Over the past several months, we have reviewed several articles that have endorsed cognitive behavioral therapy for the treatment of depression. In some cases, CBT has appeared even more effective than antidepressants, at least for the long-term prevention of relapse. But now, along comes a paper that appears to show that CBT isn’t particu- larly effective after all. Well, at least this is how the media has been reporting it. The actual results are not cut and dried.

A team of researchers identified all controlled clinical trials of CBT for schiz- ophrenia, depression, and bipolar disor- der that had been published over the past 20 years, likely including all rele- vant studies ever done on these topics. For their meta-analysis, they included tri- als that compared CBT to some sort of nonspecific psychotherapy (e.g., sup- portive therapy, psychoeducation, recre- ational therapy), treatment as usual (TAU), or a placebo pill. They excluded trials that compared CBT to a wait list control because they were examining the effectiveness of CBT compared to other treatments as opposed to CBT compared to no treatment. What was “TAU” in these studies? TAU was the treatment that patients would typically get in the community if they were not in any study, including medication, miscel- laneous forms of psychotherapy, and case management. Across nine trials examining psychosis (primarily schizo- phrenia) the researchers found that CBT was no more effective than nonspecific psychotherapies. While there seemed to be a small advantage for CBT in reducing positive symptoms, this advantage evaporated in studies where the clinical raters were unaware of whether patients were assigned to either CBT or nonspe- cific therapy. In 10 studies examining depression, CBT was more effective than nonspecific therapies and pill placebo by a statistically significant but clinically questionable margin (the effect size was 0.28). In the long term, CBT resulted in less depressive relapse than TAU. In four trials of bipolar disorder, CBT was not more effective than TAU for pre- venting a relapse of either mania or depression (Lynch D et al., Psychol Med; online ahead of print).

TCPR's Take: Over the years, CBT has developed the reputation of being the most evidence-based psychotherapy, with the implication that it must be the “best” therapy out there, especially for major depression and the anxiety disor- ders. But this analysis shows that CBT beat non-specific depression therapies by only a small margin, although it has a more robust advantage for preventing depressive relapse in the long term. With regard to bipolar disorder and schizophrenia, it now seems crystal clear that CBT provides no benefit beyond treatment as usual. In a future issue of TCPR, we will look at whether CBT truly beats other forms of psychotherapy for panic disorder and obsessive compulsive disorder.