Well-conducted RCTs employ an elegant research design that allows the researcher to make reasonable conclusions about the treatment(s) under investigation. Nonetheless, this form of research has some limitations. For example, the generalizability of RCT results to routine clinical practice is sometimes limited by the level of control exerted over the experimental situation (Leichsenring et al. 2006). The therapists involved in RCTs typically have substantial skill in delivering the treatment(s), and patients may or may not be representative of the general
population of people with the disorder under study because of exclusion criteria. Another concern about efficacy research is researcher allegiance, or the tendency of the authors of a comparative
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treatment study to prefer one treatment over another, introducing bias in favor of the preferred treatment (Butler et al. 2006). Difficulties in conducting long-term outcome assessments include ethical restrictions on maintaining participants in control conditions for extended periods of time.
In this chapter we relied predominantly on meta-analyses to reach broad conclusions about the efficacy of CBT across psychiatric disorders. Meta-analysis has itself been critiqued as a method, for the following reasons:
The outcome measures employed across different studies often differ. The choice of outcome measures (e.g., self-reporting vs. clinician ratings) can bias the relative strength of a treatment effect. Thus, the total effect size for a particular treatment calculated by meta-analysis will be biased by the inclusion of various dependent measures (Clum et al. 1993), as cited in Gould et al. 1997a, 1997b).
The number of treatment sessions and length per session can vary across studies, systematically bolstering or weakening effect sizes depending on the studies included in the analysis.
Meta-analysis tends to collapse treatment effects across divergent patient samples, potentially reducing the attention to interactions between various treatments and patient characteristics.
The computational formulae and procedures for meta-analysis have evolved over time, and such issues as the use of unweighted or weighted effect size estimates, and within-study or community comparisons for the computation of effect size, can affect the conclusions of different meta-analyses within a given treatment area.
In addition to the limitations to efficacy research in general, and to meta-analysis as a statistical tool, the extant research on the efficacy of CBT also has specific limitations. In particular, there is still very little literature on the comparison of other psychotherapies with CBT, especially for the anxiety disorders. The lack of long-term evidence for the majority of psychiatric disorders constitutes another knowledge gap in the literature on the efficacy of CBT. Many studies do not assess long-term outcomes at all, some provide only relatively short-term outcomes, and others do not explicitly report the time points at which follow-ups were conducted. Most studies that
incorporate waiting-list controls provide treatment to control participants after a certain period of time, thereby rendering the comparative assessment of long-term outcomes between treatment groups and controls impossible. Some studies have resolved this issue by conducting within-group analyses, thus providing the long-term outcome for the treatment group without comparison to a control group (e.g., Gould et al. 1995, 1997a, 1997b). However, findings calculated by this method are not as informative as the alternative. Further research comparing the long-term efficacy of different active treatments is indicated.
Parker et al. (2003) raised some concerns about the Dobson (1989) and Gloaguen et al. (1998) meta-analyses, asserting that amalgamating placebo controls and wait-listed participants into a composite control condition provides confounding results. Control subjects receiving placebo may have a hopeful reaction to "treatment" because they are under the assumption that they are being treated, whereas waiting-list control subjects may be discouraged because they are not yet
undergoing any treatment. Parker et al. recommended that future research compare active
treatments to each of these control conditions separately. In the same vein, Gould and colleagues (1995, 1997a, 1997b, 2001) have argued that CBT is favored in comparisons with
pharmacotherapy, because CBT is frequently compared with a waiting-list control condition, whereas drug trials typically involve placebo pill controls. In this regard, nondirective therapy has been recommended as a psychological placebo, because it has greater credibility than waiting-list or no-treatment control conditions. In addition, placebo pills and nondirective therapy are similar to each other in terms of resulting positive treatment effects.
The issue of treatment labeling stands out as a significant concern in the literature. Behavioral therapies are sometimes classified as behavioral and sometimes as cognitive-behavioral, even when they use highly similar treatment elements, and comparisons between studies are therefore confounded. Moreover, the comparison between cognitive therapy and other kinds of
psychotherapy may be blurred in some trials. As one notable example, analysis of the videotaped therapy sessions of the National Institute of Mental Health collaborative project comparing
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interpersonal therapy, cognitive therapy, placebo, and pharmacotherapy demonstrated that therapists in the interpersonal therapy group adhered more to the cognitive therapy protocol than to the interpersonal therapy protocol (Ablon and Jones 2002). This example underscores the importance of adherence to treatment manuals in research trials, and assessment of therapist fidelity to treatment conditions, to ensure a fair test of the treatments under investigation (McGlinchey and Dobson 2003).
Several other knowledge gaps exist. For example, although the depression literature has examined the efficacy of CBT in geriatric populations, and the PTSD literature has looked at minority
populations, there is generally insufficient empirical research with diverse populations. More research is needed to assess the efficacy of CBT in preventing relapses across disorders.
Comorbidities are frequent among psychiatric disorders but may be either controlled for in RCTs through exclusionary criteria or simply not addressed. The exclusionary approach to comorbid diagnoses makes RCT results less generalizable, increasing the discrepancy between efficacy and effectiveness research findings. Finally, aside from research on ERP, research on the efficacy of specific forms of CBT for specific disorders is still largely lacking. Such efficacy research could provide better insight into the mechanisms of change that are most beneficial for each disorder.
In summary, a considerable and growing body of evidence generally supports the continued use of CBT as a treatment for a wide variety of disorders. Additional research is needed comparing the efficacy of CBT with and without the use of pharmacotherapy. Also, the relative efficacy of CBT versus other bona fide psychological treatments has not been extensively examined. The long-term benefits of CBT have been studied considerably less than its short-term and acute treatment
effects. Finally, firm conclusions about the generalizability of CBT to a broad range of patient groups with a large set of patient characteristics must await further study. The design of randomized trials, in which treatment interactions can be studied by patient type or
characteristics, will help to advance the field in the direction of treatment guidelines, a necessary step in maximizing the successful treatment of the broad range of mental health disorders.
KEY POINTS
Cognitive-behavioral therapy (CBT) is prefaced on the theory that cognition mediates the individual's behavioral and emotional responses to his or her environment and thus influences individuals'
adjustment or maladjustment to their environment.
CBT has been extensively studied and found to be efficacious for a wide range of psychiatric disorders and problems—mood, anxiety, psychotic, eating, personality, somatoform, and sleep disorders; alcohol abuse, fibromyalgia, chronic fatigue syndrome, hypochondria, sexual dysfunctions, couples' problems, anger, stress, and suicide—and as an adjunctive treatment for problems related to some medical conditions (e.g., incontinence, arthritis, chronic pain, procedural distress, diabetes, sickle cell disease, dementia, obesity, chronic prostatitis, cancer, pediatric brain injury).
CBT has been demonstrated to be highly efficacious for mild, moderate, and severe depression.
Although pharmacotherapy and CBT are equally efficacious as acute treatment, CBT maintains treatment effects at follow-up; the effects of pharmacotherapy attenuate following medication discontinuation.
Preliminary evidence for bipolar disorder indicates that as an adjunctive treatment with
pharmacotherapy, CBT can reduce relapse rates in the short term and improve symptoms acutely and in the longer term.
CBT is an efficacious treatment for anxiety disorders; more research is needed comparing its efficacy with that of pharmacotherapy.
As an adjunct to pharmacotherapy for the treatment of schizophrenia, CBT has been found to be superior to other psychotherapies and has shown lasting effects.
CBT promotes remission in bulimia nervosa and has demonstrated superiority over medication, though a combination of CBT and medication may be more effective than CBT alone.
Literature on the efficacy of CBT to treat personality disorders is scarce. However, the available evidence indicates that some forms of CBT can reduce symptoms and increase quality of life for individuals with borderline personality disorder.
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For some disorders, CBT has lower drop-out rates than pharmacotherapy, and for others it is perceived as less aversive or intrusive than some behavioral interventions. Thus, CBT has been found to be both a highly efficacious and an acceptable treatment choice.
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SUGGESTED READINGS
Butler AC, Chapman JE, Forman EM, et al: The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev 26:17–31, 2006
Chambless DL, Ollendick TH: Empirically supported psychological interventions: controversies and evidence.
Annu Rev Psychol 52:685–716, 2001
Deacon BJ, Abramowitz JS: Cognitive and behavioral treatments for anxiety disorders: a review of meta-analytic findings. J Clin Psychol 60:429–441, 2004
Roth A, Fonagy P (eds): What Works for Whom? A Critical Review of Psychotherapy Research, 2nd Edition. New York, Guilford, 2005
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