Cognitive restructuring, behavioral activation and cognitive-behavioral therapy in the treatment of adult depression: A network meta-analysis

Marketa Ciharova, Toshi A. Furukawa, Orestis Efthimiou, Eirini Karyotaki, Clara Miguel, Hisashi Noma, Andrea Cipriani, Heleen Riper, Pim Cuijpers

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32 Citations (Scopus)


OBJECTIVE: To examine if cognitive restructuring (CR), behavioral activation (BA), and cognitive-behavioral therapy (CBT) result in differential effects in the treatment of adult depression. METHOD: We extracted randomized controlled trials (RCTs) from a database updated yearly from PubMed, PsycINFO, Embase, and Cochrane Library. Network and pairwise meta-analyses were conducted to investigate the effects of CR, BA, and CBT delivered in a face-to-face individual format, compared with waiting list (WL) and care-as-usual (CAU), on adult depression. The primary outcome was a standardized mean difference (SMD) in posttreatment depression severity. Tolerability of treatments and depression severity at follow-up were also assessed. RESULTS: A total of 45 studies with 3,382 participants were included. There was no evidence of a difference in effectiveness between CR, BA, and CBT. All three interventions were superior to CAU; SMD 0.57, 95% confidence interval [CI 0.08-1.07]; 0.52 [0.34-0.71]; 0.44 [0.28-0.60], respectively and WL 1.20 [0.69-1.70]; 1.15 [0.90-1.40]; 1.07 [0.87-1.26]. No difference in tolerability was found (risk ratio [RR] vs. CAU: 1.01 [0.04-22.81], 0.84 [0.63-1.11], and 0.96 [0.76-1.21], respectively). Metaregression and sensitivity analyses did not produce material differences. CONCLUSIONS: Results suggest that CR or BA alone and their combination (CBT) may be effective interventions in comparison to WL and CAU in the treatment of adult depression. There was no evidence suggesting differences in effectiveness among the three treatments. More research is needed to derive conclusions about the performance of CR. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Original languageEnglish
Pages (from-to)563-574
Number of pages12
JournalJournal of consulting and clinical psychology
Issue number6
Publication statusPublished - 1 Jun 2021


  • behavioral activation
  • cognitive restructuring
  • cognitive-behavioral therapy
  • depression
  • network meta-analysis

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