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Anxiety Disorder Unit Hopital Neurologique, 59 boulevard Pinel, 69394 Lyon, France
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 d 1 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. 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
Since the first controlled study of cognitive
therapy (CT) in depression (Rush et al., 1977),
several meta-analytic studies have been carried out.
Steinbruek et al. (1983) concluded, in a metaanalysis including 56 studies, that psychotherapies
*Corresponding author. Tel.: 133 72 118065; fax.: 133 72
357330; e-mail: cottraux@univ-lyon1.fr
1
Currently at Hopital du Vinatier U.M.A. 95 boulevard Pinel 69
Bron, France.
60
placebo. However, these authors evaluated psychotherapy in general without reference to technical
specifications and theoretical backgrounds.
Miller and Berman (1983), in a meta-analysis of
48 studies, found cognitive behaviour therapy superior to no-treatment; pure cognitive therapy and
the combination of cognitive with behavioural methods were equal; cognitive behaviour therapies were
at least as effective as drug treatments for depressed
patients. However, their conclusions were tentative:
only ten studies (21%) involved the treatment of
depressed patients.
A meta-analysis by Dobson (1989) reviewed 28
CT studies, and concluded that CT was superior to
waiting list control, drug treatment, behaviour
therapy and miscellaneous therapies. Gaffan et al.
(1995) found a correlation between researcher allegiance and outcome in the studies selected by
Dobson, but not in subsequent ones. One may notice
that both Dobson and Gaffan included studies which
were not randomised.
The present paper will attempt to answer five
pragmatic questions:
1. Is CT superior to control conditions? If it were
not true, placebo effects and demand characteristics may explain its outcomes.
2. Is CT superior to the reference treatment of
depression, antidepressants? If it were true, there
would be an alternative to pharmacological treatments of depression.
3. Is CT superior to behaviour therapy? If it were
true, this would suggest that direct cognitive
modification is the key factor in depression
improvement.
4. Is CT superior to other psychotherapies (behaviour therapy excluded)? If it were true, it would
mean that cognitive therapy is a specific psychological treatment for depression.
5. Are the outcomes of CT long lasting? Does CT
prevent relapses? A relapse is considered as the
return of a full depressive state (BDI . 16)
between 6 and 9 months after a 2 month remission. Beyond this point, a return of full blown
depression is termed recurrence (Shea et al.,
1992). The main problem with antidepressants
being the high rate of relapses and recurrences
after withdrawal, some authors have recom-
2. Method
61
g5
(mean cognitive therapy) 2 (mean comparison group)
]]]]]]]]]]]]]
pooled SD
2. We applied the Hedges (1981) correction which
includes the number of subjects to correct for the
small sample bias. A d score was computed for
each study:
3
d 5 1 2 ]] g
4N 2 9
N was the sum of the number of patients in CT
and the comparison group.
3. Then the Hedges and Olkin (1985) d1, which
represents a combined estimate of the effect size
of a set of studies, was computed. Each trial was
weighted by the reciprocal of its estimated variance. The required level of significance was set at
P,0.01 to correct for multiple comparisons,
according to the meta-analysis cooperative group
recommendations (Boissel et al., 1989). When the
effect size was negative, this indicated that the
patients improved more in cognitive therapy.
When it was positive this indicated that the
patients improved more in the comparison group.
4. Z scores were computed for statistical comparisons. These calculations allowed for the expression of the meta-analysis in % of therapeutic
benefit: if the average patient of the comparison
group were treated with CT he or she would
move from the 50th to a higher percentile (CT.
Comparison group) or a lower percentile (CT,
Comparison group).
3. Homogeneity
Meta-analysis assumes that the effect-size of a
treatment is the sum of all the pooled trials. To
Dependencies of the effect size on several characteristics of the patients (BDI score, sex and age)
were studied with a linear multivariate model without interaction term taking trials as statistical units.
5. Results
62
Table 1
Excluded trials
Study (year)
1.
2.
3.
4.
5.
63
Table 2
Included trials
Author
Year
Sample
(outpatients)
Treatments
Cell
size
Clinic
Cognitive
Cognitive and Antidepressants
(Amitriptyline)
18
15
Clinic
Cognitive
Behavioural marital
Waiting list
15
15
15
Geriatric
12
Cognitive
Expressive therapy
Supportive therapy
21
Cognitive
Antidepressant
(amitriptyline or clomipramine)
Combination
22
20
Antidepressant
(Nortriptyline)
Antidepressant and cognitive
Antidepressant and relaxation
10
6/ Bowers, 1990
7/ Comas-Diaz, 1981
Clinic
Hospital
Hospital
Weeks of
therapy
27.1
72.7
12.0
40.7
50.0
14.0
70.7
55.4
20.0
15
16
13
46.
69.7
20.0
22
20
43.7
64.0
12.9
36.2
80.0
4.2
38.0
100.0
5..3
8
10
43.8
60.0
15 sessions
70.0
4.0
85.0
70.3
16 sessions
51.85
16.0
10
10
Clinic
(Puerto
Rican)
Cognitive
Behavioural
Waiting list
Voluntary
Consultant
Cognitive (group)
Cognitive (group) and
Antidepressant (Imipramine)
Psychodynamic
27
23
20
9/ Dunn, 1979
Psychiatric
Cognitive
Antidepressant and
supportive therapy
10
10
Clinic
Cognitive
Interpersonal
Antidepressant
(Imipramine)
Placebo
37
Cognitive
Behavioural
14
13
Community
%
women
22
M
age
47
36
35
38.4
64
Table 2. ( Continued)
Author
Year
Sample
(outpatients)
Treatments
Cell
size
Geriatric
Cognitive
Behavioural
Insight psychotherapy
10
10
10
Geriatric
caregiver
Cognitive-behavioural
Psychodynamic
36
30
Non
endogenous
depression
Cognitive-Behavioural
Antidepressant
(Amitriptyline)
Cognitive-Behavioural and
antidepressant
68
66
Cognitive
Interpersonal
Waiting list
13
Antidepressant
(Imipramine)
Cognitive
Cognitive and antidepressant
57
25
25
7
8
8
Student
Hospital
Consultant
Community
Cognitive
Behavioural
Cognitive and Behavioural
Female
Cognitive
Assertiveness training
Insight-oriented group
12
10
11
Student
Cognitive
Cognitive and Parent group
Waiting list
21
19
21
Community
and Antidepressant
Cognitive (RET)
10
Antidepressant
(Lofepramine)
10
Women
Cognitive
Supportive therapy
Waiting list
10
6
14
Hospital
Cognitive-behavioural
Psychotherapy
Relaxation
Antidepressant
(Amitryptiline)
Normal controls
44
51
48
53
1993
%
women
Weeks of
therapy
67.8
76.7
12.0
62.0
92.0
39.0
62.8
8.0*
28.1
62.2
8.0
14
10
32.6
80.0
12.0
38.5
50.0
20 sessions
35.1
100.0
6.0
16.25
61.0
7.0
38.15
70.0
24.0
43.3
100.0
12.0
39.2
72.0
23.0
73.0
8.5
62
M
age
55
65
Table 2 ( Continued)
Author
Year
Sample
(outpatients)
Treatments
Cell
size
University
Cognitive
Behavioural
Cognitive-behavioural
High-demand controls
10
10
10
10
Hospital
Standard treatment
Standard treatment1cognitive
Standard treatment1
social skills training
17
15
14
Clinic
Cognitive
Antidepressant
(Nortriptyline)
Cognitive and Antidepressant
Cognitive and placebo
19
16
M
age
%
women
Weeks of
therapy
36.8
73.9
15.0
33.9
74.0
12.0
39.4
70.3
16.0
78.4
10.0*
22.1
78.4
5.5
15.65
63.3
33.0
62.7
12.0
63.4
10.9
65.2
12.0*
70.5
79.3
75.2
18
17
Voluntary
Cognitive
Relaxation
Antidepressant
(Desipramine)
11
14
12
Voluntary
63
63
33
39
Student
Cognitive
Waiting list
31
43
Adolescent
Cognitive-behavioural
Relaxation training
Waiting list
9
11
10
Clinic
General
practitioner
Cognitive
Cognitive (group)
Waiting list
30
30
21
Clinic
Cognitive
Antidepressant
19
22
32/ Rotzer-Zimmer
et al., 1985
Consultant
Cognitive-behavioural
Cognitive-behavioural and
Antidepressant
(Amitriptyline or Maprotyline)
14
14
15
Community
Cognitive
Alternative bibliotherapy
Waiting list
9
8
8
31.8
66
Table 2. ( Continued)
Author
Year
Sample
(outpatients)
Treatments
Cell
size
Hospital
General
practitioner
Antidepressant
(Amitriptyline)
Cognitive
Support
Standard treatment
31
Consultant
Voluntary
Cognitive-behavioural
(computer)
Cognitive-behavioural
Waiting list
12
M
age
%
women
Weeks of
therapy
30
30
30
28.2
63.9
6 sessions
30.0
64.0
10 sesssions
40.5
52.1
12.0
20.1
68.75
16 sessions
66.0
76.0
37.5
22.4
71.4
5.5
37.5
94.1
9.6
67.1
67.4
16.5
37.8
8.0
6.0
39.5
80.0
8.0
33.1
00.0
9.0
12
12
Clinic
Cognitive (group)
Interpersonal process
Cognitive (individual)
10
13
12
Clinic
Stratification
on depression
severity
Cognitive-behavioural
Interpersonal psychodynamic
59
58
Student
Cognitive
Behavioural
Nondirective
Waiting list
Geriatric
Cognitive
Psychodynamic
Student
Cognitive
Behavioural
Cognitive-behavioural
Waiting list
Community
14
17
Geriatric
Behavioural
Cognitive
Psychodynamic
Delayed treatment
25
27
24
19
Voluntary
Cognitive
Rational-emotive
Waiting list
10
11
12
Community
Group cognitive
Individual cognitive
Waiting list
9
9
20
Clinic
Cognitive
Behavioural
Waiting list
8
8
8
8
26
27
7
7
7
7
8
8
9
67
Table 2 ( Continued)
Author
Year
Sample
(outpatients)
Treatments
Cell
size
Prison
Male
Cognitive
Support
5
5
Voluntary
Cognitive (complete)
Cognitive (partial)
Behavioural
10
10
11
Chronic
resistant
depression
Cognitive-behavioural
Cognitive-behavioural and
couple therap
Antidepressant
40
40
M
age
%
women
41.3
100.0
Weeks of
therapy
10.8
18.0 *
40
*, Unpublished studies.
Table 3
Meta-analysis of cognitive therapy in mild or moderate depression: results
Comparisons
d1
Confidence
interval
95%
d1
%
benefit
Q
(df)
Waiting-list
or placebo
20
20.82
29
28.72
,0.0001
Antidepressants
17
20.38
15
25.16
,0.0001
Behaviour therapy
13
20.05
20.07
0.95
Other therapies
22
20.24
(20.83;
20.81)
(20.39;
20.37)
(20.08;
20.02)
(20.25;
20.23)
10
22.93
,0.01
137.1*
(19)
19.6
(16)
2.5
(12)
73*
(21)
placebo. The hypothesis of between trial homogeneity was rejected (Q5137.1, df 19). This may
suggest that in some trials non-specific factors were
operating both in CT and control conditions. The
trials of Neimeyer et al. (1983); Elkin et al. (1989);
Beach and OLeary (1992) had a d50. As the
NIMH study had the largest number of patients, and
its outcomes were related to therapeutic alliance in
CT, interpersonal therapy, imipramine, and placebo
(Krupnick et al., 1996), we suppressed it from the
meta-analysis to evaluate its impact on the homogeneity. A Q of 134.1, df 18, P,0.001 was obtained, which was far from reaching the homogeneity
criterion.
CT was superior to antidepressants (P,0.0001).
The hypothesis of between-trial homogeneity was
not rejected.
68
Table 4
Relapse rate (%) Cognitive Therapy (CT) versus Antidepressant (AD)
Study
(year)
Follow-up
years
CT
Sample size
CT
% relapse
AD
Sample size
AD
% relapse
n519
35%
n525
56%
n518
45%
n515
18%
n524
12%
n524
66%
n515
21%
n510
78%
n514
46%
n517
82%
n510
20%
n510
80%
n510
21%
n510
50%
1.5
n522
36%
n518
50%
6. Discussion
We may now answer the five questions we posed
at the beginning of this paper.
Firstly, relative to control conditions (waiting-list
or placebo), CT was found to be superior. This
indicates that its effects are not due to placebo
and / or demand characteristics. But this outcome
self-talk (Lewinsohn et al., 1990) which is reminescent of the Beckian Socratic discussion of negative
automatic thoughts. A meta-analysis by Miller and
Berman (1983) found that CT was equal to the
combination of behavioural and cognitive techniques.
Fourthly, we found a superiority of CT over other
therapies suggesting that therapies without strong
behavioural and / or cognitive components may be
less active in depression. But, there was a betweentrial heterogeneity. Moreover, the category other
therapies was not homogeneous: this may raise the
question of the pertinence of lumping them together.
However, our outcome is in line with those of
Dobson (1989); Svartberg and Stiles (1991) who
concluded that cognitive behavioural therapies were
superior to psychodynamic therapies. In contrast, the
meta-analysis of Crits-Cristoph (1992) found CT and
psychodynamic therapy equivalent, but the sample
also included non depressed patients.
Fifthly, CT demonstrated relapse prevention effects that exceeded those of antidepressants in naturalistic follow-ups ranging from 12 years. But our
conclusion resulted from a simple comparison of the
percentage of relapses which was twice as high in
the patients treated with antidepressants alone, than
in the patients treated with CT alone or combined
with medication.
In addition, multivariate analysis failed to find any
covariate that modified the effect-sizes. This is at
variance with Dobson (1989), who found an effect of
age, with univariate regression. However, Dobson
acknowledged his study lacked adequate reprensentativeness of various age groups.
7. Conclusion
Although its therapeutic process may be shared
with behaviour therapy, cognitive therapy has been
demonstrated effective in patients with mild or
moderate depression and its effects exceed those of
antidepressants. This is consonant with the prevalent
opinion that drugs are the first line of treatment for
patients with high-severity or psychotic depression,
especially inpatients (Scott, 1995). Studies and metaanalyses dealing with prevention of recurrence with
CT versus antidepressant drugs are now overdue.
69
Acknowledgements
A first version of this paper was presented at the
World congress of Behavioural and Cognitive
Therapies, EABCT, Copenhagen, July 1016, 1995.
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72