Sudden gains during psychological treatments of anxiety and depression: A meta-analysis
Abstract
OBJECTIVE: The present study quantitatively reviewed the literature on sudden gains in psychological treatments for anxiety and depression. The authors examined the short- and long-term effects of sudden gains on treatment outcome as well as moderators of these effects. METHOD: The authors conducted a literature search using PubMed, PsycINFO, the Cochrane Library, and manual searches. The meta-analysis was based on 16 studies and included 1,104 participants receiving psychological treatment for major depressive disorder or an anxiety disorder. RESULTS: Effect size estimates suggest that sudden gains had a moderate effect on primary outcome measures at posttreatment (Hedges's g = 0.62) and follow-up (Hedges's g = 0.56). These effect sizes were robust and unrelated to publication year or number of treatment sessions. The effect size of sudden gains in cognitive-behavioral therapy was higher (Hedges's g = 0.75) than in other treatments (Hedges's g = 0.23). CONCLUSIONS: These results suggest that sudden gains are associated with short-term and long-term improvements in depression and anxiety, especially in cognitive-behavioral therapy.
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Almost half of clients with depression and anxiety exhibit sudden large gains within the first two to four CBT treatment sessions.
“For example, almost half of clients with depression and anxiety exhibit sudden large gains within the first two to four CBT treatment sessions [39,40].”
Growing evidence suggests briefer interventions can effect substantial change for clients.
“Indeed, growing evidence suggests briefer interventions can effect substantial change for clients.”
Rapid response to CBT is associated with long-term improvements in functioning and a reduction in long-term relapse rates.
“Furthermore, this rapid response is associated with long-term improvements in functioning and a reduction in long-term relapse rates [39,43,45].”
Psychotherapy is a complex and multi-level process that is likely to work through a complex chain of changes, with different mechanisms of change occurring at different time points and rates, and certain changes might occur suddenly instead of gradually.
“Psychotherapy is a complex and multi-level process that is likely to work through a complex chain of changes: different mechanisms of change (at either the physiological, cognitive, behavioral, or affective level or on multiple levels) occur at different time points and rates during treatment, and certain changes might occur suddenly instead of gradually (Aderka et al., 2012).”
From Which emotion regulation strategies are mediating the outcome of acceptance and commitment therapy compared to cognitive-behaviour therapy in the treatment of anxiety symptoms? (2025) · cites this paper as Aderka et al., 2012
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Sudden Gains Can Occur in Psychotherapy Even When the Pattern of Change Is Gradual
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Helmich, M. A., Smit, A. C., Bringmann, L. F., Schreuder, M. J., Oldehinkel, A. J., Wichers, M., & Snippe, E. (2022) · Clinical Psychological Science · doi:10.1177/21677026221137006 · Cited by 41 · see citing works
Snippe, E., Schroevers, M. J., Annika Tovote, K., Sanderman, R., Emmelkamp, P. M. G., & Fleer, J. (2015) · Cognitive Therapy and Research · doi:10.1007/s10608-014-9667-z · Cited by 34 · see citing works
“Such early gains may be important for clinical outcomes of CBT as it has been found that significant depressive symptom reduction can occur in the first few sessions of CBT and that such early gains have a moderate effect on treatment outcome, even at follow-up (Aderka et al. 2012).”
BackgroundWucherpfennig, F., Rubel, J. A., Hofmann, S. G., & Lutz, W. (2017) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000263 · Cited by 34 · see citing works
Self-citationSudden gains in behavioural activation for depression
Masterson, C., Ekers, D., Gilbody, S. M., Richards, D. A., Toner-Clewes, B., & McMillan, D. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.06.008 · Cited by 33 · see citing works
“The meta-analysis of Aderka et al. (2012) found similar rates of sudden gains in non-CBT and CBT treatments, but while the presence of a sudden gain appeared to predict improvement at post-treatment in CBT, the relationship appeared less clear for other therapies.”
BackgroundResultInfluentialSudden gains in internet-based cognitive behaviour therapy for severe health anxiety
Hedman, E., Lekander, M., Ljótsson, B., Lindefors, N., Rück, C., Hofmann, S. G., Andersson, E., Andersson, G., & Schulz, S. M. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2013.12.007 · Cited by 32 · see citing works
“In short, the treatment comprised online bibliotherapy with therapist support through an online messaging system resembling email (Andersson, 2009). The hypothesized mechanism of change of internet-based CBT is similar to face-to-face CBT as described by Furer and Walker (2005). It also shares similarities to CBT for…”
BackgroundMethodSelf-citationA Revised Theory of Sudden Gains in Psychological Treatments
Aderka, I. M., & Shalom, J. G. (2021) · Behaviour Research and Therapy · doi:10.1016/j.brat.2021.103830 · Cited by 32 · see citing works
Self-citationKrüger, A., Ehring, T. W., Priebe, K., Dyer, A., Steil, R., & Bohus, M. (2014) · European Journal of Psychotraumatology · doi:10.3402/ejpt.v5.24470 · Cited by 32 · see citing works
Pretreatment Changes in Drinking: Relationship to Treatment Outcomes
Stasiewicz, P., Schlauch, R., Bradizza, C., Bole, C. W., & Coffey, S. (2012) · Psychology of Addictive Behaviors · doi:10.1037/a0031368 · Cited by 35 · see citing works
Wiedemann, M., Stott, R. B., Nickless, A., Beierl, E. T., Wild, J., Warnock‐Parkes, E., Grey, N., Clark, D. M., & Ehlers, A. (2020) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000488 · Cited by 31 · see citing works
“…life and the absence of comorbidity were predictive of sudden gains in depression (Lemmens, DeRubeis, Arntz, Peeters, & Huibers, 2016), or younger age in PTSD (Jun et al., 2013), whereas others found no baseline predictors (e.g., Aderka et al., 2011, 2012; HunnicuttFerguson, Hoxha, & Gollan, 2012).”
BackgroundVittengl, J. R., Clark, L. A., Thase, M. E., & Jarrett, R. B. (2014) · Current Psychiatry Reviews · doi:10.2174/1573400510666140929195441 · Cited by 30 · see citing works
“A recent meta-analysis of sudden gains in both anxiety and depression reached a similar conclusion [32].”
ResultDose response effects of cognitive-behavioral therapy in a school mental health program
Kirk, A., Michael, K. D., Bergman, S. M., Schorr, M., & Jameson, J. P. (2018) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2018.1550527 · Cited by 28 · see citing works
Sudden gains in the alliance in cognitive behavioral therapy versus brief relational therapy.
Zilcha‐Mano, S., Eubanks, C. F., & Muran, J. C. (2019) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000397 · Cited by 28 · see citing works
“Third, given the fact that no significant differences in outcome were found between the treatments, and that sudden gains in symptoms were found to be consistent predictors of treatment outcome (Aderka et al., 2012), it is less likely that the BRT treatment showed more sudden gains in symptoms, but rather that sudden…”
ResultSudden gains in two psychotherapies for posttraumatic stress disorder
König, J., Karl, R., Rosner, R., & Butollo, W. H. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.06.005 · Cited by 28 · see citing works
“However, in the meta-analysis (Aderka et al., 2012), sudden gains in non-CBT treatments showedweaker average relationships to outcome than those in CBT treatments.”
BackgroundResultInfluentialSudden gains in two trauma-focused treatments for posttraumatic stress disorder
Sloan, D., Thompson-Hollands, J., Hayes, A. M., Lee, D. J., Alpert, E., & Marx, B. P. (2021) · The Behavior Therapist · doi:10.1016/j.beth.2021.08.003 · Cited by 21 · see citing works
Melchior, H., Schulz, H., Kriston, L., Hergert, A., Hofreuter-Gätgens, K., Bergelt, C., Morfeld, M., Koch, U., & Watzke, B. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.02.046 · Cited by 27 · see citing works
“…changes may not always follow a steady and linear pattern across time; thus, the exploration of changes during treatment should also allow the identification of nonlinear and discontinuous changes (Aderka et al., 2012b; Castonguay et al., 2013; Clapp et al., 2013; Lambert, 2005; Lutz et al., 2009).”
BackgroundResultInfluentialVittengl, J. R., Clark, L. A., Thase, M. E., & Jarrett, R. B. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.08.008 · Cited by 25 · see citing works
“Previous evidence supporting the superiority of a single trajectory group against all others during follow-up (e.g., patients with vs. without sudden gains; Aderka et al., 2012; Vittengl et al., 2015a) may be limited by combining several trajectories (e.”
BackgroundLavelle, J., Storan, D., Eswara Murthy, V., De Dominicis, N., Mulcahy, H. E., & McHugh, L. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11102757 · Cited by 23 · see citing works
“For example, almost half of clients with depression and anxiety exhibit sudden large gains within the first two to four CBT treatment sessions [39,40].”
BackgroundThorisdottir, A. S., Tryggvadóttir, A., Saevarsson, S. T., & Bjornsson, A. S. (2018) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2018.1466909 · Cited by 24 · see citing works
“…treatment factors ARTICLE HISTORY received 3 February 2017 accepted 10 april 2018 © 2018 Swedish association for Behaviour therapy CONTACT audur S. thorisdottir audursjofn@gmail.com university of regina, 3737 Wascana pkwy, regina SK S4S 0a2, Canada. the phenomena difficult (Aderka et al., 2012).”
InfluentialHelmich, M. A., Snippe, E., Kunkels, Y. K., Riese, H., Smit, A. C., & Wichers, M. (2021) · doi:10.31234/osf.io/fertq · Cited by 24 · see citing works
Dour, H. J., Chorpita, B. F., Lee, S., & Weisz, J. R. (2013) · Behaviour Research and Therapy · doi:10.1016/j.brat.2013.05.012 · Cited by 22 · see citing works
Sudden Gains in the Cognitive-Behavioral Treatment of Generalized Anxiety Disorder
Deschênes, S. S., & Dugas, M. J. (2012) · Cognitive Therapy and Research · doi:10.1007/s10608-012-9504-1 · Cited by 23 · see citing works
Singla, D. R., Hollon, S. D., Fairburn, C. G., Dimidjian, S., & Patel, V. (2019) · Clinical Psychological Science · doi:10.1177/2167702619825860 · Cited by 23 · see citing works
“Similar to early response, there is accumulating evidence to suggest that sudden gains represent a common phenomenon among depression and anxiety patients that influence clinical outcome across treatment modalities (Aderka et al., 2012; Lemmens et al., 2016) including BA-based psychological treatments for depression (…”
BackgroundCallan, J. A., Kazantzis, N., Park, S. Y., Moore, C. G., Thase, M. E., Minhajuddin, A., Kornblith, S., & Siegle, G. J. (2019) · Behavior Therapy · doi:10.1016/j.beth.2018.05.010 · Cited by 22 · see citing works
“The evidence shows that sudden gains and rapid response can occur during the first 8 sessions, or in the last 8 sessions, of a standard protocol of 16-20 session protocol (Aderka et al., 2012).”
BackgroundShalom, J. G., Strauss, A. Y., Huppert, J. D., Andersson, G., Agassi, O. D., & Aderka, I. M. (2020) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000587 · Cited by 22 · see citing works
Self-citationRoesmann, K., Leehr, E., Böhnlein, J., Gathmann, B., Herrmann, M. J., Junghöfer, M., Schwarzmeier, H., Seeger, F., Siminski, N., Straube, T., et al. (2023) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2023.102790 · Cited by 15 · see citing works
Sudden gains in exposure therapy for obsessive-compulsive disorder
Collins, L. M., & Coles, M. E. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.03.003 · Cited by 22 · see citing works
Rahmani, A. M., Lai, J., Jafarlou, S., Azimi, I., Yunusova, A., Rivera, A. P., Labbaf, S., Anzanpour, A., Dutt, N. D., Jain, R., et al. (2022) · Frontiers in Digital Health · doi:10.3389/fdgth.2022.933587 · Cited by 23 · see citing works
“dual – for instance, with some clients, it might be able to be relatively rapid, but with others it might need to be a slow, iterative process of getting them to be open to seeing another perspective [31, 32, 33]. As discussed in Section 5, the mental health state of an individual is defined in a high-dimensional space…”
BackgroundEarly trajectory features and the course of psychotherapy
Koffmann, A. (2018) · Psychotherapy Research · doi:10.1080/10503307.2018.1506950 · Cited by 21 · see citing works
“, 2007; some studies included in the meta-analysis of Aderka et al., 2012) have included a subset of participants who reported initial symptomatic distress in the non-clinical range. It is difficult to demonstrate significant change in such individuals, and the concept of “remission” has little meaning. Their inclusio…”
BackgroundInfluentialJoesch, J. M., Golinelli, D., Sherbourne, C. D., Sullivan, G., Stein, M. B., Craske, M. G., & Roy‐Byrne, P. (2013) · Depression and Anxiety · doi:10.1002/da.22149 · Cited by 21 · see citing works
Wucherpfennig, F., Rubel, J. A., Hollon, S. D., & Lutz, W. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.11.003 · Cited by 22 · see citing works
Using machine-learning to predict sudden gains in treatment for major depressive disorder
Aderka, I. M., Kauffmann, A., Shalom, J. G., Beard, C., & Björgvinsson, Þ. (2021) · Behaviour Research and Therapy · doi:10.1016/j.brat.2021.103929 · Cited by 20 · see citing works
Self-citationHegarty, B. D., Marceau, E. M., Gusset, M., & Grenyer, B. F. S. (2019) · Psychotherapy Research · doi:10.1080/10503307.2019.1609114 · Cited by 20 · see citing works
Ietsugu, T., Crane, C., Hackmann, A., Brennan, K., Gross, M., Crane, R. S., Silverton, S., Radford, S., Eames, C., Fennell, M. J. V., et al. (2015) · Mindfulness · doi:10.1007/s12671-014-0358-3 · Cited by 19 · see citing works
“2002; Ilardi and Craighead 1994), and that sudden gains are a common phenomenon that represents an important predictor of the overall effect of the therapy (Aderka et al. 2012; Tang and DeRubeis 1999).”
BackgroundShape of change in internet based behavioral activation treatment for depression
O'Mahen, H. A., Wilkinson, E., Bagnall, K., Richards, D. A., & Swales, A. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.05.011 · Cited by 25 · see citing works
Within-day sudden gains and generalized anxiety disorder psychotherapy outcome.
Newman, M. G., Schwob, J. T., & Rackoff, G. N. (2022) · Psychotherapy · doi:10.1037/pst0000445 · Cited by 19 · see citing works
suddengains: An R package to identify sudden gains in longitudinal data
Wiedemann, M., Thew, G. R., Stott, R. B., & Ehlers, A. (2020) · PLoS ONE · doi:10.1371/journal.pone.0230276 · Cited by 19 · see citing works
“2% of participants [2]), which may partly be due to differences in the methods used to identify them.”
BackgroundMethodInfluentialLorenz, T. K., Pulverman, C. S., & Meston, C. M. (2012) · Cognitive Therapy and Research · doi:10.1007/s10608-012-9510-3 · Cited by 19 · see citing works
“Recent meta-analyses on sudden gains in treatments for anxiety and depression have shown that effect sizes on outcome measures in cognitive treatments are greater than that seen in noncognitive treatments (Aderka et al. 2012).”
BackgroundEmotion suppression, not reappraisal, predicts psychotherapy outcome
Scherer, A., Boecker, M., Pawelzik, M. R., Gauggel, S., & Forkmann, T. (2015) · Psychotherapy Research · doi:10.1080/10503307.2015.1080875 · Cited by 19 · see citing works
Vincent, L., & Norton, P. J. (2018) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2018.1513557 · Cited by 19 · see citing works
Brodbeck, J., Berger, T., Biesold, N., Rockstroh, F., Schmidt, S. J., & Znoj, H. (2021) · JMIR Mental Health · doi:10.2196/27707 · Cited by 18 · see citing works
“However, the speed and shape of change are not necessarily linear, and sudden gains or losses may occur (for more details, see the study by Aderka et al [44]).”
Pretreatment and process predictors of nonresponse at different stages of inpatient psychotherapy
Reuter, L., Münder, T., Altmann, U., Hartmann, A., Strauss, B. M., & Scheidt, C. E. (2015) · Psychotherapy Research · doi:10.1080/10503307.2015.1030471 · Cited by 19 · see citing works
Dozois, D., Bieling, P., Evraire, L. E., Patelis-Siotis, I., Hoar, L., Chudzik, S. M., Mccabe, K., & Westra, H. (2014) · International Journal of Cognitive Therapy · doi:10.1521/ijct.2014.7.3.217 · Cited by 24 · see citing works
Butler, R. M., O'Day, E. B., Kaplan, S. C., Swee, M. B., Horenstein, A., Morrison, A. S., Goldin, P. R., Gross, J. J., & Heimberg, R. G. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2019.103453 · Cited by 17 · see citing works
Andrews, L. A., Hayes, A. M., Abel, A., & Kuyken, W. (2020) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000467 · Cited by 16 · see citing works
Lancaster, C. L., Monfils, M., & Telch, M. J. (2020) · Behaviour Research and Therapy · doi:10.1016/j.brat.2020.103730 · Cited by 17 · see citing works
Kaiser, T., & Laireiter, A. (2018) · Psychotherapy Research · doi:10.1080/10503307.2018.1497213 · Cited by 16 · see citing works
“These sudden changes are in turn predictive of overall therapy outcome (Aderka et al., 2012).”
BackgroundSnippe, E., Schroevers, M. J., Tovote, K. A., Sanderman, R., Emmelkamp, P. M. G., & Fleer, J. (2018) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2332 · Cited by 16 · see citing works
Working with emotion predicts sudden gains during experiential therapy for depression
Singh, T., Pascual‐Leone, A., Morrison, O.-P., & Greenberg, L. S. (2020) · Psychotherapy Research · doi:10.1080/10503307.2020.1866784 · Cited by 16 · see citing works
“Study 1: Discussion Sudden gains were found to occur among individuals undergoing experiential psychotherapy for depression, further demonstrating the generalizability of sudden gains to a wide variety of treatment approaches and which is consistent with previous studies (Aderka et al., 2012).”
ResultInfluentialWorking along sudden gains: Responsiveness on small and subtle early changes and exceptions.
Flückiger, C., Holtforth, M. G., Re, A. C. D., & Lutz, W. (2013) · Psychotherapy · doi:10.1037/a0031940 · Cited by 16 · see citing works
The Process of Seeking Psychotherapy and Its Impact on Therapy Expectations and Experiences
Elliott, K. P., Westmacott, R. P., Hunsley, J. D., Rumstein-McKean, O., & Best, M. (2014) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.1900 · Cited by 16 · see citing works
Smith, A. H., Paulus, D. J., & Norton, P. J. (2016) · Anxiety Stress & Coping · doi:10.1080/10615806.2016.1186272 · Cited by 15 · see citing works
Dispositional optimism as predictor of outcome in short‐ and long‐term psychotherapy
Heinonen, E., Heiskanen, T., Lindfors, O., Härkäpää, K., & Knekt, P. (2016) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12109 · Cited by 15 · see citing works
Zhong, J., Liu, J., Xu, G., Zheng, H., Bowker, J. C., & Coplan, R. J. (2021) · European Journal of Psychological Assessment · doi:10.1027/1015-5759/a000689 · Cited by 15 · see citing works
- Authors
- Aderka, I. M., Nickerson, A., Bøe, H. J., & Hofmann, S. G.
- Affiliations
- Boston University (US)
- UNSW Sydney (AU)
- Norwegian University of Science and Technology (NO)
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2012
- Volume
- 80
- Issue
- 1
- Pages
- 93-101
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- OpenAlex
- W2127477641
- Cited by
- 240
- References
- 38
- Citations by year
- 2026: 6 · 2025: 13 · 2024: 9 · 2023: 9 · 2022: 9 · 2021: 44 · 2020: 17 · 2019: 18 · 2018: 25 · 2017: 17 · 2016: 20 · 2015: 17 · 2014: 22 · 2013: 7 · 2012: 7
- FWCI
- 12.78
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute of Mental Health
- 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
- sudden gains, psychological intervention, anxiety disorders, major depressive disorder, cognitive behavioral therapy, treatment outcomes, treatment moderators, long-term treatment outcomes
- MeSH terms
- Anxiety Disorders, Depressive Disorder, Major, Major Depressive Disorder, Follow-Up Studies, Humans, Cognitive Behavioral Therapy, Treatment Outcome
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