Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies

Abstract

Cognitive–behavioral therapy (CBT) helps individuals to eliminate avoidant and safety-seeking behaviors that prevent self-correction of faulty beliefs, thereby facilitating stress management to reduce stress-related disorders and enhance mental health. The present review evaluated the effectiveness of CBT in stressful conditions among clinical and general populations, and identified recent advances in CBT-related techniques. A search of the literature for studies conducted during 1987–2021 identified 345 articles relating to biopsychosocial medicine; 154 (45%) were review articles, including 14 systemic reviews, and 53 (15%) were clinical trials including 45 randomized controlled trials. The results of several randomized controlled trials indicated that CBT was effective for a variety of mental problems (e.g., anxiety disorder, attention deficit hypersensitivity disorder, bulimia nervosa, depression, hypochondriasis), physical conditions (e.g., chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, breast cancer), and behavioral problems (e.g., antisocial behaviors, drug abuse, gambling, overweight, smoking), at least in the short term; more follow-up observations are needed to assess the long-term effects of CBT. Mental and physical problems can likely be managed effectively with online CBT or self-help CBT using a mobile app, but these should be applied with care, considering their cost-effectiveness and applicability to a given population.

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R E V I E W Open Access
Cognitive–behavioral therapy for
management of mental health and stress-
related disorders: Recent advances in
techniques and technologies
Mutsuhiro Nakao
1*
, Kentaro Shirotsuki
2
and Nagisa Sugaya
3
Abstract
Cognitive–behavioral therapy (CBT) helps individuals to eliminate avoidant and safety-seeking behaviors that
prevent self-correction of faulty beliefs, thereby facilitating stress management to reduce stress-related disorders
and enhance mental health. The present review evaluated the effectiveness of CBT in stressful conditions among
clinical and general populations, and identified recent advances in CBT-related techniques. A search of the literature
for studies conducted during 1987–2021 identified 345 articles relating to biopsychosocial medicine; 154 (45%)
were review articles, including 14 systemic reviews, and 53 (15%) were clinical trials including 45 randomized
controlled trials. The results of several randomized controlled trials indicated that CBT was effective for a variety of
mental problems (e.g., anxiety disorder, attention deficit hypersensitivity disorder, bulimia nervosa, depression,
hypochondriasis), physical conditions (e.g., chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, breast
cancer), and behavioral problems (e.g., antisocial behaviors, drug abuse, gambling, overweight, smoking), at least in
the short term; more follow-up observations are needed to assess the long-term effects of CBT. Mental and physical
problems can likely be managed effectively with online CBT or self-help CBT using a mobile app, but these should
be applied with care, considering their cost-effectiveness and applicability to a given population.
Keywords: Biopsychosocial approach, Cognitive–behavioral therapy, Stress management
History of cognitive–behavioral therapy (CBT)
CBT is a type of psychotherapeutic treatment that helps
people to identify and change destructive or disturbing
thought patterns that have a negative influence on their
behavior and emotions [1]. Under stressful conditions,
some individuals tend to feel pessimistic and unable to
solve problems. CBT promotes more balanced thinking
to improve the ability to cope with stress. The origins of
CBT can be traced to the application of learning theory
principles, such as classical and operant conditioning, to
clinical problems. So-called “first-wave”behavioral ther-
apy was developed in the 1950s [2]. In the US, Albert El-
lis founded rational emotive therapy to help clients
modify their irrational thoughts when encountering
problematic events, and Aaron Beck employed cognitive
therapy for depressed clients using Ellison’s model [3].
Behavioral therapy and cognitive therapy were later inte-
grated in terms of theory and practice, leading to the
emergence of “second-wave”CBT in the 1960s. The
first- and second-wave forms of CBT arose via attempts
to develop well-specified and rigorous techniques based
on empirically validated basic principles [4]. From the
1960s onward, the dominant psychotherapies worldwide
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* Correspondence: m-nakao@iuhw.ac.jp
1
Department of Psychosomatic Medicine, School of Medicine, International
University of Health and Welfare, 4-3, Kozunomori, Narita-shi, Chiba 286-8686,
Japan
Full list of author information is available at the end of the article
Nakao et al. BioPsychoSocial Medicine (2021) 15:16
https://doi.org/10.1186/s13030-021-00219-w
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have been second-wave forms of CBT. Recently, how-
ever, a third-wave form of CBT has attracted increasing
attention, leading to new treatment approaches such as
acceptance and commitment therapy, dialectical behav-
ior therapy, mindfulness-based cognitive therapy, func-
tional analytic psychotherapy, and extended behavioral
activation; other forms may also exist, although this is
subject to conjecture [4]. In a field of psychosomatic
medicine, it has been reported that cognitive restructur-
ing is effective in improving psychosomatic symptoms
[5], exposure therapy is suitable for a variety of anxious
disease conditions like panic disorder and agoraphobia
[6], and mindfulness reduces stress-related pain in fibro-
myalgia [7]. Several online and personal computer-based
CBT programs have also been developed, with or with-
out the support of clinicians; these can also be accessed
by tablets or smartphones [8]. Against this background,
this review focused on the effectiveness of CBT with a
biopsychosocial approach, and proposed strategies to
promote CBT application to both patient and non-
patient populations.
Research on CBT
Using “CBT “and “biopsychosocial”as PubMed search
terms, 345 studies published between January 1987 and
May 2021 were identified (Fig. 1); 14 of 154 review arti-
cles were systemic reviews, and 45 of 53 clinical trials
were randomized controlled trials. Most clinical trials re-
cruited the samples from patient populations in order to
assess specific diseases, but some targeted at those from
non-patient populations like a working population in
order to assessing mind-body conditions relating to sick
leave [9]. The use of biopsychosocial approaches to treat
chronic pain is shown to be clinically and economically
efficacious [10]; for example, CBT is effective for chronic
low-back pain [11]. The prevalence of chronic low-back
pain, defined as pain lasting for more than 3 months,
was reported to be 9% in primary-care settings and 7–
29% in community settings [12]. Chronic low-back pain
is not only prevalent, but is a source of significant phys-
ical disability, role impairment, and diminished psycho-
logical well-being and quality of life [11]. Interestingly,
according to the results of our own study [13], CBT was
effective among hypochondriacal patients without
chronic low-back pain, but not in hypochondriacal pa-
tients with chronic low-back pain. These group differ-
ences did not seem to be due to differences in the
baseline levels of hypochondriasis. Although evidence
has suggested that both hypochondriasis and chronic
low-back pain can be treated effectively with CBT [10,
11,14], this has not yet been validated. Chronic low-
back pain may be associated with a variety of conditions,
including anxiety, depression, and somatic disorders
such as illness conviction, disease phobia, and bodily
preoccupation. The core psychopathology of hypochon-
driacal chronic low-back pain should be clarified to pro-
mote adequate symptom management [13].
Since 2000, Cochrane reviews have evaluated the ef-
fectiveness of CBT for a variety of mental, physical, and
behavioral problems. Through a search of the Cochrane
Library database up to May 2021 [15], 124 disease con-
ditions were assessed to clarify the effects of CBT in ran-
domized controlled trials; the major conditions for
which CBT showed efficacy are listed in Table 1. These
include a broad range of medical problems such as psy-
chosomatic illnesses (e.g., chronic fatigue syndrome, ir-
ritable bowel syndrome, and fibromyalgia), psychiatric
disorders (e.g., anxiety, depression, and developmental
disability), and socio-behavioral problems (drug abuse,
smoking, and problem gambling). For most of these con-
ditions, CBT proved effective in the short term after
completion of the randomized controlled trial. Although
the number of literature was still limited, some studies
have reported significant and long-term treatment ef-
fects of CBT on some aspects of mental health like
obsessive-compulsive disorder [16] 1 year after the
Fig. 1 Number of articles per year identified by a PubMed search from 1989 to the present
Nakao et al. BioPsychoSocial Medicine (2021) 15:16 Page 2 of 4
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completion of intervention. Future research should in-
vestigate the duration of CBT’s effects and ascertain the
optimal treatment intensity, including the number of
sessions.
Future directions for CBT application in
biopsychosocial domains
In Japan, CBT for mood disorders was first covered
under the National Health Insurance (NHI) in 2010, and
CBT for the following psychiatric disorders was subse-
quently added to the NHI scheme: obsessive–compulsive
disorder, social anxiety disorder, panic disorder, post-
traumatic stress disorder, and bulimia nervosa [17]. The
treatment outcomes and health insurance costs for these
six disorders should be analyzed as the first step, for ap-
propriate allocation of medical resources according to
disease severity and complexity [18]. In Japan, health in-
surance coverage is provided only when physicians apply
for remuneration. A system promoting nurse involve-
ment in CBT delivery [19], as well as shared responsibil-
ity between the CBT instructor and certified
psychologists (or even a complete shift from physicians
to psychologists), has yet to be established. Information
and communication technology (ICT) devices may allow
CBT delivery to be shared between medical staff and
psychologists, in medical, community and self-help
Table 1 Example diseases and problems for which CBT is expected to be effective (Cochrane reviews)
Major disease conditions Summary of evidence Update
Psychiatric disorders:
Depression, general
‘Third -wave’CBT as effective treatment of acute depression
Reduced depressive symptoms in dementia and mild cognitive impairment
Improved response and remission rates for treatment-resistant depression
Reduced depressive symptoms in children with long-term physical conditions
Reduced depressive symptoms in chronic obstructive pulmonary disease
Reduced depressive symptoms in dialysis patients
Reduced the number of sickness absence days in workers
October 2013
January 2014
May 2018
December 2018
March 2019
December 2019
October 2020
Anxiety, general
Obsessive–compulsive disorder
Panic disorder
Reduced anxiety symptoms in adults by “media-delivered CBT”(self-help)
Reduced anxiety symptoms in dementia and mild cognitive impairment
Reduced anxiety symptoms in adults by therapist-supported internet CBT
Reduced anxiety symptoms in children with long-term physical conditions
Effective for attention control in children and adolescents
Effective in children and adolescents with this disorder
Effective in adults with this disorder
Efficacy of both CBT alone and CBT and antidepressants
Efficacy of both CBT and benzodiazepines
September 2013
January 2014
March 2016
December 2018
November 2020
October 2006
April 2007
January 2007
January 2009
Post-traumatic stress disorder (PTSD)
Social anxiety disorder
Effective in children and adolescents for up to 1 month following CBT
Reduced clinician-assessed PTSD symptoms in adults
Reduced PTSD symptoms when used as couple and family therapies
Reduced social phobia via brief CBT
December 2012
December 2013
December 2019
September 2018
Acute stress disorder Reduced acute traumatic stress symptoms via brief trauma-focused CBT March 2010
Attention deficit–hyperactivity disorder Beneficial for treating adults with this disorder in the short term March 2018
Bulimia nervosa
Hypochondriasis
Somatoform disorder
Efficacy of a specific manual-based form of CBT for bulimia nervosa
Reduced hypochondriacal symptoms and general functioning
Reduced symptom severity in adults with somatoform disorders
October 2009
October 2007
November 2014
Physical diseases:
Breast cancer
Improved survival at 12 months (metastatic)
Favorable effects on anxiety, depression and mood disturbance (non-metastatic)
June 2013
May 2015
Chronic fatigue syndrome
Fibromyalgia
Reduced fatigue symptoms
Reduced pain, negative mood, and disability
July 2008
September 2013
Irritable bowel syndrome
Recurrent abdominal pain
Reduced symptoms of irritable bowel syndrome and improved quality of life
Reduced pain in the short term in children and adolescents
January 2009
January 2017
Tinnitus Reduced negative impacts on quality of life and depression January 2020
Behavioral and other problems:
Antisocial behaviors
Benzodiazepine use
Burden of care for dementia
Early behavioral problems
Needle-related problems
Obesity and overweight
Occupational stress
Problem gambling
Self-harm
Sexual abuse
Reduced antisocial behaviors in young people in the short term
Effective in the short term for reducing benzodiazepine harmful use
Reduced psychological stress in family caregivers of people with dementia
Improved child conduct problems, parental mental health, and parenting skills
Reduced children’s needle-related pain and distress in children and adolescents
Reduced weight, predominantly useful when combined with diet and exercise
Reduced stress at work in healthcare workers
Reduced pathological and problem gambling behaviors immediately after CBT
Resulted in fewer adults repeatedly self-poisoning and self-injuring
Reduced symptoms of PTSD, anxiety, and depression in children
October 2007
May 2015
November 2011
February 2012
October 2018
April 2005
April 2015
November 2012
May 2016
May 2012
Smoking Effective for smoking cessation in indigenous populations January 2012
Nakao et al. BioPsychoSocial Medicine (2021) 15:16 Page 3 of 4
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settings [8]. The journal BioPsychoSocial Medicine pub-
lished 334 relevant articles up to the end of May 2021,
112 (33.5%) of which specifically addressed CBT [20].
CBT is a hot topic in biopsychosocial medicine, and
more research is required to encourage its application to
clinical and general populations.
Abbreviations
CBT: Cognitive–behavioral therapy; ICT: Information and communication
technology; NHI: National Health Insurance; PTSD: Post-traumatic stress
disorder
Acknowledgments
None.
Authors’contributions
MN organized the project and wrote the entire manuscript. KS and NS
conducted the literature search and were involved in the conceptualization
of the review. All authors (MN, KS and NS) share final responsibility for the
decision to submit the manuscript for publication. The authors read and
approved the final manuscript.
Funding
The study was supported in part by a Research Grant (Kiban C) from the
Japanese Ministry of Education, Culture, Sports, Science and Technology.
Availability of data and materials
Not applicable.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
All authors have consented to the publication of this manuscript.
Competing interests
Not applicable.
Author details
1
Department of Psychosomatic Medicine, School of Medicine, International
University of Health and Welfare, 4-3, Kozunomori, Narita-shi, Chiba 286-8686,
Japan.
2
Graduate School of Human and Social Sciences, Musashino
University, Tokyo, Japan.
3
Unit of Public Health and Preventive Medicine,
School of Medicine, Yokohama City University, Yokohama, Japan.
Received: 22 July 2021 Accepted: 24 September 2021
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