Combining Imagination and Reason in the Treatment of Depression: A Randomized Controlled Trial of Internet-Based Cognitive-Bias Modification and Internet-CBT for Depression

Objective: Computerized cognitive-bias modification (CBM) protocols are rapidly evolving in experi-mental medicine yet might best be combined with Internet-based cognitive behavioral therapy (iCBT). No research to date has evaluated the combined approach in depression. The current randomized controlled trial aimed to evaluate both the independent effects of a CBM protocol targeting imagery and interpretation bias (CBM-I) and the combined effects of CBM-I followed by iCBT. Method: Patients diagnosed with a major depressive episode were randomized to an 11-week intervention (1 week/CBM-I 10 weeks/iCBT; n 38) that was delivered via the Internet with no face-to-face patient contact or to a wait-list control (WLC; n 31). Results: Intent-to-treat marginal models using restricted maximum likelihood estimation demonstrated significant reductions in primary measures of depressive symptoms and distress corresponding to medium-large effect sizes (Cohen’s d 0.62–2.40) following CBM-I and the combined (CBM-I iCBT) intervention. Analyses demonstrated that the change in interpretation bias at least partially mediated the reduction in depression symptoms following CBM-I. Treatment superiority over the WLC was also evident on all outcome measures at both time points (Hedges gs .59–.98). Significant reductions were also observed following the combined intervention on secondary measures associated with depression: disability, anxiety, and repetitive negative thinking (Cohen’s d 1.51–2.23). Twenty-seven percent of patients evidenced clinically significant change following CBM-I