Comprehensive Meta-Analysis Supports Use of CBT for the Treatment of Depression

According to a comprehensive meta-analysis published in World Psychiatry, cognitive behavior therapy (CBT) was an effective treatment for depression across subgroups of patients and in different settings. However, its comparative efficacy remained unclear.

Investigators from the Vrije Universiteit Amsterdam in The Netherlands searched publication databases through January 2022 for randomly assigned controlled trials evaluating CBT for the treatment of depression. The investigators defined CBT as work with a therapist focusing on the effects dysfunctional thoughts on behavior and functioning coupled with cognitive restructuring techniques.

A total of 409 studies comprising 52,702 patients were included in this analysis. The studies described 518 comparisons, including individual CBT (39.8%), group CBT (27.2%), guided self-help CBT (16.2%), and unguided self-help CBT (7.5%).

The pooled study population was aged mean 40.1±14.98 years and 69% were women.

Over time, more studies recruited patients with depression and general medical disorders (P =.007) and women with perinatal depression (P =.012), the number of participants in each comparison increased (P <.001), the number of CBT sessions decreased (P =.003), the number of studies that used waitlist control decreased (P =.001), and the number of studies conducted in non-Western countries increased (P =.005).

The main effect of CBT compared with control was significant (g, 0.79; 95% CI, 0.70-0.89; I², 85%).

The CBT interventions were favored over control for the outcomes of response to treatment (relative risk [RR], 2.13; 95% CI, 1.96-2.32; I², 47%) and remission (RR, 2.45; 95% CI, 2.06-2.92; I², 26%).

The effects of CBT remained significant at 6–9-month (g, 0.74; 95% CI, 0.36-1.11) and 10-12-month (g, 0.49; 95% CI, 0.01-0.98) follow-ups but not at the 13-24-month follow-ups (g, 0.22; 95% CI, -0.12 to 0.56).

Stratified by type of CBT, unguided self-help CBT (g, 0.45; 95% CI, 0.31-0.60; I², 78%), CBT in institutional settings (g, 0.65; 95% CI, 0.21-1.08; I², 70%), and CBT for children and adolescents (g, 0.41; 95% CI, 0.25-0.57; I², 78%) were favored over control conditions.

In noncontrol comparisons, CBT tended to be favored over psychotherapies (g, 0.06; 95% CI, 0-0.12; I², 31%). These findings were not robust to sensitivity analyses, in which CBT was not favored over other psychotherapies in any comparison. For the comparison of CBT with pharmacotherapies, CBT was not favored overall (g, 0.08; 95% CI, -0.07 to 0.24; I², 66%), however, CBT was preferred over pharmacotherapies in the long-term analysis at 6-12-months (g, 0.34; 95% CI, 0.09-0.58; I², 53%).

The major limitation of this analysis was the high heterogeneity.

Study authors concluded, “We can conclude that CBT is effective in the treatment of depression with a moderate to large effect size, and that its effect is still significant up to 12 months. The superiority of CBT over other psychotherapies does not emerge clearly from this meta-analysis. CBT appears to be as effective as pharmacotherapies at the short term, but more effective at the longer term.”