Cuijpers, P., Harrer, M., Miguel, C., Ciharova, M., & Karyotaki, E. (2025). Five decades of research on psychological treatments of depression: A historical and meta-analytic overview. American Psychologist, 80(3), 297–310. https://doi.org/10.1037/amp0001250
Key Takeaways
- Psychological treatments for depression are extensively studied, with over five decades of randomized trials.
- Cognitive Behavioral Therapy (CBT) is the most examined treatment modality, although other types show comparable effectiveness.
- The proportion of studies focusing on children and adolescents, and older adults has significantly decreased.
- Trials show a steady increase in quality over time, but many still fail to meet basic methodological standards.
- Psychotherapies demonstrate clear effectiveness for depression, with a modest overall effect size (g = 0.67).
- Higher-quality studies show smaller effect sizes, suggesting previous estimates might be inflated by methodological biases.
Rationale
Depression is a prevalent mental health disorder globally, necessitating effective treatment options.
Psychotherapies, such as CBT, interpersonal psychotherapy, and psychodynamic therapy, have long been employed to manage depressive symptoms.
However, previous research has been fragmented, with variability in treatment effectiveness and methodologies (Cuijpers et al., 2020; Furukawa et al., 2021).
This systematic review addresses these gaps by examining changes in trial characteristics over five decades and provides updated evidence of psychotherapy efficacy for depression.
Key gaps addressed include the historical neglect of certain demographic groups, such as children and adolescents, and inconsistencies in methodological quality across studies (Cuijpers et al., 2023).
Method
- The review adhered to PRISMA guidelines.
- Databases searched: PubMed, APA PsycInfo, Embase, and the Cochrane Library (1966 – September 1, 2022).
- Search terms: Included index terms and free text indicative of depression, psychotherapies, and randomized controlled trials.
- Inclusion criteria: Randomized controlled trials comparing psychological treatments to control conditions (waiting list, care-as-usual, pill placebo, or inactive controls). Excluded were inpatient studies and unguided interventions.
- Final inclusion: 562 randomized controlled trials (669 comparisons; 66,361 patients).
- Data extraction involved calculating effect sizes (Hedges’ g) and coding various participant, intervention, and study characteristics.
Statistical Measures
- Poisson regression analyses: examined historical trends.
- Meta-analyses: pooled effect sizes calculated using random-effects models, sensitivity analyses, and robustness checks.
- Statistical measures included Hedges’ g for effect sizes, I² for heterogeneity, and number-needed-to-treat (NNT).
Results
- Participants and Demographics: Most studies targeted adults (36%), with decreasing trends for children/adolescents and older adults.
- Diagnosis and Recruitment: Increased use of self-report depression measures over diagnostic interviews.
- Therapy Types: CBT dominates, accounting for 52% of studies; other therapies, including interpersonal and problem-solving therapies, showed declining proportions.
- Formats and Sessions: Increase in brief, guided self-help interventions; decline in longer-term treatments (>12 sessions).
- Study Quality: Improved methodological rigor over time but still significant room for improvement; studies with low bias showed smaller effect sizes.
- Overall Efficacy: Pooled effect size of psychotherapy versus controls was moderate (g = 0.67), lower in high-quality studies (g = 0.49).
Insight
The study underscores the solid evidence base for psychotherapy’s effectiveness in treating depression while highlighting methodological improvements and ongoing gaps.
These findings enhance the understanding of psychotherapy efficacy, particularly emphasizing the necessity for higher quality trials.
Compared to prior studies, this review uniquely highlights historical trends, indicating critical areas needing attention, such as youth and older adult populations and non-CBT interventions.
Future research should prioritize underrepresented populations, investigate long-term effects, and employ rigorous trial designs to enhance therapeutic outcomes further.
Clinical Implications
Findings suggest that psychotherapies remain a robust treatment for depression and should be integrated into standard practice guidelines and healthcare policies.
Practitioners should particularly consider evidence-based brief interventions like guided self-help for broad implementation.
Policymakers need to address the shortfall in youth and older adult research by funding targeted psychotherapy trials for these populations.
Additionally, training and resources should be allocated to expand practitioners’ skill sets beyond CBT, incorporating interpersonal and psychodynamic therapies proven to be equally effective.
Given the variability in outcomes, practitioners should carefully consider patient characteristics, preferences, and contexts when selecting treatment modalities.
Challenges include ensuring treatment fidelity in broader clinical practice, maintaining patient engagement with shorter interventions, and addressing methodological biases that may overstate treatment effectiveness.
Developing standardized protocols and promoting high-quality research will further enhance the effectiveness of psychotherapies in clinical settings.
Strengths
- Comprehensive, up-to-date systematic review covering extensive trials.
- Adherence to rigorous PRISMA guidelines.
- Detailed historical trend analysis enhancing understanding of psychotherapy evolution.
- Robust statistical analyses and sensitivity checks.
Limitations
- High heterogeneity in studies.
- Restricted analysis of outcomes (only depressive symptoms, short-term effects).
- Publication bias evident, inflating reported effect sizes.
- Potential selection bias due to inclusion/exclusion criteria.
Socratic Questions
- How might the decreasing proportion of research in youth and elderly populations affect mental health practices and policy development?
- Given the prominence of CBT, what implications arise for clinicians trained primarily in other psychotherapeutic methods?
- In what ways can future psychotherapy trials address current methodological limitations identified by this review?
- How might the findings differ if the meta-analysis included long-term outcomes beyond immediate depressive symptom relief?
- Considering methodological biases noted in the review, what alternative research designs might offer more accurate assessments of psychotherapy effectiveness?
References
Cuijpers, P., Harrer, M., Miguel, C., Ciharova, M., & Karyotaki, E. (2025). Five decades of research on psychological treatments of depression: A historical and meta-analytic overview. American Psychologist, 80(3), 297–310. https://doi.org/10.1037/amp0001250
Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Papola, D., Ebert, D., & Karyotaki, E. (2023). Psychological treatment of depression: A systematic overview of a ‘meta-analytic research domain’. Journal of Affective Disorders, 335, 141–151.
Cuijpers, P., Noma, H., Karyotaki, E., Vinkers, C. H., Cipriani, A., & Furukawa, T. A. (2020). A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 19(1), 92–107.
Furukawa, T. A., Shinohara, K., Sahker, E., Karyotaki, E., Miguel, C., Ciharova, M., Bockting, C. L. H., Breedvelt, J. J. F., Tajika, A., Imai, H., Ostinelli, E. G., Sakata, M., Toyomoto, R., Kishimoto, S., Ito, M., Furukawa, Y., Cipriani, A., Hollon, S. D., & Cuijpers, P. (2021). Initial treatment choices to achieve sustained response in major depression: A systematic review and network meta-analysis. World Psychiatry, 20(3), 387–396.
