Efficacy of CBTs for Depression in China vs. World

CBTs like behavioral therapy, cognitive therapy, and cognitive behavioral therapy are evidence-based first-line treatments recommended for depression in guidelines across the U.S., Canada, and Europe (Qaseem et al., 2016).

Third-wave CBTs emphasize mindfulness, emotions, acceptance, client experiences, values, and metacognition (Hayes & Hofmann, 2021).

Studies show third-wave CBTs also effectively reduce Western depression (Sierra et al., 2018).

Li, X.-M., Huang, F.-F., Cuijpers, P., Liu, H., Karyotaki, E., Li, Z.-J., Miguel, C., Ciharova, M., & Dobson, K. (2024). The efficacy of cognitive behavioral therapies for depression in China in comparison with the rest of the world: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 92(2), 105–117. https://doi.org/10.1037/ccp0000854

Key Points

• The systematic review and meta-analysis examined the efficacy of cognitive behavioral therapies (CBTs) for adult depression in China compared to the rest of the world through a systematic review and meta-analysis.
• The effect size of CBTs on depression in China (g = 1.19) was significantly larger than the rest of the world (g = 0.82), even after controlling for study characteristics.
• Factors related to study design, clinical features, cultural values, and methodological factors may explain the higher efficacy of CBTs for depression treatment in China.

Rationale

CBTs are evidence-based psychotherapies developed largely based on Western cultural values and emphasize changing maladaptive thoughts and behaviors (Beck et al., 1979).

The cultural congruence hypothesis proposes that treatments matching the cultural context may have higher efficacy (Liao et al., 2005; Xu & Tracey, 2016).

CBTs may be less congruent as China has a more collective culture emphasizing emotional control (Kim, Yang et al., 2001). However, some scholars propose CBTs may fit Chinese values on structure and authority (Chen & Davenport, 2005; Williams et al., 2006).

No study has systematically compared CBT efficacy for depression between China and other countries. Comparing China to global research can inform dissemination and reveal cultural factors affecting efficacy.

Following other literature (Dobson & Dozois, 2021), this paper refers to behavioral therapy, cognitive therapy, CBT, and third-wave approaches collectively as cognitive behavioral therapies or CBTs.

Method

This systematic review and meta-analysis followed PRISMA guidelines (Moher et al., 2009). Chinese (CNKI, Wan Fang, ChongqingVIP) and English (PsycINFO, PubMed etc.) databases were searched for RCTs on CBTs for adult depression published before 2022, yielding 341 eligible studies (307 non-Chinese).

Study characteristics were extracted, and study quality was assessed using Cochrane Risk of Bias criteria.

Inclusion criteria

The inclusion criteria for the studies in the meta-analysis were:

1. Randomized controlled trial
2. Comparing different formats of cognitive behavioral therapies (except completed unguided trials)
3. For depressed adults and older adults (aged 18+)
4. Compared to an inactive control group (waiting list, care-as-usual, placebo, other inactive treatment)
5. Reported sufficient data (e.g. pre and post measures, changes in means, dichotomous data) to calculate effect sizes
6. Conducted in China (mainland China, Hong Kong, Macau, Taiwan) or other countries around the world

The following were excluded:

• Pharmacotherapy arms
• Maintenance studies for previously depressed patients
• Studies with patients only having bipolar disorder
• Theses and dissertations (not peer reviewed)
• Unpublished studies

Participants

34,043 depressed adult participants from 341 studies were included. 3,710 participants were from 34 Chinese studies and 30,333 were from 307 non-Chinese worldwide studies.

Analysis

Effect sizes (Hedges’ g) were calculated and compared between Chinese (n = 34) and non-Chinese (n = 307) studies.

Meta-regressions controlling for moderators (format, diagnosis etc.) compared cross-cultural efficacy. Publication bias was assessed through funnel plots and Egger’s tests.

Results

The effect size of CBTs for depression was significantly higher in China (g = 1.19) than the rest of the world (g = 0.82), even after controlling for moderators (β = .351, p = .011).

Publication bias was indicated in both Chinese and non-Chinese studies.

Insight

This first worldwide comparison found CBTs have significantly higher depression treatment efficacy in China than in other global regions.

The large effects imply CBTs, though developed in the West, effectively alleviate Chinese depression. The higher effects may be due to CBTs being relatively newer and less familiar in China.

Chinese cultural emphasis on logic and authority may also facilitate engagement. However, limitations like small samples and heterogeneity indicate cautious interpretation.

The researchers looked at whether smaller studies showing cognitive behavioral therapy (CBT) didn’t work were missing from their analysis. If many studies showing no effect are missing, it can make the therapy seem better than it really is.

Both visual graphs and a statistical test found asymmetry – smaller negative studies were likely unpublished. So, the true benefit of the therapy may be lower if these missing studies were included. This means we have to be careful not to overestimate how well it really works.

Further identifying cultural factors in CBTs can improve dissemination globally.

Strengths

• Included Chinese and English publications for comprehensive data coverage
• Assessed study quality systematically
• Controlled for moderators affecting efficacy
• First worldwide CBT efficacy comparison for any disorder in China

Limitations

• The small number of Chinese studies (n = 34) and high heterogeneity limit generalizability
• Self-report measures and non-blinded assessments may have biased efficacy ratings
• Grouping global English studies as one benchmark has limitations
• Cultural adaptation factors were unexamined. Interrater reliability for coding was not reported.

Implications

Despite limitations, significantly higher CBT depression efficacy in China has clinical implications.

Wider dissemination of CBTs in China could improve outcomes. Tailoring CBTs to Chinese cultural factors may also strengthen effects. Understanding why CBTs achieve better outcomes can refine approaches globally.

References

Primary reference

Li, X.-M., Huang, F.-F., Cuijpers, P., Liu, H., Karyotaki, E., Li, Z.-J., Miguel, C., Ciharova, M., & Dobson, K. (2024). The efficacy of cognitive behavioral therapies for depression in China in comparison with the rest of the world: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 92(2), 105–117. https://doi.org/10.1037/ccp0000854

Other references

Beck, A. T., Shaw, B. F., Rush, A. J., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press.

Chen, S. W. H., & Davenport, D. S. (2005). Cognitive-behavioral therapy with Chinese American clients: Cautions and modifications. Psychotherapy, 42(1), 101-110.

Hayes, S. C., & Hofmann, S. G. (2021). “Third-wave” cognitive and behavioral therapies and the emergence of a process-based approach to intervention in psychiatry. World Psychiatry, 20(3), 363–375. https://doi.org/10.1002/wps.20884

Kim, B. S., Yang, P. H., Atkinson, D. R., Wolfe, M. M., & Hong, S. (2001). Cultural value similarities and differences among Asian American ethnic groups. Cultural Diversity and Ethnic Minority Psychology, 7(4), 343–361. https://doi.org/10.1037/1099-9809.7.4.343

Liao, H. Y., Rounds, J., & Klein, A. G. (2005). A test of Cramer’s (1999) help-seeking model and acculturation effects with Asian and Asian American college students. Journal of Counseling Psychology, 52(3), 400–411. https://doi.org/10.1037/0022-0167.52.3.400

Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. https://doi.org/10.1371/journal.pmed1000097

Qaseem, A., Barry, M. J., Kansagara, D., & the Clinical Guidelines Committee of the American College of Physicians. (2016). Nonpharmacologic versus pharmacologic treatment of adult patients with major depressive disorder: A clinical practice guideline from the American college of physicians. Annals of Internal Medicine, 164(5),350–359. https://doi.org/10.7326/M15-2570

Sierra, M. A., Ruiz, F. J., & Flo´rez, C. L. (2018). A systematic review and meta-analysis of third-wave online interventions for depression. Revista Latinoamericana de Psicología, 50(2), 126–135. https://doi.org/10
.14349/rlp.2018.v50.n2.6

Williams, M. M., Foo, K. H., & Haarhoff, B. A. (2006). Cultural considerations in using cognitive behaviour therapy with Chinese people: A case study of an elderly Chinese woman with generalised anxiety disorder. New Zealand Journal of Psychology, 35(3), 153–162.

Xu, H., & Tracey, T. J. (2016). Cultural congruence with psychotherapy efficacy: A network meta-analytic examination in China. Journal of Counseling Psychology, 63(3), 359–365. https://doi.org/10.1037/cou0000145

Keep Learning

1. How might cultural factors explain why CBTs have better depression outcomes in China versus other countries? What are the implications for disseminating and refining CBT approaches cross-culturally?
2. What questions remain about why CBTs achieved higher effects in China? What future research directions could help clarify the mechanisms?
3. How could we design depression interventions that effectively blend evidence-based CBT principles with compatible cultural values and beliefs? What might such integrated approaches look like in China or other world regions?
4. If utilizing cultural traditions bolsters CBTs, does this support arguments for cultural relativism in judging therapeutic approaches? When might universal ethical principles still be relevant despite cultural differences?
5. How could we improve research quality and reporting standards for psychotherapy trials globally? What policy or education initiatives might assist?