The Efficacy of Cognitive Behavioral Therapy a Review of Meta-analyses

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The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses

Abstract

Cerebral behavioral therapy (CBT) refers to a popular therapeutic approach that has been applied to a diverseness of problems. The goal of this review was to provide a comprehensive survey of meta-analyses examining the efficacy of CBT. We identified 269 meta-analytic studies and reviewed of those a representative sample of 106 meta-analyses examining CBT for the following problems: substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to general medical conditions, chronic hurting and fatigue, distress related to pregnancy complications and female person hormonal weather. Additional meta-analytic reviews examined the efficacy of CBT for various problems in children and elderly adults. The strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or control conditions. CBT showed higher response rates than the comparison weather in vii of these reviews and just one review reported that CBT had lower response rates than comparing treatments. In general, the prove-base of CBT is very strong. However, boosted research is needed to examine the efficacy of CBT for randomized-controlled studies. Moreover, except for children and elderly populations, no meta-analytic studies of CBT accept been reported on specific subgroups, such as ethnic minorities and depression income samples.

Keywords: CBT, efficacy, meta-analyses, comprehensive review

Cognitive-behavioral therapy (CBT) refers to a class of interventions that share the bones premise that mental disorders and psychological distress are maintained by cerebral factors. The core premise of this treatment arroyo, as pioneered by Beck (1970) and Ellis (1962), holds that maladaptive cognitions contribute to the maintenance of emotional distress and behavioral problems. According to Beck'south model, these maladaptive cognitions include full general beliefs, or schemas, virtually the earth, the cocky, and the future, giving ascent to specific and automatic thoughts in particular situations. The basic model posits that therapeutic strategies to change these maladaptive cognitions lead to changes in emotional distress and problematic behaviors.

Since these early formulations, a number of disorder-specific CBT protocols accept been developed that specifically address diverse cognitive and behavioral maintenance factors of the various disorders. Although these disorder-specific treatment protocols prove considerable differences in some of the specific handling techniques, they all share the same cadre model and the general approach to handling.

Consequent with the medical model of psychiatry, the overall goal of treatment is symptom reduction, comeback in functioning, and remission of the disorder. In order to achieve this goal, the patient becomes an agile participant in a collaborative problem-solving process to test and challenge the validity of maladaptive cognitions and to alter maladaptive behavioral patterns. Thus, modern CBT refers to a family of interventions that combine a diverseness of cognitive, behavioral, and emotion-focused techniques (eastward.thousand., Hofmann, 2011; Hofmann, Asmundson, & Beck, in printing). Although these strategies greatly emphasize cognitive factors, physiological, emotional, and behavioral components are besides recognized for the office that they play in the maintenance of the disorder.

A recent review of meta-analyses of CBT identified 16 quantitative reviews that included 332 clinical trials covering 16 different disorders or populations (Butler, Chapman, Forman, & Brook, 2006). To our knowledge, this was the first review of meta-analytic studies examining the efficacy of CBT for a number of psychological disorders. This commodity has since get i of the near influential reviews of CBT. However, the search strategy was restrictive, because just one meta-assay was selected for each disorder. Furthermore, the search only covered the flow up to 2004, but many reviews have been published since and then. In fact, the majority of studies (84%) was published subsequently 2004. The goal of our review was to provide a comprehensive survey of all contemporary meta-analyses examining the evidence base of operations for the efficacy of CBT to date. The meta-analyses included in the present review were all judged to exist methodologically audio.

Methods

Search Strategy and Study Choice

To obtain the articles for this review, nosotros searched PubMed, PsychInfo, and Cochrane library databases using the following key words: meta-analysis AND cognitive behav*, meta-analysis AND cognitive therapy, quantitative review AND cognitive behav*, quantitative review AND cognitive therapy. This initial search yielded ane,163 hits, of which 355 were duplicates and had to be excluded. The remaining 808 non-indistinguishable manufactures were further examined to decide if they met specific inclusionary criteria for the purposes of this review. All included studies had to be quantitative reviews (i.e., meta-analyses) of CBT. In order to limit this review to contemporary studies, simply articles published since 2000 were included. The final sample included in this review consisted of 269 meta-analyses (Figure one). Out of those, we described a representative sample of 106 meta-analytic studies. The complete reference list for the final sample of included meta-analyses can exist obtained by accessing the webpage www.bostonanxiety.org/cbtreview.html. As already noted, the bulk (84%) of these studies was published afterwards 2004, the most recent year covered by the meta-analysis by Butler and colleagues (2006). The number of meta-analytic reviews per year is depicted in Effigy 2.

Flow diagram showing effects of inclusionary and exclusionary criteria on final sample selection.

Number of meta-analyses published past yr since 2000. Note that the number of studies respective to 2011 merely covered studies until September of that year.

Categorization of Meta-analyses

The 269 meta-analyses were categorized into groups to provide the most meaningful and extensive examination of the efficacy of CBT across a range of problem areas and study populations. The major groupings were the following: substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, indisposition, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to general medical atmospheric condition, chronic pain and fatigue, pregnancy complications and female hormonal conditions. In addition, some meta-analyses specifically examined CBT for disorders in children and elderly adults. For each disorder and population grouping, information were described qualitatively, considering the findings of all meta-analyses within that group. The 269 meta-analyses included a wide variety of studies that employed dissimilar methodologies and effect size estimates. Therefore, we used the designation small, medium, and large for the magnitude of event sizes in our review of the 106 representative meta-analyses (Cohen, 1988). In add-on, we provide reported response rates, a widely accepted and common metric in psychiatry, from a subsample of 11 studies that examined the efficacy of CBT in randomized controlled trials.

Results

Habit and Substance Use Disoder

In that location was evidence for the efficacy of CBT for cannabis dependence, with testify for higher efficacy of multi-session CBT versus single session or other briefer interventions, and a lower driblet out rate compared to control conditions (Dutra et al., 2008). However, the effect size of CBT was small as compared to other psychosocial interventions (e.m. contingency direction, relapse prevention, and motivational approaches) for substance dependence, and agonist treatments showed a greater consequence size than CBT in certain drug dependencies, such as opioid and alcohol dependence (Powers, Vedel, & Emmelkamp, 2008).

Treatments for smoking cessation found that coping skills, which were partially based on CBT techniques, were highly effective in reducing relapse in a customs sample of nicotine quitters (Song, Huttunen-Lenz, & Holland, 2010), and some other meta-analysis noted superiority of CBT (either solitary or in combination with nicotine replacement therapy) over nicotine replacement therapy solitary (Garcia-Vera & Sanz, 2006). Furthermore, there was evidence for superior performance of behavioral approaches in the handling of problematic gambling as compared to control treatments (Oakley-Browne et al., 2000). One meta-analysis (Leung & Cottler, 2009) reported larger effect sizes of CBT when this handling was grouped with other non-pharmacological treatments (such every bit brief interventions) every bit compared to pharmacological agents (e.chiliad. naltrexone, carbamazepine, and topiramate), but CBT was not more than efficacious than these other briefer, less expensive approaches.

Schizophrenia and Other Psychotic Disorders

Meta-analyses examining the efficacy of psychological treatments for schizophrenia revealed a beneficial effect of CBT on positive symptoms (i.e., delusions and/or hallucinations) of schizophrenia (e.thousand., Gould et al., 2001; Rector & Beck, 2001). In that location was as well show (eastward.g., Zimmerman et al., 2005) that CBT is a particularly promising adjunct to pharmacotherapy for schizophrenia patients who suffer from an acute episode of psychosis rather than a more chronic condition.

CBT appeared to have footling effect on relapse or infirmary admission compared to other interventions, such equally early on intervention services or family intervention (due east.thou., Bird et al., 2010; Álvarez-Jiménez et al., 2011). However, CBT had a benign effect on secondary outcomes. For instance, a more recent meta-analysis past Wykes and colleagues (2008) examined controlled trials of CBT for schizophrenia and confirmed findings from previous meta-analyses (e.g., Gould et al., 2001; Rector & Beck, 2001), suggesting that CBT had a small to medium upshot size equally compared to control conditions on both positive and negative symptoms. In improver, this meta-analysis revealed medium issue sizes for improvements in secondary outcomes that were not the direct targets of handling, including general operation, mood, and social anxiety.

Depression and Dysthymia

CBT for low was more than effective than control conditions such as waiting listing or no treatment, with a medium upshot size (van Straten, Geraedts, Verdonck-de Leeuw, Andersson, & Cuijpers, 2010; Beltman, Oude Voshaar, & Speckens, 2010). Nevertheless, studies that compared CBT to other agile treatments, such every bit psychodynamic treatment, trouble-solving therapy, and interpersonal psychotherapy, found mixed results. Specifically, meta-analyses found CBT to be equally effective in comparison to other psychological treatments (east.g., Beltman, Oude Voshaar, & Speckens, 2010; Cuijpers, Smit, Bohlmeijer, Hollon, & Andersson, 2010; Pfeiffer, Heisler, Piette, Rogers, & Valenstein, 2011). Other studies, however, found favorable results for CBT (e.g. Di Giulio, 2010; Jorm, Morgan, & Hetrick, 2008; Tolin, 2010). For example, Jorm and colleagues (2008) found CBT to be superior to relaxation techniques at post-treatment. Additionally, Tolin (2010) showed CBT to be superior to psychodynamic therapy at both post-treatment and at 6 months follow-up, although this occurred when low and anxiety symptoms were examined together.

Compared to pharmacological approaches, CBT and medication treatments had similar effects on chronic depressive symptoms, with consequence sizes in the medium-large range (Vos, Haby, Barendregt, Kruijshaar, Corry, & Andrews, 2004). Other studies indicated that pharmacotherapy could be a useful addition to CBT; specifically, combination therapy of CBT with pharmacotherapy was more constructive in comparison to CBT alone (Chan, 2006).

Bipolar Disorder

Meta-analyses examining the efficacy of CBT for bipolar disorder revealed pocket-size to medium overall upshot sizes of CBT at postal service-treatment, with furnishings typically diminishing slightly at follow-up. These findings emerged from examinations of both manic and depressive symptoms associated with bipolar disorder (e.g., Gregory, 2010a, 2010b). There is piffling evidence that CBT as a stand-alone handling (rather than as an adjunct to pharmacotherapy) is constructive for the handling of bipolar disorder.

In addition to examining CBT for attenuating symptoms of bipolar disorder, some meta-analyses focused on the efficacy of CBT for preventing relapse in bipolar patients. 1 report (Beynon et al., 2008) examined the efficacy of CBT for preventing relapse and establish information technology to be somewhat effective when comparing CBT vs. handling as usual. Overall, CBT for bipolar disorder was an constructive method of preventing or delaying relapses (due east.g., Lam, Burbeck, Wright, & Pilling, 2009; Cakir & Ozerdem, 2010). Furthermore, the efficacy of CBT at preventing relapse did not seem to exist influenced by the number of previous manic or depressive episodes.

Anxiety Disorders

In general, CBT is a reliable offset-line approach for treatment of this course of disorders (Hofmann & Smits, 2008), with back up for significant positive effects of CBT on secondary symptoms such equally sleep dysfunction and anxiety sensitivity (Ghahramanlou, 2003). Farther, internet-delivered or guided self-aid CBT showed some hope in immediate symptom relief as compared to no treatment, but the long-term maintenance with this modality of CBT remains unclear (Öst, 2008; Coull & Morris, 2011).

CBT for social anxiety disorder evidenced a medium to big issue size at firsthand postal service-treatment as compared to control or waitlist treatments, with significant maintenance and even improvement of gains at follow-upward (Gil, Carrillo, & Meca, 2001). Further, exposure, cognitive restructuring, social skills training and both group/individual formats were every bit efficacious (Powers, Sigmarsson, & Emmelkamp, 2008), with superior functioning over psychopharmacology in the long term (Fedoroff & Taylor, 2001). Similarly, interoceptive exposure for treatment of panic disorder was moderately effective and superior to control/pill placebo treatments and practical relaxation (Haby, Donnelly, Corry, & Vos, 2006; Furukawa, Watanabe, & Churchill, 2007). For panic disorder without agoraphobia, combination handling of CBT and applied relaxation was equal in efficacy to use of either therapy approach alone, and use of either or both were superior to utilize of medications (Mitte, 2005).

Diverse CBT techniques for specific phobia (systematic desensitization, exposure, cerebral therapy) were as constructive as applied relaxation and applied tension, producing upshot sizes in the large range, with long-term maintenance of gains (Ruhmland & Margraf, 2001). For generalized anxiety disorder, CBT was superior as compared to control or pill placebo conditions, and as efficacious every bit relaxation therapy, supportive therapy, or psychopharmacology, but less efficacious in comparison to attending placebos and in those with more severe generalized feet disorder symptoms.

CBT for post-traumatic stress disorder was equal in efficacy to eye movement desensitization and reprocessing (Bisson et al., 2007), with both being superior to treatment as usual, waitlist, or other treatments (such as supportive counseling) for post-traumatic stress disorder (Bisson & Andrew, 2008). However, it is questionable whether the eye-motility technique is an agile treatment ingredient.

Clinical trials also revealed a large effect size for CBT and/or exposure response prevention for obsessive compulsive disorder, with evidence suggesting that a combination of in vivo and imaginal exposures outperformed the use of only in vivo exposures (Ruhmland & Margraf, 2001). Furthermore, CBT was establish to exist similarly efficacious than clomipramine and selective reuptake inhibitors (Boil, Dutra, Bradley, & Westen, 2004).

Somatoform Disorders

Within the somatoform disorders category of DSM-IV, meta-analyses primarily examined the efficacy of psychological interventions for hypochondriasis and trunk dysmorphic disorder. One meta-analysis plant a large hateful effect size for CBT, which outperformed other psychological treatments (i.eastward., psychoeducation, explanatory therapy, cognitive therapy, exposure and response prevention, and behavioral stress management), with effect sizes in the large range, as well as pharmacotherapy treatments (paroxetine, fluoxetine, fluvoxamine, and nefazodone), which also evidenced large effect sizes (Taylor, Asmundson, & Coons, 2005). The mean issue size for control conditions (e.thou., wait-list command) was small. These results were partially supported by other evidence, as a more recent meta-analysis found superior outcomes of CBT for hypochondriasis compared to waiting listing command, usual medical care or placebo at twelve-calendar month follow-up (Thomson & Folio, 2007). However, this meta-analysis also found no differences between CBT and waiting list/placebo at postal service-treatment.

Meta-analyses comparing the efficacy of CBT to control treatments found that CBT was superior in significantly reducing body dysmorphic disorder symptoms (Ipser, Sander, & Stein, 2009). In comparing relative efficacy of CBT versus pharmacotherapy, issue sizes were large on body dysmorphic disorder severity measures for CBT, and ranged from medium to big for pharmacotherapy (Williams, Hadjistavropoulos, & Sharpe, 2006). In addition, another meta-analysis found that CBT for trunk prototype disturbances was effective, with consequence sizes ranging from medium to large (Jarry & Ip, 2005).

Eating Disorders

For bulimia nervosa, meta-analyses compared the efficacy of CBT to control treatments and institute effect sizes in the medium range (Thompson-Brenner, 2002). However, the issue of behavior therapy was greater than that of CBT, with the average effect size for behavior therapy in the large range (Thompson-Brenner, 2003). Another meta-analysis comparison CBT with control treatments establish remission response rates to be higher for CBT, with a medium relative risk ratio (Hay, Bacaltchuk, Stefano, & Kashyap, 2009). When comparing CBT to other psychotherapies, specifically, interpersonal therapy, dialectical behavioral therapy, hypno-behavioral therapy, supportive psychotherapy, behavioral weight loss handling, and self-monitoring, CBT fared significantly meliorate in remission response rates for bulimia nervosa, with a big relative risk ratio (Hay et al., 2009).

For rampage eating disorder, a recent meta-assay found that psychotherapy and structured cocky-assist yielded large result sizes, when compared to pharmacotherapy, which yielded medium effect sizes (Vocks et al., 2010). Although this study did not parse out the efficacy of CBT specifically, a majority of the included trials for psychotherapy involved CBT (xix out of 23 trials). Furthermore, a review and meta-assay by Reas and Grilo (2008) suggested that combination treatment of psychotherapy and medications did not raise binge-eating outcomes, only may have enhanced weight loss outcomes.

Insomnia

CBT for indisposition (CBT-I) has long been shown to be more efficacious than control treatments. A recent meta-analysis examined its efficacy on both subjective and objective sleep parameters in comparison to a control group for individuals with primary indisposition (Okajima, Komada, & Inoue, 2011). Consequence sizes for the efficacy of CBT-I versus command at the finish of treatment on subjective sleep measures, which included sleep onset latency, full sleep time, wake subsequently sleep onset, total wake time, time in bed, early forenoon awakening, and sleep efficiency, ranged from minimal (total slumber time) to large (early on morning awakening) (Okajima et al., 2011). For objective measures using a polysomnogram or actigraphic evaluation, effect sizes ranged from small (full sleep time) to big (total wake time) (Okajima et al., 2011). These findings were consistent with results from some other meta-assay, which examined the relative efficacy of behavioral interventions for insomnia including CBT, relaxation, and only behavioral techniques (Irwin, Cole, & Nicassio, 2006). This written report reported effect sizes ranging from −.75 to 1.47 for CBT, −.60 to .53 for relaxation techniques, and −.82 to .91 for only behavioral techniques on subjective sleep outcomes.

Personality Disorders

In that location was 1 meta-analysis that examined the relative efficacy of CBT versus psychodynamic therapy for the treatment of personality disorders (Leichsenring & Leibing, 2003). The findings indicated a larger overall consequence size for psychodynamic therapy compared to CBT. This was consistent with observer-rated measures, which showed a similar pattern of upshot sizes: stronger for psychodynamic therapy than for CBT (although this effect size was also large). Self-report measures, however, indicated larger effect sizes for CBT than for psychodynamic therapy.

Another meta-analysis compared the efficacy of eleven different psychological therapies, including CBT, for antisocial personality disorder (Gibbon et al., 2010). Results suggested that compared to control treatment, CBT plus standard maintenance was more efficacious in terms of leaving the study early and cocaine use for outpatients with antisocial personality disorder and comorbid cocaine dependence. However, CBT plus treatment as usual was not meliorate than a control condition for these antisocial personality disorder patients with regard to levels of recent verbal or physical assailment. The relative efficacy of psychological treatments for borderline personality disorder, in particular, was likewise examined, which yielded no differences between dialectical behavioral therapy and treatment equally usual in individuals coming together criteria for borderline personality disorder at half-dozen months, or in hospital admissions in the previous three months (Binks et al., 2009).

Anger and Aggression

Two meta-analytic reviews focused on anger control problems and assailment (Del Vecchio & O'Leary, 2004; Saini, 2009). The findings from these meta-analyses suggested that CBT is moderately effective at reducing anger bug. Findings from these reviews likewise suggested that CBT may exist most effective for patients with problems regarding anger expression.

CBT produced medium issue sizes as compared to other psychosocial treatments and control conditions across the two reviews that conducted quantitative analyses. A meta-analysis on the effectiveness of anger treatments for specific anger problems (Del Vecchio & O'Leary, 2004) included only studies in which subjects met clinically significant levels of anger on standardized anger measurements prior to treatment. This meta-assay examined the effects of CBT, cognitive therapy, relaxation, and 'other' (due east.g., social skills training, process group counseling) on various anger bug including driving acrimony, anger suppression, and anger expression difficulties.

Criminal Behaviors

Four separate meta-analytic studies supported the efficacy of CBT for criminal offenders (Illescas, Sanchez-Meca, & Genovés, 2001; Lösel & Schmucker, 2005; Pearson, Lipton, Cleland, & Yee, 2002; Wilson, Bouffard, Mackenzie, 2005). Out of several theoretical orientations and types of psychological interventions for criminal activity, beliefs therapy and CBT appeared to be the superior interventions in reducing backsliding rates, both with medium mean effect sizes (Illescas, Sanchez-Meca, & Genovés, 2001). Effect sizes for other interventions ranged from small to medium (Illescas et al., 2001). Another study demonstrated consistent findings with a small weighted mean effect size of behavior therapy or CBT for reducing recidivism (Pearson, Lipton, Cleland, & Yee, 2002). Similarly, Wilson and colleagues (2005) found an overall small-to-medium mean issue size for CBT programs for bedevilled offenders.

For sexual offenders in item, physical treatments, such as surgical castration and hormonal treatment, were demonstrated to have greater efficacy in reducing sexual recidivism in comparison to CBT, with large meaning odds ratios for both of these alternative interventions (Lösel & Schmucker, 2005). Of the diverse psychological interventions for sexual offenders, however, classical behavioral and CBT approaches indicated the strongest efficacy, with odds ratios in the medium to large range (Lösel & Schmucker, 2005) as compared to insight-oriented and therapeutic community interventions.

A written report of CBT for domestic violence indicated no differences between CBT and the Duluth model (which is based on a feminist psycho-educational approach) for treating domestically trigger-happy males (Babcock, Dark-green, & Robie, 2004). The aggregated data from experimental and quasi-experimental studies showed that CBT had an overall small effect size, and the Duluth model had an overall slightly larger, merely still pocket-size upshot size (Babcock et al., 2004).

Full general Stress

Iv meta-analyses examined occupational stress and the bulk of their results were quite similar: CBT interventions were more than effective in comparing to other intervention types such as system focused therapies, especially when CBT focused on psycho-social outcomes in employees (Kim, 2007; Richardson & Rothstein, 2008; van der Klink, Blonk, Schene, & van Dijk, 2001). For example, Richardson and Rothstein (2008) found CBT alone to be more than effective in comparing to CBT combined with additional psychological components. These studies found a large effect size for overall CBT interventions, big result size for unmarried-mode CBT interventions, and small effect size for CBT interventions with four or more components. In contrast, Marine and colleagues (2006) chose not to compare CBT with other interventions, such every bit relaxation techniques for psychological stress, because most interventions comprised both elements and could not be evaluated separately. With respect to stress in parents of children with developmental disabilities, positive furnishings were found for CBT, but the effect size was relatively small (Vocalizer, Ethridge, & Aldana, 2007). In contrast to the results of Richardson and Rothstein (2008), this meta-assay found multiple component interventions which combined CBT, behavioral parent preparation and in some cases other forms of support services, to have a higher and large effect size in comparison to CBT lonely (Vocalizer, Ethridge, & Aldana, 2007).

Distress Due to Full general Medical Atmospheric condition

Limited well-controlled studies existed in the report of not-ulcer dyspepsia, multiple sclerosis, physical inability following traumatic injury, not-epileptic seizures, post-concussion syndrome, chronic obstructive pulmonary disease, hypertension, Blazon II diabetes, and burning rima oris syndrome (due east.g. Soo et al., 2004; Thomas, Thomas, Hillier, Galvin, & Bakery, 2006; Baker, Brooks, Goodfellow, Bodde, & Aldenkamp, 2007; Ismail, Winkley, & Rabe-Hesketh, 2004). Withal, cancer was studied more rigorously and with more robust methodological attention, indicating small to medium effect sizes of individual CBT as compared to patient teaching only in gynecological and caput/neck cancers (Zimmerman & Heinrichs, 2006; Luckett, Britton, Clover, & Rankin, 2011), on secondary outcomes such as quality of life, psychological distress (i.east., depression and anxiety), and pain. Further, CBT was shown to be every bit effective as practise interventions in treating cancer-related fatigue (Kangas, Bovbjerg, & Montgomery, 2008).

Minor to medium effect sizes were observed in handling of secondary symptoms (anxiety and stress) experienced past individuals who were HIV positive, with particular efficacy (particularly for stress management) in reducing anger symptoms as compared to supportive therapy (Crepaz et al., 2008), merely not for outcomes such as low cell count, medication adherence, or when used with marginalized populations such as ethnic minorities and women (Crepaz et al., 2008; Rueda et al., 2006).

CBT was shown to be superior in the treatment of secondary symptoms of spinal string injury equally compared to controls in assertiveness skills, coping, depression and quality of life (Dorstyn, Mathias, & Denson, 2011), better than placebo or diet/exercise alone (Shaw, O'Rourke, Del Mar, & Kenardy, 2005), only equal to yoga/educational activity in depressive symptoms (Martinez-Devesa, Perera, Theodoulou, & Waddell, 2010). CBT was only slightly more constructive than usual care or waitlist condition in the treatment of irritable bowel syndrome, with peppermint oil having greater efficacy in providing relief in this item disorder (Enck, Junne, Klosterhalfen, Zipfel, & Martens, 2010).

Chronic Pain and Fatigue

Meta-analyses examining the efficacy of psychosocial treatments for chronic pain have investigated chronic low back pain, fibromyalgia, rheumatoid arthritis, chronic fatigue syndrome, chronic musculoskeletal pain, and non-specific chest pain. These reviews take examined the effect of a range on treatments on chronic pain, including relaxation techniques, mindfulness-based techniques, acceptance-based techniques, biofeedback, psycho-education, and behavioral and cognitive-behavioral treatments. Results of these meta-analyses revealed varying consequence sizes for these treatments depending on the blazon of chronic hurting targeted; however, CBT treatments for chronic pain were consistently in the small to medium effect size range.

Similar results were found in a meta-analysis examining psychological treatments for fibromyalgia (Glombiewski et al., 2010). This meta-analysis revealed that CBT was superior to other psychological treatments for decreasing pain intensity. Pre-mail analyses revealed a medium effect size for CBT as compared to a minor effect size for all other psychological treatments combined (excluding CBT). CBT treatments for chronic fatigue syndrome were moderately effective (e.g., Malouff et al., 2008; Cost et al., 2008). Malouff and colleagues (2008) conducted a meta-assay revealing a medium effect size in post-treatment fatigue for participants receiving CBT versus those in control conditions.

Pregnancy Complications and Female person Hormonal Conditions

I meta-assay found CBT to be more than effective in comparison to control weather for perinatal low (Sockol, Epperson, & Barber, 2011), and another meta-analysis found beneficial effects of CBT for postnatal depression, merely these results need to be interpreted with caution because it is difficult to causally link low with pregnancy and hormonal changes in these studies (Dennis, & Hodnett, 2007). Farther, Bledsoe and Grote (2006) institute greater decreases in depression for women experiencing non-psychotic major low in pregnancy and postnatal periods treated with combination handling in comparing to antidepressant medication alone, which was itself more effective in comparing to CBT lone. The effect size for postnatal treatments was big in comparison to the small to medium effects of prenatal treatments, just when pharmacological treatments were excluded, the effect size for postnatal treatments decreased to the medium range.

For the treatment of premenstrual syndrome, Busse and colleagues (2009) found that CBT significantly reduced depressive and anxiety symptoms associated with this syndrome, as indicated by a medium effect size. In one case over again, these results need to exist interpreted carefully due to the small number of well-controlled studies on which these reviews were based.

CBT for Special Populations

Children

Within internalizing symptoms, there was support for the preferential apply of CBT approaches in treatment of anxiety disorders in children and adolescents, with result sizes in the large range (Santacruz et al., 2002; James, Soler, & Weatherall, 2005). Further, CBT treatment for obsessive compulsive disorder as compared to alternative approaches (no handling, other psychosocial treatments and medications such as clomipramine and fluvoxamine) resulted in significantly better outcomes (Phillips, 2003; Guggisberg, 2005). The data supporting CBT for depression was less strong, merely still in the medium issue size range across meta-analyses, with maintenance in 6-month follow-up periods (Santacruz et al., 2002). In addition, CBT seemed to work equally well as other psychotherapies (i.e. interpersonal therapy and family systems therapy), but was regarded as superior to selective reuptake inhibitors due to reduced gamble of side effects and greater price effectiveness (Haby, Tonge, Littlefield, Carter & Vos, 2004). The studies on efficacy of CBT for addressing suicidal behaviors were deficient (Robinson, Hetrick, & Martin, 2011), and warrant further investigation.

The picture show was more than mixed for other disorders, with CBT showing equal efficacy in reducing disruptive classroom behaviors and aggressive/antisocial behaviors, every bit other psychosocial treatments, better efficacy every bit compared to no treatment or handling as usual, and less efficacy than pharmacological approaches (Lösel & Beelmann, 2003; Özabaci, 2011). Similarly, CBT for attention arrears hyperactivity disorder showed some efficacy, but was not superior to medications (Van der Oord, Prins, Oosterlaan, & Emmelkamp, 2008). The efficacy of behavioral techniques (e.m. motivational enhancement and behavioral contingencies) was small to medium for the treatment of boyish smoking and substance utilize every bit compared to no treatment, only not more so than other psychotherapies. In addition, at that place was a medium to big effect size of CBT over waitlist across meta-analyses examining chronic headache pain. Finally, the data on efficacy for CBT in juvenile sex offenders, babyhood sexual abuse survivors, childhood obesity, fecal incontinence, and juvenile diabetes was limited, showing preliminary back up for CBT equally compared to no treatment, only equal efficacy to other psychosocial approaches (Walker, McGovern, Poey, & Otis, 2005; Macdonald, Higgins, & Ramchandani, 2006).

Elderly Adults

With respect to mood disorders, with low as the most commonly examined disorder, well-nigh all meta-analyses showed that CBT was more effective than waiting list control weather condition, but equally constructive in comparing to other active treatment methods, such every bit reminiscence, (an intervention that uses recollect of past events, feelings and thoughts to facilitate pleasance, quality of life or adaptation to the present; Peng, Huang, Chen, & Lu, 2009), psychodynamic therapy, and interpersonal therapy (Krishna et al., 2011; Wilson, Mottram, & Vassilas, 2008). Pinquart and colleagues (2007), still, found a large effect size for CBT, whereas the outcome sizes for the other agile handling conditions were in the medium-large range. When long-term outcomes were examined, results of one meta-analysis indicated that handling gains of CBT for depression were maintained at 11-months follow-upwardly (Krishna et al., 2011), but long-term follow-up data remained scarce in the other meta-analyses. In a meta-analysis assessing the additive furnishings of CBT and pharmacological approaches, Peng and colleagues (2009) found that CBT was more constructive in comparison to placebo, but CBT as an adjunct to antidepressant medication did non increase the effectiveness of antidepressants in this population.

For anxiety disorders in the elderly, CBT (alone or augmented with relaxation training) did not heighten outcomes beyond relaxation training lone (Thorp et al., 2009), although many of these studies were uncontrolled. In contrast to the findings by Thorp and colleagues (2009), Hendriks and colleagues (2008) found that anxiety symptoms were significantly decreased post-obit CBT than after either a waiting-list control condition or other treatment methods. Additionally, CBT significantly alleviated accompanying symptoms of worry and depression when compared to waiting-listing control or an active command condition.

Response Rates of Randomized Controlled Studies

The meta-analytic studies that provided response rates are listed in Tabular array 1. The response rates of CBT varied between 38% for treating obsessive compulsive disorder (Eddy et al., 2004) and 82% for treating trunk dysmorphic disorder (Ipser et al, 2009). In contrast, the response rates of the waitlist groups ranged from 2% for the treatment of bulimia nervosa (Thompson-Brenner, 2003) to 14% for generalized anxiety disorder (Hunot et al., 2007). CBT too demonstrated higher response rates in comparison to treatment as usual in treatment of generalized anxiety disorder and chronic fatigue (Price et al., 2008), and higher or equal response rates as compared to other therapies or psychopharmacological interventions in near studies. CBT only produced a lower response charge per unit than psychodynamic therapy for the personality disorders (47% vs. 59%; Leichsenring & Leibing, 2003).

Table 1

Pooled meta-analytic response rates for CBT versus other weather across disorders.

Disorder	Author (twelvemonth)	Number of Studies	CBT	MED	OT	PBO	TAU	WL	Comparing
Boderline Personality Disorder	Ipser et al. (2009)	two	82%i	56%1	-	18%1	-	-	CBT, MED>PBO
Panic disorder	Siev et al. (2008)	five	77%	-	l%	-	-	-	CBT>OT
Anger/Aggression	Del Vecchio & O'Leary (2004)	23	66–69%	-	65–70%	-	-	-	CBT = OT
Low	Leichsenring (2001)	vi	51–87%	-	45–70%	-	-	-	CBT>OT
Childhood Feet	James et al. (2005)	13	56%	-	-	28%2	-	-	CBT>PBO
Chronic Fatigue	Malouff et al. (2008)	five	fifty%	-	-	-	-	-	-
Personality Disorders	Leichsenring & Leibing (2003)	25	47%3	-	59%4	-	-	-	CBT<OT
Generalized Anxiety Disorder	Hunot et al. (2007)	8	46%5	-	-	-	xiv%	14%	CBT=OT; CBT>TAU,WL
Chronic Fatigue	Price et al. (2008)	6	40%	-	-	-	26%	-	CBT>TAU
Bulimia Nervosa	Thompson-Brenner (2003)	26	xl–44%	-	-	27%	-	2%	CBT>PBO, WL
Obsessive Compulsive Disorder	Eddy et al. (2004)	3	38–50%	-	-	-	-	-	-

Discussion

CBT is arguably the almost widely studied class of psychotherapy. Nosotros identified 269 meta-analytic reviews that examined CBT for a variety of bug, including substance utilise disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, acrimony and aggression, criminal behaviors, general stress, distress due to general medical conditions, chronic pain and fatigue, distress related to pregnancy complications and female person hormonal conditions. Additional meta-analytic reviews examined the efficacy of CBT for various problems in children and elderly adults. The vast majority of studies (84%) was published afterwards 2004, which was the last year of coverage of the review by Butler and colleagues (2006), making the present study the most comprehensive and contemporary review of meta-analytic studies of CBT to date.

For the treatment of addiction and substance employ disorder, the effect sizes of CBT ranged from small to medium, depending on the type of the substance of abuse. CBT was highly effective for treating cannabis and nicotine dependence, but less effective for treating opioid and alcohol dependence. For treating schizophrenia and other psychotic disorders, the empirical literature suggested appreciable efficacy of CBT especially for positive symptoms and secondary outcomes in the psychotic disorders, only lesser efficacy than other treatments (e.g. family intervention or psychopharmacology) for chronic symptoms or relapse prevention.

The meta-analytic literature on the efficacy of CBT for depression and dysthymia was mixed with some studies suggesting stiff evidence and others reporting weak support. Some authors have suggested that the strong effects in some studies may exist an overestimation due to a publication bias (Cuijpers, et al., 2010). Similarly, the efficacy of CBT for bipolar disorder was small to medium in the short-term in comparison to handling as usual. However, at that place was limited testify for the superiority of CBT alone over pharmacological approaches; for the treatment of depressive symptoms in bipolar disorder, the use of CBT was well supported. However, the long-term superiority compared to other treatments is still uncertain.

The efficacy of CBT for anxiety disorders was consistently stiff, despite some notable heterogeneity in the specific feet pathology, comparison conditions, follow-upwards data, and severity level. Large effect sizes were reported for the treatment of obsessive compulsive disorder, and at least medium effect sizes for social anxiety disorder, panic disorder, and post-traumatic stress disorder. Medium to large CBT treatment effects were reported for somatoform disorders, such equally hypochondriasis and body dysmorphic disorder. However, more studies using larger trials and greater sample sizes are needed to draw more conclusive findings with regard to CBT'south relative efficacy in comparison to other active treatments.

For the handling of bulimia, CBT was considerably more constructive than other forms of psychotherapies, simply less is known for other eating disorders. Similarly, CBT demonstrated superior efficacy as compared to other interventions for treating indisposition when examining slumber quality, total sleep time, waking time, and sleep efficiency outcomes. Still, although at that place were pocket-size effects of CBT for sleep problems among older adults (anile 60+), these furnishings may not exist long lasting (Montgomery & Dennis, 2009).

For personality disorders, there was some evidence for superior efficacy of CBT as compared to other psychosocial treatments for the personality disorders. All the same, the studies showed considerable variation in measurement methods, comorbid disorders, and demographic variables. CBT likewise produced medium to large effect sizes for treating anger and aggression (due east.yard., Saini, 2009), although a greater number of well-controlled studies are needed to more than adequately parse out the specific efficacy of CBT compared to the psychosocial treatments for anger on the whole. Similarly, more than studies are needed before whatsoever house conclusions can be fatigued most the efficacy of this treatment for criminal behaviors.

As a stress direction intervention, CBT was more effective that other treatments, such as organization-focused therapies. Notwithstanding, more than enquiry on the long-term effects of CBT for occupational stress is needed. Furthermore, at that place are open up questions about the relative efficacy of CBT versus pharmacological approaches to stress management. Similarly, several mutual concerns recurred beyond meta-analytic examinations of CBT for chronic medical weather condition, chronic fatigue and chronic hurting, namely: (ane) a scarcity of studies and pocket-size sample sizes; (2) poor methodological design of studies that are included in meta-analyses; and (3) group of CBT with a host of other psychotherapies (such as psychodynamic therapy, hypnotherapy, mindfulness, relaxation, and supportive counseling), which fabricated it difficult to parse out whether at that place are any superior effects of CBT in the bulk of medical conditions examined.

There was preliminary evidence for CBT for treating distress related to pregnancy complications and female hormonal conditions. However, more than research is needed due to a scarcity of follow-upward information and depression quality studies. This appeared to be a highly promising area for CBT given that the alternative – pharmacological treatments – tin can be associated with serious risks of agin furnishings for meaning women and breastfeeding mothers.

In our review of meta-analyses, CBT tailored to children showed robust back up for treating internalizing disorders, with benefits outweighing pharmacological approaches in mood and feet symptoms. The show was more than mixed for externalizing disorders, chronic hurting, or bug post-obit abuse. Moreover, there remains a demand for a greater number of loftier-quality trials in demographically diverse samples. Similarly, CBT was moderately efficacious for the handling of emotional symptoms in the elderly, merely no conclusions nigh long-term outcomes of CBT or combination therapies consisting of CBT, and medication could be fabricated.

Finally, our review identified 11 studies that compared response rates between CBT and other treatments or control atmospheric condition. In vii of these reviews, CBT showed higher response rates than the comparing weather, and in simply one review (Leichsenring & Leibig, 2003), which was conducted past authors with a psychodynamic orientation, reported that CBT had lower response rates than comparison treatments.

In sum, our review of meta-analytic studies examining the efficacy of CBT demonstrated that this treatment has been used for a wide range of psychological problems. In general, the evidence-base of CBT is very stiff, and particularly for treating anxiety disorders. However, despite the enormous literature base, there is nonetheless a clear need for high-quality studies examining the efficacy of CBT. Furthermore, the efficacy of CBT is questionable for some issues, which suggests that further improvements in CBT strategies are withal needed. In addition, many of the meta-analytic studies included studies with small sample sizes or inadequate control groups. Moreover, except for children and elderly populations, no meta-analytic studies of CBT have been reported on item subgroups, such as ethnic minorities and low income samples.

Despite these weaknesses in some areas, it is clear that the evidence-base of CBT is enormous. Given the loftier cost-effectiveness of the intervention, it is surprising that many countries, including many developed nations, take not yet adopted CBT as the first-line intervention for mental disorders. A notable exception is the Improving Access to Psychological Therapies initiative by the National Health Commissioning in the Britain (Rachman & Wilson, 2008). Nosotros believe that it is time that others follow conform.

Acknowledgments

The authors would similar to admit the post-obit research assistants who provided crucial and much-appreciated assistance with background literature reviews, initial identification of articles, and obtained articles for use by the authors: Dan Brager, Rachel Kaufmann, Rebecca Grossman, and Brian Hall.

Dr. Hofmann is a paid consultant of Merck Pharmaceutical (Schering-Plough) for work unrelated to this report. This study was partially supported by NIMH grants MH-078308 and MH-081116 awarded to Dr. Hofmann and MH-73937.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/

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