A meta-analysis of the effects of CT in depressed patients

Abstract

Cognitive therapy (CT) has been studied in 78 controlled clinical trials from 1977 to 1996.
The meta-analysis used Hedges and Olkin d+ and included 48 high-quality controlled trials. The 2765 patients presented non-psychotic and non-bipolar major depression, or dysthymia of mild to moderate severity.
At post-test CT appeared significantly better than waiting-list, antidepressants (P < 0.0001) and a group of miscellaneous therapies (P < 0.01). But, CT was equal to behaviour therapy. As between-trial homogeneity was not met, the comparisons of CT with waiting-list or placebo, and other therapies should be taken cautiously. In contrast, between-trial homogeneity was high for the comparisons of CT with behaviour therapy and antidepressants. A review of eight follow-up studies comparing CT with antidepressants suggested that CT may prevent relapses in the long-term, while relapse rate is high with antidepressants in naturalistic studies.
CT is effective in patients with mild or moderate depression.

Full text

Journal of Affective Disorders 49 (1998) 59–72
Research report
A meta-analysis of the effects of cognitive therapy in depressed
patients
1,a a, a b
*
´
Valerie Gloaguen , Jean Cottraux , Michel Cucherat , Ivy-Marie Blackburn
a
Anxiety Disorder Unit Hopital Neurologique
,59
boulevard Pinel
, 69394
Lyon
,
France
b
Professor of Clinical Psychology
,
Durham University and Cognitive Therapy Center
,
Newcastle
,
UK
Received 17 April 1997; received in revised form 10 November 1997; accepted 11 November 1997
Abstract
Background. Cognitive therapy (CT) has been studied in 78 controlled clinical trials from 1977 to 1996. Method. The
meta-analysis used Hedges and Olkin d1and included 48 high-quality controlled trials. The 2765 patients presented
non-psychotic and non-bipolar major depression, or dysthymia of mild to moderate severity. Results. At post-test CT
appeared significantly better than waiting-list, antidepressants (P,0.0001) and a group of miscellaneous therapies
(P,0.01). But, CT was equal to behaviour therapy. As between-trial homogeneity was not met, the comparisons of CT with
waiting-list or placebo, and other therapies should be taken cautiously. In contrast, between-trial homogeneity was high for
the comparisons of CT with behaviour therapy and antidepressants. A review of eight follow-up studies comparing CT with
antidepressants suggested that CT may prevent relapses in the long-term, while relapse rate is high with antidepressants in
naturalistic studies. Conclusion. CT is effective in patients with mild or moderate depression. 1998 Elsevier Science B.V.
Keywords
:
Cognitive therapy; Behaviour therapy; Depression; Meta-analysis; Psychotherapy; Antidepressants
1. Introduction were superior to no-treatment and pharmacological
methods of treatment. Robinson et al. (1990) made a
Since the first controlled study of cognitive meta-analysis of 58 studies of psychotherapy in
therapy (CT) in depression (Rush et al., 1977), depression and found that depressed patients bene-
several meta-analytic studies have been carried out. fited substantially from psychotherapy and these
Steinbruek et al. (1983) concluded, in a meta- gains appeared comparable to those observed with
analysis including 56 studies, that psychotherapies psychopharmacological treatments. Conte et al.
(1986) quantitatively reviewed 11 studies combining
pychotherapy with drug. The combined treatments
*Corresponding author. Tel.: 133 72 118065; fax.: 133 72 were more effective than placebo conditions, but
357330; e-mail: cottraux@univ-lyon1.fr
1
only slightly superior to psychotherapy alone, phar-
Currently at Hopital du Vinatier U.M.A. 95 boulevard Pinel 69
Bron, France. macotherapy alone, or either of these combined with
0165-0327/98 / $19.00 1998 Elsevier Science B.V. All rights reserved.
PII S0165-0327(97)00199-7

60 V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
placebo. However, these authors evaluated psycho- mended long term treatment with antidepressants
therapy in general without reference to technical as prevention (Kupfer, 1992).
specifications and theoretical backgrounds.
Miller and Berman (1983), in a meta-analysis of
48 studies, found cognitive behaviour therapy su- 2. Method
perior to no-treatment; pure cognitive therapy and
the combination of cognitive with behavioural meth-
2.1.
Inclusion
.
Exclusion
ods were equal; cognitive behaviour therapies were
at least as effective as drug treatments for depressed To be included in the study, trials had to be
patients. However, their conclusions were tentative: randomised and have at least one CT group, and one
only ten studies (21%) involved the treatment of comparison group: waiting list or placebo, antide-
depressed patients. pressants, behaviour therapy or another psychothera-
A meta-analysis by Dobson (1989) reviewed 28 peutic treatment. The inclusion criteria reported were
CT studies, and concluded that CT was superior to those of major depression or dysthymic disorder,
waiting list control, drug treatment, behaviour according to RDC (Feighner et al., 1972; Spitzer et
therapy and miscellaneous therapies. Gaffan et al. al., 1978), the American Psychiatric Association
(1995) found a correlation between researcher al- DSM-3. (1980) DSM-III or the American Psychiatric
legiance and outcome in the studies selected by Association (1987) DSM-III-R, with the exclusion of
Dobson, but not in subsequent ones. One may notice psychotic depression and bipolar affective disorder.
that both Dobson and Gaffan included studies which
were not randomised.
2.2.
Literature search
The present paper will attempt to answer five
pragmatic questions: The sources used for the literature search were
data bases: medline on the internet and embase
1. Is CT superior to control conditions? If it were medica, references in papers or books, previous
not true, placebo effects and demand characteris- reviews and meta-analyses, abstracts from congress
tics may explain its outcomes. presentations, and pre-prints sent by authors.
2. Is CT superior to the reference treatment of
depression, antidepressants? If it were true, there
2.3.
General criterion of improvement
would be an alternative to pharmacological treat-
ments of depression. To evaluate the severity of the depression, we
3. Is CT superior to behaviour therapy? If it were used the Beck Depression Inventory (BDI: Beck et
true, this would suggest that direct cognitive al., 1988) which was the common measure of
modification is the key factor in depression effectiveness of all the trials. The BDI score ranges
improvement. 0–63. Beck et al. (1988) defined the cut-offs of the
4. Is CT superior to other psychotherapies (behav- scale: ,10: no depression, 10–18: mild depression,
iour therapy excluded)? If it were true, it would 19–29: moderate depression, 30 and more: severe
mean that cognitive therapy is a specific psycho- depression
logical treatment for depression.
5. Are the outcomes of CT long lasting? Does CT
2.4.
Statistical methods
prevent relapses? A relapse is considered as the
return of a full depressive state (BDI .16) Analyses included only the completers when intent
between 6 and 9 months after a 2 month remis- to treat data were missing.
sion. Beyond this point, a return of full blown
depression is termed ‘‘recurrence’’ (Shea et al.,
2.5.
Effect size
1992). The main problem with antidepressants
being the high rate of relapses and recurrences Our meta-analysis was based on Hedges and Olkin
after withdrawal, some authors have recom- (1985). When means and variances of the compared

V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
61
groups were not available, effect size was estimated interpret the outcomes of the meta-analysis the
from Student t-test as suggested by Jenicek (1987). between-trial heterogeneity Qstatistic was com-
puted. Qhas a Chi-square distribution with k21 df.
The null hypothesis is rejected when P,0.05: in this
1. 72 comparisons were made. For each trial, case the sample of trials is heterogeneous.
Hedges (1981) gwas calculated on the post-test
BDI values in the CT and comparison group, and
corresponding pooled within group standard de-
viation according to the formula: 4. Multiple regression study
g5
(mean cognitive therapy) 2(mean comparison group)
Dependencies of the effect size on several charac-
]]]]]]]]]]]]
]
pooled SD
teristics of the patients (BDI score, sex and age)
were studied with a linear multivariate model with-
2. We applied the Hedges (1981) correction which out interaction term taking trials as statistical units.
includes the number of subjects to correct for the
small sample bias. A dscore was computed for
each study:
5. Results
3
]
]
SD
d512g
4N29
5.1.
Patients and studies
N was the sum of the number of patients in CT
and the comparison group. We found 78 trials published between January 1st
3. Then the Hedges and Olkin (1985) d1, which 1977 and December 1st 1996. Some trials were
represents a combined estimate of the effect size presented in international congresses, but not pub-
of a set of studies, was computed. Each trial was lished in scientific journals (Hautzinger and De Jong-
weighted by the reciprocal of its estimated vari- ¨
Meyer, 1995; Rotzer-Zimmer et al., 1985; Zimmer et
ance. The required level of significance was set at al., 1987; Neimeyer et al., 1983). All the patients
P,0.01 to correct for multiple comparisons, were without psychotic features or bipolar disorder.
according to the meta-analysis cooperative group The patients were mainly outpatients. Thirty trials
recommendations (Boissel et al., 1989). When the were excluded for methodological reasons. Among
effect size was negative, this indicated that the these, four had been included in Dobson (1989)
patients improved more in cognitive therapy. meta-analysis and Gaffan’s meta-analysis (see Table
When it was positive this indicated that the 1).
patients improved more in the comparison group. Eventually, the comparisons included 48 trials and
4. Zscores were computed for statistical compari- 2765 patients. Sex ratio was available in only 43
sons. These calculations allowed for the expres- trials: the mean percentage of women was 71.1
sion of the meta-analysis in % of therapeutic (range: 0–100%). The mean age was available in 42
benefit: if the average patient of the comparison trials: m539.3. The rate of lost-to-follow-up patients
group were treated with CT he or she would was known for 38 of the 48 trials (mean drop-out
move from the 50th to a higher percentile (CT.rate: 17.2%) which was as high as usual in psycho-
Comparison group) or a lower percentile (CT,therapy research. Studies were small size ones: mean
Comparison group). n568.45. The NIMH study (Elkin et al., 1989) had
the largest sample (n5239). Mean BDI at pre-test
ranged from 10–31. In all the trials double-blindness
3. Homogeneity was not possible as in any research on psychother-
apies. The type of random allocation was never
Meta-analysis assumes that the effect-size of a specified. Table 2 represents the included trials and
treatment is the sum of all the pooled trials. To their characteristics.

62 V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
Table 1
Excluded trials
Study (year) Reasons for exclusion
1. Zeiss et al. (1979) Measure: MMPI depression scale
2. Fennel and Teasdale (1983)* No randomisation: patient resistant to drugs were allocated to CT
3. Keller (1983)* No control group
4. Steuer and Hammen (1983)* No control group
5. Baker and Wilson (1985)* No control group; CT with booster was compared with
CT without booster
6. Shapiro and Firth (1987) Cross-over design; sample of anxious or depressive
patients
7. Fremont and Craighead (1987)** CT was compared with aerobic exercise
8. Collet et al. (1987) No-randomisation; multiple baseline design across patients
9. Schlosser et al. (1988)** No-randomisation
10. Persons et al. (1988)** No-randomisation
11. Kavanagh and Wilson (1989)** No-randomisation
12. Barkham et al. (1989)** Prescriptive therapy was compared with Explorative
therapy
13. Linehan et al. (1991) Sample of deliberate self-harm in borderline patients
14. Neimeyer and Feixas (1990)** No control group; CT with homework assignments was
compared with CT without homework assignments
15. Waring et al. (1990) BDI was not used
16. Usaf and Kavanagh (1990)** No-randomisation
17. Salkovskis et al. (1990) Sample of deliberate self-harm in borderline patients
18. Thase et al. (1991)** No control group
19. Free et al. (1991)** No-randomisation
20. Haaga et al. (1991)** No control group
21. Whisman (1991) Cognitive dysfunction but not depression was studied
22. Mercier et al. (1992) Sequential design; no randomisation
23. Propst et al. (1992) Sample bias: religious patients
24. Simons and Thase (1992)** No control group
25. McKnight et al. (1992)** Dexamethasone suppression test and response to CT and
antidepressant were studied
26. Zettle et al. (1992)** No control group; individual CT was compared with
group CT
27. Thase et al. (1993)** No control group; CT by outpatients was compared with
CT by inpatients
28. Stravynski et al. (1994) Therapy was predominantly behavioural
29. Wilson et al. (1995) No control group; augmentation study
30. Munoz et al. (1995) Patients were not depressed; prevention study
*, Included in the Dobson (1989) meta-analysis.
**, Included in the Gaffan et al. (1995) meta-analysis.
CT: Cognitive Therapy; BT: Behaviour Therapy; BDI: Beck Depression Inventory; MMPI: Minnesota Multiphasic Personality Inventory.
5.2.
Meta-analysis
:
outcomes Interpersonal therapy was identified as distinct
from both cognitive therapy, behaviour therapy or
The number of comparisons, d1, 95% confidence cognitive-behaviour therapy as demonstrated in the
intervals of d1, % benefit, Z,Pand Qvalues are works of De Rubeis et al. (1982); Weissman and
represented in Table 3. The four studies which Markowitz (1994).
compared CT with relaxation (McLean and Hakstian, We found a highly significant difference (P,
1979; Reynolds and Coats, 1986; Bowers, 1990; 0.0001) in favour of CT versus waiting-list or
Murphy et al., 1995) were grouped with other placebo. The average subject in CT is better of 29%
therapies. than the average subject in the waiting-list or

V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
63
Table 2
Included trials
Author Year Sample Treatments Cell M % Weeks of
(outpatients) size age women therapy
27.1 72.7 12.0
1. Beck et al., 1985 Clinic –Cognitive 18
–Cognitive and Antidepressants 15
(Amitriptyline)
2/ Beach and O’Leary, 1992 40.7 50.0 14.0
Clinic –Cognitive 15
–Behavioural marital 15
–Waiting list 15 70.7 55.4 20.0
3/ Beutler et al., 1987 Geriatric –Alprazolam and support 12
–Placebo and support 15
–Cognitive and placebo 16
–Cognitive and Alprazolam 13
46. 69.7 20.0
4/ Beutler et al., 1991 Clinic –Cognitive 21
–Expressive therapy 22
–Supportive therapy 20
5/ Blackburn et al., 1981 43.7 64.0 12.9
Blackburn et al., 1986 Hospital –Cognitive 22
–Antidepressant 20
(amitriptyline or clomipramine)
–Combination 22 36.2 80.0 4.2
6/ Bowers, 1990 Hospital –Antidepressant 10
(Nortriptyline)
–Antidepressant and cognitive 10
–Antidepressant and relaxation 10 38.0 100.0 5..3
7/ Comas-Diaz, 1981 Clinic –Cognitive 8
(Puerto –Behavioural 8
Rican) –Waiting list 10
8/ Covi and Lipman, 1987 43.8 60.0 15 sessions
Voluntary –Cognitive (group) 27
Consultant –Cognitive (group) and 23
Antidepressant (Imipramine)
–Psychodynamic 20 — 70.0 4.0
9/ Dunn, 1979 Psychiatric –Cognitive 10
–Antidepressant and 10
supportive therapy 85.0 70.3 16 sessions
10/ Elkin et al., 1989 Clinic –Cognitive 37
–Interpersonal 47
–Antidepressant 36
(Imipramine)
–Placebo 35
38.4 51.85 16.0
11/ Emanuels-Zuurveen and Emmelkamp, 1996 Community –Cognitive 14
–Behavioural 13

64 V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
Table 2.
(
Continued
)
Author Year Sample Treatments Cell M % Weeks of
(outpatients) size age women therapy
12/ Gallagher and Thompson, 1982 67.8 76.7 12.0
Geriatric –Cognitive 10
Gallagher and Thompson, 1983 –Behavioural 10
–Insight psychotherapy 10 62.0 92.0 —
13/ Gallagher-Thompson and Steffen, 1994 Geriatric –Cognitive-behavioural 36
caregiver –Psychodynamic 30 39.0 62.8 8.0*
14/ Hautzinger and De Jong-Meyer, 1995 Non –Cognitive-Behavioural 68
endogenous –Antidepressant 66
depression (Amitriptyline)
–Cognitive-Behavioural and 62
antidepressant 28.1 62.2 8.0
15/ Hogg and Deffenbacher, 1988 Student –Cognitive 13
–Interpersonal 14
–Waiting list 10
32.6 80.0 12.0
16/ Hollon et al., 1992 Hospital –Antidepressant 57
Evans et al., 1992 Consultant (Imipramine)
–Cognitive 25
–Cognitive and antidepressant 25 38.5 50.0 20 sessions
17/ Jacobson et al., 1991 Community –Cognitive 7
–Behavioural 8
–Cognitive and Behavioural 8 35.1 100.0 6.0
18/ Lapointe and Rimm, 1980 Female –Cognitive 12
–Assertiveness training 10
–Insight-oriented group 11 16.25 61.0 7.0
19/ Lewinsohn et al., 1990 Student –Cognitive 21
–Cognitive and Parent group 19
–Waiting list 21 38.15 70.0 24.0
20/ Macaskill and Macaskill, 1996 Community –Cognitive (RET) 10
and Antidepressant –Antidepressant 10
(Lofepramine) 43.3 100.0 12.0
21/ Maynard, 1993 1993 Women –Cognitive 10
–Supportive therapy 6
–Waiting list 14 39.2 72.0 —
22/ McLean and Hakstian, 1979 Hospital –Cognitive-behavioural 44
–Psychotherapy 51
–Relaxation 48
–Antidepressant 53
(Amitryptiline)
–Normal controls 55 23.0 73.0 8.5

V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
65
Table 2
(
Continued
)
Author Year Sample Treatments Cell M % Weeks of
(outpatients) size age women therapy
23/ McNamara and Horan, 1986 University –Cognitive 10
–Behavioural 10
–Cognitive-behavioural 10
–High-demand controls 10 36.8 73.9 15.0
24/ Miller et al., 1989 Hospital –Standard treatment 17
–Standard treatment1cognitive 15
–Standard treatment114
social skills training 33.9 74.0 12.0
25/ Murphy et al., 1984 Clinic –Cognitive 19
Simons et al., 1984 –Antidepressant 16
(Nortriptyline)
–Cognitive and Antidepressant 18
–Cognitive and placebo 17 39.4 70.3 16.0
26/ Murphy et al., 1995 Voluntary –Cognitive 11
–Relaxation 14
–Antidepressant 12
(Desipramine) — 78.4 10.0*
27/ Neimeyer et al., 1983 Voluntary –Cognitive with assignment 63
Neimeyer and Feixas, 1990 –Cognitive without assignment 63
–Interpersonal therapy 33
–Waiting list 39 22.1 78.4 5.5
28/ Pace and Dixon, 1993 Student –Cognitive 31
–Waiting list 43 15.65 63.3 —
29/ Reynolds and Coats, 1986 Adolescent –Cognitive-behavioural 9
–Relaxation training 11
–Waiting list 10 33.0 62.7 12.0
30/ Ross and Scott, 1985 Clinic –Cognitive 30
General –Cognitive (group) 30
practitioner –Waiting list 21 — 63.4 10.9
31/ Rush et al., 1977 Clinic –Cognitive 19
Kovacs et al., 1981 –Antidepressant 22 — 65.2 12.0*
¨
32/ Rotzer-Zimmer et al., 1985 Consultant –Cognitive-behavioural 14
–Cognitive-behavioural and 14
–Antidepressant 15
(Amitriptyline or Maprotyline) 70.5 79.3
33/ Scogin et al., 1987 Community –Cognitive 9
–Alternative bibliotherapy 8
–Waiting list 8 31.8 75.2 —

66 V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
Table 2.
(
Continued
)
Author Year Sample Treatments Cell M % Weeks of
(outpatients) size age women therapy
34/ Scott and Freeman, 1992 Hospital –Antidepressant 31
General (Amitriptyline)
practitioner –Cognitive 30
–Support 30
–Standard treatment 30 28.2 63.9 6 sessions
35/ Selmi et al., 1990 Consultant –Cognitive-behavioural 12
Voluntary (computer)
–Cognitive-behavioural 12
–Waiting list 12 30.0 64.0 10 sesssions
36/ Shapiro et al., 1982 Clinic –Cognitive (group) 10
–Interpersonal process 13
–Cognitive (individual) 12 40.5 52.1 12.0
37/ Shapiro et al., 1994 Clinic –Cognitive-behavioural 59
Stratification –Interpersonal psychodynamic 58
on depression
severity 20.1 68.75 16 sessions
38/ Shaw, 1977 Student –Cognitive 8
–Behavioural 8
–Nondirective 8
–Waiting list 8 66.0 76.0 37.5
39/ Steuer et al., 1984 Geriatric –Cognitive 26
–Psychodynamic 27 22.4 71.4 5.5
40/ Taylor and Marshall, 1977 Student –Cognitive 7
–Behavioural 7
–Cognitive-behavioural 7
–Waiting list 7 37.5 94.1 9.6
41/ Teasdale et al., 1984 Community –Therapy as usual (TAU) 14
Fennel and Teasdale, 1987 –Cognitive and TAU 17 67.1 67.4 16.5
42/ Thompson et al., 1987 Geriatric –Behavioural 25
–Cognitive 27
–Psychodynamic 24
–Delayed treatment 19 37.8 — 8.0
43/ Warren et al., 1988 Voluntary –Cognitive 10
–Rational-emotive 11
–Waiting list 12 — — 6.0
44/ Wierzbicki and Bartlett, 1987 Community –Group cognitive 9
–Individual cognitive 9
–Waiting list 20 39.5 80.0 8.0
45/ Wilson et al., 1983 Clinic –Cognitive 8
–Behavioural 8
–Waiting list 9 33.1 00.0 9.0

V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
67
Table 2
(
Continued
)
Author Year Sample Treatments Cell M % Weeks of
(outpatients) size age women therapy
46/ Wilson, 1990 Prison –Cognitive 5
Male –Support 5 41.3 100.0 10.8
47/ Zettle and Rains, 1989 Voluntary –Cognitive (complete) 10
–Cognitive (partial) 10
–Behavioural 11 — — 18.0 *
48/ Zimmer et al., 1987 Chronic –Cognitive-behavioural 40
resistant –Cognitive-behavioural and 40
depression couple therap
–Antidepressant 40
*, Unpublished studies.
Table 3
Meta-analysis of cognitive therapy in mild or moderate depression: results
Comparisons nd1Confidence % ZP Q
interval benefit (df)
95%
d1
Waiting-list
or placebo 20 20.82 (20.83; 29 28.72 ,0.0001 137.1*
20.81) (19)
Antidepressants 17 20.38 (20.39; 15 25.16 ,0.0001 19.6
20.37) (16)
Behaviour therapy 13 20.05 (20.08; 220.07 0.95 2.5
20.02) (12)
Other therapies 22 20.24 (20.25; 10 22.93 ,0.01 73*
20.23) (21)
*, Between-trial heterogeneity (P,0.05).
placebo. The hypothesis of between trial homogen- CT was equal to behaviour therapy. Effect-size
eity was rejected (Q5137.1, df 19). This may was negative. However, this was statistically non-
suggest that in some trials non-specific factors were significant (P50.95) for a Psignificance level set at
operating both in CT and control conditions. The P,0.01. The hypothesis of between-trial homogen-
trials of Neimeyer et al. (1983); Elkin et al. (1989); eity was not rejected.
Beach and O’Leary (1992) had a d50. As the CT was superior to a set of miscellaneous psycho-
NIMH study had the largest number of patients, and therapies (P,0.01): psychodynamic therapies (n57
its outcomes were related to therapeutic alliance in trials), interpersonal therapies (n54), non-directive
CT, interpersonal therapy, imipramine, and placebo (n52), supportive (n54), relaxation (n54) and
(Krupnick et al., 1996), we suppressed it from the alternative bibliotherapy (n51). However, the hy-
meta-analysis to evaluate its impact on the homo- pothesis of between trial homogeneity was rejected.
geneity. A Qof 134.1, df 18, P,0.001 was ob- After adjustment for the type of treatment, multi-
tained, which was far from reaching the homogeneity ple regression found no relation between the effect
criterion. size and BDI score, sex and age: CT vs waiting-list,
CT was superior to antidepressants (P,0.0001). r50.31; CT vs Antidepressants, r50.29; CT vs
The hypothesis of between-trial homogeneity was Behaviour Therapy, r50.42; CT vs other therapies,
not rejected. r50.30.

68 V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
Table 4
Relapse rate (%) Cognitive Therapy (CT) versus Antidepressant (AD)
Study Follow-up CT CT AD AD
(year) years Sample size % relapse Sample size % relapse
1. Kovacs et al. (1981) 1 n519 35% n525 56%
CT.AD (trend)
2. Beck et al. (1985) 1 n518 45% n515 18%
CT5AD
3. Simons et al. (1986) 1 n524 12% n524 66%
CT.AD
4. Blackburn et al. (1986) 2 n515 21% n510 78%
CT.AD
5. Miller et al. (1989) 1 n514 46% n517 82%
CT.AD
6. Bowers (1990) 1 n510 20% n510 80%
CT.AD
7. Evans et al. (1992) 2 n510 21% n510 50%
CT.AD
8. Shea et al. (1992) 1.5 n522 36% n518 50%
NIMH
CT5AD
5.3.
Prevention of recurrence
:
ct versus should be taken with caution: between-trial homo-
antidepressants geneity was not met.
Secondly, the superiority of CT over antidepres-
Among the 48 trials only 8 allowed a comparison sants, with high between-trial homeogeneity, indi-
of CT with antidepressants at a follow-up point of at cates that CT, although less acessible, is a viable
least 1 year. Considering the small number of studies alternative to pharmacological treatment. This find-
and the various lengths of these follow-ups, we made ing confirms the Dobson (1989) meta-analysis of CT
a simple comparison of the percentage of relapse and other meta-analyses on psychotherapy in general
after CT or antidepressants (see Table 4). which included CT trials (Robinson et al., 1990;
Inspection of Table 4 suggests a preventive effect Conte et al., 1986; Steinbruek et al., 1983; Miller and
of CT on relapse rate in 5/8 studies. No difference Berman, 1983).
was found between CT and antidepressants in the Thirdly, CT was equal to behaviour therapy, with
NIMH study (Elkin et al., 1989; Shea et al., 1992) high between trial homeogeneity. The contention that
and the Beck et al. (1985) study. A non significant cognitive modification could be the key factor in the
trend towards superiority was found in the study by psychotherapeutic treatment of depression was not
Kovacs et al. (1981). On average, only 29.5% of the supported by our meta-analysis. This is at variance
patients treated with CT relapsed versus 60% of with Dobson (1989) who found a superiority of CT
those treated with antidepressants. over behaviour therapy, but he included only nine
studies and used Cohen’s d. These comparable
effects could be due to the fact that the two methods
6. Discussion share common characteristics that may over-ride
their differences. For instance, homeworks that in-
We may now answer the five questions we posed crease activity are proposed both in cognitive and
at the beginning of this paper. behaviour therapy. Cognitive therapists advocate the
Firstly, relative to control conditions (waiting-list use of a wide range of behavioural techniques
or placebo), CT was found to be superior. This including skills training and activity scheduling
indicates that its effects are not due to placebo (Beck et al., 1979). Behaviour therapists use a
and/or demand characteristics. But this outcome technique coined: ‘‘disputing your non-constructive

V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
69
self-talk’’ (Lewinsohn et al., 1990) which is remines- Acknowledgements
cent of the Beckian Socratic discussion of negative
automatic thoughts. A meta-analysis by Miller and A first version of this paper was presented at the
Berman (1983) found that CT was equal to the World congress of Behavioural and Cognitive
combination of behavioural and cognitive tech- Therapies, EABCT, Copenhagen, July 10–16, 1995.
niques.
Fourthly, we found a superiority of CT over other
therapies suggesting that therapies without strong References
behavioural and/or cognitive components may be
less active in depression. But, there was a between- American Psychiatric Association DSM-3, 1980. Diagnostic and
trial heterogeneity. Moreover, the category ‘‘other Statistical Manual of Mental Disorders (DSM-III), 3rd ed.
therapies’’ was not homogeneous: this may raise the APA, Washington, DC.
question of the pertinence of lumping them together. American Psychiatric Association, 1987. Diagnostic and Statistical
However, our outcome is in line with those of Manual of Mental Disorders (DSD-III-R), 3rd rev. ed. APA,
Dobson (1989); Svartberg and Stiles (1991) who Washington, DC.
Baker, A., Wilson, P.H., 1985. Cognitive-behavior therapy for
concluded that cognitive behavioural therapies were depression: the effects of booster sessions on relapse. Behav.
superior to psychodynamic therapies. In contrast, the Ther. 16, 335–344.
meta-analysis of Crits-Cristoph (1992) found CT and Barkham, M., Firth-Cozens, J., Shapiro, D.A., 1989. Change in
psychodynamic therapy equivalent, but the sample prescriptive vs. exploratory therapy: older clients’ responses to
also included non depressed patients. therapy. Consult. Psychol. Q. 2, 395–403.
Fifthly, CT demonstrated relapse prevention ef- Beach, S.R.H., O’Leary, K.I., 1992. Treating depression in the
context of marital discord: outcome and predictors of response
fects that exceeded those of antidepressants in natu- of marital therapy versus cognitive therapy. Behav. Ther. 23,
ralistic follow-ups ranging from 1–2 years. But our 507–528.
conclusion resulted from a simple comparison of the Beck, A.T., Rush, A.J., Shaw, B.F. et al., 1979. Cognitive Therapy
percentage of relapses which was twice as high in of Depression. Guilford Press, New York, pp. 117–140.
the patients treated with antidepressants alone, than Beck, A.T., Steer, R.A., Garbin, M.G., 1988. Psychometric
propeties of the Beck depression inventory. Clin. Psychol. Rev.
in the patients treated with CT alone or combined 8 (1), 77–100.
with medication. Beck, A.T., Hollon, S.D., Young, J.E. et al., 1985. Treatment of
In addition, multivariate analysis failed to find any depression with cognitive therapy and amitriptyline. Arch. Gen.
covariate that modified the effect-sizes. This is at Psychiatry 42, 142–148.
variance with Dobson (1989), who found an effect of Beutler, L., Scogin, F., Kirkish, P. et al., 1987. Group cognitive
age, with univariate regression. However, Dobson therapy and alprazolam in the treatment of depression in older
adults. J. Consult. Clin. Psychol. 55 (4), 550–556.
acknowledged his study lacked adequate reprensenta- Beutler, L.E., Engle, D., Mohr, D. et al., 1991. Predictors of
tiveness of various age groups. differential response to cognitive experential and self-directed
psychotherapeutic procedures. Journal of Consulting and Clini-
cal Psychology 59, 333–340.
7. Conclusion Blackburn, I.M., Bishop, S., Glen, A.I.M. et al., 1981. The
efficacy of cognitive therapy in depression: a treatment trial
using cognitive therapy and pharmacotherapy each alone and in
Although its therapeutic process may be shared combination. Br. J. Psychiatry 139, 181–189.
with behaviour therapy, cognitive therapy has been Blackburn, I.M., Euson, K., Bishop, S., 1986. A 2-year naturalistic
demonstrated effective in patients with mild or follow-up of depressed patients treated with cognitive therapy,
moderate depression and its effects exceed those of pharmacotherapy and a combination of both. J. Affect. Disord.
10, 67–75.
antidepressants. This is consonant with the prevalent Boissel, J.P., Blanchard, J., Panak, E. et al., 1989. Considerations
opinion that drugs are the first line of treatment for for the meta-analysis of randomized clinical trials. Summary of
patients with high-severity or psychotic depression, a panel discussion. Control. Clin. Trials 10, 254–281.
especially inpatients (Scott, 1995). Studies and meta- Bowers, W.A., 1990. Treatment of depressed in-patients. Cognitive
analyses dealing with prevention of recurrence with therapy plus medication, and medication alone. Br. J. Psychi-
CT versus antidepressant drugs are now overdue. atry 156, 73–78.

70 V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
Crits-Cristoph, P., 1992. The efficacy of brief dynamic psychother- Gallagher-Thompson, D.E., Steffen, A.M., 1994. Comparative
apy: a meta-analysis. Am. J. Psychiatry 149 (2), 151–158. effects of cognitive behavioral therapy and brief psycho-
Collet, L., Cottraux, J., Ladouceur, R., 1987. Cognitive therapy of dynamic psychotherapies for depressed family caregivers. J.
depression and counterdemand effects: a pilot study. Psychol. Consult. Clin. Psychol. 62 (3), 543–549.
Rep. 60, 555–560. Haaga, D.A.F., De Rubeis, R.J., Stewart, B.L. et al., 1991.
Comas-Diaz, L., 1981. Effects of cognitive and behavioral group Relationship of intelligence with cognitive therapy outcome.
treatment on the depressive symptomatology of Puerto Rico Behav. Res. Ther. 29, 277–281.
women. J. Consult. Clin. Psychol. 42 (5), 627–632. Hautzinger, M., De Jong-Meyer, R., 1995. Cognitive behavior
Conte, H.R., Plutchik, R., Wild, K.V. et al., 1986. Combined therapy versus pharmacotherapy in depression. Two collabora-
psychotherapy and pharmacotherapy for depression. Arch. Gen. tive treatment outcome studies with unipolar depressed in and
Psychiatry 43, 471–479. out-patients (in Press).
Covi, L., Lipman, R.S., 1987. Cognitive behavioral group psycho- Hedges, L.V., 1981. Distribution theory for Glass’s estimator of
therapy combined with imipramine in major depression. Psy- effect size and related estimators. J. Educ. Stat. 6, 107–128.
chopharmacol. Bull. 23 (1), 173–176. Hedges, L.V., Olkin, I., 1985. Statistical Methods for Meta-analy-
De Rubeis, R.J., Hollon, S.D., Evans, M.D., Bemis, K.M., 1982. sis. Academic Press, New York.
Can psychotherapies for depression be discriminated? A sys- Hogg, J.A., Deffenbacher, J.I., 1988. A comparison of cognitive
tematic investigation of cognitive therapy and interpersonal and interpersonal process group therapies in the treatment of
therapy. J. Consult. Clin. Psychol. 50 (5), 744–756. depression among college students. J. Consel. Psychol. 35,
Dobson, K.S., 1989. A meta-analysis of the efficacy of cognitive 304–310.
therapy for depression. J. Consult. Clin. Psychol. 57 (3), Hollon, S.D., 1992. De Rubeis, R.J., Evans, M. et al., Cognitive
414–419. therapy and pharmacotherapy for depression. Arch. Gen.
Dunn, R.J., 1979. Cognitive modification with depression-prone Psychiatry 49, 774–781.
psychiatric patients. Cogn. Ther. Res. 3 (3), 307–317. Jacobson, N.S., Dobson, K., Fruzetti, A.E. et al., 1991. Marital
Elkin, I., Shea, M.T., Watkins, J. et al., 1989. National Institute of therapy as a treatment for depression. J. Consult. Clin. Psychol.
Mental Health Treatment of Depression Collaborative Research 59, 547–557. ´
Program. General effectiveness of treatments. Archives of Jenicek, M., 1987. Meta-analyse en medecine. Evaluation et
`´´
General Psychiatry 46, 971–982. synthese de l’information clinique et epidemiologique. Edisem
Emanuels-Zuurveen, L., Emmelkamp, P.M.G., 1996. Individual and Maloine, Paris, pp. 99–145.
behavioural cognitive therapy vs. marital therapy for depres- Kavanagh, D.J., Wilson, P.H., 1989. Prediction of outcome with
sion in maritally distressed couples. Br. J. Psychiatry 169, group cognitive therapy for depression. Behav. Res. Ther. 27,
181–188. 333–343.
Evans, M.D., Hollon, S.D., 1992. De Rubeis, R.J. et al., Differen- Keller, K.E., 1983. Dysfunctional attitudes and the cognitive
tial relapse following therapy and pharmacotherapy for depres- therapy for depression. Cogn. Ther. Res. 7, 437–444.
sion. Arch. Gen. Psychiatry 49, 802–808. Kovacs, M., Rush, J., Beck, A.T. et al., 1981. Depressed outpati-
Feighner, J.P., Robins, E., Guze, S.B. et al., 1972. Diagnostic ents treated with cognitive therapy or pharmacotherapy. Arch.
criteria for use in psychiatric research. Arch. Gen. Psychiatry Gen. Psychiatry 38, 33–39.
26, 57–63. Krupnick, J.L., Sotsky, S.M., Simmens, S. et al., 1996. The role of
Fennel, M.J.V., Teasdale, J.D., 1983. Cognitive therapy with therapeutic alliance in psychotherapy and pharmacotherapy
chronic drug-refractory depressed outpatients: a note of cau- outcome: findings in the nationa institute of Mental Health
tion. Cogn. Ther. Res. 7, 437–444. Treatment of Depression Collaborative Research Program. J.
Fennel, M.J.V., Teasdale, J.D., 1987. Cognitive therapy for depres- Consult. Clin. Psychol. 64 (3), 523–539.
sion: individual differences and the process of change. Cogni- Kupfer, D.J., 1992. Maintenance treatment in recurrent depression:
tive Therapy and Research 11, 253–271. current an future directions. The first William Sargent lecture.
Free, M.J., Tian, P.S.O., Sanders, M.R., 1991. Treatment outcome Br. J. Psychiatry 161, 309–316.
of a group cognitive therapy program for depression. Int. J. Lapointe, K.A., Rimm, D.C., 1980. Cognitive, assertive and
Group Psychother. 41, 533–547. insight-oriented group therapies in the treatment of reactive
Fremont, J., Craighead, I.W., 1987. Aerobic exercise and cognitive depression in women. Psychother. Theory Res. Pract. 17 (3),
therapy in the treatment of disphoric moods. Cogn. Ther. Res. 312–321.
11, 241–251. Lewinsohn, P.M., Clarke, G.N., Hops, H., Andrews, J.A., 1990.
Gaffan, E.A., Tsaouis, I., Kemp-Wheeler, S.M., 1995. Researcher Cognitive behavioral treatment for depressed adolescents.
allegiance and meta-analysis: the case of cognitive therapy for Behav. Ther. 21, 385–401.
depression. J. Consult. Cin. Psychol. 63 (6), 966–980. Linehan, M.M., Armstrong, H., Suarez, A. et al., 1991. Cognitive-
Gallagher, D.E., Thompson, L.W., 1982. Treatment of major behavioral treatment of chronically parasuicidal borderline
depressive disorder in older adult outpatients with brief psy- patients. Arch. Gen. Psychiatry 48, 1060–1064.
chotherapies. Psychother. Theory Res. Pract. 19 (4), 482–490. Macaskill, N.D., Macaskill, A., 1996. Rational-emotive therapy
Gallagher, D.E., Thompson, L.W., 1983. Effectiveness of psycho- plus pharmacotherapy vs. pharmacotherapy alone in the treat-
therapy for both endogenous and nonendogenous depression in ment of high cognitive dysfunction depression. Cogn. Ther.
older adult oupatients. J. Gerontol. 38, 707–712. Res. 20, 575–592.

V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
71
Maynard, C.K., 1993. Comparison of effectiveness of group individual and group cognitive therapy in the treatment of
interventions for depression in women. Arch. Psychiatr. Nurs. depressed patients in an inner city health center. J. R. Coll.
7, 277–283. Gen. Pract. 35, 239–242.
¨
McKnight, D.L., Nelson-Gray, R.O., Barnhill, J., 1992. Dexa- Rotzer-Zimmer, F.T., Axman, D., Giedke, H., et al., 1985. One
methasone suppression test and response to cognitive therapy year follow-up of cognitive-behaviour therapy for depressed
and antidepressant medication. Behav. Ther. 23, 99–101. patients: a comparison of cognitive behavioural therapy alone,
in combination with pharmacotherapy and pharmacotherapy
McLean, P.D., Hakstian, A.R., 1979. Clinical depression: com- alone. Paper presented at the 15th annual meeting of the
parative efficacy of outpatient treatments. J. Consult. Clin. ¨
European Association for Behaviour Therapy Munchen 1985.
Psychol. 47 (5), 818–836. Rush, A.J., Beck, A.T., Hollon, S.D. et al., 1977. Comparative
McNamara, K., Horan, J.J., 1986. Experimental construct validity efficacy of cognitive therapy and pharmacotherapy in the
and the evaluation of cognitive and behavioral treatment for treatment of depressed outpatients. Cogn. Ther. Res. 1 (1),
depression. J. Consult. Clin. Psychol. 33 (1), 23–30. 17–37.
Mercier, M.A., Stewart, J.W., Quitkin, F.M., 1992. A pilot Salkovskis, P.M., Atha, C., Storer, D., 1990. Cognitive-behav-
sequential study of cognitive therapy and pharmacotherapy of ioural problem solving in the treatment of patients who
atypical depression. J. Clin. Psychiatry 53 (5), 166–170. repeatedly attempt suicide. A controlled trial. Br. J. Psychiatry
Miller, I.W., Norman, W., Keitner, G. et al., 1989. Cognitive- 157, 871–876.
behavorial treatment of depressed inpatients. Behav. Ther. 20, Schlosser, D., Kavanagh, D.J., Wilson, P.H., 1988. Intensive
25–47. cognitive-behaviour therapy for depression: preliminary find-
Miller, R.C., Berman, J.S., 1983. The efficacy of cognitive ings with four country residents. Behav. Change 5, 28–31.
behavior therapies: a quantitative review of research evidence. Scogin, F., Hamblin, D., Beutler, L., 1987. Bibliotherapy for
Psychol. Bull. 94 (1), 39–53. depressed olders adults: a self-help alternative. Gerontologist
Munoz, R.F., Ying, Y.W., Bernal, G. et al., 1995. Prevention of 27, 383–387.
depression with primary care patients: a randomized controlled Scott, A.I.F., Freeman, C.P.L., 1992. Edinburgh primary care
trial. Am. J. Commun. Psychol. 23 (2), 199–222. depression study: treatment outcome, patient satisfaction and
Murphy, G.E., Simons, A.D., Wetzel, R.D. et al., 1984. Cognitive cost after 16 weeks. Br. Med. J. 304, 883–887.
therapy and pharmacotherapy singly and together in the Scott, J., 1995. Psychological treatment for depression. Br. J.
treatment of depression. Arch. Gen. Psychiatry 41, 33–41. Psychiatry 167, 289–292.
Murphy, G.E., Carney, R.M., Knesevitc, M.A. et al., 1995.
Cognitive behavior therapy, relaxation training, and tricyclic Selmi, P.M., Klein, M.H., Greist, J.H., 1990. Computer-adminis-
antidepressant medicatio n in the treatment of depression. tered cognitive behavioral therapy for depression. Am. J.
Psychol. Rep. 77 (2), 403–420. Psychiatry 147 (1), 51–56.
Neimeyer, R.A., Twentyman, C., Prezant, D., 1983. A comparison Shapiro, D.A., Sank, L., Shaffer, C.S. et al., 1982. Cost effective-
of cognitive and interpersonal group therapies for depression: ness of individual versus group cognitive therapy for problems
an outcome evaluation. Paper presented at the Association for of depression and anxiety in an HMO population. J. Clin.
the Advancement of Behavior Therapy World Congress on Psychology 38 (3), 674–677.
Behavior Therapy, Washington. Shapiro, D.A., Firth, J., 1987. Prescriptive versus exploratory
Neimeyer, R.A., Feixas, G., 1990. The role of homework and skill psychotherapy. Outcomes of the Sheffield psychotherapy pro-
acquisition in the outcome of group therapy for depression. ject. Br. J. Psychiatry 151, 790–799.
Behav. Ther. 21, 281–292. Shapiro, D.A., Barkham, M., Rees, A. et al., 1994. Effects of
Pace, J.M., Dixon, D.N., 1993. Changes in depressive self- treatment duration and severity of depression in the mainte-
schemata and depressive symptoms following cognitive nance of gains following cognitive/behavioural and psycho-
therapy. J. Counsel. Psychol. 40, 288–294. dynamic/interpersonal psychotherapy. J. Consult. Clin. Psy-
chology 62 (3), 522–534.
Persons, J.B., Burns, D.D., Perloff, J.M., 1988. Predictors of
dropout and outcome in cognitive therapy for depression in a Shaw, B.F., 1977. Comparison of cognitive therapy and behavior
private practice setting. Cogn. Ther. Res. 12, 557–575. therapy in the treatment of depression. J. Consult. Clin.
Psychology 45 (4), 543–551.
Propst, R.L., Ostrom, R., Watkins, P., 1992. Comparative efficacy
of religious and nonreligious cognitive-behavioral therapy for Shea, M.T., Elkin, I., Imber, S.D., 1992. NIMH. Course of
the treatement of clinical depression in religious individual. J. depressive symptoms over follow-up. Arch. Gen. Psychiatry
Consult. Clin. Psychol. 60 (1), 94–103. 49, 782–787.
Reynolds, W.M., Coats, K.I., 1986. A comparison of cognitive- Simons, A.D., Levine, J.E., Lustman, P.J. et al., 1984. Patient
behavorial therapy and relaxation training for the treatment of attrition in a comparative study of depression. A follow-up
depression in adolescents. J. Consult. Clin. Psychol. 54 (5), report. J. Affect. Disord. 6, 163–173.
653–660. Simons, A.D., Murphy, G.D., Levine, J.L. et al., 1986. Cognitive
Robinson, L.A., Berman, J.S., Neimeyer, R.A., 1990. Psychother- therapy and pharmacotherapy for depression. Substained im-
apy for the treatment of depression: a comprehensive review of provement over 1 year. Arch. Gen. Psychiatry 43, 43–48.
controlled outcome research. Psychol. Bull. 108 (1), 30–49. Simons, A.D., Thase, M.E., 1992. Biological markers, treatment
Ross, M., Scott, M., 1985. An evaluation of the effectiveness of outcome, and 1 year follow-up in endogeneous depression:

72 V
.
Gloaguen et al
.
/Journal of Affective Disorders
49 (1998) 59
–
72
electroencephalographic sleep studies and response to cognitive Waring, E.M., Carver, C., Stalker, C.A., 1990. A randomized
therapy. J. Consult. Clin. Psychol. 60 (1992), 392–401. clinical trial of cognitive marital therapy. J. Sex Marital Ther.
Spitzer, R.L., Endicott, J. and Robins, E. (1978) Research 16 (3), 165–180.
Diagnostic Criteria (RDC) for a selected group of functional Warren, R., McLellarn, R.W., Ponzoha, C., 1988. Rational emotive
disorder. New York State Psychiatric Institute. Biometrics therapy vs. general cognitive-behavior therapy in the treatment
Research. of low self-esteem and related emotional disturbances. Cogn.
Steinbruek, S.M., Maxwell, S.E., Howard, G.S. et al., 1983. A Ther. Res. 12, 21–37.
meta-analysis of psychotherapy and drug therapy in the treat- Weissman, M.M., Markowitz, J.C., 1994. Interpersonal psycho-
ment of unipolar depression with adults. J. Consult. Clin. therapy. Arch. Gen. Psychiatry 51, 599–606.
Psychol. 51 (6), 856–863. Whisman, M.A., 1991. Cognitive therapy with depressed inpati-
Steuer, J.L., Mintz, J., Hammen, C.L. et al., 1984. Cognitive- ents: specific effects on dysfunctional cognitions. J. Consult.
behavorial and psychodynamic group psychotherapy in treat- Clin. Psychology 59 (2), 282–288.
ment of geriatric depression. J. Consult. Clin. Psychol. 52 (2), Wierzbicki, M., Bartlett, T.S., 1987. The efficacy of group and
180–189. individual cognitive therapy for mild depression. Cogn. Ther.
Steuer, J.L., Hammen, C.L., 1983. Cognitive-behavioral group Res. 11 (3), 337–342.
therapy for the depressed elderly: issues and adaptations. Cogn. Wilson, P.H., Goldin, J.C., Charbonneau-Powis, M., 1983. Com-
Ther. Res. 7 (4), 285–296. parative efficacy of cognitive treatments of depression. Cogn.
Stravynski, A., Verreault, R., Gaudette, G. et al., 1994. The Ther. Res. 7 (2), 111–124.
treatment of depression with group behavioural-cognitive Wilson, G.L., 1990. Psychotherapy with depresssed incarcerated
therapy and imipramine. Can. J. Psychiatry 39 (7), 387–390. felons: a comparative evaluation of treatments. Psychol. Rep.
Svartberg, M., Stiles, T.C., 1991. Comparative effects of short- 67, 1027–1041.
term psychodynamic psychotherapy: a meta-analysis. J. Con- Wilson, K.C.M., Scott, M., Abou-Saleh, M. et al., 1995. Long
sult. Clin. Psychol. 59 (5), 704–714. term effects of cognitive-behavioural therapy and lithium
Taylor, F.G., Marshall, W.L., 1977. Experimental analysis of a therapy on depression in the elderly. Br. J. Psychiatry 167,
cognitive-behavioral therapy for depression. Cogn. Ther. Res. 1 653–658. ˜
(7), 59–72. Zeiss, A.M., Lewinsohn, P.M., Munoz, R.F., 1979. Non specific
Teasdale, J.D., Fennell, M.J., Hibbert, G.A. et al., 1984. Cognitive improvement effects in depression using interpersonal skills
therapy for major depressive disorder in primary care. Br. J. training, pleasant activity schedules or cognitive training. J.
Psychiatry 144, 400–406. Consult. Clin. Psychol. 47 (3), 427–439.
Thase, M.E., Simons, A.D., Cahalane, J. et al., 1991. Severity of Zettle, R.D., Rains, J.C., 1989. Group cognitive and contextual
depression and response to cognitive behavior therapy. Am. J. therapies in treatment of depression. J. Consult. Clin. Psychol.
Psychiatry 148, 784–789. 3, 436–445.
Thase, M.E., Simons, A.D., Reynolds, C.F., 1993. Psycho- Zettle, R.D., Haflich, J.L., Reynolds, R.A., 1992. Responsivity to
biological correlates of poor response to cognitive therapy: cognitive therapy as a function of treatment format and client
Potential indications for psychotherapy. Psychopharmacology personality dimensions. J. Clin. Psychol. 45, 436–445.
Bulletin 29, 293–301. Zimmer, F.T., Polzer, H., Zimmer, D. et al. (1987) Chronic and
Thompson, L.W., Gallagher, D., Breckentidge, J.S., 1987. Com- treatment-resistant depression: a multicenter evaluation of
parative effectiveness of psychotherapies for depressed elders. cognitive behavior therapy, with and without marital therapy
J. Consult. Clin. Psychol. 55 (3), 385–390. and pharmacotherapy. Paper presented at the annual meeting of
Usaf, S.O., Kavanagh, D.J., 1990. Mechanisms of improvement in the European Association for Behaviour Therapy Amsterdam.
treatment for depression: test of self-efficacy and performance
model. J. Cogn. Psychother. 4 (1), 51–70.