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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.
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Journal of Affective Disorders 49 (1998) 59–72
Research report
A meta-analysis of the effects of cognitive therapy in depressed
1,a a, a b
Valerie Gloaguen , Jean Cottraux , Michel Cucherat , Ivy-Marie Blackburn
Anxiety Disorder Unit Hopital Neurologique
boulevard Pinel
, 69394
Professor of Clinical Psychology
Durham University and Cognitive Therapy Center
Received 17 April 1997; received in revised form 10 November 1997; accepted 11 November 1997
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.
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:
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
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-
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.
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
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
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.,
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
Gloaguen et al
/Journal of Affective Disorders
49 (1998) 59
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
(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
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.
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Gloaguen et al
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49 (1998) 59
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
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
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.
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
Gloaguen et al
/Journal of Affective Disorders
49 (1998) 59
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
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
–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
–Placebo 35
38.4 51.85 16.0
11/ Emanuels-Zuurveen and Emmelkamp, 1996 Community –Cognitive 14
–Behavioural 13
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Gloaguen et al
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49 (1998) 59
Table 2.
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
–Normal controls 55 23.0 73.0 8.5
Gloaguen et al
/Journal of Affective Disorders
49 (1998) 59
Table 2
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
–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 —
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Gloaguen et al
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49 (1998) 59
Table 2.
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
Gloaguen et al
/Journal of Affective Disorders
49 (1998) 59
Table 2
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)
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.
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Gloaguen et al
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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%
3. Simons et al. (1986) 1 n524 12% n524 66%
4. Blackburn et al. (1986) 2 n515 21% n510 78%
5. Miller et al. (1989) 1 n514 46% n517 82%
6. Bowers (1990) 1 n510 20% n510 80%
7. Evans et al. (1992) 2 n510 21% n510 50%
8. Shea et al. (1992) 1.5 n522 36% n518 50%
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
Gloaguen et al
/Journal of Affective Disorders
49 (1998) 59
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.
Fourthly, we found a superiority of CT over other
therapies suggesting that therapies without strong References
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... Cognitive behaviour therapy (CBT) is an extensively studied and well-established treatment for depression (Cuijpers et al., 2013;Gloaguen et al., 1998). However, CBT has been criticised for being west-centric and grounded in an 'ineffably western version of a person' (Summerfield and Veale, 2008). ...
Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, culture can influence engagement and treatment efficacy of CBT. Several attempts have been made in Asian countries to develop a culturally adapted CBT for depression. However, research in the Indian context documenting the views on cultural influence of CBT is limited. The present study is an attempt to explore the views of patients and therapists in India by following an evidence-based approach that focuses on three areas for adaptation: (1) awareness of relevant cultural issues and preparation for therapy; (2) assessment and engagement; and (3) adjustments in therapy techniques. Semi-structured interviews with three consultant clinical psychologists/therapists, a focused group discussion with six clinical psychologists, and two patients undergoing CBT for depression were conducted. The data were analysed using a thematic framework analysis by identifying emerging themes and categories. The results highlight therapists’ experiences, problems faced, and recommendations in all three areas of adaptation. The findings highlight the need for adaptation with understanding and acknowledging the culture differences and clinical presentation. Culturally sensitive assessment and formulation with minor adaptation in clinical practice was recommended. Therapists emphasised the use of proverbs, local stories and simplified terminologies in therapy. The findings will aid in providing culturally sensitive treatment to patients with depression in India. Key learning aims (1) To understand the views of Indian patients and therapists based on their experience of CBT. (2) To understand the need for cultural adaptation of CBT in India. (3) To understand the adaptations by therapists while using CBT in clinical practice. (4) To gain perspective on how CBT can be culturally adapted to meet the needs of the Indian population.
... Con respecto a la salud, es poca aún la evidencia empírica para la prevención de reacciones psicofisiológicas, el incremento del bienestar psicológico o la atención de la depresión debido al desempleo (Yáñez, 2005;Aránguiz, 2006; Arévalo-Pachón, 2012), pero la tendencia en los tratamientos depresivos reconoce la eficacia del modelo cognitivo-conductual por encima de la medicación, en los casos leves o moderados (Carro y Sanz, 2015;Gloaguen et al., 1998;López-Petersen, 2011). ...
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Cuando las mujeres rurales buscan incrementar sus ingresos, combinan el quehacer de casa y el trabajo productivo remunerado. Algo poco investigado en las reas rurales de M xico es la separaci n entre ambas funciones, aunque s es claro que se incrementa la carga de trabajo de las mujeres cuando participan en alguna iniciativa organizada productiva, casi siempre en el marco de la econom a informal. Esta sobrecarga de trabajo es a n mayor para las mujeres con hijos, jefas de familia y sin acceso a tecnolog a dom stica y de producci n b sica. El objetivo de este cap tulo es sistematizar la experiencia de intervenci n para mejorar las pr cticas de gesti n empresarial de proyectos productivos, como capacidad funcional en la calidad de vida de mujeres productoras de leche bovina en una comunidad rural del Estado de M xico. En el marco de la investigaci n acci n, se realiz trabajo de campo en comunidades rurales (2017-2018). En las primeras sesiones, fue notorio que las mujeres participantes ten an en su lenguaje el t rmino “calidad de vida”, entendi ndolo como “estar mejor” y “darles m s educaci n a sus hijos” a partir del esfuerzo personal. Durante y despu s de la intervenci n, dicho t rmino se vincul a “saber c mo controlar la unidad de producci n para hacerla m s productiva”, mediante el trabajo colectivo organizado y la formalizaci n de la empresa social.
... Although there is evidence that cognitive therapy (CT) may be effective with a variety of disorders such as depression (Cuijpers et al., 2013;Gloaguen et al., 1998), anxiety disorders (Carpenter et al., 2018;Hofmann & Smits, 2008) as well as Cluster C personality disorders (Emmelkamp et al., 2006;Svartberg et al., 2004), the therapeutic ingredients associated with a beneficial treatment outcome are generally poorly understood (Addis & Jacobson, 2000;Kazdin, 2007). Both from a theoretical and practical point of view, it is therefore important to examine specific therapist interventions that may facilitate or hamper the treatment process and final outcome. ...
Background Research indicates that therapist competence in assigning homework may play a prominent role for outcome in cognitive therapy (CT) with various psychiatric disorders, including Cluster C personality disorders. Potentially cofounding factors need to be addressed though, and the present study examined to what extent therapist competence in (a) assigning homework and (b) agenda setting, as well as (c) the quality of the therapeutic alliance, contributes uniquely to a positive outcome in CT with cluster C personality disorders.Methods Twenty-four patients receiving CT were taken from a previously published randomized controlled trial, and a residualized composite score of psychopathology/distress was used as outcome measure. The quality of the therapeutic alliance was rated by patients at session four, whereas therapist competence in assigning homework and agenda setting was assessed by independent raters in an early session (typically session six). ResultsTherapist competence in assigning homework was a strong predictor of outcome in CT, even when taking into account potentially confounding factors such as the quality of the therapeutic alliance and therapist competence in agenda setting.Conclusions Structuring sessions to increase the benefits of homework assignments appear to be important in CT with cluster C personality disorders.
... Cognitive Behavioral interventions in the perinatal period have been found to be an effective intervention treatment for depression (Gloaguen et al., 1998;Barkham et al., 1999;Sockol, 2015;Ziemeng et al., 2020;Holt et al., 2021). These interventions have typically targeted evaluating potentially problematic styles such as catastrophic thinking and including behavioral strategies such as relaxation to assist in coping with stressful situations. ...
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The period of infancy and early childhood is a critical time for interventions to prevent future mental health problems. The first signs of mental health difficulties can be manifest in infancy, emphasizing the importance of understanding and identifying both protective and risk factors in pregnancy and the early postnatal period. Parents are at a higher risk of developing mental health problems during the perinatal period. An understanding of the evidence around prevention and intervention for parental anxiety and depression is vital to the process of prevention of early mental health disorders in infants and young children. Here we review the existing prevention and treatment interventions in the early years focusing on the period from conception to 3 years – the majority targeting parents in order to improve their mental health, and that of their infants. Elements of successful programs for parents include psychoeducation and practical skills training, as well as work on the co-parenting relationship, developing secure attachment, and enhancing parental reflective functioning. While both targeted and universal programs have produced strong effect sizes, universal programs have the added benefit of reaching people who may otherwise not have sought treatment. In synthesizing this information, our goal is to inform the development of integrated models for prevention and novel early intervention programs as early in life as possible.
... CBT has shown robustness of effect superior to other psychotherapy offers, when 78 controlled clinical trials were evaluated, with a sample size of 2765 patients, with controls that included placebo administration and a waiting list and moderately superior to antidepressant medication, taking self-registration measures, scales, that will assess mood, with the inter-test results being consistent. The effects of CBT are robust, sustained longer than drug therapy, when compared on a longitudinal time line [33][34][35]. ...
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In the present, the nosological characterization of depression is approached, as an entity susceptible to clinical diagnosis, the semiotics of its symptomatological manifestations and pathognomonic signs are described, according to standardized criteria, to then illustrate the underlying processes that, according to different models explanatory, cognitive, and behavioral, account; of the genesis, development, and feedback mechanisms and maintenance of depressive clinical symptoms. Finally, a screening of controlled clinical trials is carried out, with treatment and control groups, where the variable to be measured was the differences or not, in the therapeutic results between cognitive and pharmacological treatment modalities of depression, regarding the prolongation of the effect, relapses and comparative improvement rates.
... Con respecto a la salud, es poca aún la evidencia empírica para la prevención de reacciones psicofisiológicas, el incremento del bienestar psicológico o la atención de la depresión debido al desempleo (Yáñez, 2005;Aránguiz, 2006; Arévalo-Pachón, 2012), pero la tendencia en los tratamientos depresivos reconoce la eficacia del modelo cognitivo-conductual por encima de la medicación, en los casos leves o moderados (Carro y Sanz, 2015;Gloaguen et al., 1998;López-Petersen, 2011). ...
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En las últimas décadas, el tema de los factores psicosociales del trabajo ha cobrado gran relevancia por su importancia en la salud, el bienestar y el desarrollo de trabajadores, organizaciones y países en general. Organismos internacionales como la Organización Mundial de Salud (OMS) y la Organización Internacional del Trabajo (OIT) han declarado el tema como altamente prioritario. En Latinoamérica existe un despliegue de normas y leyes alrededor de temas como el acoso laboral y los factores de riesgo psicosocial; sin embargo, la aplicación de esta normativa sigue siendo incipiente y se ha centrado principalmente en la evaluación de estos factores, pero poco o nada en medidas específicas de mitigación y seguimiento para una eficaz prevención e intervención. Asimismo, los programas de intervención que se realizan en grandes empresas son guardados como secretos industriales de los que se desconoce su verdadera eficacia y validez científica, sin mencionar la charlatanería que lamentablemente ocurre en el mundo de la consultoría. En este contexto surge la iniciativa de esta obra cuyo propósito es dar a conocer el estado del arte en temas selectos de intervención psicosocial en el trabajo y, sobre todo, compartir experiencias de intervención aplicadas en distintas organizaciones latinoamericanas que incluyen: sector público, centros de salud, centros educativos, centros de asistencia, empresas privadas de la industria farmacéutica y del sector minero, supermercados, museos y organizaciones de economía solidaria, entre otros. Las reflexiones y pesquisas mostradas en el texto combinan la experiencia aplicada y el enfoque científico de sus coautores, desde ocho naciones latinoamericanas: Argentina, Brasil, Chile, Colombia, México, Perú, Puerto Rico y Venezuela
Background Cognitive behavioral therapy (CBT) is an established treatment for Major Depressive Disorder (MDD). MDD is characterized by imbalanced communication patterns among three networks: the central executive network (CEN), the default mode network (DMN) and the salience network (SN). The effect of CBT in restoring communications among these networks in MDD is unknown. Methods Thirty-three patients with MDD and 27 healthy controls (HC) participated in the study. Patients were treated with CBT. Resting-state functional magnetic resonance imaging (rs-fMRI) data were obtained in patients at three stages (T0: before treatment; T1: after 6 weeks CBT; T2: after 28 weeks CBT) and in HC (only T0). Both independent component analysis (ICA) and granger causal analysis (GCA) were used to explore dynamic causal communication patterns among the three networks (CEN, DMN, SN) over a course of CBT treatment. Results In the HC group, the SN had an inhibitory causal effect on CEN; the CEN and DMN had an excitatory causal effect on the SN. The SN had an inhibitory causal effect on the CEN and the DMN; only the DMN had an excitatory causal effect on the SN in the MDD patients at the T0 stage. As the CBT treatment went on for MDD patients, the CEN restored excitatory causal effect on the SN, and the SN lost inhibitory effect on the DMN. This result mimicked the one found in the HC group. Four regions, left ventromedial prefrontal cortex (lvmPFC), posterior cingulate gyrus (PCC), right inferior parietal lobule (rIPL) and right insula, were implicated in mediating network communications. Limitations The findings should be considered preliminary given the small sample sizes, and assessed only one stage in HC subjects. Conclusion CBT may enhance the regulatory function of the SN, and rehabilitate the imbalanced brain network communication mode in the MDD. PCC, lvmPFC and rIPL may all be potential targets of CBT.
Background: Previous research has confirmed that symptoms of postnatal depression (PND) can be ameliorated through internet-delivered psychological interventions. Advantages of internet-delivered treatment include anonymity, convenience, and catering to women who are unable to access face-to-face (FTF) treatments. To date, no research has examined the efficacy of such interventions compared directly with FTF treatments in women clinically diagnosed with PND. Objective: This study aims to compare the efficacy of one of the first web-based cognitive behavioral therapy (CBT) interventions (internet CBT+coach calls) for PND (MumMoodBooster [MMB]) with FTF-CBT in a randomized controlled trial (RCT). Methods: In this study, 116 postnatal women with a Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) diagnosis of major or minor depression were randomized to MMB (39/116, 33.6%), FTF-CBT (39/116, 33.6%), or a treatment-as-usual (TAU) control condition (38/116, 32.8%). Diagnostic status was determined at baseline and at 21-week follow-up using the Structured Clinical Interview for the DSM-IV. Severity of anxiety and depressive symptoms was evaluated using the Depression Anxiety Stress Scales and the revised Beck Depression Inventory at baseline, 12-week follow-up (after treatment), and 21-week follow-up. Results: Of the 116 participants, 107 (92.2%) had a diagnosis of major depression at baseline. Rates of remission from a major or minor depressive episode at 21 weeks in both the FTF-CBT and MMB groups were superior to that of the TAU group (56.6% and 47.7% less likely to be depressed, respectively) and they were not significantly different from each other. Although remission rates differed between TAU and FTF-CBT, growth models showed that, in terms of symptom reduction across time, the FTF-CBT treatment was not significantly better than TAU. By comparison, MMB was statistically superior to both TAU and FTF-CBT in reducing symptoms of depression, anxiety, and stress from baseline to the 21-week follow-up (large and moderate effect sizes). Thus, after 21 weeks, the average symptom scores for depression and anxiety of women receiving MMB were approximately half those of women in both the TAU and FTF-CBT groups. Conclusions: In this RCT, MMB was at least as effective as FTF-CBT in achieving remission from a diagnosed PND episode. MMB was superior to TAU and FTF-CBT in encouraging and maintaining reduction of symptom severity over the 21-week follow-up for depressed postnatal women. These findings replicate results of prior studies on MMB that showed clinically significant improvements in depressive symptoms, and they provide direct empirical support that internet-delivered treatment for depressed postnatal women is a viable alternative to FTF treatment. The generalizability of the results needs to be examined in future research, as RCTs of internet-based versus FTF treatments necessarily involve a subset of people who are willing to undertake either modality of treatment. Trial registration: Australia and New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000881730;
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In meta-analysis format the effectiveness of Beck's cognitive therapy for depression was reviewed. Twenty-eight studies were identified that used a common outcome measure of depression, and comparisons of cognitive therapy with other therapeutic modalities were made. The results document a greater degree of change for cognitive therapy compared with a waiting list or no-treatment control, pharmacotherapy, behavior therapy, and other psychotherapies. The degree of change associated with cognitive therapy was not significantly related to the length of therapy or the proportion of women in the studies, and although it was related to the age of the clientele, a lack of adequate representativeness of various age groups renders these results equivocal. Implications for further outcome and process studies in cognitive therapy are discussed.
• Determined whether it is possible to identify distinct and theoretically meaningful differences between 2 forms of therapy used in the treatment of depression: cognitive-behavioral therapy (C/B) and interpersonal therapy (IPT). Six videotapes of actual therapy sessions in each of the treatment modes were presented to 12 naive raters (professionals and graduate students). Each listened to and/or viewed 4 tapes, 2 from each of the therapeutic schools. For each tape, Ss completed a 48-item Likert-type scale designed for use in this study. In addition, experts in both of the therapeutic modes were asked to indicate the characteristics of a "good, typical" C/B or IPT session using the same scale. Analysis indicated that 38 of the items discriminated significantly between the types of therapy. The direction of the differences was generally consistent with the experts' predictions. Factor analysis yielded 4 principal factors, 2 related to modality-specific techniques and 2 to nonspecific factors. No consistent bias attributable to observational medium was obtained. It is concluded that relatively naive raters working from taped samples of actual clinical practice can detect clear procedural differences between 2 types of therapy and that these detected differences are related to the differences expected by experts associated with each approach. (25 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved) • Determined whether it is possible to identify distinct and theoretically meaningful differences between 2 forms of therapy used in the treatment of depression: cognitive-behavioral therapy (C/B) and interpersonal therapy (IPT). Six videotapes of actual therapy sessions in each of the treatment modes were presented to 12 naive raters (professionals and graduate students). Each listened to and/or viewed 4 tapes, 2 from each of the therapeutic schools. For each tape, Ss completed a 48-item Likert-type scale designed for use in this study. In addition, experts in both of the therapeutic modes were asked to indicate the characteristics of a "good, typical" C/B or IPT session using the same scale. Analysis indicated that 38 of the items discriminated significantly between the types of therapy. The direction of the differences was generally consistent with the experts' predictions. Factor analysis yielded 4 principal factors, 2 related to modality-specific techniques and 2 to nonspecific factors. No consistent bias attributable to observational medium was obtained. It is concluded that relatively naive raters working from taped samples of actual clinical practice can detect clear procedural differences between 2 types of therapy and that these detected differences are related to the differences expected by experts associated with each approach. (25 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study was designed to explore the relative and combined effectiveness of alprazolam (Xanax) and group cognitive therapy among elderly adults experiencing major affective disorder. Fifty-six subjects with Diagnostic and Statistical Manual of Mental Disorders (DSM-III) diagnoses of major, unipolar depression were treated over a 20-week period in one of four groups: alprazolam support, placebo support, cognitive therapy plus placebo support, and cognitive therapy plus alprazolam support. The results revealed that individuals assigned to group cognitive therapy showed consistent improvement in subjective state and sleep efficiency relative to non-group-therapy subjects. No differences between alprazolam and placebo were noted, regardless of whether individuals received group cognitive therapy. Subjects assigned to group cognitive therapy were less likely than their counterparts to prematurely terminate treatment.
• Patients successfully treated during a 3-month period with either imipramine hydrochloride pharmacotherapy, cognitive therapy, or combined cognitive-pharmacotherapy were monitored during a 2-year posttreatment follow-up period. Half of the patients treated with pharmacotherapy alone continued to receive study medications for the first year of the follow-up. All other patients discontinued treatment at the end of the acute treatment phase. Patients treated with cognitive therapy (either alone or in combination with medication) evidenced less than half the rate of relapse shown by patients in the medication—on continuation condition, and their rate did not differ from that of patients provided with continuation medication. It appears that providing cognitive therapy during acute treatment prevents relapse. Whether this preventive effect extends to recurrence remains to be determined.
This study examined the effects of 6-8 sessions of Beck's cognitive therapy on mildly and moderately depressed college students' depressive symptoms and depressive self-schemata. Participants were randomly assigned to either cognitive therapy (n = 31) or no treatment (n = 43). The Beck Depression Inventory was used to assess depressive symptoms, and self-referent judgment, recall, and reaction time measures were used to assess depressive self-schemata. Results supported the efficacy of cognitive therapy in reducing depressive symptoms and depressive self-schemata, as measured by self-referent judgment and self-referent recall. The reduction in the recall of negative self-referent judgments may play a role in the outcome of cognitive therapy for depression.
Assessed whether depressed geriatric patients would respond to group psychotherapy and, if so, whether they would respond differently to cognitive-behavioral and psychodynamic group psychotherapy. 33 55-78 yr olds entered the study, and 20 completed the 9-mo course of treatment. Ss in both types of groups showed statistically and clinically significant reductions on observer-rated measures of depression and anxiety (Hamilton Rating Scale for Depression and Hamilton Anxiety Scale), as well as on self-report measures of depression (Self-Rating Depression Scale and Beck Depression Inventory). There were no clinically significant differences, but a statistically significant difference between the types of groups was found for the Beck Depression Inventory, and this favored the cognitive-behavioral treatment. Limitations on interpretation of these results because of the lack of a control condition are discussed. (44 ref) (PsycINFO Database Record (c) 2006 APA, all rights reserved).
Diagnostic criteria for 14 psychiatric illnesses (and for secondary depression) along with the validating evidence for these diagnostic categories comes from workers outside our group as well as from those within; it consists of studies of both outpatients and inpatients, of family studies, and of follow-up studies. These criteria are the most efficient currently available; however, it is expected that the criteria be tested and not be considered a final, closed system. It is expected that the criteria will change as various illnesses are studied by different groups. Such criteria provide a framework for comparison of data gathered in different centers, and serve to promote communication between investigators.