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Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
NIH-PA Author Manuscript Published in final edited form as: Cognit Ther Res. 2012 October 1; 36(5): 427–440. doi:10.1007/s10608-012-9476-1.
The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-
Stefan G. Hofmann, Ph.D., Anu Asnaani, M.A., Imke J.J. Vonk, M.A., Alice T. Sawyer, M.A.,
and Angela Fang, M.A.
Boston University, Boston, MA
Cognitive behavioral therapy (CBT) refers to a popular therapeutic approach that has been appliedto a variety 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 ofthose a representative sample of 106 meta-analyses examining CBT for the following problems: NIH-PA Author Manuscript substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia,bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personalitydisorders, anger and aggression, criminal behaviors, general stress, distress due to general medicalconditions, chronic pain and fatigue, distress related to pregnancy complications and femalehormonal conditions. Additional meta-analytic reviews examined the efficacy of CBT for variousproblems in children and elderly adults. The strongest support exists for CBT of anxiety disorders,somatoform disorders, bulimia, anger control problems, and general stress. Eleven studiescompared response rates between CBT and other treatments or control conditions. CBT showedhigher response rates than the comparison conditions in 7 of these reviews and only one reviewreported that CBT had lower response rates than comparison treatments. In general, the evidence-base of CBT is very strong. However, additional research is needed to examine the efficacy ofCBT for randomized-controlled studies. Moreover, except for children and elderly populations, nometa-analytic studies of CBT have been reported on specific subgroups, such as ethnic minoritiesand low income samples.
CBT; efficacy; meta-analyses; comprehensive review NIH-PA Author Manuscript Cognitive-behavioral therapy (CBT) refers to a class of interventions that share the basicpremise that mental disorders and psychological distress are maintained by cognitive factors.
The core premise of this treatment approach, as pioneered by Beck (1970) and Ellis (1962),holds that maladaptive cognitions contribute to the maintenance of emotional distress andbehavioral problems. According to Beck's model, these maladaptive cognitions includegeneral beliefs, or schemas, about the world, the self, and the future, giving rise to specificand automatic thoughts in particular situations. The basic model posits that therapeuticstrategies to change these maladaptive cognitions lead to changes in emotional distress andproblematic behaviors.
Since these early formulations, a number of disorder-specific CBT protocols have beendeveloped that specifically address various cognitive and behavioral maintenance factors of Corresponding author for proofs and reprints: Stefan G. Hofmann, Ph.D., Department of Psychology, Boston University, 648 BeaconSt., 6th floor, Boston, MA 02215,
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the various disorders. Although these disorder-specific treatment protocols showconsiderable differences in some of the specific treatment techniques, they all share the NIH-PA Author Manuscript same core model and the general approach to treatment.
Consistent with the medical model of psychiatry, the overall goal of treatment is symptomreduction, improvement in functioning, and remission of the disorder. In order to achievethis goal, the patient becomes an active participant in a collaborative problem-solvingprocess to test and challenge the validity of maladaptive cognitions and to modifymaladaptive behavioral patterns. Thus, modern CBT refers to a family of interventions thatcombine a variety of cognitive, behavioral, and emotion-focused techniques (e.g., Hofmann,2011; Hofmann, Asmundson, & Beck, in press). Although these strategies greatly emphasizecognitive factors, physiological, emotional, and behavioral components are also recognizedfor the role that they play in the maintenance of the disorder.
A recent review of meta-analyses of CBT identified 16 quantitative reviews that included332 clinical trials covering 16 different disorders or populations (Butler, Chapman, Forman,& Beck, 2006). To our knowledge, this was the first review of meta-analytic studiesexamining the efficacy of CBT for a number of psychological disorders. This article hassince become one of the most influential reviews of CBT. However, the search strategy wasrestrictive, because only one meta-analysis was selected for each disorder. Furthermore, the NIH-PA Author Manuscript search only covered the period up to 2004, but many reviews have been published sincethen. In fact, the majority of studies (84%) was published after 2004. The goal of our reviewwas to provide a comprehensive survey of all contemporary meta-analyses examining theevidence base for the efficacy of CBT to date. The meta-analyses included in the presentreview were all judged to be methodologically sound.
Search Strategy and Study Selection
To obtain the articles for this review, we searched PubMed, PsychInfo, and Cochrane librarydatabases using the following key words: meta-analysis AND cognitive behav*, meta-analysis AND cognitive therapy, quantitative review AND cognitive behav*, quantitativereview AND cognitive therapy. This initial search yielded 1,163 hits, of which 355 wereduplicates and had to be excluded. The remaining 808 non-duplicate articles were furtherexamined to determine if they met specific inclusionary criteria for the purposes of thisreview. All included studies had to be quantitative reviews (i.e., meta-analyses) of CBT. Inorder to limit this review to contemporary studies, only articles published since 2000 wereincluded. The final sample included in this review consisted of 269 meta-analyses (Figure NIH-PA Author Manuscript 1). Out of those, we described a representative sample of 106 meta-analytic studies. Thecomplete reference list for the final sample of included meta-analyses can be obtained by. As already noted, themajority (84%) of these studies was published after 2004, the most recent year covered bythe meta-analysis by Butler and colleagues (2006). The number of meta-analytic reviews peryear is depicted in Figure 2.
Categorization of Meta-analyses
The 269 meta-analyses were categorized into groups to provide the most meaningful andextensive examination of the efficacy of CBT across a range of problem areas and studypopulations. The major groupings were the following: substance use disorder, schizophreniaand other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders,somatoform disorders, eating disorders, insomnia, personality disorders, anger andaggression, criminal behaviors, general stress, distress due to general medical conditions, Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
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chronic pain and fatigue, pregnancy complications and female hormonal conditions. Inaddition, some meta-analyses specifically examined CBT for disorders in children and NIH-PA Author Manuscript elderly adults. For each disorder and population grouping, data were described qualitatively,considering the findings of all meta-analyses within that group. The 269 meta-analysesincluded a wide variety of studies that employed different methodologies and effect sizeestimates. Therefore, we used the designation small, medium, and large for the magnitude ofeffect sizes in our review of the 106 representative meta-analyses (Cohen, 1988). Inaddition, we provide reported response rates, a widely accepted and common metric inpsychiatry, from a subsample of 11 studies that examined the efficacy of CBT inrandomized controlled trials.
Addiction and Substance Use Disoder
There was evidence for the efficacy of CBT for cannabis dependence, with evidence forhigher efficacy of multi-session CBT versus single session or other briefer interventions, anda lower drop out rate compared to control conditions (Dutra et al., 2008). However, theeffect size of CBT was small as compared to other psychosocial interventions (e.g.
contingency management, relapse prevention, and motivational approaches) for substancedependence, and agonist treatments showed a greater effect size than CBT in certain drug NIH-PA Author Manuscript dependencies, such as opioid and alcohol dependence (Powers, Vedel, & Emmelkamp,2008).
Treatments for smoking cessation found that coping skills, which were partially based onCBT techniques, were highly effective in reducing relapse in a community sample ofnicotine quitters (Song, Huttunen-Lenz, & Holland, 2010), and another meta-analysis notedsuperiority of CBT (either alone or in combination with nicotine replacement therapy) overnicotine replacement therapy alone (Garcia-Vera & Sanz, 2006). Furthermore, there wasevidence for superior performance of behavioral approaches in the treatment of problematicgambling as compared to control treatments (Oakley-Browne et al., 2000). One meta-analysis (Leung & Cottler, 2009) reported larger effect sizes of CBT when this treatmentwas grouped with other non-pharmacological treatments (such as brief interventions) ascompared to pharmacological agents (e.g. naltrexone, carbamazepine, and topiramate), butCBT was not more efficacious than these other briefer, less expensive approaches.
Schizophrenia and Other Psychotic Disorders
Meta-analyses examining the efficacy of psychological treatments for schizophreniarevealed a beneficial effect of CBT on positive symptoms (i.e., delusions and/or NIH-PA Author Manuscript hallucinations) of schizophrenia (e.g., Gould et al., 2001; Rector & Beck, 2001). There wasalso evidence (e.g., Zimmerman et al., 2005) that CBT is a particularly promising adjunct topharmacotherapy for schizophrenia patients who suffer from an acute episode of psychosisrather than a more chronic condition.
CBT appeared to have little effect on relapse or hospital admission compared to otherinterventions, such as early intervention services or family intervention (e.g., Bird et al.,2010; Álvarez-Jiménez et al., 2011). However, CBT had a beneficial effect on secondaryoutcomes. For example, a more recent meta-analysis by Wykes and colleagues (2008)examined controlled trials of CBT for schizophrenia and confirmed findings from previousmeta-analyses (e.g., Gould et al., 2001; Rector & Beck, 2001), suggesting that CBT had asmall to medium effect size as compared to control conditions on both positive and negativesymptoms. In addition, this meta-analysis revealed medium effect sizes for improvements in Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
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secondary outcomes that were not the direct targets of treatment, including generalfunctioning, mood, and social anxiety.
NIH-PA Author Manuscript Depression and Dysthymia
CBT for depression was more effective than control conditions such as waiting list or notreatment, with a medium effect size (van Straten, Geraedts, Verdonck-de Leeuw,Andersson, & Cuijpers, 2010; Beltman, Oude Voshaar, & Speckens, 2010). However,studies that compared CBT to other active treatments, such as psychodynamic treatment,problem-solving therapy, and interpersonal psychotherapy, found mixed results.
Specifically, meta-analyses found CBT to be equally effective in comparison to otherpsychological treatments (e.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) foundCBT 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 sixmonths follow-up, although this occurred when depression and anxiety symptoms wereexamined together.
Compared to pharmacological approaches, CBT and medication treatments had similar NIH-PA Author Manuscript effects on chronic depressive symptoms, with effect sizes in the medium-large range (Vos,Haby, Barendregt, Kruijshaar, Corry, & Andrews, 2004). Other studies indicated thatpharmacotherapy could be a useful addition to CBT; specifically, combination therapy ofCBT with pharmacotherapy was more effective in comparison to CBT alone (Chan, 2006).
Meta-analyses examining the efficacy of CBT for bipolar disorder revealed small to mediumoverall effect sizes of CBT at post-treatment, with effects typically diminishing slightly atfollow-up. These findings emerged from examinations of both manic and depressivesymptoms associated with bipolar disorder (e.g., Gregory, 2010a, 2010b). There is littleevidence that CBT as a stand-alone treatment (rather than as an adjunct to pharmacotherapy)is effective for the treatment 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. Onestudy (Beynon et al., 2008) examined the efficacy of CBT for preventing relapse and foundit to be somewhat effective when comparing CBT vs. treatment as usual. Overall, CBT forbipolar disorder was an effective method of preventing or delaying relapses (e.g., Lam, NIH-PA Author Manuscript Burbeck, Wright, & Pilling, 2009; Cakir & Ozerdem, 2010). Furthermore, the efficacy ofCBT at preventing relapse did not seem to be influenced by the number of previous manic ordepressive episodes.
In general, CBT is a reliable first-line approach for treatment of this class of disorders(Hofmann & Smits, 2008), with support for significant positive effects of CBT on secondarysymptoms such as sleep dysfunction and anxiety sensitivity (Ghahramanlou, 2003). Further,internet-delivered or guided self-help CBT showed some promise in immediate symptomrelief as compared to no treatment, but the long-term maintenance with this modality ofCBT remains unclear (Öst, 2008; Coull & Morris, 2011).
CBT for social anxiety disorder evidenced a medium to large effect size at immediate post-treatment as compared to control or waitlist treatments, with significant maintenance and Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
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even improvement of gains at follow-up (Gil, Carrillo, & Meca, 2001). Further, exposure,cognitive restructuring, social skills training and both group/individual formats were equally NIH-PA Author Manuscript efficacious (Powers, Sigmarsson, & Emmelkamp, 2008), with superior performance overpsychopharmacology in the long term (Fedoroff & Taylor, 2001). Similarly, interoceptiveexposure for treatment of panic disorder was moderately effective and superior to control/pill placebo treatments and applied relaxation (Haby, Donnelly, Corry, & Vos, 2006;Furukawa, Watanabe, & Churchill, 2007). For panic disorder without agoraphobia,combination treatment of CBT and applied relaxation was equal in efficacy to use of eithertherapy approach alone, and use of either or both were superior to use of medications (Mitte,2005).
Various CBT techniques for specific phobia (systematic desensitization, exposure, cognitivetherapy) were as effective as applied relaxation and applied tension, producing effect sizesin the large range, with long-term maintenance of gains (Ruhmland & Margraf, 2001). Forgeneralized anxiety disorder, CBT was superior as compared to control or pill placeboconditions, and equally efficacious as relaxation therapy, supportive therapy, orpsychopharmacology, but less efficacious in comparison to attention placebos and in thosewith more severe generalized anxiety disorder symptoms.
CBT for post-traumatic stress disorder was equal in efficacy to eye movement NIH-PA Author Manuscript desensitization and reprocessing (Bisson et al., 2007), with both being superior to treatmentas usual, waitlist, or other treatments (such as supportive counseling) for post-traumaticstress disorder (Bisson & Andrew, 2008). However, it is questionable whether the eye-movement technique is an active treatment ingredient.
Clinical trials also revealed a large effect size for CBT and/or exposure response preventionfor obsessive compulsive disorder, with evidence suggesting that a combination of in vivoand imaginal exposures outperformed the use of only in vivo exposures (Ruhmland &Margraf, 2001). Furthermore, CBT was found to be similarly efficacious than clomipramineand selective reuptake inhibitors (Eddy, Dutra, Bradley, & Westen, 2004).
Within the somatoform disorders category of DSM-IV, meta-analyses primarily examinedthe efficacy of psychological interventions for hypochondriasis and body dysmorphicdisorder. One meta-analysis found a large mean effect size for CBT, which outperformedother psychological treatments (i.e., psychoeducation, explanatory therapy, cognitivetherapy, exposure and response prevention, and behavioral stress management), with effectsizes in the large range, as well as pharmacotherapy treatments (paroxetine, fluoxetine, NIH-PA Author Manuscript fluvoxamine, and nefazodone), which also evidenced large effect sizes (Taylor, Asmundson,& Coons, 2005). The mean effect size for control conditions (e.g., wait-list control) wassmall. These results were partially supported by other evidence, as a more recent meta-analysis found superior outcomes of CBT for hypochondriasis compared to waiting listcontrol, usual medical care or placebo at twelve-month follow-up (Thomson & Page, 2007).
However, this meta-analysis also found no differences between CBT and waiting list/placebo at post-treatment.
Meta-analyses comparing the efficacy of CBT to control treatments found that CBT wassuperior in significantly reducing body dysmorphic disorder symptoms (Ipser, Sander, &Stein, 2009). In comparing relative efficacy of CBT versus pharmacotherapy, effect sizeswere large on body dysmorphic disorder severity measures for CBT, and ranged frommedium to large for pharmacotherapy (Williams, Hadjistavropoulos, & Sharpe, 2006). Inaddition, another meta-analysis found that CBT for body image disturbances was effective,with effect sizes ranging from medium to large (Jarry & Ip, 2005).
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For bulimia nervosa, meta-analyses compared the efficacy of CBT to control treatments and NIH-PA Author Manuscript found effect sizes in the medium range (Thompson-Brenner, 2002). However, the effect ofbehavior therapy was greater than that of CBT, with the average effect size for behaviortherapy in the large range (Thompson-Brenner, 2003). Another meta-analysis comparingCBT with control treatments found remission response rates to be higher for CBT, with amedium relative risk ratio (Hay, Bacaltchuk, Stefano, & Kashyap, 2009). When comparingCBT to other psychotherapies, specifically, interpersonal therapy, dialectical behavioraltherapy, hypno-behavioral therapy, supportive psychotherapy, behavioral weight losstreatment, and self-monitoring, CBT fared significantly better in remission response rates forbulimia nervosa, with a large relative risk ratio (Hay et al., 2009).
For binge eating disorder, a recent meta-analysis found that psychotherapy and structuredself-help yielded large effect sizes, when compared to pharmacotherapy, which yieldedmedium effect sizes (Vocks et al., 2010). Although this study did not parse out the efficacyof CBT specifically, a majority of the included trials for psychotherapy involved CBT (19out of 23 trials). Furthermore, a review and meta-analysis by Reas and Grilo (2008)suggested that combination treatment of psychotherapy and medications did not enhancebinge-eating outcomes, but may have enhanced weight loss outcomes.
NIH-PA Author Manuscript CBT for insomnia (CBT-I) has long been shown to be more efficacious than controltreatments. A recent meta-analysis examined its efficacy on both subjective and objectivesleep parameters in comparison to a control group for individuals with primary insomnia(Okajima, Komada, & Inoue, 2011). Effect sizes for the efficacy of CBT-I versus control atthe end of treatment on subjective sleep measures, which included sleep onset latency, totalsleep time, wake after sleep onset, total wake time, time in bed, early morning awakening,and sleep efficiency, ranged from minimal (total sleep time) to large (early morningawakening) (Okajima et al., 2011). For objective measures using a polysomnogram oractigraphic evaluation, effect sizes ranged from small (total sleep time) to large (total waketime) (Okajima et al., 2011). These findings were consistent with results from another meta-analysis, which examined the relative efficacy of behavioral interventions for insomniaincluding CBT, relaxation, and only behavioral techniques (Irwin, Cole, & Nicassio, 2006).
This study reported effect sizes ranging from −.75 to 1.47 for CBT, −.60 to .53 forrelaxation techniques, and −.82 to .91 for only behavioral techniques on subjective sleepoutcomes.
NIH-PA Author Manuscript There was one meta-analysis that examined the relative efficacy of CBT versuspsychodynamic therapy for the treatment of personality disorders (Leichsenring & Leibing,2003). The findings indicated a larger overall effect size for psychodynamic therapycompared to CBT. This was consistent with observer-rated measures, which showed asimilar pattern of effect sizes: stronger for psychodynamic therapy than for CBT (althoughthis effect size was also large). Self-report measures, however, indicated larger effect sizesfor 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 suggestedthat compared to control treatment, CBT plus standard maintenance was more efficacious interms of leaving the study early and cocaine use for outpatients with antisocial personalitydisorder and comorbid cocaine dependence. However, CBT plus treatment as usual was notbetter than a control condition for these antisocial personality disorder patients with regard Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
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to levels of recent verbal or physical aggression. The relative efficacy of psychologicaltreatments for borderline personality disorder, in particular, was also examined, which NIH-PA Author Manuscript yielded no differences between dialectical behavioral therapy and treatment as usual inindividuals meeting criteria for borderline personality disorder at six months, or in hospitaladmissions in the previous three months (Binks et al., 2009).
Anger and Aggression
Two meta-analytic reviews focused on anger control problems and aggression (Del Vecchio& O'Leary, 2004; Saini, 2009). The findings from these meta-analyses suggested that CBTis moderately effective at reducing anger problems. Findings from these reviews alsosuggested that CBT may be most effective for patients with issues regarding angerexpression.
CBT produced medium effect sizes as compared to other psychosocial treatments andcontrol 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 ofanger on standardized anger measurements prior to treatment. This meta-analysis examinedthe effects of CBT, cognitive therapy, relaxation, and ‘other' (e.g., social skills training,process group counseling) on various anger problems including driving anger, anger NIH-PA Author Manuscript suppression, and anger expression difficulties.
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 theoreticalorientations and types of psychological interventions for criminal activity, behavior therapyand CBT appeared to be the superior interventions in reducing recidivism rates, both withmedium mean effect sizes (Illescas, Sanchez-Meca, & Genovés, 2001). Effect sizes for otherinterventions ranged from small to medium (Illescas et al., 2001). Another studydemonstrated consistent findings with a small weighted mean effect size of behavior therapyor CBT for reducing recidivism (Pearson, Lipton, Cleland, & Yee, 2002). Similarly, Wilsonand colleagues (2005) found an overall small-to-medium mean effect size for CBT programsfor convicted offenders.
For sexual offenders in particular, physical treatments, such as surgical castration andhormonal treatment, were demonstrated to have greater efficacy in reducing sexualrecidivism in comparison to CBT, with large significant odds ratios for both of these NIH-PA Author Manuscript alternative interventions (Lösel & Schmucker, 2005). Of the various psychologicalinterventions for sexual offenders, however, classical behavioral and CBT approachesindicated 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 study of CBT for domestic violence indicated no differences between CBT and the Duluthmodel (which is based on a feminist psycho-educational approach) for treating domesticallyviolent males (Babcock, Green, & Robie, 2004). The aggregated data from experimental andquasi-experimental studies showed that CBT had an overall small effect size, and the Duluthmodel had an overall slightly larger, but still small effect size (Babcock et al., 2004).
Four meta-analyses examined occupational stress and the majority of their results were quitesimilar: CBT interventions were more effective in comparison to other intervention types Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
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such as organization focused therapies, especially when CBT focused on psycho-socialoutcomes in employees (Kim, 2007; Richardson & Rothstein, 2008; van der Klink, Blonk, NIH-PA Author Manuscript Schene, & van Dijk, 2001). For example, Richardson and Rothstein (2008) found CBT aloneto be more effective in comparison to CBT combined with additional psychologicalcomponents. These studies found a large effect size for overall CBT interventions, largeeffect size for single-mode CBT interventions, and small effect size for CBT interventionswith four or more components. In contrast, Marine and colleagues (2006) chose not tocompare CBT with other interventions, such as relaxation techniques for psychologicalstress, because most interventions comprised both elements and could not be evaluatedseparately. With respect to stress in parents of children with developmental disabilities,positive effects were found for CBT, but the effect size was relatively small (Singer,Ethridge, & Aldana, 2007). In contrast to the results of Richardson and Rothstein (2008),this meta-analysis found multiple component interventions which combined CBT,behavioral parent training and in some cases other forms of support services, to have ahigher and large effect size in comparison to CBT alone (Singer, Ethridge, & Aldana, 2007).
Distress Due to General Medical Conditions
Limited well-controlled studies existed in the study of non-ulcer dyspepsia, multiplesclerosis, physical disability following traumatic injury, non-epileptic seizures, post-concussion syndrome, chronic obstructive pulmonary disease, hypertension, Type II NIH-PA Author Manuscript diabetes, and burning mouth syndrome (e.g. Soo et al., 2004; Thomas, Thomas, Hillier,Galvin, & Baker, 2006; Baker, Brooks, Goodfellow, Bodde, & Aldenkamp, 2007; Ismail,Winkley, & Rabe-Hesketh, 2004). However, cancer was studied more rigorously and withmore robust methodological attention, indicating small to medium effect sizes of individualCBT as compared to patient education only in gynecological and head/neck cancers(Zimmerman & Heinrichs, 2006; Luckett, Britton, Clover, & Rankin, 2011), on secondaryoutcomes such as quality of life, psychological distress (i.e., depression and anxiety), andpain. Further, CBT was shown to be equally effective as exercise interventions in treatingcancer-related fatigue (Kangas, Bovbjerg, & Montgomery, 2008).
Small to medium effect sizes were observed in treatment of secondary symptoms (anxietyand stress) experienced by individuals who were HIV positive, with particular efficacy(particularly for stress management) in reducing anger symptoms as compared to supportivetherapy (Crepaz et al., 2008), but not for outcomes such as low cell count, medicationadherence, or when used with marginalized populations such as ethnic minorities andwomen (Crepaz et al., 2008; Rueda et al., 2006).
CBT was shown to be superior in the treatment of secondary symptoms of spinal cord injury NIH-PA Author Manuscript as 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), but equal to yoga/education in depressive symptoms(Martinez-Devesa, Perera, Theodoulou, & Waddell, 2010). CBT was only slightly moreeffective than usual care or waitlist condition in the treatment of irritable bowel syndrome,with peppermint oil having greater efficacy in providing relief in this particular disorder(Enck, Junne, Klosterhalfen, Zipfel, & Martens, 2010).
Chronic Pain and Fatigue
Meta-analyses examining the efficacy of psychosocial treatments for chronic pain haveinvestigated chronic low back pain, fibromyalgia, rheumatoid arthritis, chronic fatiguesyndrome, chronic musculoskeletal pain, and non-specific chest pain. These reviews haveexamined the effect of a range on treatments on chronic pain, including relaxationtechniques, mindfulness-based techniques, acceptance-based techniques, biofeedback, Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
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psycho-education, and behavioral and cognitive-behavioral treatments. Results of thesemeta-analyses revealed varying effect sizes for these treatments depending on the type of NIH-PA Author Manuscript chronic pain targeted; however, CBT treatments for chronic pain were consistently in thesmall to medium effect size range.
Similar results were found in a meta-analysis examining psychological treatments forfibromyalgia (Glombiewski et al., 2010). This meta-analysis revealed that CBT was superiorto other psychological treatments for decreasing pain intensity. Pre-post analyses revealed amedium effect size for CBT as compared to a small effect size for all other psychologicaltreatments combined (excluding CBT). CBT treatments for chronic fatigue syndrome weremoderately effective (e.g., Malouff et al., 2008; Price et al., 2008). Malouff and colleagues(2008) conducted a meta-analysis revealing a medium effect size in post-treatment fatiguefor participants receiving CBT versus those in control conditions.
Pregnancy Complications and Female Hormonal Conditions
One meta-analysis found CBT to be more effective in comparison to control conditions forperinatal depression (Sockol, Epperson, & Barber, 2011), and another meta-analysis foundbeneficial effects of CBT for postnatal depression, but these results need to be interpretedwith caution because it is difficult to causally link depression with pregnancy and hormonalchanges in these studies (Dennis, & Hodnett, 2007). Further, Bledsoe and Grote (2006) NIH-PA Author Manuscript found greater decreases in depression for women experiencing non-psychotic majordepression in pregnancy and postnatal periods treated with combination treatment incomparison to antidepressant medication alone, which was itself more effective incomparison to CBT alone. The effect size for postnatal treatments was large in comparisonto the small to medium effects of prenatal treatments, but when pharmacological treatmentswere excluded, the effect size for postnatal treatments decreased to the medium range.
For the treatment of premenstrual syndrome, Busse and colleagues (2009) found that CBTsignificantly reduced depressive and anxiety symptoms associated with this syndrome, asindicated by a medium effect size. Once again, these results need to be interpreted carefullydue 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 use of CBT
approaches in treatment of anxiety disorders in children and adolescents, with effect 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
treatment, other psychosocial treatments and medications such as clomipramine and
NIH-PA Author Manuscript fluvoxamine) resulted in significantly better outcomes (Phillips, 2003; Guggisberg, 2005).
The data supporting CBT for depression was less strong, but still in the medium effect sizerange across meta-analyses, with maintenance in 6-month follow-up periods (Santacruz etal., 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 selectivereuptake inhibitors due to reduced chance of side effects and greater cost effectiveness(Haby, Tonge, Littlefield, Carter & Vos, 2004). The studies on efficacy of CBT foraddressing suicidal behaviors were scarce (Robinson, Hetrick, & Martin, 2011), and warrantfurther investigation.
The picture was more mixed for other disorders, with CBT showing equal efficacy inreducing disruptive classroom behaviors and aggressive/antisocial behaviors, as otherpsychosocial treatments, better efficacy as compared to no treatment or treatment as usual,and less efficacy than pharmacological approaches (Lösel & Beelmann, 2003; Özabaci, Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
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2011). Similarly, CBT for attention deficit hyperactivity disorder showed some efficacy, butwas not superior to medications (Van der Oord, Prins, Oosterlaan, & Emmelkamp, 2008).
NIH-PA Author Manuscript The efficacy of behavioral techniques (e.g. motivational enhancement and behavioralcontingencies) was small to medium for the treatment of adolescent smoking and substanceuse as compared to no treatment, but not more so than other psychotherapies. In addition,there was a medium to large effect size of CBT over waitlist across meta-analysesexamining chronic headache pain. Finally, the data on efficacy for CBT in juvenile sexoffenders, childhood sexual abuse survivors, childhood obesity, fecal incontinence, andjuvenile diabetes was limited, showing preliminary support for CBT as compared to notreatment, but equal efficacy to other psychosocial approaches (Walker, McGovern, Poey, &Otis, 2005; Macdonald, Higgins, & Ramchandani, 2006).
Elderly Adults: With respect to mood disorders, with depression as the most commonly
examined disorder, nearly all meta-analyses showed that CBT was more effective than
waiting list control conditions, but equally effective in comparison to other active treatment
methods, such as reminiscence, (an intervention that uses recall of past events, feelings and
thoughts to facilitate pleasure, 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), however, found a
large effect size for CBT, whereas the effect sizes for the other active treatment conditions
NIH-PA Author Manuscript were in the medium-large range. When long-term outcomes were examined, results of onemeta-analysis indicated that treatment gains of CBT for depression were maintained at 11-months follow-up (Krishna et al., 2011), but long-term follow-up data remained scarce inthe other meta-analyses. In a meta-analysis assessing the additive effects of CBT andpharmacological approaches, Peng and colleagues (2009) found that CBT was moreeffective in comparison to placebo, but CBT as an adjunct to antidepressant medication didnot increase the effectiveness of antidepressants in this population.
For anxiety disorders in the elderly, CBT (alone or augmented with relaxation training) didnot enhance outcomes beyond relaxation training alone (Thorp et al., 2009), although manyof these studies were uncontrolled. In contrast to the findings by Thorp and colleagues(2009), Hendriks and colleagues (2008) found that anxiety symptoms were significantlydecreased following CBT than after either a waiting-list control condition or other treatmentmethods. Additionally, CBT significantly alleviated accompanying symptoms of worry anddepression when compared to waiting-list control or an active control condition.
Response Rates of Randomized Controlled Studies
NIH-PA Author Manuscript The meta-analytic studies that provided response rates are listed in Table 1. The responserates of CBT varied between 38% for treating obsessive compulsive disorder (Eddy et al.,2004) and 82% for treating body dysmorphic disorder (Ipser et al, 2009). In contrast, theresponse 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 also demonstrated higher response rates in comparison to treatment as usual intreatment of generalized anxiety disorder and chronic fatigue (Price et al., 2008), and higheror equal response rates as compared to other therapies or psychopharmacologicalinterventions in most studies. CBT only produced a lower response rate than psychodynamictherapy for the personality disorders (47% vs. 59%; Leichsenring & Leibing, 2003).
CBT is arguably the most widely studied form of psychotherapy. We identified 269 meta-analytic reviews that examined CBT for a variety of problems, including substance use Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
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disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolardisorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality NIH-PA Author Manuscript disorders, anger and aggression, criminal behaviors, general stress, distress due to generalmedical conditions, chronic pain and fatigue, distress related to pregnancy complicationsand female hormonal conditions. Additional meta-analytic reviews examined the efficacy ofCBT for various problems in children and elderly adults. The vast majority of studies (84%)was published after 2004, which was the last year of coverage of the review by Butler andcolleagues (2006), making the present study the most comprehensive and contemporaryreview of meta-analytic studies of CBT to date.
For the treatment of addiction and substance use disorder, the effect sizes of CBT rangedfrom small to medium, depending on the type of the substance of abuse. CBT was highlyeffective for treating cannabis and nicotine dependence, but less effective for treating opioidand alcohol dependence. For treating schizophrenia and other psychotic disorders, theempirical literature suggested appreciable efficacy of CBT particularly for positivesymptoms and secondary outcomes in the psychotic disorders, but lesser efficacy than othertreatments (e.g. family intervention or psychopharmacology) for chronic symptoms orrelapse prevention.
The meta-analytic literature on the efficacy of CBT for depression and dysthymia was mixed NIH-PA Author Manuscript with some studies suggesting strong evidence and others reporting weak support. Someauthors have suggested that the strong effects in some studies may be an overestimation dueto a publication bias (Cuijpers, et al., 2010). Similarly, the efficacy of CBT for bipolardisorder was small to medium in the short-term in comparison to treatment as usual.
However, there was limited evidence for the superiority of CBT alone over pharmacologicalapproaches; for the treatment of depressive symptoms in bipolar disorder, the use of CBTwas well supported. However, the long-term superiority compared to other treatments is stilluncertain.
The efficacy of CBT for anxiety disorders was consistently strong, despite some notableheterogeneity in the specific anxiety pathology, comparison conditions, follow-up data, andseverity level. Large effect sizes were reported for the treatment of obsessive compulsivedisorder, and at least medium effect sizes for social anxiety disorder, panic disorder, andpost-traumatic stress disorder. Medium to large CBT treatment effects were reported forsomatoform disorders, such as hypochondriasis and body dysmorphic disorder. However,more studies using larger trials and greater sample sizes are needed to draw more conclusivefindings with regard to CBT's relative efficacy in comparison to other active treatments.
For the treatment of bulimia, CBT was considerably more effective than other forms of NIH-PA Author Manuscript psychotherapies, but less is known for other eating disorders. Similarly, CBT demonstratedsuperior efficacy as compared to other interventions for treating insomnia when examiningsleep quality, total sleep time, waking time, and sleep efficiency outcomes. However,although there were small effects of CBT for sleep problems among older adults (aged 60+),these effects may not be long lasting (Montgomery & Dennis, 2009).
For personality disorders, there was some evidence for superior efficacy of CBT ascompared to other psychosocial treatments for the personality disorders. However, thestudies showed considerable variation in measurement methods, comorbid disorders, anddemographic variables. CBT also produced medium to large effect sizes for treating angerand aggression (e.g., Saini, 2009), although a greater number of well-controlled studies areneeded to more adequately parse out the specific efficacy of CBT compared to thepsychosocial treatments for anger on the whole. Similarly, more studies are needed before Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
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any firm conclusions can be drawn about the efficacy of this treatment for criminalbehaviors.
NIH-PA Author Manuscript As a stress management intervention, CBT was more effective that other treatments, such asorganization-focused therapies. However, more research on the long-term effects of CBT foroccupational stress is needed. Furthermore, there are open questions about the relativeefficacy of CBT versus pharmacological approaches to stress management. Similarly,several common concerns recurred across meta-analytic examinations of CBT for chronicmedical conditions, chronic fatigue and chronic pain, namely: (1) a scarcity of studies andsmall sample sizes; (2) poor methodological design of studies that are included in meta-analyses; and (3) grouping of CBT with a host of other psychotherapies (such aspsychodynamic therapy, hypnotherapy, mindfulness, relaxation, and supportive counseling),which made it difficult to parse out whether there are any superior effects of CBT in themajority of medical conditions examined.
There was preliminary evidence for CBT for treating distress related to pregnancycomplications and female hormonal conditions. However, more research is needed due to ascarcity of follow-up data and low quality studies. This appeared to be a highly promisingarea for CBT given that the alternative – pharmacological treatments – can be associatedwith serious risks of adverse effects for pregnant women and breastfeeding mothers.
NIH-PA Author Manuscript In our review of meta-analyses, CBT tailored to children showed robust support for treatinginternalizing disorders, with benefits outweighing pharmacological approaches in mood andanxiety symptoms. The evidence was more mixed for externalizing disorders, chronic pain,or problems following abuse. Moreover, there remains a need for a greater number of high-quality trials in demographically diverse samples. Similarly, CBT was moderatelyefficacious for the treatment of emotional symptoms in the elderly, but no conclusions aboutlong-term outcomes of CBT or combination therapies consisting of CBT, and medicationcould be made.
Finally, our review identified 11 studies that compared response rates between CBT andother treatments or control conditions. In 7 of these reviews, CBT showed higher responserates than the comparison conditions, and in only one review (Leichsenring & Leibig, 2003),which was conducted by authors with a psychodynamic orientation, reported that CBT hadlower response rates than comparison treatments.
In sum, our review of meta-analytic studies examining the efficacy of CBT demonstratedthat this treatment has been used for a wide range of psychological problems. In general, theevidence-base of CBT is very strong, and especially for treating anxiety disorders. However, NIH-PA Author Manuscript despite the enormous literature base, there is still a clear need for high-quality studiesexamining the efficacy of CBT. Furthermore, the efficacy of CBT is questionable for someproblems, which suggests that further improvements in CBT strategies are still needed. Inaddition, many of the meta-analytic studies included studies with small sample sizes orinadequate control groups. Moreover, except for children and elderly populations, no meta-analytic studies of CBT have been reported on particular subgroups, such as ethnicminorities and low income samples.
Despite these weaknesses in some areas, it is clear that the evidence-base of CBT isenormous. Given the high cost-effectiveness of the intervention, it is surprising that manycountries, including many developed nations, have not yet adopted CBT as the first-lineintervention for mental disorders. A notable exception is the Improving Access toPsychological Therapies initiative by the National Health Commissioning in the UnitedKingdom (Rachman & Wilson, 2008). We believe that it is time that others follow suit.
Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
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The authors would like to acknowledge the following research assistants who provided crucial and much- NIH-PA Author Manuscript appreciated assistance with background literature reviews, initial identification of articles, and obtained articles foruse 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 study. Thisstudy was partially supported by NIMH grants MH-078308 and MH-081116 awarded to Dr. Hofmann andMH-73937.
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NIH-PA Author Manuscript Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
Hofmann et al.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Figure 1.
Flow diagram showing effects of inclusionary and exclusionary criteria on final sample
Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.

Hofmann et al.
NIH-PA Author Manuscript NIH-PA Author Manuscript Figure 2.
Number of meta-analyses published by year since 2000. Note that the number of studies
corresponding to 2011 only covered studies until September of that year.
NIH-PA Author Manuscript Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.
Hofmann et al.
NIH-PA Author Manuscript NIH-PA Author Manuscript Number of
NIH-PA Author Manuscript Ipser et al. (2009) Siev et al. (2008) Del Vecchio & O'Leary (2004) Leichsenring (2001) James et al. (2005) Malouff et al. (2008) Leichsenring & Leibing (2003) Hunot et al. (2007) Price et al. (2008) Thompson-Brenner (2003) Eddy et al. (2004) . The table shows response rate percentages for CBT (from highest to lowest) compared to each comparison condition for every meta-analaytic study reporting such data across disorder groups; -: no Pooled meta-analytic response rates for CBT versus other conditions across disorders.
Boderline Personality Childhood Anxiety Personality Disorders Generalized Anxiety Compulsive Disorder heterogeneous response rate pooling placebo/control, waitlist, and supportive treatment conditions; response rate of OT not reported in paper; stated as being equal to CBT (as indicated in comparison column) data reported; >: higher efficacy; <: lower efficacy; =: equal efficacy. MED = Medication/ pharmacological approaches; OT = Other therapies (consisting of relaxation therapy, supportive therapy, or psychodynamic therapy); PBO = placebo/control treatments; TAU= Treatment as usual; WL= Waitlist treatment; BDD: Body dysmorphic disorder; PD: Panic disorder without agoraphobia; GAD = Generalized anxiety disorder; OCD = Obsessive-compulsive disorder.
Cognit Ther Res. Author manuscript; available in PMC 2013 February 28.


Microsoft word - man1251_1262.doc

M.A. Al-Bayati/Medical Veritas 4 (2007) 1251–1262 Analysis of causes that led to the development of vitiligo in Jeanett's case with recommendations for clinical tests and treatments Mohammed Ali Al-Bayati, Ph.D., DABT, DABVT Toxicologist & Pathologist Toxi-Health International 150 Bloom Drive, Dixon, CA 95620 Phone: +1 707 678 4484 Fax: +1 707 678 8505

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