Williams et al. (2013)

Combining imagination and reason in the treatment of depression: A randomised control trial of internet based cognitive bias modification and internet-CBT for depression


What do I need to know before tackling this study?

  1. What is Major depressive disorder or uni-polar depression?
  2. How do cognitive psychologists explain depression with regard to information processing biases?
  3. What is cognitive behavioural therapy? What is meant by a top-down approach in CBT?
  4. What is cognitive bias modification and mental imagery?
  5. What are the strengths and weaknesses of cognitive behavioural therapy?
  6. starsIf you would like to read more about Cognitive Bias Modification before you start, try this 😀 https://www.anxiety.org/cognitive-bias-modification-internet-based-treatment-for-anxiety-disorders.
  7. You can also read the original paper here: http://psycnet.apa.org/fulltext/2013-20188-001.html
  8. Learn more about the AST-D, one of the standardised tests used in this study: here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3149299/

Aim: The study aimed to investigate the effectiveness of a brief 7 day internet-delivered imagery-based cognitive bias modification (CBM-I) as a “stand-alone” intervention for depression (known as a bottom up intervention as it starts with inputting new information) and in combination with the more traditional top-down approach to CBT (that is scrutinizing pre-existing thinking biases), involving a 10 week iCBT program, also delivered remotely on the Internet.  The study explored whether preparing Pps with the CBM-I would optimize engagement with the more challenging iCBT components.

Design:  The 69 people who completed an electronic informed consent were randomized by an independent person to either the intervention (n = 38) or wait-list control (WLC) group (n = 31). The WLC group completed iCBT after the intervention group had completed all study components.  The study aimed to see whether the the level of success of CBM-I mediated the success of the iCBT.

Ethics: The study was approved by the Human Research Ethics Committee (HREC) of St. Vincent’s Hospital in Sydney and the HREC of the University of New South Wales, also in Sydney.

Participants: The sample comprised 69 Pps recruited via virtualclinic.org.au (Clinical Research Unit for Anxiety and Depression), a not-for-profit clinical and research unit in Sydney, Australia. Applicants first completed online screening questionnaires.

Materials: There were two main categories with regard to the measured variables:

Primary measures were taken of depression severity and distress using…

  • Pps were telephoned for a diagnostic interview using the Mini International Neuropsychiatric Interview
  • The Beck Depression Inventory–2nd edition (BDI-II) and the nine-item Depression Scale of the Patient Health Questionnaire (PHQ-9) were the primary outcomes measures of depression severity.
  • The 10-item Kessler Psychological Distress Scale (K10) was used to index distress.
  • Interpretation bias was measured with the Ambiguous Scenarios Test–Depression (AST-D) and an electronic version of the Scrambled Sentences Test (SST); two versions of the AST-D were presented in counterbalanced order

Secondary measures included degree of disability, anxiety and repetitive negative thinking) using:

  • the World Health Organization Disability Assessment Schedule–II (WHODAS-II),
  • the State Trait Anxiety Inventory–Trait Version (STAI-T)
  • the Repetitive Thinking Questionnaire (RTQ10
  • Our Treatment Expectancy and Outcomes Questionnaire contained these three questions:
    • “At this point, how logical does the program offered to you seem? (0 = Not at all logical to 4 = Very logical)
    • “At this point, how useful do you think this treatment will be in reducing your depression symptoms?” (0 = Not at all usefulto 4 = Very useful)
    • “Overall, how satisfied are you with your treatment?” (1 = Very dissatisfiedto 5 = Very satisfied). 

The interventions

CBM-I: seven sessions (20 min each) of imagery-focused CBM-I completed daily over the course of 1 week; individuals were repeatedly presented with ambiguous scenarios that are consistently resolved in a positive manner; the aim of this was to train the user to have an automatic positive bias with regard to the way that they interpret novel ambiguous information in their day-to-day lives

iCBT: consisted of the Sadness Program, which has been evaluated in three previous trials. The program consists of six online lessons representing best practice CBT as well as regular homework assignments and access to supplementary resources

The procedure:

  • The entire assessment and intervention was conducted online with no face-to-face contact
  • All patients first completed baselines measures of their depression, distress, anxiety and thinking biases (see questionnaires listed above)
  • Half the Pps then completed the 7-day CBM-I component, the other half were on the waiting list.
  • All patients then completed the primary measures after the 7-day intervention phase.
  • Next the experiment al group completed the 10-week iCBT component, whilst the others were again “on the waiting list”.
  • All patients completed the baseline battery of questionnaires after 10 weeks.
  • The WLC group then commenced deferred treatment (iCBT but without CBM-I).


Measure Group Baseline After CBM-I After iCBT
BDI -II Intervention 27.97 18.96 10.40
Waiting List 28.00 24.82 20.54
PHQ-9 Intervention 12.38 9.88 5.15
Waiting List 13.81 13.03 10.59
K10 Intervention 29.26 24.11 17.40
Waiting List 28.62 28.33 24.45
AST-D Intervention 4.18 4.67 N/A
Waiting List 4.60 4.32 N/A
  • There were no significant group differences in any of the baseline measures or in age, gender, or medication use
  • There were no differences in patients’ ratings of treatment expectations, although standard e-mail contact did differ due to technical assistance required in the intervention group, the amount of personal contact with the research team did not vary.
  • Following CBM-I, the reductions in BDI-II, PHQ-9, and K10 scores in the intervention group were all significant and corresponded to medium-large effects.
  • The intervention group showed improved scores on all measures, corresponding to medium effects.
  • Mean AST-D scores did not differ between groups, but the increase in mean scores (more positive interpretations) in the intervention group was significant, corresponding to a medium effect.
  • There was no significant change in the WLC group.
  • There was no main effect or interaction for SST-Negativity scores
  • Clinically significant change was evident in 27% (n= 7) of the intervention group compared to 0.07% (n = 2) in the WLC group, χ2(1, 53) = 3.57, p = .05
  • The direct effect of group on BDI-II was not significant (p= .09), but critically, the indirect effect of AST-D on the change in BDI-II scores was
  • Analyses of the combined intervention demonstrated significant reductions in all primary measures (BDI-II, PHQ-9, K10) in the intervention group, corresponding to large effects
  • Significant reductions were also observed in the WLC group corresponding to medium effects, but intervention group superiority was observed for all measures.
  • For WHODAS-II, STAI-T, and RTQ10, all scores were significantly lower in the intervention group relative to the WLC group, corresponding to medium-large effect sizes.
  • Sixty-five percent (n= 13) of patients in the intervention group evidenced clinically significant change on the BDI-II compared to 36% (n = 8) in the WLC, χ2(1, 42) = 3.43, p = .06.
  • The majority of patients who completed the combined intervention indicated
    • the instructions were eithereasy or very easy to follow (77%)
    • that CBM-I was at least moderately logical (88%)
    • rated the quality of the combined intervention asgood or excellent (84%)
    • Mean ratings of confidence in recommending the intervention to a friend with depression (1 =not at all confident to 10 = extremely confident) were 7.77 (SD = 2.10).


The current RCT represents the first investigation within a clinical trials framework of Internet-delivered CBM for depression targeting interpretation and imagery and the results suggest that Internet-delivered CBM-I for depression can effect rapid symptom reduction over just 1 week, via seven 20-min sessions, and no additional “homework.”  Moreover, the effect of the CBM-I intervention on symptoms of depression was at least partially mediated by the trained change in imagery-based interpretive bias (AST-D). The study demonstrates the feasibility of integrating CBM into existing iCBT treatment programs for depression. The combined intervention was effective in reducing depressive symptoms, distress, disability, anxiety, and rumination in patients diagnosed with a major depressive episode.

Evaluation points

Applications to the real world: Internet-based iCBT is obviously much more practical fr many people with depression however its success will of course depend on the patient’s perception of the effectiveness of intervention and their ability to complete each of the daily activities.

Validity: The researchers note that further research needs to be conducted to find out exactly what the nature of the mediating effect of CBM-I prior to iCBT; they note that it could have been due to increased motivation to complete the iCBT but it could equally have been down to the CBM-I training actually helping Pps to generate more positive/alternative thoughts in the iCBT intervention, thus making it more effective. They also note that replications are necessary in order to know whether the effects would be maintained long term.

Generalisability: They also note that the study needs to be replicated to reveal the extent to which findings may be generalizable to other groups

Assessment activity: Killing two birds with one stone!

Assessment Questions:

Describe the aim of one study in Clinical Psychology. Do not use Rosenhan (1973) for this study. (2)

Describe the procedure of one study in Clinical Psychology. Do not use Rosenhan (1973) for this study. (4)

Describe the results/findings of one study in Clinical Psychology. Do not use Rosenhan (1973) for this study. (4)

Describe the conclusions of one study in Clinical Psychology. Do not use Rosenhan (1973) for this study. (2)

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© Amanda J Wood, 2017