The impact of psychological distress tolerance in the treatment of depression
Open accessAbstract
Distress tolerance refers to the perceived ability to experience and withstand negative emotional states. Minimal research has investigated distress tolerance in the context of mood disorders despite poor emotional coping featuring in theoretical models of depression. The aims of the current investigation were to identify the relationship between psychological distress tolerance and depression, and to evaluate the impact of distress tolerance on treatment adherence and outcome following an internet-based cognitive behavioural therapy (iCBT) program for depression (the Sadness Program). Study 1 included 75 patients prescribed the Sadness Program by their primary care practitioner. Study 2 included 34 patients diagnosed with a major depressive episode participating in a randomized trial. Results of both studies indicated a significant inverse relationship between distress tolerance (DTS) and both depression severity (PHQ9) and psychological distress (K10). Results of intent-to-treat (ITT) marginal model analyses demonstrated that the Sadness Program was effective in reducing depression symptoms and psychological distress (Cohen's ds > 1), and in increasing distress tolerance (Cohen's ds > .28). However, patients who entered treatment with lower distress tolerance scores evidenced higher baseline and post-treatment scores on the outcome measures following iCBT. Collectively the findings suggest that distress tolerance is an important variable to consider in the context of treatments for depression. Clinical implications, future directions, and limitations are discussed.
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Patients with lower initial distress tolerance scores had higher symptomatology at baseline and post-treatment in CBT for depression.
“A study investigating Cognitive Behaviour Therapy (CBT) for depression found that patients with lower initial distress tolerance scores had higher symptomatology at baseline and post-treatment (Williams et al. 2013).”
From Brief psychological intervention for distress tolerance in an adult secondary care community mental health service: an evaluation (2020) · cites this paper as Williams et al. 2013
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“Furthermore, given that depression (Ellis et al. 2010; Williams et al. 2013) and anxiety (Cougle et al. 2011; Keough et al. 2010) have been shown to be negatively correlated with distress tolerance, depression and anxiety were included as covariates for study analyses to examine the unique…”
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“Specifically, among individuals with MDD, those with low distress tolerance endorsed a greater number of depressive symptoms.(34) A similar pattern exists in non-clinical samples, where individuals with low distress tolerance report greater symptoms of depression.”
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Daundasekara, S., Iwundu, C. N., Hernandez, D., Maria, D. M. S., Zvolensky, M. J., Kendzor, D. E., & Businelle, M. (2021) · Journal of Social Distress and Homelessness · doi:10.1080/10530789.2021.1908488 · Cited by 3 · see citing works
“Also, in domiciled samples, research has found an inverse relationship between depression and each of the DTS subscales (Rogers et al., 2018; Williams et al., 2013).”
BackgroundResultMalas, O., & Gómez-Domenech, A. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13092603 · Cited by 4 · see citing works
Erdoğan, A. (2022) · Nişantaşı Üniversitesi Sosyal Bilimler dergisi · doi:10.52122/nisantasisbd.1127433 · Cited by 2 · see citing works
Sommers, B. (2017) · doi:10.32597/dissertations/1633 · Cited by 5 · see citing works
“Thus, both studies evidence the possibility of increasing DT through CBT interventions.”
BackgroundMethodInfluentialTian, X., Chen, J., Wang, B., Wan, X., & Wang, S. (2026) · Journal of Youth and Adolescence · doi:10.1007/s10964-026-02391-0 · Cited by 1 · see citing works
“For instance, Williams et al. (2013 ) found that distress tolerance significantly improved following a 10-week internet-based cognitive behavioral therapy intervention for depressive symptoms, suggesting that reductions in depressive symptoms may contribute to subsequent improvements in distress…”
Pezzino, V., Berbary, C. M., McKinney, C., Sangiorgio, C., Moriuchi, E., Klimczak, K. S., Cooper, R. K., Kniffen, W., Hareli, M., Crane, C. A., et al. (2026) · Behavioral Sciences · doi:10.3390/bs16050719
“…life experiences, young adults are more likely to experience mental health struggles and are at greater risk of developing psychiatric disorders compared to any other age group (Kessler et al., 2005; Substance Abuse and Mental Health Services Administration [SAMHSA], 2024; Williams et al., 2013).”
Tolerance on campus: the impact of religious commitment and respect among university students
Thalgi, M. J., Al-Refai, N., Gömbeyaz, K., Bdoor, H., & Furat, A. Z. (2026) · International Journal of Evaluation and Research in Education (IJERE) · doi:10.11591/ijere.v15i1.32607 · Cited by 1
“Additionally, reliability was assessed using Cronbach’s alpha and Pearson correlation, and multiple regression analyses were conducted to test the impact of the study variable on the tolerance scale [31].”
Depression Severity and Its Predictors: Findings from a Nationally Representative Canadian Sample
Tessier, E. D., Rachor, G. S., Boehme, B. A. E., Hysuick-Weik, B., & Asmundson, G. J. G. (2025) · Psychiatry International · doi:10.3390/psychiatryint6030114 · Cited by 1 · see citing works
“Evidence indicates a negative relationship between depression and physical health (e.g., cardiovascular disease, neurotransmitter dysregulation) and psychological functioning (e.g., distress tolerance, rumination) while increasing the risk of all-cause mortality by 52% [4–7].”
Abdelrazek, M. N., El-Ashry, A., & Abdelaal, H. M. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-06119-x · Cited by 1 · see citing works
“Patients with high levels of emotional inhibition tend to suppress their emotions to avoid social rejection or shame, a phenomenon described by cognitive pathology theory, which suggests that maladaptive schemas are activated when individuals face emotional challenges [5, 21, 22].”
BackgroundPrior, K., Ross, J., Mills, K. L., & Teesson, M. (2019) · International Journal of Mental Health and Addiction · doi:10.1007/s11469-019-00131-z · Cited by 1 · see citing works
“2007; Nolen-Hoeksema and Harrell 2002; Raes 2012) and poorer depression treatment outcomes (Michalak et al. 2011; Williams et al. 2013).”
BackgroundBelen, H., & Öztürk, F. (2026) · Current Psychology · doi:10.1007/s12144-026-09953-2
“Consistent with this, individuals with high distress intolerance perceive stressful situations as unbearable, thereby diminishing their capacity to cope effectively (Allan et al., 2014; Craske et al., 2011; McHugh et al., 2013; Williams et al., 2013).”
Basili, S., Baroni, M., Colombini, G., Guazzini, A., & Duradoni, M. (2026) · Psychology International · doi:10.3390/psycholint8030044
“Higher DT has consistently been linked to lower levels of distress (Leyro et al., 2010; Segal et al., 2025; A. D. Williams et al., 2013).”
Sevi, T. A., & Gungor, A. (2025) · Journal of Human Sciences · doi:10.14687/jhs.v22i2.6560
Baban, D., Karimi, Q., & Yārahmadi, Y. (2025) · مجله علمی دانشگاه علوم پزشکی رفسنجان · doi:10.61186/jrums.24.3.271
Taheri, E., Amiri, M., & Ensan, N. (2023) · International journal of high risk behaviors and addiction · doi:10.5812/ijhrba-133759
Kanigolzar, V. A., Karimi, Q., Moradi, O., & Akbari, M. (2023) · مجله علمی دانشگاه علوم پزشکی رفسنجان · doi:10.52547/jrums.22.1.35
Rappaport, L. M., Berenz, E. C., Lejuez, C. W., & Roberson‐Nay, R. (2018) · Cambridge University Press eBooks · doi:10.1017/9781108140416.009 · Cited by 2 · see citing works
A Randomized Controlled Trial of a Hatha Yoga Intervention for Smokers
Jeffries, E. R. (2018) · doi:10.31390/gradschool_dissertations.4692
“…factors among smokers with clinical levels of anxiety/depression, as these individuals would also likely have higher levels of AS (e.g., Otto et al., 1995; Taylor et al., 2007) and Anh (e.g., Kashdan, 2004; Lewinsohn, 1974), and lower DT (e.g., Keough et al., 49 2010; Williams et al., 2013).”
Background
- Authors
- Williams, A. D., Thompson, J., & Andrews, G.
- Affiliations
- UNSW Sydney (AU)
- Corresponding author
- Williams, Alishia D.
- ORCID
- Andrews, Gavin
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2013-08
- Volume
- 51
- Issue
- 8
- Pages
- 469-475
- ISSN
- 0005-7967 (ISSN-L)
- OpenAlex
- W2038136495
- Cited by
- 77
- References
- 49
- Citations by year
- 2026: 4 · 2025: 4 · 2024: 7 · 2023: 9 · 2022: 5 · 2021: 9 · 2020: 5 · 2019: 8 · 2018: 7 · 2017: 8 · 2016: 4 · 2015: 2 · 2014: 4 · 2013: 1
- FWCI
- 5.65
- Type
- journal article
- Language
- en
- Open access
- green
- hdl.handle.net
- Licence
- cc-by-nc-nd
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- UNSWorks (University of New South Wales, Sydney, Australia) (submittedVersion, cc-by-nc-nd)
- UNSWorks (UNSW Sydney) (submittedVersion, cc-by-nc-nd)
- Funders
- University of New South Wales
- Medical Research Council
- National Health and Medical Research Council (630746)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Keywords
- distress tolerance, depression, internet-based cognitive behavioral therapy, medication adherence, treatment outcomes, psychological distress, depression severity, major depressive episode, primary care
- MeSH terms
- Adult, Depression, Depressive Disorder, Major, Major Depressive Disorder, Emotions, Female, Humans, Male, Patient Compliance, Pilot Projects, Stress, Psychological, Therapy, Computer-Assisted, Cognitive Behavioral Therapy, Treatment Outcome, Internet
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