A Propensity Score Analysis of Homework Adherence-Outcome Relations in Cognitive Behavioral Therapy for Depression
Open accessAbstract
Little is known about whether or not a consistently high level of homework adherence over the course of therapy benefits patients. This question was examined in two samples of patients who were receiving individual Cognitive Behavioral Therapy (CBT) for depression (Ns = 128 [Sequenced Treatment Alternatives to Relieve Depression: STAR-D] and 183 [Continuation Phase Cognitive Therapy Relapse Prevention: C-CT-RP]). Logistic and linear regression and propensity score models were used to identify whether or not clinician assessments of homework adherence differentiated symptom reduction and remission, as assessed by the Hamilton Depression Rating Scale-17 (HDRS-17), the Quick Inventory of Depressive Symptomatology-Self-Reported Scale (QIDS-SR), and the QIDS-Clinician Scale (QIDS-C). CBT-related response and remission were equally likely between both high and low homework adherers in both studies and in all models. But in propensity adjusted models that adjusted for session attendance, for both the STAR-D and C-CT-RP samples, greater homework adherence was significantly associated with greater response and remission from depression in the first and last 8 sessions of CBT. Our results suggest that homework adherence can account for response and remission early and late in treatment, with adequate session attendence.
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Without sufficient out-of-session skills practice, clients tend to experience suboptimal outcomes, including increased likelihood of premature treatment dropout, slower symptom improvements, and ultimately worse symptoms at end of care.
“Without sufficient out-of-session skills practice, clients tend to experience suboptimal outcomes, including increased likelihood of premature treatment dropout, slower symptom improvements (presumably due to slower skills acquisition), and ultimately worse symptoms at end of care [7,12-14].”
From Clinical Effects of Asynchronous Provider-Guided Practice Sessions During Blended Care Therapy for Anxiety and Depression: Pragmatic Retrospective Cohort Study (2024) · cites this paper as [12]
The Discussion (page unavailable) reports that greater homework adherence was associated with better response in the first and last eight sessions of CBT for depression. But the Results found no association with dropout (p = 0.96), and the Discussion says overall end-of-treatment response and remission were equally likely among high and low adherers. The paper also says its assessments could not establish week-to-week symptom improvement, so it does not substantiate slower improvement. (LLM, conf=0.88)
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References 69 · Cited by 22
Research works printed but not linked: 1
- Beck AT, Rush AJ, Shaw B, & Emery G (1979). Cognitive therapy of depression. New York: The Guilford Press.
- Authors
- Callan, J. A., Kazantzis, N., Park, S. Y., Moore, C. G., Thase, M. E., Minhajuddin, A., Kornblith, S., & Siegle, G. J.
- Affiliations
- University of Pittsburgh (US)
- Monash University (AU)
- University of Pennsylvania (US)
- The University of Texas Southwestern Medical Center (US)
- Mental Health Association of Southeastern Pennsylvania (US)
- Corresponding author
- Callan, Judith A.
- ORCID
- Venue
- Behavior Therapy
- Publisher
- Elsevier BV
- Published
- 2019-03
- Volume
- 50
- Issue
- 2
- Pages
- 285-299
- ISSN
- 0005-7894 (ISSN-L)
- PMC
- PMC6489494
- OpenAlex
- W2805609026
- Cited by
- 22
- References
- 69
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 4 · 2023: 3 · 2022: 5 · 2021: 4 · 2020: 2 · 2019: 2
- FWCI
- 2.35
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Behavior Therapy (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Center For Advancing Translational Sciences (KL2TR000146)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- homework adherence, cognitive behavioral therapy, depression, treatment response, remission, session attendance, STAR*D, relapse prevention, treatment outcomes
- MeSH terms
- Adult, Chronic Disease, Major Depressive Disorder, Female, Humans, Male, Middle Aged, Patient Education as Topic, Self Care, Cognitive Behavioral Therapy, Treatment Outcome, Propensity Score
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