Psychotherapy for depression: A randomized clinical trial comparing schema therapy and cognitive behavior therapy (2023)

Journal of Affective Disorders

Volume 151, Issue 2,

November 2013

, Pages 500-505

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The efficacy of Cognitive Behavior Therapy (CBT) for depression has been robustly supported, however, up to fifty percent of individuals do not respond fully. A growing body of research indicates Schema Therapy (ST) is an effective treatment for difficult and entrenched problems, and as such, may be an effective therapy for depression.


In this randomized clinical trial the comparative efficacy of CBT and ST for depression was examined. 100 participants with major depression received weekly cognitive behavioral therapy or schema therapy sessions for 6 months, followed by monthly therapy sessions for 6 months. Key outcomes were comparisons over the weekly and monthly sessions of therapy along with remission and recovery rates. Additional analyses examined outcome for those with chronic depression and comorbid personality disorders.


ST was not significantly better (nor worse) than CBT for the treatment of depression. The therapies were of comparable efficacy on all key outcomes. There were no differential treatment effects for those with chronic depression or comorbid personality disorders. Limitations: This study needs replication.


This preliminary research indicates that ST may provide an effective alternative therapy for depression.


Cognitive behavior therapy (CBT) is recommended as one of the first-line treatments for individuals with major depression (Ellis et al., 2003, National Institute for Clinical Excellence (NICE), 2004). Despite the proven effectiveness of CBT only 40–50% with depression will make a full recovery with their first course of treatment, and some are likely to have a poor outcome despite completing treatment. Moreover, 3–5% may develop a chronic clinical course of depression which is resistant to treatment (Fournier et al., 2009, Hollon et al., 2005, Kessler et al., 1994). Other than chronicity, a number of other factors have been proposed to limit the effectiveness of CBT. Perhaps with the most contradictory evidence, is the treatment outcome when personality disorders are comorbid. A number of studies indicate that treatments are less effective when a comorbid personality disorder is present (e.g. Bagby et al., 2008, Gorwood et al., 2010), with a recent meta analysis reporting the risk of poor outcome doubles (Newton-Howes et al., 2006). Other studies and reviews report no difference in outcome between depressed individuals with and without personality disorders (Kelly et al., 2009, Kool et al., 2005, Niemeyer and Musch, 2013, van den Hout et al., 2006).

Limitations in the effectiveness of traditional CBT for depression, and growing recognition that depression is a chronic and/or recurrent disorder for many people often associated with other comorbid axis I and II problems, has led to increased use by clinicians of Schema Therapy (ST) in the treatment of depression. Schema Therapy was initially developed by Young (1990) for the treatment of personality dysfunction. In contrast to traditional CBT, ST concentrates immediately and specifically on the schema and related developmental processes that prevent individuals having their core needs met in an adaptive manner. It has been proposed that these schema must be modified in order to bring about lasting change, particularly for individuals with more difficult or entrenched problems such as chronic or recurrent depression (Overholser, 1997, Riso et al., 2003, Safran and Segal, 1990, Young, 1990). Further, it has been proposed that any treatment that fails to reorganize or disrupt these fundamental assumptions leaves people cognitively at risk for the reactivation of maladaptive schemas during times of personal stress (Segal et al., 1988), and therefore at increased risk of depression reoccurring. These propositions are supported by research indicating that therapy that focuses more on interpersonal and developmental issues promotes long lasting recovery from depression and, importantly, reduces the risk of relapse (Hayes et al., 1996). Schema change has been associated with the resolution of symptomatic distress (Nordahl and Nysaeter, 2005).

Despite the widespread application of ST, there is still limited research investigating the efficacy of this therapy. Existing research indicates that ST is an effective treatment for borderline personality disorder (Farrell et al., 2009, Giesen-Bloo et al., 2006, Nadort et al., 2009, Nordahl et al., 2005, Nordahl and Nysaeter, 2005), substance dependence (Ball, 1998), chronic agoraphobia (Bamber, 2004) and borderline personality disorder and post-traumatic stress disorder in war veterans (Young, 2005). In the recent randomized clinical trial comparing ST and transference focused psychotherapy, ST also had a significantly lower rate of drop out from treatment than transference focused therapy (Giesen-Bloo et al., 2006). To date the efficacy of ST in treating depression has not been examined, however, specific schemas identified by Young have been shown to be a risk factor for depression (Halvorsen et al., 2010) and preliminary evidence suggests that ST may be effective for depression (Hawke and Provencher, 2011).

The primary aim of the current study was to compare the efficacy of ST with that of traditional CBT for individuals with a current major depressive episode. It was hypothesized that ST would be superior to CBT in achieving sustained change (percentage improvement on the Mongomery Asberg Depression Rating Scale (MADRS)) in depression. Secondary aims were to compare sustained change on self-report (percentage improvement on Beck Depression Inventory-II (BDI-II)) between ST and CBT and to compare the rates of remission and recovery.

Given the proposition that ST may be more effective for chronic problems and/or entrenched problems, we also examined whether or not ST would be more effective in those with chronic depression. Similarly, given that ST was initially developed for those with personality disorders, and given the equivocal treatment outcome findings when depression is comorbid with personality disorders, we examined whether or not ST would produce better outcomes for those depressed patients with a personality disorder.

Section snippets


Participants (males n=31; females n=69) recruited for this study had a principal current diagnosis of major depressive disorder (DSM-IV American Psychiatric Association, 1994) and were over the age of 18 years. Participants were assessed and treated in an outpatient clinical research unit in the Department of Psychological Medicine, University of Otago, Christchurch, New Zealand. Participants were required to be free of any centrally active drug, other than an occasional hypnotic and the oral


Fig. 1 shows the flow of participants through the study. 192 depressed individuals were screened for the study, 100 were randomized to therapy; 50 to CBT and 50 to ST. Seventy eight percent of participants randomized to ST completed (minimum 15 sessions) weekly sessions and 60% completed monthly sessions (minimum 3), and 68% of participants randomized to CBT completed the weekly sessions and 50% completed the monthly sessions. There was no significant difference between ST and CBT in the number


The present study found no difference between ST and CBT outcomes for depression when outcome was assessed with the MADRS and the BDI-II at the end of weekly and monthly (end treatment) therapy sessions. Rates of remission and recovery were also similar between the therapies. At the end of treatment the average percentage change on the clinician-rated MADRS was 50%, with 53 percent of the sample defined as recovered, finding that are consistent with previous treatment studies despite

Role of funding source

This research was funded by grants from the Health Research Council of New Zealand (HRC). The HRC had no further role in any aspect of the study.

Conflict of interest

There are no conflicts of interest.


This research was funded by grants from the Health Research Council of New Zealand (HRC). Particular thanks to the researchers, therapists and clinicians who worked on this study and a special thanks to all those who participated in the study.

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    What is the most effective type of psychological treatment for depression according to empirical research? ›

    Cognitive behavioral therapy (CBT) is one of the most evidence-based psychological interventions for the treatment of several psychiatric disorders such as depression, anxiety disorders, somatoform disorder, and substance use disorder.

    Which form of therapy is most effective for major depression? ›

    Cognitive behavioral therapy (CBT)

    This type of psychotherapy focuses on changing both negative thought processes and behaviors that contribute to depression symptoms. According to research, CBT offers some of the most promising evidence for effective therapeutic treatment for depression available.

    What are the 3 types of cognitive therapies? ›

    Types of Cognitive Behavioral Therapy

    Cognitive Therapy (CT) Dialectical Behavior Therapy (DBT) Rational Emotive Behavior Therapy (REBT)

    What is the difference between CBT and schema therapy? ›

    In CBT, recognizing automatic thoughts and how they make patients feel and behave is sufficient. However, in schema therapy, the focus is to do all of the above while changing the schemas so that they are no longer a hindrance to the patient's adult life.

    What are the 2 most effective treatment methods for most types of depression? ›

    Medications and psychotherapy are effective for most people with depression. Your primary care doctor or psychiatrist can prescribe medications to relieve symptoms.

    What 3 types of therapy have been found to be most effective in treating depression? ›

    Three of the more common methods used in depression treatment include cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy. Often, a blended approach is used.

    What is one of the better approaches to treating depression? ›

    Education, lifestyle changes, social support and psychological therapy are important treatments for depression. People may also require antidepressant medication. Medications may take up to six weeks to be effective, so be patient. Take the time to find the treatment that's right for you.

    What is the most successful form of therapy? ›

    Cognitive behavioral therapy is considered the gold standard in psychotherapy.

    Which psychological therapy would be beneficial to treat depression? ›

    Cognitive behavioural therapy focuses on helping patients become aware of how certain negative automatic thoughts, attitudes, expectations, and beliefs contribute to feelings of sadness and anxiety.

    What is the difference between cognitive therapy and psychotherapy? ›

    Cognitive therapy is more focused on changing unhealthy thought patterns while traditional psychotherapy focuses more on understanding the underlying causes of the condition. Depending on the individual's needs, either approach may be beneficial.

    Who is CBT best suited for? ›

    Uses for CBT

    In addition to depression or anxiety disorders, CBT can also help people with: bipolar disorder. borderline personality disorder. eating disorders – such as anorexia and bulimia.

    What is the cognitive approach to treating depression? ›

    The cognitive approach to treating depression is a type of therapy that focuses on identifying and challenging negative thought patterns that contribute to depressive symptoms. The goal is to help individuals develop more positive and realistic ways of thinking, leading to improved mental health and well-being.

    What is schema therapy best for? ›

    Who can benefit from Schema Therapy? Studies show Schema Therapy is effective for people diagnosed or presenting with features of personality disorders. It can help people with childhood traumas, eating disorders and addictions, to identify and address the underlying schemas from which issues arise.

    What is an example of a schema therapy? ›

    Another example can be given for the Defectiveness schema: A person using an avoidance coping style might avoid situations that make them feel defective, or might try to numb the feeling with addictions or distractions. A person using a surrender coping style might tolerate unfair criticism without defending themself.

    What is the success rate of schema therapy? ›

    This study demonstrates that schema therapy leads to complete recovery in about 50% of the patients, and to significant improvement in two-thirds.

    What is the fastest and probably most effective treatment for severe cases of depression? ›

    Antidepressants can be helpful for people with moderate or severe depression. They're the most effective treatment for relieving symptoms quickly, particularly in severe depression.

    What is currently the most effective treatment for severe or treatment resistant depression? ›

    Psychological counseling (psychotherapy) by a psychiatrist, psychologist or other mental health professional can be very effective. For many people, psychotherapy combined with medication works best. It can help identify underlying concerns that may be adding to your depression.

    What are the two most effective forms of treatment for mental health disorders? ›

    Medication paired with psychotherapy is the most effective way to promote recovery.

    What are two psychological treatments for depression? ›

    Depth psychotherapy: This is similar to analytical therapy, but it focuses more on current conflicts. Systemic therapy: Systemic therapy is based on the assumption that relationships between people, especially those within the family, play an important role in the development and treatment of depression.

    What is the most intense psychotherapy? ›

    Psychoanalysis. One of the earliest forms of psychotherapy, psychoanalysis was invented by Dr. Sigmund Freud, who sought to uncover the mechanisms behind patients' seemingly illogical responses. Psychoanalysis is one of the more intense forms of therapy and is typically composed of three-to-five sessions each week.

    Which type of psychotherapy is most effective for anxiety and depression in general? ›

    Cognitive-Behavioral Therapy (CBT)

    A well-established, highly effective, and lasting treatment is called cognitive-behavioral therapy, or CBT. It focuses on identifying, understanding, and changing thinking and behavior patterns.

    What is the new treatment for depression? ›

    Esketamine is a prescription nasal spray. The low-dose psychedelic drug boosts the activity of glutamate in parts of your brain related to mood. Glutamate's job is to excite cells in the brain and nervous system. Esketamine can trigger new connections in your brain too.

    Which two therapies may be equally effective in reducing depression? ›

    For depression, two kinds of psychotherapy called cognitive-behavioral therapy and interpersonal psychotherapy, as well as antidepressant medications, have been shown to be helpful. There is some evidence that combining psychotherapy and medications may be more effective than either treatment alone.

    What is the best strategy in treating major depressive disorder and persistent depressive disorder? ›

    Talk therapy

    Different types of psychotherapy, such as cognitive behavioral therapy, can be effective for persistent depressive disorder. You and your therapist can discuss your goals for therapy and other issues, such as the length of treatment.

    What is the newest form of therapy? ›

    And while hypnotherapy has been around for a while, therapists are finding new ways to utilize it in treatment.
    1. Brainspotting. Brainspotting has a lot to do with your brain and your eyes. ...
    2. Neurofeedback Therapy. ...
    3. Transcranial Magnetic Stimulation (TMS) ...
    4. Hypnotherapy. ...
    5. Cognitive Control Training.

    What is the success rate of cognitive behavioral therapy? ›

    CBT alone is 50-75% effective for overcoming depression and anxiety after 5 – 15 modules.

    What is the single strongest therapist determinant of successful therapy? ›

    The single greatest determinant of improvement in therapy is the client's resources.

    What does cognitive therapy rely on the most to treat depression? ›

    Cognitive therapy is a treatment process that helps patients correct false self-beliefs that lead to certain moods and behaviors. The fundamental principle behind cognitive therapy is that a thought precedes a mood, and that both are interrelated with a person's environment, physical reaction, and subsequent behavior.

    Which psychological treatments found to be most effective for mood disorders? ›

    Cognitive Behavioral Therapy (CBT) is the most widely researched form of therapy for mood disorders, including depression and bipolar disorder.

    What is the most effective form of therapy for psychological problems? ›

    Cognitive Therapy

    Adopting strategies to change thinking patterns is the focus here. This treatment approach is effective and can be used with patients who experience depression, anxiety, or phobias. Cognitive therapy may be combined with behavior therapy, which can provide a more comprehensive experience for patients.

    Is CBT more effective than psychotherapy? ›

    In fact, CBT is actually a form of psychotherapy, although people commonly think they are different. In a nutshell: psychotherapy tends to cover a broad range of therapy options, including CBT, and provides improvements with consistent sessions over the longer term.

    Do I need psychotherapy or CBT? ›

    CBT might use your past experiences to help make sense of your current patterns, but the focus remains on making changes in the here and now. Psychodynamic psychotherapy is particularly useful when unresolved issues from childhood and adolescence get in the way of making changes in your life.

    Why is CBT the best psychotherapy? ›

    It's often the preferred type of psychotherapy because it can quickly help you identify and cope with specific challenges. It generally requires fewer sessions than other types of therapy and is done in a structured way. CBT is a useful tool to address emotional challenges.

    What are the weaknesses of cognitive behavioral therapy? ›

    Disadvantages of CBT

    Due to the structured nature of CBT, it may not be suitable for people with more complex mental health needs or learning difficulties. As CBT can involve confronting your emotions and anxieties, you may experience initial periods where you are more anxious or emotionally uncomfortable.

    Who is not a good candidate for CBT? ›

    Those who have maladaptive coping mechanisms that greatly impact their mental health are typically good candidates for CBT. However, individuals who experience mental health issues due to racism, classism, ableism, etc. may not find relief with CBT.

    Is CBT the gold standard for psychotherapy? ›

    Taking into account the number of publications/studies, academic programs, and/or practicing professionals, cognitive behavioral therapy (CBT) is arguably the gold standard of the psychotherapy field.

    Which therapist developed a cognitive therapy for depression? ›

    In the 1960s, Aaron Beck developed cognitive behavior therapy (CBT) or cognitive therapy.

    What are the three cognitive explanations for major depressive disorder? ›

    Beck also asserts that there are three main dysfunctional belief themes (or "schemas") that dominate depressed people's thinking: 1) I am defective or inadequate, 2) All of my experiences result in defeats or failures, and 3) The future is hopeless.

    What are the weaknesses of cognitive explanation of depression? ›

    However, one weakness of the cognitive approach is that it does not explain the origins of irrational thoughts and most of the research in this area is correlational. Therefore, we are unable to determine if negative, irrational thoughts cause depression, or whether a person's depression leads to a negative mindset.

    What are the disadvantages of schema therapy? ›

    There are some limitations to schema-focused therapy, including:
    • Possibility of not being as effective in inpatient settings in which catering to individual needs is difficult4.
    • The process of change could include the emergence of intense emotions, which can overwhelm people14.
    Sep 13, 2022

    What are the 5 needs of schema therapy? ›

    The Schema Domains define 5 broad categories of emotional needs of a child (connection, mutuality, reciprocity, flow and autonomy). When these needs are not met, schemas develop that lead to unhealthy life patterns.

    What are the problems with schema therapy? ›

    One major concern regarding schema therapy relates to the cost and length of time of the treatment. Given that schema therapy works to treat chronic problems, treatment often takes longer and costs more than other time-limited evidence-based interventions.

    What are 3 examples of schemas? ›

    Examples of schemata include rubrics, perceived social roles, stereotypes, and worldviews.

    What are the four goals of schema therapy? ›

    The main goals of Schema Therapy are: to help patients strengthen their Healthy Adult mode; weaken their Maladaptive Coping Modes so that they can get back in touch with their core needs and feelings; to heal their early maladptive schemas; to break schema-driven life patterns; and eventually to get their core ...

    What is schema therapy model of depression? ›

    Schema Therapy (ST) is an integrative treatment approach that targets maladaptive cognitive schemas through cognitive, behavioral, interpersonal, and experiential interventions. ST has been studied in patients with chronic depression with good results.

    How many sessions are needed for schema therapy? ›

    As an approximation, a typical course of Schema Therapy may require 30 – 50 sessions of 1 hour duration for moderate difficulties. For very entrenched or severe difficulties schema therapy may be delivered longer term. Therapy sessions are usually provided on a weekly basis.

    What is the main criticism of schema theory? ›

    Abstract. Schema Theory is intuitively appealing although it has not always received positive press; critics of the approach argue that the concept is too ambiguous and vague and there are inherent difficulties associated with measuring schemata. As such, the term schema can be met with scepticism and wariness.

    Why is schema therapy better than CBT? ›

    In CBT, recognizing automatic thoughts and how they make patients feel and behave is sufficient. However, in schema therapy, the focus is to do all of the above while changing the schemas so that they are no longer a hindrance to the patient's adult life.

    What psychotherapy approach currently has the most empirical support? ›

    (2)]: (1) CBT is the most researched form of psychotherapy. (2) No other form of psychotherapy has been shown to be systematically superior to CBT; if there are systematic differences between psychotherapies, they typically favor CBT.

    What is empirical research used for with psychological treatments? ›

    Empirical research in psychology is very important. Firstly, it helps to identify how well-intentioned people, like therapists and police detectives, can elicit inaccurate information.

    What is the most effective psychological treatment? ›

    Psychotherapy, also known as talk therapy, can help those with mental disorders or emotional difficulties. It can lessen symptoms and help individuals function better in their everyday lives.

    What is considered to be an empirically supported treatment option for depressive disorders? ›

    Evidence-based treatments for major depression include: Medication. Cognitive Behavioral Therapy (CBT) Interpersonal Therapy.

    Why is CBT the most effective therapy? ›

    It's often the preferred type of psychotherapy because it can quickly help you identify and cope with specific challenges. It generally requires fewer sessions than other types of therapy and is done in a structured way. CBT is a useful tool to address emotional challenges.

    Which therapy is the most widely used form of psychotherapy? ›

    Common Types Of Therapy: Cognitive Behavioral Therapy (CBT)

    Cognitive behavioral therapy, or CBT, is the “most common type of therapy, no doubt,” says Johnsen.

    What are the pros of empirically supported treatments? ›

    Focusing on empirically supported treatments serves as a quality control system for the field of Psychology, and protects it from becoming “watered down” by treatment approaches that lack efficacy. By using this system it also becomes less likely that one will make ethical missteps.

    Why do psychologists use empirical methods? ›

    Psychologists use the scientific method to collect, analyze, and interpret evidence. Employing the scientific method allows the scientist to collect empirical data objectively, which adds to the accumulation of scientific knowledge.

    What is an example of empirical method in psychology? ›

    An example of empirical analysis would be if a researcher was interested in finding out whether listening to happy music promotes prosocial behaviour. An experiment could be conducted where one group of the audience is exposed to happy music and the other is not exposed to music at all.

    What is the most effective psychotherapy for treating mental disorders? ›

    Psychotherapy paired with medication is the most effective way to promote recovery. Examples include: Cognitive Behavioral Therapy, Exposure Therapy, Dialectical Behavior Therapy, etc.

    Which therapy has the highest success rate? ›

    1. Inpatient treatment. Inpatient treatment is one of the most effective mental health treatment options available. This type of treatment involves staying in a hospital or other facility where you can receive 24-hour care and supervision.

    What is the best initial treatment for depression? ›

    In general, because of the side effect and safety profile, selective serotonin reuptake inhibitors (SSRIs) are considered to be the first line antidepressants. Other preferred options include tricyclic antidepressants, mirtazapine, bupropion, and venlafaxine.

    What is the most widely used behavioral treatment model for depression? ›

    The kind of psychological treatment that is most commonly used for depression is known as cognitive behavioral therapy (often called “CBT” for short).

    What kind of psychotherapy is used for depression? ›

    Three common types of psychotherapy for the treatment of major depressive disorder and generalized anxiety disorder are cognitive behavioural therapy (CBT), interpersonal therapy, and supportive therapy.


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