Nakao et al.

BioPsychoSocial Medicine (2021) 15:16

https://doi.org/10.1186/s13030-021-00219-w

REVIEW Open Access

Cognitive–behavioral therapy for

management of mental health and stress-
related disorders: Recent advances in
techniques and technologies
Mutsuhiro Nakao1*, Kentaro Shirotsuki2 and Nagisa Sugaya3

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) principles, such as classical and operant conditioning, to
CBT is a type of psychotherapeutic treatment that helps clinical problems. So-called “first-wave” behavioral ther-
people to identify and change destructive or disturbing apy was developed in the 1950s [2]. In the US, Albert El-
thought patterns that have a negative influence on their lis founded rational emotive therapy to help clients
behavior and emotions [1]. Under stressful conditions, modify their irrational thoughts when encountering
some individuals tend to feel pessimistic and unable to problematic events, and Aaron Beck employed cognitive
solve problems. CBT promotes more balanced thinking therapy for depressed clients using Ellison’s model [3].
to improve the ability to cope with stress. The origins of Behavioral therapy and cognitive therapy were later inte-
CBT can be traced to the application of learning theory 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
* Correspondence: m-nakao@iuhw.ac.jp
1
Department of Psychosomatic Medicine, School of Medicine, International to develop well-specified and rigorous techniques based
University of Health and Welfare, 4-3, Kozunomori, Narita-shi, Chiba 286-8686, on empirically validated basic principles [4]. From the
Japan
1960s onward, the dominant psychotherapies worldwide
Full list of author information is available at the end of the article

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Nakao et al. BioPsychoSocial Medicine (2021) 15:16 Page 2 of 4

have been second-wave forms of CBT. Recently, how- 29% in community settings [12]. Chronic low-back pain
ever, a third-wave form of CBT has attracted increasing is not only prevalent, but is a source of significant phys-
attention, leading to new treatment approaches such as ical disability, role impairment, and diminished psycho-
acceptance and commitment therapy, dialectical behav- logical well-being and quality of life [11]. Interestingly,
ior therapy, mindfulness-based cognitive therapy, func- according to the results of our own study [13], CBT was
tional analytic psychotherapy, and extended behavioral effective among hypochondriacal patients without
activation; other forms may also exist, although this is chronic low-back pain, but not in hypochondriacal pa-
subject to conjecture [4]. In a field of psychosomatic tients with chronic low-back pain. These group differ-
medicine, it has been reported that cognitive restructur- ences did not seem to be due to differences in the
ing is effective in improving psychosomatic symptoms baseline levels of hypochondriasis. Although evidence
[5], exposure therapy is suitable for a variety of anxious has suggested that both hypochondriasis and chronic
disease conditions like panic disorder and agoraphobia low-back pain can be treated effectively with CBT [10,
[6], and mindfulness reduces stress-related pain in fibro- 11, 14], this has not yet been validated. Chronic low-
myalgia [7]. Several online and personal computer-based back pain may be associated with a variety of conditions,
CBT programs have also been developed, with or with- including anxiety, depression, and somatic disorders
out the support of clinicians; these can also be accessed such as illness conviction, disease phobia, and bodily
by tablets or smartphones [8]. Against this background, preoccupation. The core psychopathology of hypochon-
this review focused on the effectiveness of CBT with a driacal chronic low-back pain should be clarified to pro-
biopsychosocial approach, and proposed strategies to mote adequate symptom management [13].
promote CBT application to both patient and non- Since 2000, Cochrane reviews have evaluated the ef-
patient populations. fectiveness of CBT for a variety of mental, physical, and
behavioral problems. Through a search of the Cochrane
Research on CBT Library database up to May 2021 [15], 124 disease con-
Using “CBT “and “biopsychosocial” as PubMed search ditions were assessed to clarify the effects of CBT in ran-
terms, 345 studies published between January 1987 and domized controlled trials; the major conditions for
May 2021 were identified (Fig. 1); 14 of 154 review arti- which CBT showed efficacy are listed in Table 1. These
cles were systemic reviews, and 45 of 53 clinical trials include a broad range of medical problems such as psy-
were randomized controlled trials. Most clinical trials re- chosomatic illnesses (e.g., chronic fatigue syndrome, ir-
cruited the samples from patient populations in order to ritable bowel syndrome, and fibromyalgia), psychiatric
assess specific diseases, but some targeted at those from disorders (e.g., anxiety, depression, and developmental
non-patient populations like a working population in disability), and socio-behavioral problems (drug abuse,
order to assessing mind-body conditions relating to sick smoking, and problem gambling). For most of these con-
leave [9]. The use of biopsychosocial approaches to treat ditions, CBT proved effective in the short term after
chronic pain is shown to be clinically and economically completion of the randomized controlled trial. Although
efficacious [10]; for example, CBT is effective for chronic the number of literature was still limited, some studies
low-back pain [11]. The prevalence of chronic low-back have reported significant and long-term treatment ef-
pain, defined as pain lasting for more than 3 months, fects of CBT on some aspects of mental health like
was reported to be 9% in primary-care settings and 7– 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 3 of 4

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: ‘Third -wave’ CBT as effective treatment of acute depression October 2013
Depression, general Reduced depressive symptoms in dementia and mild cognitive impairment January 2014
Improved response and remission rates for treatment-resistant depression May 2018
Reduced depressive symptoms in children with long-term physical conditions December 2018
Reduced depressive symptoms in chronic obstructive pulmonary disease March 2019
Reduced depressive symptoms in dialysis patients December 2019
Reduced the number of sickness absence days in workers October 2020
Anxiety, general Reduced anxiety symptoms in adults by “media-delivered CBT” (self-help) September 2013
Obsessive–compulsive disorder Reduced anxiety symptoms in dementia and mild cognitive impairment January 2014
Panic disorder Reduced anxiety symptoms in adults by therapist-supported internet CBT March 2016
Reduced anxiety symptoms in children with long-term physical conditions December 2018
Effective for attention control in children and adolescents November 2020
Effective in children and adolescents with this disorder October 2006
Effective in adults with this disorder April 2007
Efficacy of both CBT alone and CBT and antidepressants January 2007
Efficacy of both CBT and benzodiazepines January 2009
Post-traumatic stress disorder (PTSD) Effective in children and adolescents for up to 1 month following CBT December 2012
Social anxiety disorder Reduced clinician-assessed PTSD symptoms in adults December 2013
Reduced PTSD symptoms when used as couple and family therapies December 2019
Reduced social phobia via brief CBT 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 Efficacy of a specific manual-based form of CBT for bulimia nervosa October 2009
Hypochondriasis Reduced hypochondriacal symptoms and general functioning October 2007
Somatoform disorder Reduced symptom severity in adults with somatoform disorders November 2014
Physical diseases: Improved survival at 12 months (metastatic) June 2013
Breast cancer Favorable effects on anxiety, depression and mood disturbance (non-metastatic) May 2015
Chronic fatigue syndrome Reduced fatigue symptoms July 2008
Fibromyalgia Reduced pain, negative mood, and disability September 2013
Irritable bowel syndrome Reduced symptoms of irritable bowel syndrome and improved quality of life January 2009
Recurrent abdominal pain Reduced pain in the short term in children and adolescents January 2017
Tinnitus Reduced negative impacts on quality of life and depression January 2020
Behavioral and other problems: Reduced antisocial behaviors in young people in the short term October 2007
Antisocial behaviors Effective in the short term for reducing benzodiazepine harmful use May 2015
Benzodiazepine use Reduced psychological stress in family caregivers of people with dementia November 2011
Burden of care for dementia Improved child conduct problems, parental mental health, and parenting skills February 2012
Early behavioral problems Reduced children’s needle-related pain and distress in children and adolescents October 2018
Needle-related problems Reduced weight, predominantly useful when combined with diet and exercise April 2005
Obesity and overweight Reduced stress at work in healthcare workers April 2015
Occupational stress Reduced pathological and problem gambling behaviors immediately after CBT November 2012
Problem gambling Resulted in fewer adults repeatedly self-poisoning and self-injuring May 2016
Self-harm Reduced symptoms of PTSD, anxiety, and depression in children May 2012
Sexual abuse
Smoking Effective for smoking cessation in indigenous populations January 2012

completion of intervention. Future research should in- treatment outcomes and health insurance costs for these
vestigate the duration of CBT’s effects and ascertain the six disorders should be analyzed as the first step, for ap-
optimal treatment intensity, including the number of propriate allocation of medical resources according to
sessions. disease severity and complexity [18]. In Japan, health in-
surance coverage is provided only when physicians apply
Future directions for CBT application in for remuneration. A system promoting nurse involve-
biopsychosocial domains ment in CBT delivery [19], as well as shared responsibil-
In Japan, CBT for mood disorders was first covered ity between the CBT instructor and certified
under the National Health Insurance (NHI) in 2010, and psychologists (or even a complete shift from physicians
CBT for the following psychiatric disorders was subse- to psychologists), has yet to be established. Information
quently added to the NHI scheme: obsessive–compulsive and communication technology (ICT) devices may allow
disorder, social anxiety disorder, panic disorder, post- CBT delivery to be shared between medical staff and
traumatic stress disorder, and bulimia nervosa [17]. The psychologists, in medical, community and self-help
Nakao et al. BioPsychoSocial Medicine (2021) 15:16 Page 4 of 4

settings [8]. The journal BioPsychoSocial Medicine pub- 7. Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. Treating
lished 334 relevant articles up to the end of May 2021, fibromyalgia with mindfulness-based stress reduction: results from a 3-
armed randomized controlled trial. Pain. 2011;152:361–9.
112 (33.5%) of which specifically addressed CBT [20]. 8. Shirotsuki K, Nonaka Y, Takano J, Abe K, Adachi SI, Adachi S, et al. Brief
CBT is a hot topic in biopsychosocial medicine, and internet-based cognitive behavior therapy program with a supplement
more research is required to encourage its application to drink improved anxiety and somatic symptoms in Japanese workers.
Biopsychosoc Med. 2017;11:25.
clinical and general populations. 9. Beck BD, Hansen ÅM, Gold C. Coping with work-related stress through
guided imagery and music: randomized controlled trial. J Music Ther. 2015;
Abbreviations 52:323–52.
CBT: Cognitive–behavioral therapy; ICT: Information and communication 10. Cheatle MD. Biopsychosocial approach to assessing and managing patients
technology; NHI: National Health Insurance; PTSD: Post-traumatic stress with chronic pain. Med Clin North Am. 2016;100:43–53.
disorder 11. Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ,
et al. Effect of mindfulness-based stress reduction vs cognitive behavioral
Acknowledgments therapy or usual care on back pain and functional limitations in adults with
None. chronic low back pain: a randomized clinical trial. JAMA. 2016;315:1240–9.
12. Verhaak PF, Kerssens JJ, Dekker J, Sorbi MJ, Bensing JM. Prevalence of
Authors’ contributions chronic benign pain disorder among adults: a review of the literature. Pain.
MN organized the project and wrote the entire manuscript. KS and NS 1998;77:231–9.
conducted the literature search and were involved in the conceptualization 13. Nakao M, Shinozaki Y, Nolido N, Ahern DK, Barsky AJ. Responsiveness of
of the review. All authors (MN, KS and NS) share final responsibility for the hypochondriacal patients with chronic low-back pain to cognitive-
decision to submit the manuscript for publication. The authors read and behavioral therapy. Psychosomatics. 2012;53:139–47.
approved the final manuscript. 14. Barsky AJ, Ahern DK. Cognitive–behavior therapy for hypochondriasis: a
randomized controlled trial. JAMA. 2004;291:1464–70.
Funding 15. Cochrane library. Cochrane reviews. [https://www.cochranelibrary.com/]
The study was supported in part by a Research Grant (Kiban C) from the Accessed 15 June 2021.
Japanese Ministry of Education, Culture, Sports, Science and Technology. 16. Cludius B, Landmann S, Rose N, Heidenreich T, Hottenrott B, Schröder J,
et al. Long-term effects of mindfulness-based cognitive therapy in patients
Availability of data and materials with obsessive-compulsive disorder and residual symptoms after cognitive
Not applicable. behavioral therapy: twelve-month follow-up of a randomized controlled
trial. Psychiatry Res. 2020;291:113–9.
Declarations 17. Ono Y, Furukawa TA, Shimizu E, Okamoto Y, Nakagawa A, Fujisawa D, et al.
Current status of research on cognitive therapy/cognitive behavior therapy
Ethics approval and consent to participate in Japan. Psychiatry Clin Neurosci. 2011;65:121–9.
Not applicable. 18. Wu Q, Li J, Parrott S, López-López JA, Davies SR, Caldwell DM, et al. Cost-
effectiveness of different formats for delivery of cognitive behavioral
therapy for depression: a systematic review based economic model. Value
Consent for publication
Health. 2020;23:1662–70.
All authors have consented to the publication of this manuscript.
19. Yoshinaga N, Nosaki A, Hayashi Y, Tanoue H, Shimizu E, Kunikata H, et al.
Cognitive behavioral therapy in psychiatric nursing in Japan. Nurs Res Pract.
Competing interests
2015;2015:529107.
Not applicable.
20. Nakao M, Komaki G, Yoshiuchi K, Deter HC, Fukudo S. Biopsychosocial
medicine research trends: connecting clinical medicine, psychology, and
Author details
1 public health. Biopsychosoc Med. 2020;14(1):30.
Department of Psychosomatic Medicine, School of Medicine, International
University of Health and Welfare, 4-3, Kozunomori, Narita-shi, Chiba 286-8686,
Japan. 2Graduate School of Human and Social Sciences, Musashino Publisher’s Note
University, Tokyo, Japan. 3Unit of Public Health and Preventive Medicine, Springer Nature remains neutral with regard to jurisdictional claims in
School of Medicine, Yokohama City University, Yokohama, Japan. published maps and institutional affiliations.

Received: 22 July 2021 Accepted: 24 September 2021

References
1. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of
cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res.
2012;36:427–40.
2. Blackwell SE, Heidenreich T. Cognitive behavior therapy at the crossroads.
Int J Cogn Ther. 2021;8:1–22.
3. Beck AT. Cognitive therapy. A 30-year retrospective. Am Psychol. 1991;46:
368–75.
4. Soler AF, Cebolla A, McCracken LM, D'Amico F, Knapp M, López-Montoyo A,
et al. Economic impact of third-wave cognitive behavioral therapies: a
systematic review and quality assessment of economic evaluations in
randomized controlled trials. Behav Ther. 2018;49:124–47.
5. Hellman CJ, Budd M, Borysenko J, McClelland DC, Benson H. A study of the
effectiveness of two group behavioral medicine interventions for patients
with psychosomatic complaints. Behav Med. 1990;16:165–73.
6. Wendt J, Hamm AO, Pané-Farré CA, Thayer JF, Gerlach A, Gloster AT, et al.
Pretreatment cardiac vagal tone predicts dropout from and residual
symptoms after exposure therapy in patients with panic disorder and
agoraphobia. Psychother Psychosom. 2018;87:187–9.