LEARNING OBJECTIVE 

1. Examine the effectiveness of cognitive behavioral therapy (CBT) in treating depression when compared to other therapies, while also assessing the duration of its peak effectiveness.

REVIEW OF: Cuijpers P et al, World Psychiatry 2023;22:105-115

STUDY TYPE: Meta-analysis of randomized trials

Clinical guidelines widely recommend cognitive behavioral therapy (CBT) for treating depression because of its demonstrated effectiveness in multiple studies compared to control conditions. However, how does it perform compared to other treatment options? This meta-analysis scrutinized CBT across various therapies, medication-only approaches, and combined treatments across different age groups and settings.

The meta-analysis involved 409 randomized control trials, encompassing over 52,702 patients (27,000 in CBT groups and 25,702 in control groups) diagnosed with depression through diagnostic interviews or self-report measures. To date, it is the largest meta-analysis ever conducted examining a specific type of psychotherapy for a particular mental disorder. It defined CBT broadly as therapy centered on cognitive restructuring, without imposing limitations on its administration format, outpatient or inpatient settings, or age groups. The meta-analysis categorized the studies accordingly and compared CBT to control conditions, other psychotherapies, pharmacotherapy alone, and combined treatments. They evaluated the study quality using the Cochrane Collaboration's Risk of Bias assessment tool.

The majority of the studies enrolled adult participants, with an average age of 40.1 years, most of whom were women. These studies were primarily conducted in the US, UK, and other European countries. Most studies were published after 2011, and individual-format CBT with more than 12 sessions emerged as the most commonly evaluated format.

The results demonstrated that CBT was significantly more effective than control conditions (usual care or waitlists) with an effect size of 0.79. This superiority persisted over 12 months of follow-up but tapered off at 13-24 months. When they compared CBT to other psychotherapies, there was no significant difference, both in the short and long term, after accounting for study bias. Similarly, CBT did not reveal any significant differences compared with pharmacotherapy or combined treatment after adjusting for publication bias.

CARLAT TAKE

This study confirms CBT’s effectiveness for depression when compared to no treatment—however, there is no clear superiority over other psychotherapies or medication. So, if your CBT patients are struggling with homework assignments or other aspects of the treatment, it’s likely that they will do just as well with different types of therapy that may suit them better.