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Journal of Affective Disorders 49 (1998) 5972

Research report

A meta-analysis of the effects of cognitive therapy in depressed


patients
Gloaguen 1 ,a , Jean Cottraux a , *, Michel Cucherat a , Ivy-Marie Blackburn b
Valerie
a

Anxiety Disorder Unit Hopital Neurologique, 59 boulevard Pinel, 69394 Lyon, France
Professor of Clinical Psychology, Durham University and Cognitive Therapy Center, Newcastle, UK
Received 17 April 1997; received in revised form 10 November 1997; accepted 11 November 1997

Abstract
Background. Cognitive therapy (CT) has been studied in 78 controlled clinical trials from 1977 to 1996. Method. The
meta-analysis used Hedges and Olkin d 1 and included 48 high-quality controlled trials. The 2765 patients presented
non-psychotic and non-bipolar major depression, or dysthymia of mild to moderate severity. Results. At post-test CT
appeared significantly better than waiting-list, antidepressants (P , 0.0001) and a group of miscellaneous therapies
(P , 0.01). But, CT was equal to behaviour therapy. As between-trial homogeneity was not met, the comparisons of CT with
waiting-list or placebo, and other therapies should be taken cautiously. In contrast, between-trial homogeneity was high for
the comparisons of CT with behaviour therapy and antidepressants. A review of eight follow-up studies comparing CT with
antidepressants suggested that CT may prevent relapses in the long-term, while relapse rate is high with antidepressants in
naturalistic studies. Conclusion. CT is effective in patients with mild or moderate depression. 1998 Elsevier Science B.V.
Keywords: Cognitive therapy; Behaviour therapy; Depression; Meta-analysis; Psychotherapy; Antidepressants

1. Introduction
Since the first controlled study of cognitive
therapy (CT) in depression (Rush et al., 1977),
several meta-analytic studies have been carried out.
Steinbruek et al. (1983) concluded, in a metaanalysis including 56 studies, that psychotherapies
*Corresponding author. Tel.: 133 72 118065; fax.: 133 72
357330; e-mail: cottraux@univ-lyon1.fr
1
Currently at Hopital du Vinatier U.M.A. 95 boulevard Pinel 69
Bron, France.

were superior to no-treatment and pharmacological


methods of treatment. Robinson et al. (1990) made a
meta-analysis of 58 studies of psychotherapy in
depression and found that depressed patients benefited substantially from psychotherapy and these
gains appeared comparable to those observed with
psychopharmacological treatments. Conte et al.
(1986) quantitatively reviewed 11 studies combining
pychotherapy with drug. The combined treatments
were more effective than placebo conditions, but
only slightly superior to psychotherapy alone, pharmacotherapy alone, or either of these combined with

0165-0327 / 98 / $19.00 1998 Elsevier Science B.V. All rights reserved.


PII S0165-0327( 97 )00199-7

60

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72

placebo. However, these authors evaluated psychotherapy in general without reference to technical
specifications and theoretical backgrounds.
Miller and Berman (1983), in a meta-analysis of
48 studies, found cognitive behaviour therapy superior to no-treatment; pure cognitive therapy and
the combination of cognitive with behavioural methods were equal; cognitive behaviour therapies were
at least as effective as drug treatments for depressed
patients. However, their conclusions were tentative:
only ten studies (21%) involved the treatment of
depressed patients.
A meta-analysis by Dobson (1989) reviewed 28
CT studies, and concluded that CT was superior to
waiting list control, drug treatment, behaviour
therapy and miscellaneous therapies. Gaffan et al.
(1995) found a correlation between researcher allegiance and outcome in the studies selected by
Dobson, but not in subsequent ones. One may notice
that both Dobson and Gaffan included studies which
were not randomised.
The present paper will attempt to answer five
pragmatic questions:
1. Is CT superior to control conditions? If it were
not true, placebo effects and demand characteristics may explain its outcomes.
2. Is CT superior to the reference treatment of
depression, antidepressants? If it were true, there
would be an alternative to pharmacological treatments of depression.
3. Is CT superior to behaviour therapy? If it were
true, this would suggest that direct cognitive
modification is the key factor in depression
improvement.
4. Is CT superior to other psychotherapies (behaviour therapy excluded)? If it were true, it would
mean that cognitive therapy is a specific psychological treatment for depression.
5. Are the outcomes of CT long lasting? Does CT
prevent relapses? A relapse is considered as the
return of a full depressive state (BDI . 16)
between 6 and 9 months after a 2 month remission. Beyond this point, a return of full blown
depression is termed recurrence (Shea et al.,
1992). The main problem with antidepressants
being the high rate of relapses and recurrences
after withdrawal, some authors have recom-

mended long term treatment with antidepressants


as prevention (Kupfer, 1992).

2. Method

2.1. Inclusion. Exclusion


To be included in the study, trials had to be
randomised and have at least one CT group, and one
comparison group: waiting list or placebo, antidepressants, behaviour therapy or another psychotherapeutic treatment. The inclusion criteria reported were
those of major depression or dysthymic disorder,
according to RDC (Feighner et al., 1972; Spitzer et
al., 1978), the American Psychiatric Association
DSM-3. (1980) DSM-III or the American Psychiatric
Association (1987) DSM-III-R, with the exclusion of
psychotic depression and bipolar affective disorder.

2.2. Literature search


The sources used for the literature search were
data bases: medline on the internet and embase
medica, references in papers or books, previous
reviews and meta-analyses, abstracts from congress
presentations, and pre-prints sent by authors.

2.3. General criterion of improvement


To evaluate the severity of the depression, we
used the Beck Depression Inventory (BDI: Beck et
al., 1988) which was the common measure of
effectiveness of all the trials. The BDI score ranges
063. Beck et al. (1988) defined the cut-offs of the
scale: , 10: no depression, 1018: mild depression,
1929: moderate depression, 30 and more: severe
depression

2.4. Statistical methods


Analyses included only the completers when intent
to treat data were missing.

2.5. Effect size


Our meta-analysis was based on Hedges and Olkin
(1985). When means and variances of the compared

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72

groups were not available, effect size was estimated


from Student t-test as suggested by Jenicek (1987).
1. 72 comparisons were made. For each trial,
Hedges (1981) g was calculated on the post-test
BDI values in the CT and comparison group, and
corresponding pooled within group standard deviation according to the formula:

61

interpret the outcomes of the meta-analysis the


between-trial heterogeneity Q statistic was computed. Q has a Chi-square distribution with k21 df.
The null hypothesis is rejected when P,0.05: in this
case the sample of trials is heterogeneous.

4. Multiple regression study

g5
(mean cognitive therapy) 2 (mean comparison group)
]]]]]]]]]]]]]
pooled SD
2. We applied the Hedges (1981) correction which
includes the number of subjects to correct for the
small sample bias. A d score was computed for
each study:

3
d 5 1 2 ]] g
4N 2 9
N was the sum of the number of patients in CT
and the comparison group.
3. Then the Hedges and Olkin (1985) d1, which
represents a combined estimate of the effect size
of a set of studies, was computed. Each trial was
weighted by the reciprocal of its estimated variance. The required level of significance was set at
P,0.01 to correct for multiple comparisons,
according to the meta-analysis cooperative group
recommendations (Boissel et al., 1989). When the
effect size was negative, this indicated that the
patients improved more in cognitive therapy.
When it was positive this indicated that the
patients improved more in the comparison group.
4. Z scores were computed for statistical comparisons. These calculations allowed for the expression of the meta-analysis in % of therapeutic
benefit: if the average patient of the comparison
group were treated with CT he or she would
move from the 50th to a higher percentile (CT.
Comparison group) or a lower percentile (CT,
Comparison group).

3. Homogeneity
Meta-analysis assumes that the effect-size of a
treatment is the sum of all the pooled trials. To

Dependencies of the effect size on several characteristics of the patients (BDI score, sex and age)
were studied with a linear multivariate model without interaction term taking trials as statistical units.

5. Results

5.1. Patients and studies


We found 78 trials published between January 1st
1977 and December 1st 1996. Some trials were
presented in international congresses, but not published in scientific journals (Hautzinger and De Jong
Meyer, 1995; Rotzer-Zimmer
et al., 1985; Zimmer et
al., 1987; Neimeyer et al., 1983). All the patients
were without psychotic features or bipolar disorder.
The patients were mainly outpatients. Thirty trials
were excluded for methodological reasons. Among
these, four had been included in Dobson (1989)
meta-analysis and Gaffans meta-analysis (see Table
1).
Eventually, the comparisons included 48 trials and
2765 patients. Sex ratio was available in only 43
trials: the mean percentage of women was 71.1
(range: 0100%). The mean age was available in 42
trials: m539.3. The rate of lost-to-follow-up patients
was known for 38 of the 48 trials (mean drop-out
rate: 17.2%) which was as high as usual in psychotherapy research. Studies were small size ones: mean
n568.45. The NIMH study (Elkin et al., 1989) had
the largest sample (n5239). Mean BDI at pre-test
ranged from 1031. In all the trials double-blindness
was not possible as in any research on psychotherapies. The type of random allocation was never
specified. Table 2 represents the included trials and
their characteristics.

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72

62
Table 1
Excluded trials
Study (year)

Reasons for exclusion

1.
2.
3.
4.
5.

Measure: MMPI depression scale


No randomisation: patient resistant to drugs were allocated to CT
No control group
No control group
No control group; CT with booster was compared with
CT without booster
Cross-over design; sample of anxious or depressive
patients
CT was compared with aerobic exercise
No-randomisation; multiple baseline design across patients
No-randomisation
No-randomisation
No-randomisation
Prescriptive therapy was compared with Explorative
therapy
Sample of deliberate self-harm in borderline patients
No control group; CT with homework assignments was
compared with CT without homework assignments
BDI was not used
No-randomisation
Sample of deliberate self-harm in borderline patients
No control group
No-randomisation
No control group
Cognitive dysfunction but not depression was studied
Sequential design; no randomisation
Sample bias: religious patients
No control group
Dexamethasone suppression test and response to CT and
antidepressant were studied
No control group; individual CT was compared with
group CT
No control group; CT by outpatients was compared with
CT by inpatients
Therapy was predominantly behavioural
No control group; augmentation study
Patients were not depressed; prevention study

Zeiss et al. (1979)


Fennel and Teasdale (1983)*
Keller (1983)*
Steuer and Hammen (1983)*
Baker and Wilson (1985)*

6. Shapiro and Firth (1987)


7. Fremont and Craighead (1987)**
8. Collet et al. (1987)
9. Schlosser et al. (1988)**
10. Persons et al. (1988)**
11. Kavanagh and Wilson (1989)**
12. Barkham et al. (1989)**
13. Linehan et al. (1991)
14. Neimeyer and Feixas (1990)**
15. Waring et al. (1990)
16. Usaf and Kavanagh (1990)**
17. Salkovskis et al. (1990)
18. Thase et al. (1991)**
19. Free et al. (1991)**
20. Haaga et al. (1991)**
21. Whisman (1991)
22. Mercier et al. (1992)
23. Propst et al. (1992)
24. Simons and Thase (1992)**
25. McKnight et al. (1992)**
26. Zettle et al. (1992)**
27. Thase et al. (1993)**
28. Stravynski et al. (1994)
29. Wilson et al. (1995)
30. Munoz et al. (1995)

*, Included in the Dobson (1989) meta-analysis.


**, Included in the Gaffan et al. (1995) meta-analysis.
CT: Cognitive Therapy; BT: Behaviour Therapy; BDI: Beck Depression Inventory; MMPI: Minnesota Multiphasic Personality Inventory.

5.2. Meta-analysis: outcomes


The number of comparisons, d1, 95% confidence
intervals of d1, % benefit, Z, P and Q values are
represented in Table 3. The four studies which
compared CT with relaxation (McLean and Hakstian,
1979; Reynolds and Coats, 1986; Bowers, 1990;
Murphy et al., 1995) were grouped with other
therapies.

Interpersonal therapy was identified as distinct


from both cognitive therapy, behaviour therapy or
cognitive-behaviour therapy as demonstrated in the
works of De Rubeis et al. (1982); Weissman and
Markowitz (1994).
We found a highly significant difference (P,
0.0001) in favour of CT versus waiting-list or
placebo. The average subject in CT is better of 29%
than the average subject in the waiting-list or

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72

63

Table 2
Included trials
Author

1. Beck et al., 1985

Year

Sample
(outpatients)

Treatments

Cell
size

Clinic

Cognitive
Cognitive and Antidepressants
(Amitriptyline)

18
15

Clinic

Cognitive
Behavioural marital
Waiting list

15
15
15

Geriatric

Alprazolam and support


Placebo and support
Cognitive and placebo
Cognitive and Alprazolam

12

Cognitive
Expressive therapy
Supportive therapy

21

Cognitive
Antidepressant
(amitriptyline or clomipramine)
Combination

22
20

Antidepressant
(Nortriptyline)
Antidepressant and cognitive
Antidepressant and relaxation

10

2/ Beach and OLeary, 1992

3/ Beutler et al., 1987

4/ Beutler et al., 1991

5/ Blackburn et al., 1981


Blackburn et al., 1986

6/ Bowers, 1990

7/ Comas-Diaz, 1981

Clinic

Hospital

Hospital

Weeks of
therapy

27.1

72.7

12.0

40.7

50.0

14.0

70.7

55.4

20.0

15
16
13
46.

69.7

20.0

22
20
43.7

64.0

12.9

36.2

80.0

4.2

38.0

100.0

5..3

8
10
43.8

60.0

15 sessions

70.0

4.0

85.0

70.3

16 sessions

51.85

16.0

10
10

Clinic
(Puerto
Rican)

Cognitive
Behavioural
Waiting list

Voluntary
Consultant

Cognitive (group)
Cognitive (group) and
Antidepressant (Imipramine)
Psychodynamic

27
23

20

9/ Dunn, 1979

Psychiatric

Cognitive
Antidepressant and
supportive therapy

10
10

10/ Elkin et al., 1989

Clinic

Cognitive
Interpersonal
Antidepressant
(Imipramine)
Placebo

37

Cognitive
Behavioural

14
13

Community

%
women

22

8/ Covi and Lipman, 1987

11/ Emanuels-Zuurveen and Emmelkamp, 1996

M
age

47
36
35
38.4

64

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72

Table 2. ( Continued)
Author

Year

Sample
(outpatients)

Treatments

Cell
size

Geriatric

Cognitive
Behavioural
Insight psychotherapy

10
10
10

13/ Gallagher-Thompson and Steffen, 1994

Geriatric
caregiver

Cognitive-behavioural
Psychodynamic

36
30

14/ Hautzinger and De Jong-Meyer, 1995

Non
endogenous
depression

Cognitive-Behavioural
Antidepressant
(Amitriptyline)
Cognitive-Behavioural and
antidepressant

68
66

Cognitive
Interpersonal
Waiting list

13

Antidepressant
(Imipramine)
Cognitive
Cognitive and antidepressant

57
25
25
7
8
8

12/ Gallagher and Thompson, 1982


Gallagher and Thompson, 1983

15/ Hogg and Deffenbacher, 1988

Student

16/ Hollon et al., 1992


Evans et al., 1992

Hospital
Consultant

Community

Cognitive
Behavioural
Cognitive and Behavioural

18/ Lapointe and Rimm, 1980

Female

Cognitive
Assertiveness training
Insight-oriented group

12
10
11

19/ Lewinsohn et al., 1990

Student

Cognitive
Cognitive and Parent group
Waiting list

21
19
21

20/ Macaskill and Macaskill, 1996

Community
and Antidepressant

Cognitive (RET)

10

Antidepressant
(Lofepramine)

10

Women

Cognitive
Supportive therapy
Waiting list

10
6
14

Hospital

Cognitive-behavioural
Psychotherapy
Relaxation
Antidepressant
(Amitryptiline)
Normal controls

44
51
48
53

22/ McLean and Hakstian, 1979

1993

%
women

Weeks of
therapy

67.8

76.7

12.0

62.0

92.0

39.0

62.8

8.0*

28.1

62.2

8.0

14
10
32.6

80.0

12.0

38.5

50.0

20 sessions

35.1

100.0

6.0

16.25

61.0

7.0

38.15

70.0

24.0

43.3

100.0

12.0

39.2

72.0

23.0

73.0

8.5

62

17/ Jacobson et al., 1991

21/ Maynard, 1993

M
age

55

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72

65

Table 2 ( Continued)
Author

Year

Sample
(outpatients)

Treatments

Cell
size

23/ McNamara and Horan, 1986

University

Cognitive
Behavioural
Cognitive-behavioural
High-demand controls

10
10
10
10

24/ Miller et al., 1989

Hospital

Standard treatment
Standard treatment1cognitive
Standard treatment1
social skills training

17
15
14

25/ Murphy et al., 1984


Simons et al., 1984

Clinic

Cognitive
Antidepressant
(Nortriptyline)
Cognitive and Antidepressant
Cognitive and placebo

19
16

M
age

%
women

Weeks of
therapy

36.8

73.9

15.0

33.9

74.0

12.0

39.4

70.3

16.0

78.4

10.0*

22.1

78.4

5.5

15.65

63.3

33.0

62.7

12.0

63.4

10.9

65.2

12.0*

70.5

79.3

75.2

18
17

26/ Murphy et al., 1995

Voluntary

Cognitive
Relaxation
Antidepressant
(Desipramine)

11
14
12

27/ Neimeyer et al., 1983


Neimeyer and Feixas, 1990

Voluntary

Cognitive with assignment


Cognitive without assignment
Interpersonal therapy
Waiting list

63
63
33
39

28/ Pace and Dixon, 1993

Student

Cognitive
Waiting list

31
43

29/ Reynolds and Coats, 1986

Adolescent

Cognitive-behavioural
Relaxation training
Waiting list

9
11
10

30/ Ross and Scott, 1985

Clinic
General
practitioner

Cognitive
Cognitive (group)
Waiting list

30
30
21

31/ Rush et al., 1977


Kovacs et al., 1981

Clinic

Cognitive
Antidepressant

19
22

32/ Rotzer-Zimmer
et al., 1985

Consultant

Cognitive-behavioural
Cognitive-behavioural and
Antidepressant
(Amitriptyline or Maprotyline)

14
14
15

33/ Scogin et al., 1987

Community

Cognitive
Alternative bibliotherapy
Waiting list

9
8
8
31.8

66

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72

Table 2. ( Continued)
Author

34/ Scott and Freeman, 1992

35/ Selmi et al., 1990

Year

Sample
(outpatients)

Treatments

Cell
size

Hospital
General
practitioner

Antidepressant
(Amitriptyline)
Cognitive
Support
Standard treatment

31

Consultant
Voluntary

Cognitive-behavioural
(computer)
Cognitive-behavioural
Waiting list

12

M
age

%
women

Weeks of
therapy

30
30
30
28.2

63.9

6 sessions

30.0

64.0

10 sesssions

40.5

52.1

12.0

20.1

68.75

16 sessions

66.0

76.0

37.5

22.4

71.4

5.5

37.5

94.1

9.6

67.1

67.4

16.5

37.8

8.0

6.0

39.5

80.0

8.0

33.1

00.0

9.0

12
12

36/ Shapiro et al., 1982

Clinic

Cognitive (group)
Interpersonal process
Cognitive (individual)

10
13
12

37/ Shapiro et al., 1994

Clinic
Stratification
on depression
severity

Cognitive-behavioural
Interpersonal psychodynamic

59
58

38/ Shaw, 1977

Student

Cognitive
Behavioural
Nondirective
Waiting list

39/ Steuer et al., 1984

Geriatric

Cognitive
Psychodynamic

40/ Taylor and Marshall, 1977

Student

Cognitive
Behavioural
Cognitive-behavioural
Waiting list

41/ Teasdale et al., 1984


Fennel and Teasdale, 1987

Community

Therapy as usual (TAU)


Cognitive and TAU

14
17

42/ Thompson et al., 1987

Geriatric

Behavioural
Cognitive
Psychodynamic
Delayed treatment

25
27
24
19

43/ Warren et al., 1988

Voluntary

Cognitive
Rational-emotive
Waiting list

10
11
12

44/ Wierzbicki and Bartlett, 1987

Community

Group cognitive
Individual cognitive
Waiting list

9
9
20

45/ Wilson et al., 1983

Clinic

Cognitive
Behavioural
Waiting list

8
8
8
8
26
27
7
7
7
7

8
8
9

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72

67

Table 2 ( Continued)
Author

Year

Sample
(outpatients)

Treatments

Cell
size

46/ Wilson, 1990

Prison
Male

Cognitive
Support

5
5

47/ Zettle and Rains, 1989

Voluntary

Cognitive (complete)
Cognitive (partial)
Behavioural

10
10
11

48/ Zimmer et al., 1987

Chronic
resistant
depression

Cognitive-behavioural
Cognitive-behavioural and
couple therap
Antidepressant

40
40

M
age

%
women

41.3

100.0

Weeks of
therapy

10.8

18.0 *

40

*, Unpublished studies.

Table 3
Meta-analysis of cognitive therapy in mild or moderate depression: results
Comparisons

d1

Confidence
interval
95%
d1

%
benefit

Q
(df)

Waiting-list
or placebo

20

20.82

29

28.72

,0.0001

Antidepressants

17

20.38

15

25.16

,0.0001

Behaviour therapy

13

20.05

20.07

0.95

Other therapies

22

20.24

(20.83;
20.81)
(20.39;
20.37)
(20.08;
20.02)
(20.25;
20.23)

10

22.93

,0.01

137.1*
(19)
19.6
(16)
2.5
(12)
73*
(21)

*, Between-trial heterogeneity (P,0.05).

placebo. The hypothesis of between trial homogeneity was rejected (Q5137.1, df 19). This may
suggest that in some trials non-specific factors were
operating both in CT and control conditions. The
trials of Neimeyer et al. (1983); Elkin et al. (1989);
Beach and OLeary (1992) had a d50. As the
NIMH study had the largest number of patients, and
its outcomes were related to therapeutic alliance in
CT, interpersonal therapy, imipramine, and placebo
(Krupnick et al., 1996), we suppressed it from the
meta-analysis to evaluate its impact on the homogeneity. A Q of 134.1, df 18, P,0.001 was obtained, which was far from reaching the homogeneity
criterion.
CT was superior to antidepressants (P,0.0001).
The hypothesis of between-trial homogeneity was
not rejected.

CT was equal to behaviour therapy. Effect-size


was negative. However, this was statistically nonsignificant (P50.95) for a P significance level set at
P,0.01. The hypothesis of between-trial homogeneity was not rejected.
CT was superior to a set of miscellaneous psychotherapies (P,0.01): psychodynamic therapies (n57
trials), interpersonal therapies (n54), non-directive
(n52), supportive (n54), relaxation (n54) and
alternative bibliotherapy (n51). However, the hypothesis of between trial homogeneity was rejected.
After adjustment for the type of treatment, multiple regression found no relation between the effect
size and BDI score, sex and age: CT vs waiting-list,
r50.31; CT vs Antidepressants, r50.29; CT vs
Behaviour Therapy, r50.42; CT vs other therapies,
r50.30.

68

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72

Table 4
Relapse rate (%) Cognitive Therapy (CT) versus Antidepressant (AD)
Study
(year)

Follow-up
years

CT
Sample size

CT
% relapse

AD
Sample size

AD
% relapse

1. Kovacs et al. (1981)


CT.AD (trend)
2. Beck et al. (1985)
CT5AD
3. Simons et al. (1986)
CT.AD
4. Blackburn et al. (1986)
CT.AD
5. Miller et al. (1989)
CT.AD
6. Bowers (1990)
CT.AD
7. Evans et al. (1992)
CT.AD
8. Shea et al. (1992)
NIMH
CT5AD

n519

35%

n525

56%

n518

45%

n515

18%

n524

12%

n524

66%

n515

21%

n510

78%

n514

46%

n517

82%

n510

20%

n510

80%

n510

21%

n510

50%

1.5

n522

36%

n518

50%

5.3. Prevention of recurrence: ct versus


antidepressants
Among the 48 trials only 8 allowed a comparison
of CT with antidepressants at a follow-up point of at
least 1 year. Considering the small number of studies
and the various lengths of these follow-ups, we made
a simple comparison of the percentage of relapse
after CT or antidepressants (see Table 4).
Inspection of Table 4 suggests a preventive effect
of CT on relapse rate in 5 / 8 studies. No difference
was found between CT and antidepressants in the
NIMH study (Elkin et al., 1989; Shea et al., 1992)
and the Beck et al. (1985) study. A non significant
trend towards superiority was found in the study by
Kovacs et al. (1981). On average, only 29.5% of the
patients treated with CT relapsed versus 60% of
those treated with antidepressants.

6. Discussion
We may now answer the five questions we posed
at the beginning of this paper.
Firstly, relative to control conditions (waiting-list
or placebo), CT was found to be superior. This
indicates that its effects are not due to placebo
and / or demand characteristics. But this outcome

should be taken with caution: between-trial homogeneity was not met.


Secondly, the superiority of CT over antidepressants, with high between-trial homeogeneity, indicates that CT, although less acessible, is a viable
alternative to pharmacological treatment. This finding confirms the Dobson (1989) meta-analysis of CT
and other meta-analyses on psychotherapy in general
which included CT trials (Robinson et al., 1990;
Conte et al., 1986; Steinbruek et al., 1983; Miller and
Berman, 1983).
Thirdly, CT was equal to behaviour therapy, with
high between trial homeogeneity. The contention that
cognitive modification could be the key factor in the
psychotherapeutic treatment of depression was not
supported by our meta-analysis. This is at variance
with Dobson (1989) who found a superiority of CT
over behaviour therapy, but he included only nine
studies and used Cohens d. These comparable
effects could be due to the fact that the two methods
share common characteristics that may over-ride
their differences. For instance, homeworks that increase activity are proposed both in cognitive and
behaviour therapy. Cognitive therapists advocate the
use of a wide range of behavioural techniques
including skills training and activity scheduling
(Beck et al., 1979). Behaviour therapists use a
technique coined: disputing your non-constructive

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72

self-talk (Lewinsohn et al., 1990) which is reminescent of the Beckian Socratic discussion of negative
automatic thoughts. A meta-analysis by Miller and
Berman (1983) found that CT was equal to the
combination of behavioural and cognitive techniques.
Fourthly, we found a superiority of CT over other
therapies suggesting that therapies without strong
behavioural and / or cognitive components may be
less active in depression. But, there was a betweentrial heterogeneity. Moreover, the category other
therapies was not homogeneous: this may raise the
question of the pertinence of lumping them together.
However, our outcome is in line with those of
Dobson (1989); Svartberg and Stiles (1991) who
concluded that cognitive behavioural therapies were
superior to psychodynamic therapies. In contrast, the
meta-analysis of Crits-Cristoph (1992) found CT and
psychodynamic therapy equivalent, but the sample
also included non depressed patients.
Fifthly, CT demonstrated relapse prevention effects that exceeded those of antidepressants in naturalistic follow-ups ranging from 12 years. But our
conclusion resulted from a simple comparison of the
percentage of relapses which was twice as high in
the patients treated with antidepressants alone, than
in the patients treated with CT alone or combined
with medication.
In addition, multivariate analysis failed to find any
covariate that modified the effect-sizes. This is at
variance with Dobson (1989), who found an effect of
age, with univariate regression. However, Dobson
acknowledged his study lacked adequate reprensentativeness of various age groups.

7. Conclusion
Although its therapeutic process may be shared
with behaviour therapy, cognitive therapy has been
demonstrated effective in patients with mild or
moderate depression and its effects exceed those of
antidepressants. This is consonant with the prevalent
opinion that drugs are the first line of treatment for
patients with high-severity or psychotic depression,
especially inpatients (Scott, 1995). Studies and metaanalyses dealing with prevention of recurrence with
CT versus antidepressant drugs are now overdue.

69

Acknowledgements
A first version of this paper was presented at the
World congress of Behavioural and Cognitive
Therapies, EABCT, Copenhagen, July 1016, 1995.

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