Major Meta-Analysis Finds CBT Effective But Not Superior

A massive meta-analysis of over 50,000 patients published recently in the journal World Psychiatry found cognitive-behavioral therapy (CBT) to be effective but not superior to other psychotherapies in the treatment of depression. The study, authored by Pim Cuijpers and colleagues, is the largest meta-analysis ever for a specific type of psychotherapy for a particular mental disorder.

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In the paper, which is available via open access, the authors write, "The superiority of CBT over other psychotherapies for depression does not emerge clearly from this meta-analysis." When the authors limited studies to those with a low risk of bias, excluded outliers, or adjusted for publication bias, they found no difference between CBT and other forms of psychotherapy.

This is not the first study to find that CBT is not superior to other psychotherapies for depression (see Cuijpers et al., 2021). These findings contrast sharply with the common assumption that CBT is the "gold standard" psychotherapy for depression, a position propagated by many CBT researchers and therapists for decades.

CBT is often compared to psychodynamic psychotherapy, a form of talk therapy and the major alternative to the symptom-focused, manualized CBT approach. In psychodynamic therapies, the therapist assists the patient in an introspective and exploratory process, examining the patient's inner conflicts, motivations, and patterns of behavior.

It should be noted that there are around 300 randomized controlled trials of psychodynamic therapies and multiple meta-analyses and systematic reviews. This includes one of the most cited papers of the past decade, “The Efficacy of Psychodynamic Psychotherapy,” authored by psychologist Jonathan Shedler.

CBT was originally developed by the late psychiatrist Aaron Beck in the 1960s at the University of Pennsylvania. Beck, who studied psychoanalysis but was denied membership in the American Psychoanalytic Association, believed that depression results from faulty and distorted thinking. Thus, the focus of CBT is on identifying and changing irrational patterns of thought and behavior.

Beginning in the 1980s, with the increased influence of managed care on the practice of psychotherapy, CBT became a favored treatment due to its time-limited and structured nature. Since CBT is a manualized treatment, it is more readily amenable to scientific research than some other forms of psychotherapy, including psychodynamic therapy. Soon, CBT researchers began to tout its superiority in the treatment of depression and other disorders.

Now, it has become clear that CBT’s effectiveness has been exaggerated; its popularity may have been driven in part by forces other than its utility as a form of psychotherapy.

The recent Cuijpers et al. paper highlights the importance of unbiased empirical research in evaluating the effectiveness of psychiatric and psychological treatments. It reveals most clearly the risk of bias in shaping the narrative around psychotherapy for generations of mental health professionals—and patients.