Effectiveness of cognitive–behavioural therapies of varying complexity in reducing depression in adults: systematic review and network meta-analysis

Ioannis Angelakis, Charlotte Huggett, Patricia Gooding, Maria Panagioti, Alexander Hodkinson

Research output: Contribution to journalSystematic Reviewpeer-review

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BACKGROUND: Cognitive-behavioural therapy (CBT) is frequently used as an umbrella term to include a variety of psychological interventions. It remains unclear whether more complex CBT contributes to greater depression reduction. AIMS: To (a) compare the effectiveness of core, complex and ultra-complex CBT against other psychological intervention, medication, treatment-as-usual and no treatment in reducing depression at post-treatment and in the long term and (b) explore important factors that could moderate the effectiveness of these interventions.

METHOD: MEDLINE, PsycInfo, Embase, Web of Science and the Cochrane Register of Controlled Trials were searched to November 2021. Only randomised controlled trials were eligible for the subsequent network meta-analysis.

RESULTS: We included 107 studies based on 15 248 participants. Core (s.m.d. = -1.14, 95% credible interval (CrI) -1.72 to -0.55 [m.d. = -8.44]), complex (s.m.d. = -1.24, 95% CrI -1.85 to -0.64 [m.d. = -9.18]) and ultra-complex CBT (s.m.d. = -1.45, 95% CrI -1.88 to -1.02 [m.d. = -10.73]) were all significant in reducing depression up to 6 months from treatment onset. The significant benefits of the ultra-complex (s.m.d. = -1.09, 95% CrI -1.61 to -0.56 [m.d. = -8.07]) and complex CBT (s.m.d. = -0.73, 95% CrI -1.36 to -0.11 [m.d. = -5.40]) extended beyond 6 months. Ultra-complex CBT was most effective in individuals presenting comorbid mental health problems and when delivered by non-mental health specialists. Ultra-complex and complex CBT were more effective for people younger than 59 years.

CONCLUSIONS: For people without comorbid conditions healthcare and policy organisations should invest in core CBT. For people <59 years of age with comorbid conditions investments should focus on ultra-complex and complex CBT delivered without the help of mental health professionals.
Original languageEnglish
Article number35
Pages (from-to)459-467
Number of pages9
JournalBritish Journal of Psychiatry
Issue number2
Early online date29 Mar 2022
Publication statusE-pub ahead of print - 29 Mar 2022


  • cognitive-behavioural therapy
  • major depressive disorder
  • treatment complexity
  • systematic review
  • network meta-analysis
  • cognitive behavioral therapy
  • PsycINFO
  • meta analysis
  • Web of Science
  • review
  • female
  • human
  • major depression
  • Cognitive–behavioural therapy
  • investment
  • randomized controlled trial (topic)
  • mental disease
  • Medline
  • controlled study
  • Embase
  • organization
  • mental health care personnel
  • depression
  • adult
  • male


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