Differential role of CBT skills, DBT skills and psychological flexibility in predicting depressive versus anxiety symptom improvement

•Cognitive behavioral skills are understudied in naturalistic psychiatric settings.•We tested whether skills predict depressive/anxiety symptom change in a hospital.•Behavioral activation (BA) strategies predicted depressive symptom improvement.•Patient severity moderated the relation between BA strategies and symptom change.•Psychological flexibility and DBT skills predicted anxiety symptom change.

ObjectiveStudies have reported associations between cognitive behavioral therapy (CBT) skill use and symptom improvement in depressed outpatient samples. However, little is known regarding the temporal relationship between different subsets of therapeutic skills and symptom change among relatively severely depressed patients receiving treatment in psychiatric hospital settings.MethodAdult patients with major depression (N = 173) receiving combined psychotherapeutic and pharmacological treatment at a psychiatric hospital completed repeated assessments of traditional CBT skills, DBT skills and psychological flexibility, as well as depressive and anxiety symptoms.ResultsResults indicated that only use of behavioral activation (BA) strategies significantly predicted depressive symptom improvement in this sample; whereas DBT skills and psychological flexibility predicted anxiety symptom change. In addition, a baseline symptom severity X BA strategies interaction emerged indicating that those patients with higher pretreatment depression severity exhibited the strongest association between use of BA strategies and depressive symptom improvement.ConclusionsFindings suggest the importance of emphasizing the acquisition and regular use of BA strategies with severely depressed patients in short-term psychiatric settings. In contrast, an emphasis on the development of DBT skills and the cultivation of psychological flexibility may prove beneficial for the amelioration of anxiety symptoms.