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Publication bias exagerrates the value of CBT for depression

May be of interest.

Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias.

Cuijpers P, Smit F, Bohlmeijer E, Hollon SD, Andersson G.

Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, Amsterdam, The Netherlands. p.cuijpers@psy.vu.nl


It is not clear whether the effects of cognitive-behavioural therapy and other psychotherapies have been overestimated because of publication bias.

To examine indicators of publication bias in randomised controlled trials of psychotherapy for adult depression.

We examined effect sizes of 117 trials with 175 comparisons between psychotherapy and control conditions. As indicators of publication bias we examined funnel plots, calculated adjusted effect sizes after publication had been taken into account using Duval & Tweedie's procedure, and tested the symmetry of the funnel plots using the Begg & Mazumdar rank correlation test and Egger's test.

The mean effect size was 0.67, which was reduced after adjustment for publication bias to 0.42 (51 imputed studies). Both Begg & Mazumbar's test and Egger's test were highly significant (P<0.001).

The effects of psychotherapy for adult depression seem to be overestimated considerably because of publication bias.



Senior Member
Logan, Queensland, Australia
In another article:


Oh, the pun about quarking ducks. I thought it was particularly dumb that cognitive researchers at the time, as many of them still do, thought they could infer thinking processes from peoples' responses to leading force choice questions on self-report questionnaires. So I came up with a Monty Pythonesque experiment, which I supposedly conducted at an AABT meeting (I actually had in some version). I asked attendees at a symposium "what is the fundamental particle of matter?" and I got various answers from the psychologists like neutron, proton, and electron. When I patiently asked the ducks swimming in a pond outside, I eventually got the correct answer "quark, quark" and on that basis concluded that ducks has a superior knowledge of physics and that's why, unlike psychologist they could fly.

Don Quichotte

Don Quichotte
People who are depressed are looking for someone to help them see another point of view.

Depression in my opinion means feeling that you are stuck, that there is nothing you can do, that you have done everything possible. It is a frame of mind not an illness. It is a request for help.

But, it is not always easy to help someone who feels he has reached a brick wall realize that there is a way out.

It requires human sensitivity, innovative thinking and truly caring and wanting to help.

If you find the way to understand the person's frame of mind and why he/she thinks they have reached a brick wall, you can usually help them see a new point of view which helps them out.

I can give you an example from my own experience on both sides.

A few years ago, one of my patients was hospitalized for the fourth time in a relatively short period due to complications of his underlying illness. His wife called me very concerned and said that in the evening he threatened to jump out of the window and they called a psychiatrist who diagnosed major depression and prescribed an antidepressant, but he is refusing to take it.
I usually do not go to see hospitalized patients (due to my own limitations) but I came to see him. He told me he doesn't want to live anymore, life sucks, there is nothing to live for etc etc. So, I asked him what does he plan to do. He said that he is going to jump out of the window of the seventh floor.
"what a great idea" I said, "I agree with you life really sucks" ( it was not too hard for me to sincerely say that, as at that time I was struggling with my own illness with very little support from those who were supposed to be my treating physicians and had to face their disbelief and use a wheelchair and respirator with my companion every where I went so couldn't say I was constantly delighted with my life ). "Let's jump together".
He looked at me quite astonished. This was not the response he expected. He expected me to argue with him, explain how great life is etc. etc. not agree with him like that.
"Well" he said "My grandchildren will probably miss me if I do that". But, he then added " I can't stay in this darn hospital room even one more single day ".
"in that case" I suggested. "the door would be a much safer and effective way than the window to get out".
we then negotiated shortening his stay (taking some risks we both agreed on with an earlier discharge).
He never required nor took those antidepressants and lived for another few years in which he fought for every moment of his life.

One day, when I was in a pretty bad mood, I told my neurologist that I feel quite worthless as a physician who can't do any physical tasks and only intellectual work. I told him I can't start a line, sometimes I can't even examine my patients and all I can do is listen to them and think about them. I need my colleagues to assist me in everything else.
"well" he said, "think about it, would you prefer it the other way around? would you want to be able to do all those physical tasks but not be capable of thinking and doing any intellectual work? would you feel less worthless as a physician then? "
He helped me see that putting in a line in was not the essential part of my work, but the complex thought process involved in patient care which I was (fortunately) still capable of just like before.

I also realized that the fact that I can help my patients during their hard times, does not mean that I am "immune" to such hard times or don't need similar help.

People can label what I did for my patient and what my neurologist did for me as CBT.
But, CBT assumes that there is some obscure disorder which can be effected by changing someone's frame of mind regarding a situation. The idea behind this approach (if I understand it correctly) is that changing the way you think, will change the way you feel and the way you act and as a result will correct that obscure behavioral problem.

I think that "depression" is no more than a frame of mind or a thought process. It is not a disorder and it can happen to all of us at one time or another. Therefore helping someone change their frame of mind (if you find the way to do it) can help.

In the past people lived in communities of people like them, who shared their way of thinking and opinions, so could quite easily give them the support they required during hard times. People's behavior and body language showed those around them that they are going through a bad period and need their help.
In the modern world such cry for help is seen as abnormal instead of simply what it is. People are not expected to express despair in their words or in their body language. People are supposed to be constantly positive and endure all the hardships of life without bothering others.

CBT is a very convoluted way of a total stranger to try and get into the frame of mind of a person he/she knows very little about and replace this normal support of the community. What worked well for my patient, could have been a disaster for someone else. It fit his way of thinking and I knew it would.
My neurologist would have not said what he said to me to a patient who was an Olympic athlete before he/she became ill.

This approach can work if you truly get to know the person, understand his way of thinking and his needs, understand why he feels that he has reached a brick wall and find the way to help him see that there is still a way.
It can be a disaster if you try to force your way of thinking, and the way you understand his needs upon that person.

It's like the difference between patiently walking along the wall and looking together for an entrance which was missed to forcing someone to bang their head against the wall numerous times with the hope that it eventually breaks (before their head does!).

I believe that some of those who see themselves as "cognitive behavioral therapists" are wise and caring people and therefore can probably help. Whereas others are cold fish, who follow "guidelines" and force them on those they treat. That is why some people benefit from it, others may be harmed by it and others neither benefit or harmed.
I think there is nothing innovative or scientific about it.