therapy was superior to antidepressants in terms of remission, frequency of binges and eating disorder psychopathology. There were no statistically significant differences for any of the individual cognitive behavioral therapy vs drug comparisons in terms of response/depression/anxiety/weight/quality of life/dropouts. Cognitive behavioral therapy was not superior to sibutramine/methylphenidate for the primary outcomes. Data are scarce, comparisons underpowered and, considering the inherent methodological limitations of psychotherapy trials, questions arise regarding the presumed superiority of cognitive behavioral therapy. Further research is needed.

Brazilian Psychiatric Association treatment guidelines for generalized anxiety disorder: perspectives on pharmacological and psychotherapeutic approaches.

Generalized anxiety disorder is a highly prevalent mental disorder. Previous data indicate that more than 18 million Brazilians suffer from this condition. Traditionally, generalized anxiety disorder has been considered a mild mental health disorder, despite its links to lower life expectancy, cardiovascular disease, and suicide. The aim of this article is to combine elements of systematic and critical reviews to produce a synthesis of the best evidence about generalized anxiety disorder treatment. Systematic reviews, meta-analyses, and randomized controlled trials were included. The descriptor used in the search was "generalized anxiety disorder," which resulted in 4,860 articles and seven other studies, of which 59 were selected. Antidepressants and benzodiazepines were indicated, as was pregabalin, and atypical antipsychotics, such as quetiapine, have been studied. Individual cognitive behavior therapy (third wave) has proven effective. There is extensive literature on many effective treatments for generalized anxiety disorder. The present review summarizes the therapeutic possibilities, emphasizing those available in Brazil. Further studies are needed to compare other available medications, assess psychotherapies and new treatments in greater depth, as well as to assess the ideal duration of therapy.

Outcomes of adding cognitive behavioral therapy to medication-assisted treatment for opioid use disorder.

With increasing rates of opioid overdose deaths throughout the United States, there is an urgent need to implement interventions to mitigate this trend. Psychosocial interventions are reported to improve retention rates in rehabilitation centers with medication-assisted treatment (MAT) programs for opioid use. In 2020, 14% (187 of 1,309) of opioid overdose deaths in Georgia were in Dougherty County where an intensive outpatient MAT program had historically used twice weekly group therapy plus individual cognitive behavioral therapy (CBT) with an inconsistent duration and frequency. Using existing clinical data, a quality-improvement project was designed and implemented to determine whether 60 min of CBT every other week, in addition to weekly group therapy, and prescription medication would result in higher opioid use disorder treatment retention rates. A 6-month data analysis of monthly MAT reports compared program retention rates from the 3 months before to 3 months after the policy change. The retention rate significantly increased from 8% to 56% (χ 2 = 8.93, p = .01) following the policy change, adding consistent (98%) individual CBT every other week. Implementing a policy with a consistent 60 min of individual CBT every other week in addition to the group counseling twice a week and the prescribed medication was associated with an increased retention rate among patients engaged in MAT for opioid use.

Blended individual and group CBT for OCD in adolescents: model description and a feasibility study

Abstract Cognitive-behavioural treatment for obsessive-compulsive disorder (OCD) is effective across the lifespan but is not widely available across the range of services. Delivering CBT as a blended treatment combining individual and group-based treatment with flexible parental involvement, adapted to the operational style of any particular service, is a promising option which we aimed to examine in OCD with adolescent samples. In a young people’s service based in a University Hospital, we evaluated the impact of a blended treatment combined with flexible parental involvement with adolescents (age 14–18 years of age). The CBT model used with OCD sufferers was a formulation driven approach, emphasising the importance of providing an alternative account linked to the way responsibility beliefs lead to compulsive behaviour. Six consecutively referred adolescents with their parents participated in a treatment group. Intervention consisted of eight individual meetings, eight group meetings and two meetings with parents. Five of six adolescents carried out the whole intervention. Of all participants, 5/5 scored in the clinical range for OCD at baseline, and 5/5 were no longer in the clinical range by the end of treatment; 5/5 were in the clinical range on general psychiatric problems at baseline, and 4/5 were rated as recovered at the end of treatment. Comparable changes were noted in measures of responsibility linked to intrusive thoughts. Use of a blended individual/group treatment based on a CBT model is feasible, with the results obtained being consistent with previous work on individual CBT treatment. Key learning aims (1) Delivering CBT to adolescents with OCD as a blended treatment combining individual and group-based treatment with flexible parental involvement is a promising option which merits further evaluation. (2) OCD symptoms and general psychiatric symptoms were reduced during and after treatment. (3) Use of a blended treatment based on a CBT model is feasible.

Cognitive Behaviour Therapy for Depersonalisation Derealisation Disorder (CBT-f-DDD): Study protocol for a randomised controlled feasibility trial.

Depersonalisation-Derealisation Disorder (DDD) is a distressing mental health condition which causes individuals to have a sense of 'unreality' or detachment about themselves and/or the world around them. DDD is chronically under-researched, and as a result, under-diagnosed, with a population prevalence of about 1%. In systematic reviews, Cognitive Behavioural Therapy (CBT) has been found to be the only intervention with significant clinical impact on alleviating the symptoms of DDD. However, previous studies have suffered from small sample sizes, reliance on expert clinicians to provide therapy and narrow population demographics. This feasibility randomised controlled trial aims to provide more robust evidence for the treatment efficacy of CBT in DDD. The study aims to recruit 40 participants from two NHS trusts, 20 per arm from two community Mental Health NHS services in London. The intervention group will receive 12-24 individual CBT sessions over a 6-month period from CBT therapists following specialist training for DDD. The control group will receive Treatment as Usual. We will assess the feasibility of a future RCT through measuring the acceptability of the intervention, and assessing our ability to recruit, retain and randomise participants. We will calculate the correlation of scores on the Cambridge Depersonalisation Scale, its baseline standard deviation, assess the magnitude/direction of change and characterise the uncertainty in the outcome scores and the probability that the results have been obtained by chance. The outputs of this trial will guide whether a definite RCT is feasible and acceptable, for both the clinician and participant. The ISRCTN registration number is ISRCTN97686121(https://doi.org/10.1186/ISRCTN97686121).

Study protocol for a single-blind, parallel-group, randomised, controlled non-inferiority trial of 4-day intensive versus standard cognitive behavioural therapy for adults with obsessive–compulsive disorder

IntroductionIndividual cognitive behavioural therapy (CBT) with exposure and response prevention is an effective treatment for obsessive–compulsive disorder (OCD). However, individual CBT is costly and time-consuming, requiring weekly therapy sessions for...

Multicultural Dance/Movement Therapy to address Adolescent Depression and Anxiety

Depression and anxiety in the United States are becoming more prevalent in the youth population in recent decades and have been exacerbated by COVID-19 pandemic. Rates of poor mental health outcomes are also more prevalent within gender and racial minorities. Current effective interventions to improve adolescent mental health is limited to individual CBT Therapy and some arts programs. Dance Therapy is a well known alternative arts program that has shown to have physiological, mental, and social benefits. However, traditional group dance therapy programs based on Western culture and ideals neither include the unique experiences of the diversifying student population nor do they wholly address students’ mental and social needs. Cultural dances, in the context of the Western world, are traditional dance practices that serve different functions within the local culture. Many are ancient practices that have shown to have deep psychological and social benefits. Our paper proposes a new school-based multicultural dance therapy program that incorporates international cultural dances to improve physical, mental, and social health. Further research is needed to prove that physical, mental, and social health issues may be resolved through the therapeutic effects of multicultural dance therapy.

Clinical case report: considerable improvement of severe and difficult-to-treat obsessive-compulsive disorder with comorbid depression under treatment with esketamine and concomitant psychotherapy

A 28-year-old man was admitted to our psychiatric ward with severe obsessive-compulsive disorder (OCD) and comorbid depression. At intake, obsessive-compulsive symptoms were present most time of the day and were related to an intense fear of causing interpersonal misunderstandings. Various treatment attempts, including cognitive-behavioural therapy (CBT) with exposure and response prevention (ERP), selective serotonin reuptake inhibitors, clomipramine, and add-on antipsychotics were either ineffective and/or were not tolerated, and the patient’s condition worsened progressively. Following an in-depth multidisciplinary team discussion and a shared decision-making process, an off-label treatment trial with esketamine and concomitant psychotherapy was started. The patient received 10 esketamine + psychotherapy sessions over a period of about 2 months, followed by two maintenance sessions in about 3-week intervals. After this, he was discharged into regular outpatient care where he continued to receive maintenance esketamine treatment every 4–6 weeks and, independent of this, individual CBT. Following the establishment of esketamine with concurrent psychotherapy, the patient exhibited a remarkable clinical improvement. Obsessive-compulsive symptoms showed a clear and sustained response (Y-BOCS before treatment >35, Y-BOCS at week 8 = 23, Y-BOCS at week 26 = 14). Paralleling this, depressive symptoms also decreased (MADRS before treatment = 47, MADRS at week 9 = 12, MADRS at week 26 = 3). At a naturalistic follow-up at week 66, obsessive-compulsive symptoms were still mild (Y-BOCS = 13), and depression was still in remission (MADRS < 6). This clinical case suggests that (es)ketamine plus concomitant psychotherapy may hold promise as a therapeutic strategy for difficult-to-treat OCD and depression and its full clinical potential should be evaluated in more comprehensive future studies.

Tailored internet-delivered cognitive behavioral therapy for individuals experiencing psychological distress associated with climate change: A pilot randomized controlled trial

Even among people who are not directly impacted by the consequences of climate change, perceptions about the ongoing crisis can have a negative effect on mental health and well-being. However, empirical evidence on interventions aiming to provide support is currently scarce. In order to address this issue, a pilot-RCT was carried out to investigate the effects of a novel ICBT treatment program. Sixty participants (23–73 years) were recruited and randomly allocated to eight weeks of therapist-supported ICBT (n = 30) or a wait-list control condition (n = 30). Measures of depressive symptoms, stress, and quality of life were used as primary outcomes, while measures of anxiety, insomnia, climate change–related distress, pro-environmental behaviour, and alcohol use were used as secondary outcomes. The treatment group had moderate to large between-group effects compared to the waitlist group on measures of depression (d = 0.87), stress (d = 0.76), quality of life (d = 0.79) and climate change–related distress (d = 0.79). There were no significant between-group differences on the other outcome measures. The results from this pilot-RCT indicate that individually tailored ICBT can be an effective way to reduce psychological distress associated with climate change without reducing pro-environmental behaviour.

Comparing the effectiveness of CBT and low-frequency rTMS in reducing symptom severity and depression and improving working memory in adults with OCD: a clinical trial

Objective This study aims to compare the effectiveness of cognitive-behavioral therapy (CBT) and low-frequency (LF) repetitive transcranial magnetic stimulation (rTMS) in reducing symptom severity and depression and improving working memory in adults with obsessive–compulsive disorder (OCD). Methods This is a randomized clinical trial conducted on 24 adults with OCD, randomly assigned into two groups of CBT (n = 12, received CBT with exposure and response prevention (ERP) individually at 20 sessions) and rTMS (n = 12, received LF (1-Hz) rTMS over the right dorsolateral prefrontal cortex (DLPFC) at 10 sessions). They completed the Yale-Brown Obsessive Compulsive Scale, the Hamilton Depression Rating Scale, and two N-Back tasks before, immediately, and 1 month after interventions. Results Results showed a significant difference between the two methods in reducing the severity of OCD symptoms (p < 0.05) and depression (p = 0.002) immediately after interventions where the CBT with ERP was more effective, but no significant difference was found in terms of working memory (p > 0.05). No significant difference was found between groups in any study variables 1 month after interventions. Conclusion Individual CBT with ERP is superior to LF rTMS for reducing the severity of symptoms and depression in OCD patients. However, there is no difference between them in improving working memory.

Cognitive change before sudden gains in cognitive behavioural therapy for panic disorder.

Sudden gains occur in a range of disorders and treatments and are of clinical and theoretical significance if they can shed light on therapeutic change processes. This study investigated the relationship between sudden gains in panic symptoms and preceding cognitive change during cognitive behavioural therapy (CBT) for panic disorder. Participants with panic disorder completed in session measures of panic symptoms and catastrophic cognitions. Independent samples t-tests were used to compare the post-treatment score of those who met criteria for one or more sudden gain during treatment with those who did not, and to compare within-session cognitive change between pre-sudden gain sessions and the previous (control) session. Twenty-two (42%) of 53 participants experienced a sudden gain during treatment. Participants demonstrating a sudden gain showed more improvement in panic symptoms from pre- to post-treatment than those without a sudden gain. The within-session cognitive change score in the pre-gain session was significantly greater than in the control session. Sudden gains occurred in individual CBT for panic disorder and within-session cognitive change was associated with sudden gains. This is consistent with the cognitive model of panic disorder and highlights how sudden gains can help to identify key change processes.

Development and preliminary validation of the Group Cognitive Therapy Scale.

The aim of this research was to create a scale to assess the competency of therapists who conduct group cognitive behavioral therapy (G-CBT). The scale is intended to serve as a tool to aid the training of therapists. Three stepped studies were conducted. Process 1: Through literature review and experts' consensus process, essential skills for G-CBT were articulated and categorized according to the criteria of the Cognitive Therapy Scale, a well-established rating scale for evaluating clinicians' skills in individual cognitive behavioral therapy. The list of those skills was organized into a rating scale. Process 2: Behavioral anchors were added to each skill and were classified by the levels of difficulty (beginner, intermediate, and advanced levels), based on the rating by G-CBT experts. Process 3: Inter-rater reliability and validity of the rating scale were examined in a sample of 41 videotaped G-CBT sessions of actual clinical sessions and educational role-plays. The 12-item Group Cognitive Therapy Scale (G-CTS) was developed. It consists of 11 items that are adapted from the original Cognitive Therapy Scale, and a new 12th item called "Intervention using relationships with other participants," which describes therapists' skills to address group dynamics. The G-CTS showed excellent internal consistency (Cronbach's α: 0.95), satisfactory inter-rater reliability (interclass correlation coefficients: 0.65-0.88), and high predictive validity. A novel rating scale to evaluate therapists' competency in G-CBT was developed and successfully validated. The G-CTS behavioral checklist created in this study provides concrete guidelines that can be used by therapists to hone their skills in G-CBT.

State of the art in psychological therapies for psychosis: Family interventions for psychosis.

It is a half-century since the coalescence of social psychiatry and systemic family therapy approaches started to inform condition-specific therapeutic work with families to reduce relapse and hospital readmission for people with schizophrenia. Today, family interventions are a cornerstone of international guidelines for the treatment of psychosis, and of workforce development initiatives. Effect sizes for clinical and economic outcomes are large, and the evidence base is robust and reliable, not only for outcomes but also for the underpinning theoretical models, which are coherent and consistent. Few, if any, psychological therapies, have so powerful a framework to drive widespread implementation. Nevertheless, delivery in clinical services is variable, often lagging behind that of individual cognitive behavioural therapy, notwithstanding its considerably weaker implementation framework. Our aim in this article is to formulate this translation failure and offer potential solutions. We summarise the model/intervention and supporting evidence, then consider why delivery remains problematic. We highlight the inter-linked issues of conceptual confusion between and conflation of, different approaches to working with families; of addressing diagnostic uncertainty, complex comorbidity and adapting interventions for specific populations; and of translation from gold-standard research trial practice, through educational curricula and training programmes, to routine delivery in frontline services. We present our view of clinical, research and workforce development priorities to address these issues and continue the collective effort, moving into the next half-century, to work more effectively with people with psychosis and their families, to further improve outcomes.

Effectiveness of eye communication training device for social anxiety disorder treatment: A single-arm pilot trial

BackgroundSocial anxiety disorder (SAD) is a common mental disorder that is characterized by severe anxiety in social situations. Individual cognitive-behavioral therapy (CBT) for SAD is the recommended first treatment, but there is a critical shortage of CBT-trained therapists. People with SAD often fear and avoid making eye contact, which can lead to social anxiety and difficulty functioning in daily life. If they become able to make eye contact more comfortably, their social life should improve. We developed a gaze training system (Eye Communication Trainer: ECOM) to treat SAD. This study aimed to investigate the efficacy and feasibility of ECOM in the single-arm, uncontrolled trial. MethodsThe ECOM gaze training program consists of 8 weekly sessions. In each session for 20 min, subjects watched forty 30-second videos to practice visual control. The effectiveness of the training was evaluated at baseline, week 4 (mid-point), week 8 (completion), and week 12 (follow-up). The primary outcome was the Liebowitz Social Anxiety Scale (LSAS). The secondary outcomes were Social Phobia Inventory (SPIN), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and EuroQol 5 dimensions (EQ-5D). ResultsTwenty-three subjects participated in the study. One subject did not complete the follow-up. The LSAS total score decreased significantly at week 8 (Hedges' g = 1.35, n = 23) and at week 12 (Hedges' g = 1.80, n = 22). The subjects also showed significant improvement in all secondary outcomes. No adverse events, except dry eye, were reported. ConclusionThe ECOM gaze training shows potential as a new treatment for SAD.

Effectiveness of Cognitive Behavior Therapy on Depression and Quality of Life in Spouse Caregivers of Inpatients With Substance Use Disorders

Background: Substance dependence in families can have a wide range of negative effects on the lives of those close to the dependent person, in addition to causing pain to the dependent person. The present study aims to investigate the effect of cognitive behavioural intervention on depression and quality of life (QoL) in wives who cared for husbands with substance use disorders. Methods: The research was conducted using a quasi-experimental design with pre- and post-tests. Purposive sampling was used to select 60 spouse carers of male inpatients with substance use disorders, who were randomly assigned to the intervention (n=30) and control (n=30) groups. At baseline and post-intervention, all participants completed the Depression Anxiety Stress Scale (DASS-21) and the World Health Organization Quality of Life-Bref (WHO QoL-BREF). The intervention group received eight sessions per week of individual cognitive behavioral therapy (CBT) for 45 to 60 minutes, while the control group did not. Data were analyzed using multivariate analysis of covariance (MANCOVA) in SPSS software, version 26. In statistical tests, the significance level was 0.05. Results: The results showed significant differences between the pre-test and post-test scores of the experimental group; therefore cognitive behavior intervention can significantly reduce depression and improve the QoL of substance dependent’s wife. Conclusion: These results have crucial implications for clinical practice in terms of improving mental health and well-being in the context of male substance use disorder spouse caregivers.

Associations between rumination, depression, and distress tolerance during CBT treatment for depression in a tertiary care setting

BackgroundRumination is strongly associated with depressive symptom severity and course. However, changes in rumination during outpatient cognitive behavioral therapy (CBT), and their links to baseline features such as distress tolerance and clinical outcomes, have received limited attention. Methods278 outpatients with depression received group or individual CBT. Measures of rumination, distress tolerance, and depression symptom severity were assessed at baseline and periodically during treatment. Mixed effect and regression-based models evaluated changes over time, and associations between rumination, distress tolerance and depression severity. ResultsDepression and rumination decreased throughout acute treatment. Rumination reduction was concurrently associated with depressive symptom reduction. Lower levels of rumination at each time point prospectively predicted lower depressive symptoms at the next time point. Distress tolerance measured at baseline was positively associated with depression symptom severity; the indirect effect on post-treatment depression symptoms via rumination measured mid-treatment was nonsignificant when rumination at baseline was accounted for. Changes in and associations between depression and rumination were replicated in sensitivity analyses; although changes in depression and rumination were smaller in magnitude in patients receiving treatment during COVID-19. LimitationsAdditional assessment points would permit a more nuanced assessment of the role rumination may play in mediating the associations between distress tolerance and depression severity. Additional investigation of treatments in community settings may also further our understanding of variability in rumination during depression treatment. ConclusionsThe current study provides unique real-world support for variability in rumination as a key indicator of change over the course of CBT for depression.