Depression and anxiety are leading causes of disability worldwide and incur significant societal costs [1,2]. The burden is especially apparent in the workplace, as evidenced by decreased productivity, poorer performance, absenteeism, and medical costs [3,4]. There is a robust empirical base supporting the efficacy of cognitive-behavioral therapy (CBT) for anxiety and depression [5], but access to evidence-based care is encumbered by various barriers. In addition, the stigma associated with receiving psychotherapy, cost of seeing out-of-pocket providers, long waitlists, and limited access to quality providers all contribute to delays in seeking and receiving treatment [3,6].

To bridge this gap, coaching has emerged as a contender to address some of these unmet mental health care needs. Historically, coaching has been proposed to facilitate improvements in well-being and performance in personal or professional capacities, using a results-oriented process [7]. As such, coaching has typically targeted individuals who do not meet criteria for clinically significant mental health problems but may present with elevated stressors or difficulties. Coaching is suited to target these broader life and performance challenges, using approaches such as establishing goals, problem-solving, and enhancing self-efficacy. Indeed, compared to psychotherapy, coaching tends to approach care using a life-enhancing model (encouraging interventions that improve the client’s overall well-being vs treating a “disorder”), and it takes a less directive stance to empower clients to devise their own solutions. Additionally, because coaching does not require advanced educational degrees or formal licensing, more coaches may be available to assist individuals, circumventing limitations in availability for licensed therapists and psychologists.

Within this context, it is important to note that less regulation in the training and qualifications of coaches does lend to more variability to the quality of care and theoretical frameworks used in coaching [8,9].Specifically, coaches have identified myriad psychological approaches in their work, including cognitive-behavioral, psychodynamic, solutions-focused, narrative, positive psychology, and mindfulness [10,11]. Because of the significant natural variability in approaches, it is important to consider how coaching can be augmented with rigorous provider selection, cognitive behavioral training, and quality assurance, and delivered within an evidence-based framework similar to those observed in psychotherapy. To address this need, cognitive-behavioral coaching (CBC) could be a promising way to operationalize and strengthen the theoretical principles used by coaches.

Cognitive-behavioral coaching has the potential to be a cost-effective method for adapting CBT principles for use within a coaching context. However, empirical support for CBC effectiveness has been variable, and the studies that do exist widely differ in their methodology [8,12]. In addition, prior studies have primarily focused on subclinical populations experiencing heightened stress or undesired health outcomes [9,13]. The relative dearth of studies examining the utility of CBC among individuals with more moderate levels of symptomology underscores the need to examine the effectiveness of CBC in a sample that generalizes to real-world settings. Additionally, a great deal of opportunity remains to augment the accessibility and delivery of these services within a short-term framework.

To decrease barriers to access, technological advancements have been increasingly effective in facilitating the dissemination of evidence-based care, especially CBT [14]. More specifically, blended care models have garnered growing empirical support, as the pairing of traditional face-to-face interventions with relevant digital activities has implications for greater dissemination, decreased costs, and robust treatment outcomes [15,16]. Although blended care has largely been examined in therapeutic contexts, there is a notable gap in the field for blended care coaching (BCC). In BCC, face-to-face sessions with coaches (in person or via teletherapy) work symbiotically with digital activities to introduce and reinforce key coaching concepts and skills. In general, the digital part of BCC exhibits a range of flexibility; some coaching programs are more regimented, with preset content and digital activities that are assigned to clients to be completed chronologically, while others are more flexible and personalize the assigned content based on what is discussed in the coaching sessions. Preliminary BCC studies have been tested for health outcomes [17,18]; however, these studies notably use psychologists, physicians, and other professionals with advanced degrees as the coaches. Consequently, further studies are needed to examine the effectiveness of BCC programs for psychological symptoms with greater real-world generalizability.

To date, there have been no studies examining CBC outcomes for addressing moderate levels of anxiety and depression using a blended care model. To fill this gap, the present study will examine the effectiveness of a BCC program in a real-world setting, using retrospective data of US-based clients receiving coaching services through Lyra Health. Establishing the effectiveness of BCC would have implications for addressing unmet mental health care needs in a more accessible, cost-effective manner.

Clients presenting with moderate levels of anxiety and depression exhibited a significant decrease in symptomology over the course of coaching, with close to 90% of clients with moderate anxiety and/or depression achieving reliable improvement or recovery. These findings suggest that cognitive-behavioral coaching is a promising method for managing these symptoms within a blended care context, assuming appropriate client selection. Additionally, it is noted that almost half of the sample belongs to an ethnic minority group. Achieving these strong outcomes within a diverse sample highlights the impact of providing culturally responsive care, as well as the potential for BCC to address some mental health disparities. Collectively, our findings are particularly exciting, as a substantial unmet need for mental health treatment remains in the United States given the shortage of licensed mental health providers.

When clients presented for coaching sessions, significant decreases in anxiety and depressive symptoms were observed for that same week as well as for the following week, reflecting the importance of session attendance. These findings highlight the crucial role of the coach in introducing and reinforcing the clinical concepts and skills in each session, which is an integral part of the blended care model. Coaches are also able to personalize the digital activities and place them in the context of the clients’ presenting issues, enhancing the precision of care. Additionally, the sessions are valuable opportunities to troubleshoot emergent issues and mitigate issues with homework compliance. Given that between-session homework compliance is a significant driver of symptom change [26], the increased accountability afforded by the coaching sessions is imperative for optimal outcomes. Taken together, coaching sessions allow for personalization of care and enhance engagement with clinical concepts and skills, contributing to durable decreases in anxiety and depression symptoms.

Additionally, the steepest declines in symptoms tended to occur during the initial weeks of coaching, emphasizing the importance of client buy-in and early engagement. The beginning stages of coaching are crucial for establishing the foundational rationale for the work to come. Solid psychoeducation about the purpose of a BCC model and how it can alleviate anxiety and depression is imperative for establishing positive expectations. Indeed, more positive expectations have been linked to better outcomes [27], highlighting the importance of collaborative care and dedicating time to clarify goals and expectations at the outset [28]. Establishing this initial momentum will also highlight the results of clients’ efforts firsthand, which is expected to maintain their buy-in and motivation to continue their work in BCC.

These findings should be considered within the context of certain limitations and future directions. First, over half of individuals seeking care were never offered the BCC program due to more severe clinical presentations such as suicidality, which limits the generalizability of the findings. Although it is a limitation to generalizability, the careful consideration that was given in determining who would be appropriate for this modality of care (eg, clients with moderate or lower levels of anxiety and depression) is arguably a strength of this program, as it is not suggested that coaching should be a substitute to therapy across a range of clinical severity. Second, the clients included in our analysis most commonly presented with anxiety and depression; future studies should evaluate the effectiveness of a BCC program for other psychiatric issues. Third, coaches in this program received extensive training in cognitive behavioral concepts, whereas traditional coaching focuses more narrowly on motivational interviewing and goal setting. Fourth, as coaching session outcomes were determined via client self-reports, it could be informative to incorporate multimethod (eg, clinical interview), multi-informant (eg, reports from significant others/family members) assessments in future evaluations for a more comprehensive understanding of symptomology and functioning. Finally, although there were robust reductions of anxiety and depression, findings were derived from a naturalistic study that examined retrospective data, which limits our ability to account for regression to the mean effects. As such, it would be helpful to conduct randomized controlled trials to impart further confidence in the effectiveness of BCC programs in reducing these symptoms beyond a control condition. Future dismantling studies should also be conducted to determine which components of the BCC model contributed to the biggest change in symptom severity. Engagement with digital CBT content (independent of coaching) has been shown to yield positive symptom improvement. By teasing apart the unique contributions of the digital components and the face-to-face coaching sessions, the active ingredients for change can be identified and fortified.

Ultimately, these data provide strong support for the use of an evidence-based CBC program within a blended care model for clients presenting with moderate levels of anxiety and depression. Under appropriate clinical supervision to ensure proper client selection and oversight, coaching appears to be a promising modality to expand access to timely mental health treatment.