Acceptability, effectiveness and cost-effectiveness of blended cognitive-behavioural therapy (bCBT) versus face-to-face CBT (ftfCBT) for anxiety disorders in specialised mental health care: A 15-week randomised controlled trial with 1-year follow-up

A large-scale evaluation of therapeutic alliance and symptom trajectories of depression and anxiety in blended care therapy

This study sought to conduct a large-scale examination (N = 14,951) into the associations between therapeutic alliance and anxiety and depression symptom trajectories within a blended care therapy (BCT) program. Clients receiving blended care services completed weekly outcome measures for anxiety and depression and therapeutic alliance ratings every other therapy session. Using a retrospective, pragmatic study design, latent change score (LCS) analysis captured individual differences in initial therapeutic alliance scores and change in alliance. The LCS variables were specified as predictors of a latent growth curve model describing changes in depression and anxiety symptoms over the course of treatment. Therapeutic alliance scores in the BCT program were generally strong (initial item average = 4.10) and improved over time. Higher initial therapeutic alliance scores and greater initial increases in alliance were associated with steeper declines in anxiety and depressive symptoms at the beginning of therapy. Higher therapeutic alliance (both initial scores and initial increases) was also associated with a deeper symptom trajectory over time, indicating lower anxiety and depressive symptoms overall, as well as sustained decreases in symptoms over time. These results highlight the clinical impact of the working relationship between the provider and the client.

Efficacy of cognitive behavioral therapy for anxiety and depression in Parkinson's disease patients: an updated systematic review and meta-analysis

BACKGROUND

Parkinson's disease (PD) patients often experience non-motor symptoms like depression and anxiety, significantly impacting their quality of life. With the limited effectiveness of pharmacological treatments, effective non-pharmacological interventions are needed. This systematic review and meta-analysis aimed to evaluate the efficacy of cognitive-behavioral therapy (CBT) in reducing depression and anxiety symptoms in PD patients.

METHODS

Randomized controlled trials (RCTs) exploring CBT's effectiveness for depression and anxiety in PD patients were included. Studies published until April 2023 were identified from PubMed, Web of Science, and Scopus. Methodological quality was assessed using the Risk of Bias-2 (ROB-2) tool. Statistical analysis involved calculating the standardized mean difference (SMD) and corresponding 95% confidence intervals (CIs) using Review Manager 5.4.1.

RESULTS

The systematic review included 12 studies involving 241 PD patients. CBT led to a substantial reduction in anxiety (SMD -0.95, 95% CI [-1.15 to -0.74], P < 0.00001) and depression (SMD -1.02, 95% CI [-1.39 to -0.65], P < 0.0001). Both traditional CBT and tele-CBT (administered over the phone or internet) were effective in treating depression and anxiety. Traditional CBT improved depression (SMD -1.16, 95% CI [-1.83 to -0.49], P < 0.00001), while tele-CBT showed comparable results (SMD -0.90, 95% CI [-1.31 to -0.48], P < 0.00001). For anxiety, both traditional CBT (SMD -0.94, 95% CI [-1.25 to -0.63], P < 0.00001) and tele-CBT (SMD -0.95, 95% CI [-1.22 to -0.67], P < 0.00001) significantly reduced symptoms. In conclusion, this systematic review and meta-analysis demonstrated the efficacy of CBT in reducing depression and anxiety in PD patients. Healthcare providers are encouraged to integrate CBT into their treatment protocols. However, additional high-quality studies with longer-term follow-up assessments are needed to further enhance understanding in this area.

PROSPERO REGISTRATION

CRD42023424758.

Blended Psychological Therapy for the Treatment of Psychological Disorders in Adult Patients: Systematic Review and Meta-Analysis

BACKGROUND

Blended therapy (BT) combines digital with face-to-face psychological interventions. BT may improve access to treatment, therapy uptake, and adherence. However, research is scarce on the structure of BT models.

OBJECTIVE

We synthesized the literature to describe BT models used for the treatment of psychological disorders in adults. We investigated whether BT structure, content, and ratio affected treatment efficacy, uptake, and adherence. We also conducted meta-analyses to examine treatment efficacy in intervention-control dyads and associations between treatment outcomes versus BT model structure.

METHODS

PsycINFO, CINAHL, Embase, ProQuest, and MEDLINE databases were searched. Eligibility criteria included articles published in English till March 2023 that described digital and face-to-face elements as part of an intervention plan for treating psychological disorders in adult patients. We developed a coding framework to characterize the BT interventions. A meta-analysis was conducted to calculate effect size (ES; Cohen d and 95% CIs) regarding pre- and posttreatment outcomes in depression and anxiety versus BT structure. The review was registered with PROSPERO and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

Searches identified 8436 articles, and data were extracted from 29 studies. BT interventions were analyzed and classified according to mode of interaction between digital and face-to-face components (integrated vs sequential), role of the components (core vs supplementary), component delivery (alternate vs case-by-case), and digital materials assignment mode (standardized vs personalized). Most BT interventions (n=24) used a cognitive behavioral therapy approach for anxiety or depression treatment. Mean rates of uptake (91%) and adherence (81%) were reported across individual studies. BT interventions were more effective or noninferior to treatment as usual, with large spread in the data and a moderate to large ES in the treatment of depression (n=9; Cohen d=-1.1, 95% CI -0.6 to -1.6, P<.001, and z score=-4.3). A small, nonsignificant ES was found for anxiety outcomes (n=5; Cohen d=-0.1, 95% CI -0.3 to 0.05, P=.17, and z score=-1.4). Higher ESs were found in blended interventions with supplementary design (depression: n=11, Cohen d=-0.75, 95% CI -0.56 to -0.95; anxiety: n=8, Cohen d=-0.9, 95% CI -0.6 to -1.2); fewer (≤6) face-to-face sessions (depression: n=9, Cohen d=-0.7, 95% CI -0.5 to -0.9; anxiety: n=7, Cohen d=-0.8, 95% CI -0.3 to -1.3); and a lower ratio (≤50%) of face-to-face versus digital sessions (depression: n=5, Cohen d=-0.8, 95% CI -0.6 to -1.1; anxiety: n=4, Cohen d=-0.8, 95% CI 0.006 to -1.6).

CONCLUSIONS

This study confirmed integrated BT models as feasible to deliver. We found BT to be effective in depression treatment, but anxiety treatment results were nonsignificant. Future studies assessing outcomes across different psychological disorders and therapeutic approaches are required.

TRIAL REGISTRATION

PROSPERO CRD42021258977; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=258977.

[Digital Interventions in Psychotherapy]

During the last 20 years, many digital interventions in psychotherapy have been developed and tested for a wide range of clinical problems. Digital interventions expand the range of treatment options and reach people who are unable or unwilling to take part in traditional psychotherapy. This article sheds light on various forms of digital interventions, such as unguided and guided self-help interventions, blended treatments, and video-based therapy, the practical use of Digital Health Applications (DiGA) in Germany, and the current state of research in digital interventions.

Integrating digital and in-person therapy for PTSD: feasibility and acceptability of blended trauma-focused cognitive therapy in routine care

Introduction

Access to evidence-based psychological therapy for posttraumatic stress disorder (PTSD) is limited. Blended Trauma-focused Cognitive Therapy (bTF-CT), merging internet-modules with a few therapy sessions, may be a pathway to enhance treatment access while maintaining the benefits of face-to-face therapy.

Objectives

This study aimed to evaluate the feasibility, acceptability, and preliminary effectiveness of bTF-CT for PTSD in routine care, as well as the feasibility of assessments and data collection.

Method

A single-arm design was adopted. bTF-CT was provided to 17 participants across two psychiatric and one primary care clinic. Assessments were conducted pre, during, post and 6-months following treatment. We assessed feasibility and acceptability via self-report questionnaires, retention, and attrition rates. To estimate preliminary treatment effectiveness the PTSD Symptom Checklist (PCL-5) was used to assess PTSD symptom severity.

Results

Treatment satisfaction was high with a mean score of 28.7 out of 32 on the Client Satisfaction Questionnaire (SD = 3.5). The dropout rate was low, with 88% treatment retention. Program adherence was satisfactory, with scores ranging from 2.13 to 3.13 out of 4 on the internet intervention patient adherence scale. On the PCL-5, 88% made a reliable change, 64% demonstrated a clinically significant change, and the mean change from pre to post was 24 points (d = 2.13). Some negative effects were reported, such as unpleasant memories, feelings, and disrupted sleep, but these were temporary according to symptom scales.

Conclusions

bTF-CT appears to be acceptable, feasible, and potentially effective when delivered in routine care. A large-scale non-inferiority trial to assess effectiveness compared to a gold-standard treatment is warranted.

Clinical Trial Registration

Clinicaltrials.gov, identifier NCT04881643.

Effectiveness of a blended group transdiagnostic treatment for emotional disorders: Study protocol for a randomized controlled trial

Introduction

Emotional disorders (ED) (mood and anxiety disorders) are very prevalent and disabling, and often appear in comorbid presentations. Although there are effective treatments for these disorders, there is still a large gap between the number of people who need them and those who actually receive them. The combination of three strategies may help in this regard, facilitating the dissemination and accessibility of treatment: the transdiagnostic perspective of ED, the group format, and the use of technologies in a blended format (i.e., the combination of online and face-to-face therapy elements). This study intends to compare the efficacy of a new ED intervention, a transdiagnostic group treatment protocol administered in a blended format, with that of a face-to-face treatment. This article describes the study protocol for the randomized controlled trial.

Method and analyses

A two-arm, parallel-group, randomized controlled clinical trial (RCT) will be conducted. Participants (N = 144) will be adult volunteers suffering from DSM-5 anxiety and/or depressive disorders and will be randomly assigned to one of two conditions: Face-to-face Group Transdiagnostic Protocol or Blended Group Transdiagnostic Protocol. The face-to-face condition will consist of a total of 16 weekly face-to-face group sessions, while the blended condition will consist of 8 biweekly face-to-face group sessions in combination with self-applied work through a web platform. Clinical and acceptability measures will be included in both groups. Assessments will be performed at baseline, during the treatment, at post-treatment, and at 3-, 6- and 12-month follow-ups. This study received the approval of the Ethics Committee of Universitat Jaume I in October 2021 (CD/91/2021). Intention-to-treat analyses will be performed. Statistical analyses will be carried out using SPSS version 28.0. The results will be reported in accordance with CONSORT recommendations.

Discussion

This is the first RCT to compare the effectiveness of an ED treatment protocol based on the transdiagnostic perspective and applied in group and blended format. It will offer relevant data to continue moving forward towards treatment alternatives that are cost-effective and more accessible, so that all patients with ED who require them can benefit.

Trial registration

ClinicalTrials.gov Identifier: NCT05569018. Registered 06 October 2022, https://clinicaltrials.gov/study/NCT05569018.

Evaluation of completely online psychotherapy with app-support versus therapy as usual for clients with depression or anxiety disorder: A retrospective matched cohort study investigating the effectiveness, efficiency, client satisfaction, and costs

INTRODUCTION

Depressive and anxiety disorders are common mental disorders ranking among the leading causes of global disease burden. Not all clients currently benefit from therapy and clients are looking for modern ways of therapy. Online psychotherapy is a promising option for better meeting clients' needs. Recently, a new psychotherapy concept has emerged that combines videoconferencing sessions with support through a mobile application. The latter allows for ecological momentary assessments and interventions, facilitates communication between patients and therapists in between sessions through chat, and allows for incorporating feedback-informed treatment principles.

MATERIAL AND METHODS

The study was a retrospective observational matched cohort study, comparing online psychotherapy with Therapy As Usual (TAU) for clients with depressive or anxiety disorders. Data were obtained via questionnaires, which are part of standard clinical care. Primary outcomes included general mental functioning, and symptoms of depression and anxiety. Secondary outcomes were efficiency, client satisfaction, and therapy costs. Primary endpoints were analyzed using linear mixed models analysis, with an interaction term between time and group. Secondary outcomes were analyzed using linear regression.

RESULTS

Larger improvements were observed in the online compared to the TAU group for general mental functioning and depressive disorder (i.e., General mental functioning: B = -8.50, 95 CI: -15.01 - -1.97, p = 0.011; Depressive disorder: B = - 3.66, 95 % CI: -5.79 - -1.54p < 0.01). No significant differences in change over time between the two groups were observed for anxiety disorder (B = -3.64, 95 % CI: (-13.10 - 5.82) p = 0.447). The total number of sessions was significantly higher in the online psychotherapy group than in TAU (B = 3.71, p < 0.01), although clients were matched on treatment time in weeks. Treatment session duration in minutes was comparable across the groups.

DISCUSSION

Online psychotherapy with app support showed to be a promising alternative to TAU for depressive and anxiety disorders. More research is needed to evaluate the effectiveness, cost-effectiveness and client satisfaction of online psychotherapy compared to TAU, such as randomized controlled trials or studies multiple baseline series designs, and in-depth qualitative research.

Cost-Effectiveness of Group Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders in Primary Care Settings: Economic Evaluation From the Healthcare System Perspective Over a 1-Year Time Horizon

AIM

To assess the incremental cost-effectiveness ratio (ICER) of group transdiagnostic cognitive-behavioural therapy (tCBT) added to treatment as usual (TAU) for anxiety disorders compared to TAU only from the healthcare system perspective over a 1-year time horizon.

METHODS

Data from a pragmatic multisite randomized controlled trial where adults (18-65 years) with an anxiety disorder were randomized to tCBT + TAU (n = 117) or TAU (n = 114). Group tCBT is a 12-week (2h weekly sessions) community-based intervention. Health service utilization and related costs were captured from medico-administrative data and included those for the intervention, ambulatory visits, hospitalizations and medications. Effectiveness was based on quality-adjusted life years (QALYs). The study included measures at baseline, 4, 8, and 12 months. Intention-to-treat and complete case analyses were carried out. Missing data were imputed using multiple imputation analyses. Seemingly unrelated regression analyses were used to assess the effect of the intervention on total costs and QALYs while also adjusting for baseline confounders. The probability of cost-effectiveness of the intervention was assessed according to different willingness-to-pay (WTP) thresholds using the net benefit regression method.

RESULTS

The ICER of tCBT + TAU as compared to TAU in the intention-to-treat analysis was $6,581/QALY. Complete case analyses showed a similar ICER of $6,642/QALY. The probability at a WTP threshold of $20,000 and $40,000 that tCBT + TAU as compared to TAU is cost-effective is 93.0% and 99.9%.

CONCLUSION

tCBT added to TAU appears to be cost-effective from the healthcare system perspective for treating adult patients with anxiety disorders. Larger trials including young and older adults as well as a range of anxiety disorders are needed to further investigate the cost-effectiveness of tCBT in different patient populations.

Efficacy of a Brief Blended Cognitive Behavioral Therapy Program for the Treatment of Depression and Anxiety in University Students: Uncontrolled Intervention Study

BACKGROUND

Blended cognitive behavioral therapy (bCBT)-the combination of cognitive behavioral therapy and digital mental health applications-has been increasingly used to treat depression and anxiety disorders. As a resource-efficient treatment approach, bCBT appears promising for addressing the growing need for mental health care services, for example, as an early intervention before the chronification of symptoms. However, further research on the efficacy and feasibility of integrated bCBT interventions is needed.

OBJECTIVE

This study aimed to evaluate the efficacy of a novel bCBT program comprising short (25 min), weekly face-to-face therapy sessions combined with a smartphone-based digital health app for treating mild to moderate symptoms of depression or anxiety.

METHODS

This prospective uncontrolled trial comprised 2 measurement points (before and after treatment) and 2 intervention groups. We recruited university students with mild to moderate symptoms of depression or anxiety. On the basis of the primary symptoms, participants were assigned to either a depression intervention group (n=67 completers) or an anxiety intervention group (n=33 completers). Participants in each group received 6 weekly individual psychotherapy sessions via videoconference and completed modules tailored to their respective symptoms in the smartphone-based digital health app.

RESULTS

The depression group displayed medium to large improvements in the symptoms of depression (Cohen d=-0.70 to -0.90; P<.001). The anxiety group experienced significant improvements in the symptoms of generalized anxiety assessed with the Generalized Anxiety Disorder-7 scale with a large effect size (Cohen d=-0.80; P<.001) but not in symptoms of anxiety assessed with the Beck Anxiety Inventory (Cohen d=-0.35; P=.06). In addition, both groups experienced significant improvements in their perceived self-efficacy (Cohen d=0.50; P<.001 in the depression group and Cohen d=0.71; P<.001 in the anxiety group) and quality of life related to psychological health (Cohen d=0.87; P<.001 in the depression group and Cohen d=0.40; P=.03 in the anxiety group). Work and social adjustment of patients improved significantly in the depression group (Cohen d=-0.49; P<.001) but not in the anxiety group (Cohen d=-0.06; P=.72). Patients' mental health literacy improved in the anxiety group (Cohen d=0.45; P=.02) but not in the depression group (Cohen d=0.21; P=.10). Patient satisfaction with the bCBT program and ratings of the usability of the digital app were high in both treatment groups.

CONCLUSIONS

This study provides preliminary evidence for the feasibility and efficacy of a novel brief bCBT intervention. The intervention effects were generalized across a broad spectrum of patient-reported outcomes. Hence, the newly developed bCBT intervention appears promising for treating mild to moderate depression and anxiety in young adults.

Influence of on emotions and behavior of adolescents with major depressive disorder

Background

Major depressive disorder in adolescents is characterized by high prevalence rate, high recurrence rate, high suicide rate and high disability rate. However, the recognition rate and cure rate are low, and the disease has a very bad influence on the family and society. The lack of psychiatrists and psychotherapists in villages and small towns makes it difficult to get timely and professional intervention and treatment for adolescent with major depressive disorder.

Methods

A total of 84 adolescents with major depressive disorder who received treatment in the department of psychosomatic medicine of the Second Affiliated Hospital of Nanchang University participated in this survey, and they were divided into the control group and the intervention group by random number table. Adolescent Non-suicidal Self-injury Assessment Questionnaire (ANSSIAQ), Self-rating Questionnaire for Adolescent Problematic Mobile Phone Use (SQAPMPU), Screen for Child Anxiety Related Emotional Disorders (SCARED) and Depression Self-Rating Scale for Childhood (DSRS) were used to investigate the negative emotions and behavior of adolescents with major depressive disorder at baseline and intervention for 12 weeks.

Results

There were no significant differences in the baseline information of adolescents (sex ratio, age, education level), including the total score of SCARED, DSRS and SQAPMPU, the total mean score of ANSSIAQ between the two groups (P > 0.05). After 12-week intervention, the score of SCARED, DSRS and SQAPMPU, the total mean score of ANSSIAQ in both groups were lower than that of the baseline, and the score of the intervention group showed a more obvious downward trend (P < 0.05).

Conclusions

In-person and remote Satir family therapy not only effectively reduced the anxiety and depression level among participants, but also validly reduced their non-suicidal self-injury behavior and mobile phone use behavior. The results verified that the model we adopted can be well applied for the out-patient management of adolescents with major depressive disorder, especially in villages and small towns.

Leveraging Mobile Health to Manage Mental Health/Behavioral Health Disorders: Systematic Literature Review

BACKGROUND

Mental health is a complex condition, highly related to emotion. The COVID-19 pandemic caused a significant spike in depression (from isolation) and anxiety (event related). Mobile Health (mHealth) and telemedicine offer solutions to augment patient care, provide education, improve symptoms of depression, and assuage fears and anxiety.

OBJECTIVE

This review aims to assess the effectiveness of mHealth to provide mental health care by analyzing articles published in the last year in peer-reviewed, academic journals using strong methodology (randomized controlled trial).

METHODS

We queried 4 databases (PubMed, CINAHL [Cumulative Index to Nursing and Allied Health Literature], Web of Science, and ScienceDirect) using a standard Boolean search string. We conducted this systematic literature review in accordance with the Kruse protocol and reported it in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) 2020 checklist (n=33).

RESULTS

A total of 4 interventions (mostly mHealth) from 14 countries identified improvements in primary outcomes of depression and anxiety as well as in several secondary outcomes, namely, quality of life, mental well-being, cognitive flexibility, distress, sleep, self-efficacy, anger, decision conflict, decision regret, digestive disturbance, pain, and medication adherence.

CONCLUSIONS

mHealth interventions can provide education, treatment augmentation, and serve as the primary modality in mental health care. The mHealth modality should be carefully considered when evaluating modes of care.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022343489; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=343489.

Feasibility of Digital Cognitive Behavioral Therapy for Depressed Older Adults With the Moodbuster Platform: Protocol for 2 Pilot Feasibility Studies

Background

Internet-based interventions can be effective in the treatment of depression. However, internet-based interventions for older adults with depression are scarce, and little is known about their feasibility and effectiveness.

Objective

To present the design of 2 studies aiming to assess the feasibility of internet-based cognitive behavioral treatment for older adults with depression. We will assess the feasibility of an online, guided version of the Moodbuster platform among depressed older adults from the general population as well as the feasibility of a blended format (combining integrated face-to-face sessions and internet-based modules) in a specialized mental health care outpatient clinic.

Methods

A single-group, pretest-posttest design will be applied in both settings. The primary outcome of the studies will be feasibility in terms of (1) acceptance and satisfaction (measured with the Client Satisfaction Questionnaire-8), (2) usability (measured with the System Usability Scale), and (3) engagement (measured with the Twente Engagement with eHealth Technologies Scale). Secondary outcomes include (1) the severity of depressive symptoms (measured with the 8-item Patient Health Questionnaire depression scale), (2) participant and therapist experience with the digital technology (measured with qualitative interviews), (3) the working alliance between patients and practitioners (from both perspectives; measured with the Working Alliance Inventory–Short Revised questionnaire), (4) the technical alliance between patients and the platform (measured with the Working Alliance Inventory for Online Interventions–Short Form questionnaire), and (5) uptake, in terms of attempted and completed modules. A total of 30 older adults with mild to moderate depressive symptoms (Geriatric Depression Scale 15 score between 5 and 11) will be recruited from the general population. A total of 15 older adults with moderate to severe depressive symptoms (Geriatric Depression Scale 15 score between 8 and 15) will be recruited from a specialized mental health care outpatient clinic. A mixed methods approach combining quantitative and qualitative analyses will be adopted. Both the primary and secondary outcomes will be further explored with individual semistructured interviews and synthesized descriptively. Descriptive statistics (reported as means and SDs) will be used to examine the primary and secondary outcome measures. Within-group depression severity will be analyzed using a 2-tailed, paired-sample t test to investigate differences between time points. The interviews will be recorded and analyzed using thematic analysis.

Results

The studies were funded in October 2019. Recruitment started in September 2022.

Conclusions

The results of these pilot studies will show whether this platform is feasible for use by the older adult population in a blended, guided format in the 2 settings and will represent the first exploration of the size of the effect of Moodbuster in terms of decreased depressive symptoms.

International Registered Report Identifier (IRRID)

PRR1-10.2196/41445

Real-World Evaluation of a Large-Scale Blended Care-Cognitive Behavioral Therapy Program for Symptoms of Anxiety and Depression

Introduction: Prior studies have supported the effectiveness of blended interventions for anxiety and depression; however, outcomes research of large-scale blended interventions for these conditions is limited. Objective: To investigate the outcomes of scaled-up blended care (BC) cognitive behavioral therapy (CBT), a program that combined video-based psychotherapy with internet CBT, for symptoms of anxiety and depression. Materials and Methods: Participants were 6,738 U.S.-based adults with elevated symptoms of anxiety (Generalized Anxiety Disorder-7 [GAD-7] ≥ 8) and/or depression (Patient Health Questionnaire-9 [PHQ-9] ≥ 10) at baseline who received BC-CBT as an employer-offered mental health benefit. The primary outcomes, anxiety (GAD-7) and depression (PHQ-9) symptoms, were routinely measured in the program. Recovery and reliable improvement in outcomes were calculated, and growth curve models evaluated change in outcomes during treatment and the effects of engaging in psychotherapy sessions on outcomes. Results: On average, participants received treatment for 7.6 (standard deviation = 6.2) weeks. By the end of care, 5,491 (81.5%) participants had reliable improvement in either anxiety or depression symptoms; in addition, 5,535 (82.1%) fell below the clinical threshold for either anxiety or depression symptoms (i.e., recovered). Declines in anxiety and depression symptoms were statistically significant over the course of BC-CBT (both p's < 0.01), with the rate of decline significantly decreasing for each outcome as treatment progressed (both p's < 0.01). Each psychotherapy session completed was significantly associated with lower anxiety and depression symptoms during the week of the session and the subsequent week (all p's < 0.01). Conclusions: This real-world study provides evidence that scaled-up BC-CBT can be effective in the treatment of symptoms of anxiety and depression.