Which evidence‑based psychotherapies are recommended for major depressive disorder, anxiety disorders, borderline personality disorder, chronic pain, health anxiety, stress‑related disorders, and post‑traumatic stress disorder, and what are the typical session frequency and duration for each?

Evidence-Based Psychotherapy Recommendations by Disorder

Major Depressive Disorder

For adults with major depressive disorder, cognitive behavioral therapy (CBT), interpersonal therapy (IPT), behavioral activation, problem-solving therapy, acceptance and commitment therapy, mindfulness-based cognitive therapy, and short-term psychodynamic psychotherapy (STPP) are all equally effective first-line treatments, with no therapy demonstrating superiority over others. 1

Recommended Psychotherapies

• CBT: Targets cognitive distortions and behavioral patterns maintaining depression 2
• Interpersonal therapy: No difference in response or remission compared to antidepressants after 12 weeks 1
• Behavioral activation: Focuses on scheduling pleasant activities to increase environmental reinforcement 2
• Problem-solving therapy: Equally effective as other evidence-based approaches 1
• Acceptance and commitment therapy: Recommended as initial treatment option 1
• Mindfulness-based cognitive therapy: Supported for initial treatment 1
• STPP: Added as recommendation based on two noninferiority trials comparing STPP to CBT 1

Treatment Structure

• Session frequency: Typically 12-20 sessions for standard treatment 2
• Duration: 8-52 weeks depending on severity and response 1
• Delivery format: Individual or group therapy show similar outcomes 1

Digital/Remote Options

• Computer or internet-based CBT with clinician guidance: Effective as adjunct to pharmacotherapy or first-line treatment based on patient preference 1
• Telephone-based CBT: No difference in response or remission compared to face-to-face delivery 1

Critical Point

The evidence indicates that universal mechanisms (working alliance, treatment rationale, belief in treatment) drive effectiveness rather than specific therapeutic techniques, meaning clinician expertise and patient preference should guide selection among these equally effective options 1

---

Anxiety Disorders (Social Anxiety, Generalized Anxiety, Panic Disorder)

CBT with exposure components is the first-line psychotherapy for anxiety disorders, with individual face-to-face CBT demonstrating the strongest evidence base. 1, 2

Core Treatment Components

• Psychoeducation: Understanding the anxiety response 1
• Cognitive restructuring: Challenging catastrophizing, overgeneralization, negative prediction, and all-or-nothing thinking 2
• Graduated exposure: Creating fear hierarchy from least to most distressing situations 2
• In vivo exposure: Real-world confrontation with anxiety-provoking situations 2
• Relaxation training: Deep breathing, progressive muscle relaxation, guided imagery 2

Treatment Structure for Social Anxiety (Heimberg Model)

• Session frequency: Approximately 9 sessions over 3-4 months 1
• Components: Psychoeducation, cognitive restructuring, gradual exposure (in-session and homework), core belief modification, relapse prevention 1

Alternative Delivery Methods

• Self-help with support based on CBT: Approximately 9 sessions over 3-4 months using self-help materials with therapist support (face-to-face or telephone) for total of approximately 3 hours 1
• Group CBT: Similar effectiveness to individual therapy 1

Treatment Duration

• Goal: Meaningful symptomatic and functional improvement within 12-20 sessions 2
• Children and adolescents (ages 6-18): CBT is first-line treatment for social anxiety, generalized anxiety, separation anxiety, specific phobia, or panic disorders 2

---

Post-Traumatic Stress Disorder (PTSD)

Trauma-focused psychotherapy is the primary treatment for PTSD, with Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR) demonstrating the strongest evidence, achieving 40-87% remission rates after 9-15 sessions. 3, 4, 5

First-Line Treatments (in order of evidence strength)

1. EMDR: Most effective at reducing symptoms (SMD -2.07) and improving remission rates post-treatment 5
2. Cognitive Processing Therapy (CPT): Average of 6 sessions showing robust efficacy 1, 4
3. Prolonged Exposure (PE): Brief protocol of 3 one-hour sessions or standard 13-session protocol 1, 4
4. Cognitive Therapy (CT): Strong evidence of clinically important effect 4

Treatment Structure

• Session frequency: 9-15 sessions for trauma-focused therapies 3, 2
• Duration: Typically 12-20 weeks 2
• Delivery: Can be delivered via telehealth (average 13 sessions for PE or CPT) 1

Alternative Evidence-Based Options

• Trauma-focused CBT: Four 2-hour weekly group meetings involving psychoeducation, breathing/relaxation, imaginal and in vivo exposure, cognitive restructuring 1
• Combined somatic/cognitive therapies: Effective at symptom reduction (SMD -1.69) 5
• Present Centered Therapy (PCT): Some supporting evidence 4

Critical Implementation Points

• Do NOT use psychological debriefing: May be harmful and does not reduce PTSD risk 3, 2, 6
• Avoid prolonged stabilization phases: Begin trauma processing even in complex presentations with multiple traumas or severe comorbidities 2
• Sustained effects: EMDR and TF-CBT show maintained improvements at 1-4 month follow-up 5

Adjunctive Approaches

• Therapy animals can complement CBT and exposure therapy protocols 7
• Brain-gut behavior therapy (BGBT) can be enhanced with animal-assisted components for comorbid conditions 7

---

Borderline Personality Disorder (BPD)

Dialectical Behavior Therapy (DBT), Mentalization-Based Therapy (MBT), Transference-Focused Therapy (TFP), and Schema Therapy are all empirically supported treatments for BPD, with no approach proving superior to others, achieving effect sizes of 0.50-0.65 for core symptom severity. 8, 9

Evidence-Based Psychotherapies

• Dialectical Behavior Therapy (DBT): Most empirical support for parasuicidal women with BPD 9
• Mentalization-Based Therapy (MBT): Empirically supported in randomized controlled trials 8
• Transference-Focused Therapy (TFP): Empirically supported in randomized controlled trials 8
• Schema Therapy: Empirically supported in randomized controlled trials 8

DBT Unique Elements

• Five functions of treatment: Must be served for treatment to constitute DBT 9
• Biosocial theory: Focusing on emotions in treatment 9
• Dialectical philosophy: Consistent throughout treatment 9
• Mindfulness and acceptance-oriented interventions: Core components 9

Treatment Considerations

• Efficacy: Compared to treatment as usual, psychotherapy shows effect sizes between 0.50 and 0.65 for core BPD symptom severity 8
• Non-responders: Almost half of patients do not respond sufficiently to psychotherapy 8
• No medication superiority: No evidence consistently shows any psychoactive medication is efficacious for core BPD features 8

Expanded Applications

• DBT for comorbid conditions: Promising findings for BPD with substance use disorders, binge-eating disorder, and depressed elderly patients 9

---

Chronic Pain and Health Anxiety

Brain-gut behavior therapy (BGBT) approaches demonstrate effectiveness for chronic pain conditions, and can be enhanced with animal-assisted components. 7

Treatment Approach

• BGBT: Addresses the brain-gut connection in chronic pain syndromes like irritable bowel syndrome 7
• Animal-assisted enhancement: Can complement BGBT protocols 7

For Health Anxiety

• CBT principles apply: Cognitive restructuring of catastrophic health beliefs and graduated exposure to health-related fears 2
• Treatment structure: 12-20 sessions following standard CBT framework 2

---

Stress-Related Disorders

CBT with stress management components, including relaxation training and cognitive restructuring, is the recommended approach for stress-related disorders. 2

Core Components

• Relaxation training: Deep breathing exercises, progressive muscle relaxation, guided imagery to reduce autonomic arousal 2
• Cognitive restructuring: Challenging stress-related cognitive distortions 2
• Behavioral activation: Counteracting avoidance patterns 2

Treatment Structure

• Duration: 12-20 sessions 2
• Homework assignments: Between sessions to reinforce skills and generalize to natural environments 2

---

Common Pitfalls Across All Disorders

• Premature termination: Ensure adequate treatment dose—stopping before completing 12-20 sessions reduces effectiveness 2
• Ignoring comorbidity: Do not exclude patients with comorbid depression from anxiety-focused CBT, as depressive symptoms commonly improve following anxiety treatment 2
• Inadequate therapist training: Effective delivery requires specialized education, training, and experience 2
• Wrong intervention timing: Do not use psychological debriefing within 24-72 hours after trauma 3, 2