Evaluating Process of Change in Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for Depression

Researching and Improving Psychotherapy Techniques in Interventions for DEpression (RIPTIDE)

This study will compare two psychological treatments for major depressive disorder (MDD): cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT). Both treatments are well-studied and supported by evidence as effective options for people experiencing depression. These treatments will be delivered in an online group format via Zoom.

The study will enroll up to 100 participants with depression. Half of the participants will receive online group CBT and half will receive online group ACT. There will be up to 10 members in each group. For both conditions, treatment will be provided over 8 weeks, with a 6-month follow-up period. Enrollment will be ongoing and groups will occur simultaneously.

Potential participants are asked to complete an initial screening and an intake evaluation to determine eligibility. They will then receive 8-weeks of treatment. Participants will complete self-report questionnaires throughout their time in the study.

Study Overview

• Status: Completed
• Conditions: Depression
• Intervention / Treatment: Behavioral: Cognitive Behavioral Therapy; Behavioral: Acceptance and Commitment Therapy

Detailed Description

Some of the most powerful tools to combat depression come in the form of psychotherapies, including Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT). While both treatments have been found to be generally effective in treating depression, they take fundamentally different treatment approaches. In CBT, clients learn techniques to challenge and change maladaptive thought and behavioral patterns. In ACT, clients learn techniques to accept their negative internal experiences and commit to action in line with their values. Despite being among the most effective treatments for depression, both CBT and ACT have a response rate of about only 50%. It is believe there are two key reasons investigators have not been able to improve these response rates. First, very little is known about which specific therapeutic skills are effective in these treatment packages. For example, do cognitive or behavioral change skills lead to therapeutic change in CBT? In ACT, do acceptance or change skills lead to therapeutic change? Second, it is not known which specific treatments or therapeutic skills work better for different individuals. Every individual has diverse needs, and therefore individuals may benefit differently from different treatment packages or from specific skills within each package.

Therefore, investigators plan to run a randomized controlled trial comparing CBT and ACT for depression in order to investigate which specific therapeutic skills are effective in these treatment packages. This approach will also allow investigators to identify predictors of differential response to treatment packages and specific treatment skills.

Upon joining the study, participants are asked to complete surveys for one week prior to starting treatment and again for one week once treatment is completed. During treatment, they are asked to complete surveys throughout the 8 weeks of therapy. Following the 8-week treatment, participants are asked to complete monthly follow-up surveys for 6 months.

There are three main objectives in this study. The first is to compare processes of change across the two treatments (i.e., what works in specific treatments?). The second is to determine client variables that predict differential treatment response (i.e., which treatment works best for a given client?). The third is to evaluate potential moderators of differential response to any specific skills across the treatments (i.e., which specific therapy skill works best for a given client?)

• Study Type: Interventional
• Enrollment (Actual): 116
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • Los Angeles, California, United States, 90007
      • University of Southern California

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• diagnosis of major depressive disorder (MDD) according to DSM-V criteria (APA, 2013)
• 18 years of age or older
• access to a private location with a stable internet connection and a working video camera
• lives in California
• able to understand and speak English
• able and willing to give informed consent

Exclusion Criteria:

• current diagnosis other than MDD if it constitutes the predominant aspect of the clinical presentation and if it requires treatment other than that being offered
• clear indication of secondary gain (e.g., court ordered treatment)
• current suicide risk or significant intentional self-harm in the last six months sufficient to preclude treatment on an outpatient basis.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Cognitive Behavioral Therapy; Over 8 sessions, clients learn techniques to challenge and change maladaptive thought and behavioral patterns	Behavioral: Cognitive Behavioral Therapy; Sessions will focus on skills such as behavioral activation, mood tracking, identifying and reframing automatic thoughts, assertion training and smart goals.
Active Comparator: Acceptance and Commitment Therapy; Over 8 sessions, clients learn techniques to accept their negative internal experiences and commit to action in line with their values	Behavioral: Acceptance and Commitment Therapy; Sessions will focus on skills such as mindfulness, acceptance and willingness training, values clarification, committed action, defusion, and self-as-context.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Chain of Change Treatment Diary (ChaCha-TD)	The ChaCha-TD designed by our research group assesses participants' affect, symptoms, quality of life, significant life events, skills use, and mechanisms of treatment change in daily life.	Three days per week during the eight-week course of treatment at 8 p.m. on preselected days.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Generalized Anxiety Disorder Questionnaire (GAD-7)	The GAD-7 (Spitzer et al., 2006) is a seven-item self-report measure of anxiety symptom severity.	Intake, Post-treatment (8 weeks)
WHO Quality of Life-Brief (WHOQOL-BREF)	The WHOQOL-BREF (WHOQOL Group; 1998) is a 26-item self-report measure that evaluates four dimensions of quality of life (physical health, psychological health, social relationships, environment. Each item ranges from 1-5 and items are summed upon completing the measure. Higher scores indicate greater satisfaction with quality of life.	Intake, Post-treatment (8-weeks), and follow-up (6-months)
Positive and Negative Affect Schedule (PANAS)	The PANAS (Watson et al., 1988) is a 20-item scale that assesses the extent to which participants are experiencing different positive and negative emotions in the present moment. 10-items assess positive emotions and 10-items assess negative emotions. Items range from 1-5 and are summed based on the valence of the emotion. Higher scores indicate more salient experiences of affect.	Intake, Post-treatment (8-weeks), and follow-up (6-months)
Patient Health Questionnaire (PHQ-9)	The PHQ-9 (Kroenke et al., 2001) is a 9-item self-report scale that measures depressive symptom severity. Each item ranges from 0-3 and items are summed upon completing the measures. Higher scores indicate greater depression symptom severity.	Intake, Post-treatment (8-weeks), and follow-up (6-months)
Discrimination-Related Vigilance Scale (DRVS)	The DRVS (Williams, unpublished; and first published by Clark et al., 2006) is a 6-item measure of heightened vigilance in response to experiences of racial discrimination. This scale will be asked as a follow-up to the Brief PEDQ- CV to assess the extent to which the client is vigilant in their surroundings because of previous discrimination they experienced.	Intake, Post-treatment (8-weeks)
Valuing Questionnaire (VQ)	The VQ (Smout et al., 2014) is a 10-item self-report measure that assesses the extent of personal values enactment during the past week.	Intake, Post-treatment (8 weeks)
Automatic Thoughts Questionnaire (ATQ)	The ATQ (adapted from Hollon & Kendall, 1980) is a 30- item self-report checklist measure of common automatic thoughts participants may or may not have experienced in the past two weeks.	Intake, Post-treatment (8 weeks)
Emotion Regulation Questionnaire (ERQ)	The ERQ (Gross & John, 2003) is a 10-item self-report measure of two emotion regulation strategies, cognitive reappraisal and expressive suppression.	Intake, Post-treatment (8 weeks)
Positive Valence Systems Scale (PVSS-21)	The PVSS-21 (Khazanov et al,. 2020 ) is a self-report scale assessing the National Institute of Mental Health Research Domain Criteria Positive Valence Systems constructs (e.g., reward anticipation and initial reward responsiveness).	Intake, Post-treatment (8 weeks)
Multidimensional Scale of Perceived Social Support (MSPSS)	The MSPSS (Zimet et al., 1988) is a 12-item measure of perceived adequacy of social support from family, friends, and significant others.	Intake, Post-treatment (8 weeks)
Group Session Rating Scale (GSRS)	The GSRS (Quirk et al., 2013) is a client-reported measure that assesses alliance, the quality of individual sessions, and helper skills.	Once per week for each session.
Drexel University ACT/CT Adherence and Competence Rating Scale (DUACRS)	The DUACRS (McGrath, 2012) is a therapist-reported measure designed to assess adherence to CBT and ACT treatment components. While the original measure was designed to assess the extent to which each of these components occurred at every 5-minute interval during a session, we slightly adapted the response options to indicate whether the treatment components occurred at all in the relevant session.	Once per week for each session.
California Psychotherapy Alliance Scale-Group- Therapist Version (CALPAS- G-TV)	The CALPAS-G-TV (Gaston & Marmar, 1994) is a therapist- report measure of the therapeutic alliance in group psychotherapy settings.	Once per week for each session.
Clinical Global Impressions Scale (CGI)	The CGI (Guy, 1976) is a standard therapist-reported measure for making global assessments of clients' illness and improvement.	Once per week for each session.
Chain of Change Ecological Momentary Assessment (ChaCha-EMA)	The ChaCha-EMA consists of the same items assessed in the ChaCha-TD with the exception that questions will be phrased to assess clients' experiences at the moment of survey completion.	Three times per day for the seven days pre- and seven days post-treatment.

Collaborators and Investigators

• Sponsor: University of Southern California
• Investigators: Principal Investigator: Iony D Ezawa, PhD, University of Southern California

Publications and helpful links

General Publications

• Dao A, Bernstein RA, Ramos FN, Beasley B, Ezawa ID. Unpacking the chain of change in group CBT and ACT for depression: A protocol for a randomized clinical trial. Contemp Clin Trials. 2025 Jun;153:107907. doi: 10.1016/j.cct.2025.107907. Epub 2025 Apr 2.

Study record dates

Study Major Dates

• Study Start (Actual): February 14, 2024
• Primary Completion (Actual): November 3, 2025
• Study Completion (Actual): April 29, 2026

Study Registration Dates

• First Submitted: January 24, 2024
• First Submitted That Met QC Criteria: February 5, 2024
• First Posted (Actual): February 7, 2024

Study Record Updates

• Last Update Posted (Actual): May 19, 2026
• Last Update Submitted That Met QC Criteria: May 14, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Behavioral Symptoms; Behavior; Depression; Behavior Therapy; Psychotherapy; Behavioral Disciplines and Activities; Cognitive Behavioral Therapy; Acceptance and Commitment Therapy
• Other Study ID Numbers: UP-23-01077

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No