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Journal of Affective Disorders 49 (1998) 5972

Research report

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

1 ,a a , a b*Valerie Gloaguen , Jean Cottraux , Michel Cucherat , Ivy-Marie BlackburnaAnxiety Disorder Unit Hopital Neurologique, 59 boulevard Pinel, 69394 Lyon, France

bProfessor 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. Themeta-analysis used Hedges and Olkin d 1 and included 48 high-quality controlled trials. The 2765 patients presentednon-psychotic and non-bipolar major depression, or dysthymia of mild to moderate severity. Results. At post-test CTappeared 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 withwaiting-list or placebo, and other therapies should be taken cautiously. In contrast, between-trial homogeneity was high forthe comparisons of CT with behaviour therapy and antidepressants. A review of eight follow-up studies comparing CT withantidepressants suggested that CT may prevent relapses in the long-term, while relapse rate is high with antidepressants innaturalistic 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 were superior to no-treatment and pharmacologicalmethods of treatment. Robinson et al. (1990) made a

Since the first controlled study of cognitive meta-analysis of 58 studies of psychotherapy intherapy (CT) in depression (Rush et al., 1977), depression and found that depressed patients bene-several meta-analytic studies have been carried out. fited substantially from psychotherapy and these

Steinbruek et al. (1983) concluded, in a meta- gains appeared comparable to those observed withanalysis including 56 studies, that psychotherapies psychopharmacological treatments. Conte et al.

(1986) quantitatively reviewed 11 studies combiningpychotherapy with drug. The combined treatments

*Corresponding author. Tel.: 133 72 118065; fax.: 133 72were more effective than placebo conditions, but357330; e-mail: [email protected]

1 only slightly superior to psychotherapy alone, phar-Currently at Hopital du Vinatier U.M.A. 95 boulevard Pinel 69Bron, France. macotherapy 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 psycho- mended long term treatment with antidepressantstherapy in general without reference to technical as prevention (Kupfer, 1992).specifications and theoretical backgrounds.

Miller and Berman (1983), in a meta-analysis of48 studies, found cognitive behaviour therapy su- 2. Methodperior to no-treatment; pure cognitive therapy andthe combination of cognitive with behavioural meth- 2.1. Inclusion. Exclusionods were equal; cognitive behaviour therapies wereat least as effective as drug treatments for depressed To be included in the study, trials had to bepatients. However, their conclusions were tentative: randomised and have at least one CT group, and oneonly ten studies (21%) involved the treatment of comparison group: waiting list or placebo, antide-depressed patients. pressants, behaviour therapy or another psychothera-

A meta-analysis by Dobson (1989) reviewed 28 peutic treatment. The inclusion criteria reported wereCT studies, and concluded that CT was superior to those of major depression or dysthymic disorder,waiting list control, drug treatment, behaviour according to RDC (Feighner et al., 1972; Spitzer ettherapy and miscellaneous therapies. Gaffan et al. al., 1978), the American Psychiatric Association(1995) found a correlation between researcher al- DSM-3. (1980) DSM-III or the American Psychiatriclegiance and outcome in the studies selected by Association (1987) DSM-III-R, with the exclusion ofDobson, but not in subsequent ones. One may notice psychotic depression and bipolar affective disorder.that both Dobson and Gaffan included studies whichwere not randomised. 2.2. Literature search

The present paper will attempt to answer fivepragmatic questions: The sources used for the literature search were

data bases: medline on the internet and embase1. Is CT superior to control conditions? If it were medica, references in papers or books, previous

not true, placebo effects and demand characteris- reviews and meta-analyses, abstracts from congresstics may explain its outcomes. presentations, and pre-prints sent by authors.

2. Is CT superior to the reference treatment ofdepression, antidepressants? If it were true, there 2.3. General criterion of improvementwould be an alternative to pharmacological treat-ments of depression. To evaluate the severity of the depression, we

3. Is CT superior to behaviour therapy? If it were used the Beck Depression Inventory (BDI: Beck ettrue, this would suggest that direct cognitive al., 1988) which was the common measure ofmodification is the key factor in depression effectiveness of all the trials. The BDI score rangesimprovement. 063. Beck et al. (1988) defined the cut-offs of the

4. Is CT superior to other psychotherapies (behav- scale: , 10: no depression, 1018: mild depression,iour therapy excluded)? If it were true, it would 1929: moderate depression, 30 and more: severemean that cognitive therapy is a specific psycho- depressionlogical treatment for depression.

5. Are the outcomes of CT long lasting? Does CT 2.4. Statistical methodsprevent relapses? A relapse is considered as thereturn of a full depressive state (BDI . 16) Analyses included only the completers when intentbetween 6 and 9 months after a 2 month remis- to treat data were missing.sion. Beyond this point, a return of full blowndepression is termed recurrence (Shea et al., 2.5. Effect size1992). The main problem with antidepressantsbeing the high rate of relapses and recurrences Our meta-analysis was based on Hedges and Olkinafter withdrawal, some authors have recom- (1985). When means and variances of the compared

V. Gloaguen et al. / Journal of Affective Disorders 49 (1998) 59 72 61

groups were not available, effect size was estimated interpret the outcomes of the meta-analysis thefrom Student t-test as suggested by Jenicek (1987). between-trial heterogeneity Q statistic was com-

puted. Q has a Chi-square distribution with k21 df.The null hypothesis is rejected when P,0.05: in this1. 72 comparisons were made. For each trial,case the sample of trials is heterogeneous.Hedges (1981) g was calculated on the post-test

BDI values in the CT and comparison group, andcorresponding pooled within group standard de-viation according to the formula:

4. Multiple regression studyg 5

(mean cognitive therapy) 2 (mean comparison group) Dependencies of the effect size on several charac-]]]]]]]]]]]]]pooled SD teristics of the patients (BDI score, sex and age)

were studied with a linear multivariate model with-2. We applied the Hedges (1981) correction which out interaction term taking trials as statistical units.

includes the number of subjects to correct for thesmall sample bias. A d score was computed foreach study:

5. Results3]]S Dd 5 1 2 g4N 2 9

5.1. Patients and studiesN was the sum of the number of patients in CTand the comparison group. We found 78 trials published between January 1st

3. Then the Hedges and Olkin (1985) d1, which 1977 and December 1st 1996. Some trials wererepresents a combined estimate of the effect size presented in international congresses, but not pub-of a set of studies, was computed. Each trial was lished in scientific journals (Hautzinger and De Jong-weighted by the reciprocal of its estimated vari-

Meyer, 1995; Rotzer-Zimmer et al., 1985; Zimmer etance. The required level of significance was set at al., 1987; Neimeyer et al., 1983). All the patientsP,0.01 to correct for multiple comparisons, were without psychotic features or bipolar disorder.according to the meta-analysis cooperative group The patients were mainly outpatients. Thirty trialsrecommendations (Boissel et al., 1989). When the were excluded for methodological reasons. Amongeffect size was negative, this indicated that the these, four had been included in Dobson (1989)patients improved more in cognitive therapy. meta-analysis and Gaffans meta-analysis (see TableWhen it was positive this indicated that the 1).patients improved more in the comparison group. Eventually, the comparisons included 48 trials and

4. Z scores were computed for statistical compari- 2765 patients. Sex ratio was available in only 43sons. These calculations allowed for the expres- trials: the mean percentage of women was 71.1sion of the meta-analysis in % of therapeutic (range: 0100%). The mean age was available in 42benefit: if the average patient of the comparison trials: m539.3. The rate of lost-to-follow-up patientsgroup were treated with CT he or she would was known for 38 of the 48 trials (mean drop-outmove from the 50th to a higher percentile (CT. rate: 17.2%) which was as high as usual in psycho-Comparison group) or a lower percentile (CT, therapy research. Studies were small size ones: meanComparison group). n568.45. The NIMH study (Elkin et al., 1989) had

the largest sample (n5239). Mean BDI at pre-testranged from 1031. In all the trials double-blindness

3. Homogeneity was not possible as in any research on psychother-apies. The type of random allocation was never

Meta-analysis assumes that the effect-size of a specified. Table 2 represents the included trials andtreatment is the sum of all the pooled trials. To their characteristics.


Table 1Excluded trials

Study (year) Reasons for exclusion1. Zeiss et al. (1979) Measure: MMPI depression scale2. Fennel and Teasdale (1983)* No randomisation: patient resistant to drugs were allocated to CT3. Keller (1983)* No control group4. Steuer and Hammen (1983)* No control group5. Baker and Wilson (1985)* No control group; CT with booster was compared with

CT without booster6. Shapiro and Firth (1987) Cross-over design; sample of anxious or depressive

patients7. Fremont and Craighead (1987)** CT was compared with aerobic exercise8. Collet et al. (1987) No-randomisation; multiple baseline design across patients9. Schlosser et al. (1988)** No-randomisation10. Persons et al. (1988)** No-randomisation11. Kavanagh and Wilson (1989)** No-randomisation12. Barkham et al. (1989)** Prescriptive therapy was compared with Explorative

therapy13. Linehan et al. (1991) Sample of deliberate self-harm in borderline patients14. Neimeyer and Feixas (1990)** No control group; CT with homework assignments was

compared with CT without homework assignments15. Waring et al. (1990) BDI was not used16. Usaf and Kavanagh (1990)** No-randomisation17. Salkovskis et al. (1990) Sample of deliberate self-harm in borderline patients18. Thase et al. (1991)** No control group19. Free et al. (1991)** No-randomisation20. Haaga et al. (1991)** No control group21. Whisman (1991) Cognitive dysfunction but not depression was studied22. Mercier et al. (1992) Sequential design; no randomisation23. Propst et al. (1992) Sample bias: religious patients24. Simons and Thase (1992)** No control group25. McKnight et al. (1992)** Dexamethasone suppression test and response to CT and

antidepressant were studied26. Zettle et al. (1992)** No control group; individual CT was compared with

group CT27. Thase et al. (1993)** No control group; CT by outpatients was compared with

CT by inpatients28. Stravynski et al. (1994) Therapy was predominantly behavioural29. Wilson et al. (1995) No control group; augmentation study30. Munoz et al. (1995) Patients were not depressed; prevention study*, 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 Interpersonal therapy was identified as distinctfrom both cognitive therapy, behaviour therapy or

The number of comparisons, d1, 95% confidence cognitive-behaviour therapy as demonstrated in theintervals of d1, % benefit, Z, P and Q values are works of De Rubeis et al. (1982); Weissman andrepresented in Table 3. The four studies which Markowitz (1994).compared CT with relaxation (McLean and Hakstian, We found a highly significant difference (P,1979; Reynolds and Coats, 1986; Bowers, 1990; 0.0001) in favour of CT versus waiting-list orMurphy et al., 1995) were grouped with other placebo. The average subject in CT is better of 29%therapies. than the average subject in the waiting-list or


Table 2Included trials

Author Year Sample Treatments Cell M % Weeks of(outpatients) size age women therapy

27.1 72.7 12.01. Beck et al., 1985 Clinic Cognitive 18

Cognitive and Antidepressants 15(Amitriptyline)

2 / Beach and OLeary, 1992 40.7 50.0 14.0Clinic Cognitive 15

Behavioural marital 15Waiting list 15

70.7 55.4 20.03/ Beutler et al., 1987 Geriatric Alprazolam and support 12

Placebo and support 15Cognitive and placebo 16Cognitive and Alprazolam 13

46. 69.7 20.04/ Beutler et al., 1991 Clinic Cognitive 21

Expressive therapy 22Supportive therapy 20

5/ Blackburn et al., 1981 43.7 64.0 12.9Blackburn et al., 1986 Hospital Cognitive 22

Antidepressant 20(amitriptyline or clomipramine)Combination 22

36.2 80.0 4.26/ Bowers, 1990 Hospital Antidepressant 10

(Nortriptyline)Antidepressant and cognitive 10Antidepressant and relaxation 10

38.0 100.0 5..37 / Comas-Diaz, 1981 Clinic Cognitive 8

(Puerto Behavioural 8Rican) Waiting list 10

8/ Covi and Lipman, 1987 43.8 60.0 15 sessionsVoluntary Cognitive (group) 27Consultant Cognitive (group) and 23

Antidepressant (Imipramine)Psychodynamic 20

70.0 4.09/ Dunn, 1979 Psychiatric Cognitive 10

Antidepressant and 10supportive therapy

85.0 70.3 16 sessions10/ Elkin et al., 1989 Clinic Cognitive 37

Interpersonal 47Antidepressant 36(Imipramine)Placebo 35

38.4 51.85 16.011/ Emanuels-Zuurveen and Emmelkamp, 1996 Community Cognitive 14

Behavioural 13


Table 2. (Continued)Author Year Sample Treatments Cell M % Weeks of

(outpatients) size age women therapy

12/ Gallagher and Thompson, 1982 67.8 76.7 12.0Geriatric Cognitive 10

Gallagher and Thompson, 1983 Behavioural 10Insight psychotherapy 10

62.0 92.0 13/ Gallagher-Thompson and Steffen, 1994 Geriatric Cognitive-behavioural 36

caregiver Psychodynamic 3039.0 62.8 8.0*

14/ Hautzinger and De Jong-Meyer, 1995 Non Cognitive-Behavioural 68endogenous Antidepressant 66depression (Amitriptyline)

Cognitive-Behavioural and 62antidepressant

28.1 62.2 8.015/ Hogg and Deffenbacher, 1988 Student Cognitive 13

Interpersonal 14Waiting list 10

32.6 80.0 12.016/ Hollon et al., 1992 Hospital Antidepressant 57Evans et al., 1992 Consultant (Imipramine)

Cognitive 25Cognitive and antidepressant 25

38.5 50.0 20 sessions17/ Jacobson et al., 1991 Community Cognitive 7

Behavioural 8Cognitive and Behavioural 8

35.1 100.0 6.018/ Lapointe and Rimm, 1980 Female Cognitive 12

Assertiveness training 10Insight-oriented group 11

16.25 61.0 7.019/ Lewinsohn et al., 1990 Student Cognitive 21

Cognitive and Parent group 19Waiting list 21

38.15 70.0 24.020/ Macaskill and Macaskill, 1996 Community Cognitive (RET) 10

and AntidepressantAntidepressant 10(Lofepramine)

43.3 100.0 12.021/ Maynard, 1993 1993 Women Cognitive 10

Supportive therapy 6Waiting list 14

39.2 72.0 22/ McLean and Hakstian, 1979 Hospital Cognitive-behavioural 44

Psychotherapy 51Relaxation 48Antidepressant 53(Amitryptiline)Normal controls 55

23.0 73.0 8.5


Table 2 (Continued)Author Year Sample Treatments Cell M % Weeks of


23/ McNamara and Horan, 1986 University Cognitive 10Behavioural 10Cognitive-behavioural 10High-demand controls 10

36.8 73.9 15.024/ Miller et al., 1989 Hospital Standard treatment 17

Standard treatment1cognitive 15Standard treatment1 14social skills training

33.9 74.0 12.025/ Murphy et al., 1984 Clinic Cognitive 19Simons et al., 1984 Antidepressant 16

(Nortriptyline)Cognitive and Antidepressant 18Cognitive and placebo 17

39.4 70.3 16.026/ Murphy et al., 1995 Voluntary Cognitive 11

Relaxation 14Antidepressant 12(Desipramine)

78.4 10.0*27/ Neimeyer et al., 1983 Voluntary Cognitive with assignment 63Neimeyer and Feixas, 1990 Cognitive without assignment 63

Interpersonal therapy 33Waiting list 39

22.1 78.4 5.528/ Pace and Dixon, 1993 Student Cognitive 31

Waiting list 4315.65 63.3

29/ Reynolds and Coats, 1986 Adolescent Cognitive-behavioural 9Relaxation training 11Waiting list 10

33.0 62.7 12.030/ Ross and Scott, 1985 Clinic Cognitive 30

General Cognitive (group) 30practitioner Waiting list 21

63.4 10.931/ Rush et al., 1977 Clinic Cognitive 19Kovacs et al., 1981 Antidepressant 22

65.2 12.0*32/ Rotzer-Zimmer et al., 1985 Consultant Cognitive-behavioural 14

Cognitive-behavioural and 14Antidepressant 15(Amitriptyline or Maprotyline)

70.5 79.333/ Scogin et al., 1987 Community Cognitive 9

Alternative bibliotherapy 8Waiting list 8

31.8 75.2


Table 2. (Continued)Author Year Sample Treatments Cell M % Weeks of


34/ Scott and Freeman, 1992 Hospital Antidepressant 31General (Amitriptyline)practitioner Cognitive 30

Support 30Standard treatment 30

28.2 63.9 6 sessions35/ Selmi et al., 1990 Consultant Cognitive-behavioural 12

Voluntary (computer)Cognitive-behavioural 12Waiting list 12

30.0 64.0 10 sesssions36/ Shapiro et al., 1982 Clinic Cognitive (group) 10

Interpersonal process 13Cognitive (individual) 12

40.5 52.1 12.037/ Shapiro et al., 1994 Clinic Cognitive-behavioural 59

Stratification Interpersonal psychodynamic 58on depressionseverity

20.1 68.75 16 sessions38/ Shaw, 1977 Student Cognitive 8

Behavioural 8Nondirective 8Waiting list 8

66.0 76.0 37.539/ Steuer et al., 1984 Geriatric Cognitive 26

Psychodynamic 2722.4 71.4 5.5

40/ Taylor and Marshall, 1977 Student Cognitive 7Behavioural 7Cognitive-behavioural 7Waiting list 7

37.5 94.1 9.641/ Teasdale et al., 1984 Community Therapy as usual (TAU) 14Fennel and Teasdale, 1987 Cognitive and TAU 17

67.1 67.4 16.542/ Thompson et al., 1987 Geriatric Behavioural 25

Cognitive 27Psychodynamic 24Delayed treatment 19

37.8 8.043/ Warren et al., 1988 Voluntary Cognitive 10

Rational-emotive 11Waiting list 12

6.044/ Wierzbicki and Bartlett, 1987 Community Group cognitive 9

Individual cognitive 9Waiting list 20

39.5 80.0 8.045/ Wilson et al., 1983 Clinic Cognitive 8

Behavioural 8Waiting list 9

33.1 00.0 9.0


Table 2 (Continued)Author Year Sample Treatments Cell M % Weeks of


46/ Wilson, 1990 Prison Cognitive 5Male Support 5

41.3 100.0 10.847/ Zettle and Rains, 1989 Voluntary Cognitive (complete) 10

Cognitive (partial) 10Behavioural 11

18.0 *48/ Zimmer et al., 1987 Chronic Cognitive-behavioural 40

resistant Cognitive-behavioural and 40depression couple therap

Antidepressant 40

*, Unpublished studies.

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

Comparisons n d1 Confidence % Z P Qinterval benefit (df)95%d1

Waiting-listor placebo 20 20.82 (20.83; 29 28.72 ,0.0001 137.1*

20.81) (19)Antidepressants 17 20.38 (20.39; 15 25.16 ,0.0001 19.6

20.37) (16)Behaviour therapy 13 20.05 (20.08; 2 20.07 0.95 2.5

20.02) (12)Other therapies 22 20.24 (20.25; 10 22.93 ,0.01 73*

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

placebo. The hypothesis of between trial homogen- CT was equal to behaviour therapy. Effect-sizeeity was rejected (Q5137.1, df 19). This may was negative. However, this was statistically non-suggest that in some trials non-specific factors were significant (P50.95) for a P significance level set atoperating both in CT and control conditions. The P,0.01. The hypothesis of between-trial homogen-trials of Neimeyer et al. (1983); Elkin et al. (1989); eity was not rejected.Beach and OLeary (1992) had a d50. As the CT was superior to a set of miscellaneous psycho-NIMH study had the largest number of patients, and therapies (P,0.01): psychodynamic therapies (n57its outcomes were related to therapeutic alliance in trials), interpersonal therapies (n54), non-directiveCT, interpersonal therapy, imipramine, and placebo (n52), supportive (n54), relaxation (n54) and(Krupnick et al., 1996), we suppressed it from the alternative bibliotherapy (n51). However, the hy-meta-analysis to evaluate its impact on the homo- pothesis of between trial homogeneity was rejected.geneity. A Q of 134.1, df 18, P,0.001 was ob- After adjustment for the type of treatment, multi-tained, which was far from reaching the homogeneity ple regression found no relation between the effectcriterion. size and BDI score, sex and age: CT vs waiting-list,

CT was superior to antidepressants (P,0.0001). r50.31; CT vs Antidepressants, r50.29; CT vsThe hypothesis of between-trial homogeneity was Behaviour Therapy, r50.42; CT vs other therapies,not rejected. r50.30.


Table 4Relapse rate (%) Cognitive Therapy (CT) versus Antidepressant (AD)Study Follow-up CT CT AD AD(year) years Sample size % relapse Sample size % relapse1. Kovacs et al. (1981) 1 n519 35% n525 56%CT.AD (trend)2. Beck et al. (1985) 1 n518 45% n515 18%CT5AD3. Simons et al. (1986) 1 n524 12% n524 66%CT.AD4. Blackburn et al. (1986) 2 n515 21% n510 78%CT.AD5. Miller et al. (1989) 1 n514 46% n517 82%CT.AD6. Bowers (1990) 1 n510 20% n510 80%CT.AD7. Evans et al. (1992) 2 n510 21% n510 50%CT.AD8. Shea et al. (1992) 1.5 n522 36% n518 50%NIMHCT5AD

5.3. Prevention of recurrence: ct versus should be taken with caution: between-trial homo-antidepressants geneity was not met.

Secondly, the superiority of CT over antidepres-Among the 48 trials only 8 allowed a comparison sants, with high between-trial homeogeneity, indi-

of CT with antidepressants at a follow-up point of at cates that CT, although less acessible, is a viableleast 1 year. Considering the small number of studies alternative to pharmacological treatment. This find-and the various lengths of these follow-ups, we made ing confirms the Dobson (1989) meta-analysis of CTa simple comparison of the percentage of relapse and other meta-analyses on psychotherapy in generalafter CT or antidepressants (see Table 4). which included CT trials (Robinson et al., 1990;

Inspection of Table 4 suggests a preventive effect Conte et al., 1986; Steinbruek et al., 1983; Miller andof CT on relapse rate in 5 /8 studies. No difference Berman, 1983).was found between CT and antidepressants in the Thirdly, CT was equal to behaviour therapy, withNIMH study (Elkin et al., 1989; Shea et al., 1992) high between trial homeogeneity. The contention thatand the Beck et al. (1985) study. A non significant cognitive modification could be the key factor in thetrend towards superiority was found in the study by psychotherapeutic treatment of depression was notKovacs et al. (1981). On average, only 29.5% of the supported by our meta-analysis. This is at variancepatients treated with CT relapsed versus 60% of with Dobson (1989) who found a superiority of CTthose treated with antidepressants. over behaviour therapy, but he included only nine

studies and used Cohens d. These comparableeffects could be due to the fact that the two methods

6. Discussion share common characteristics that may over-ridetheir differences. For instance, homeworks that in-

We may now answer the five questions we posed crease activity are proposed both in cognitive andat the beginning of this paper. behaviour therapy. Cognitive therapists advocate the

Firstly, relative to control conditions (waiting-list use of a wide range of behavioural techniquesor placebo), CT was found to be superior. This including skills training and activity schedulingindicates that its effects are not due to placebo (Beck et al., 1979). Behaviour therapists use aand/or demand characteristics. But this outcome technique coined: disputing your non-constructive


self-talk (Lewinsohn et al., 1990) which is remines- Acknowledgementscent of the Beckian Socratic discussion of negativeautomatic thoughts. A meta-analysis by Miller and A first version of this paper was presented at theBerman (1983) found that CT was equal to the World congress of Behavioural and Cognitivecombination of behavioural and cognitive tech- Therapies, EABCT, Copenhagen, July 1016, 1995.niques.

Fourthly, we found a superiority of CT over othertherapies suggesting that therapies without strong

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