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Home Health Mental Health

The strengths and limitations of CBT across mental health conditions

July 30, 2025
in Mental Health
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Cognitive Behavioural Therapy (CBT) has long been the poster child of evidence-based psychological treatments. It is a first-line treatment recommended by NICE guidelines for mental health disorders and acts as the cornerstone of the NHS’s Improving Access to Psychological Therapies (IAPT).

But with hundreds of individual studies scattered across different disorders with different methodologies, it can be difficult to get a clear picture of CBT’s true effectiveness. Previous meta-analyses and umbrella reviews have shown CBT’s efficacy for specific disorders, such as depression and anxiety (and some of these covered in the Mental Elf too, e.g. here and here), but they have often also used different methods, making it hard to compare results across conditions. For instance, previous reviews (e.g. Hofmann et al. (2012); Butler et al. (2006)) have either focused on single disorders or have tended to rely on previous meta-analyses, which may be outdated, and use different inclusion criteria, study periods, and analytic strategies.

Cuijpers and colleagues (2025) have delivered the most comprehensive enquiry into CBT treatment outcomes to date with their unified series of meta-analyses covering 11 major mental disorders and using standardised methods throughout, i.e. consistent methods for data extraction, bias assessment, and meta-analytic techniques. This unified approach offers major advantages because it enables direct comparison of CBT’s effectiveness and acceptability across disorders, provides a more up-to-date and complete overview than previous umbrella reviews, and allows examination of factors that may influence outcomes across conditions. With over 32,000 participants from 375 trials, this study offers the most up-to-date snapshot of CBT’s strengths as well as its limitations across the mental health spectrum.

CBT’s effectiveness across 11 mental disorders is evaluated in a major new meta-analysis using consistent, up-to-date research methodologies.

CBT’s effectiveness across 11 mental disorders is evaluated in a major new meta-analysis using consistent, up-to-date research methodologies.

Methods

Cuijpers et al. (2025) set out to answer the question: ‘How effective is cognitive behavioural therapy (CBT) for adults diagnosed with major mental disorders, when assessed across a wide range of conditions using consistent and rigorous meta-analytic methods?’. The paper synthesised data from 375 randomised controlled trials (RCTs) (423 comparisons), encompassing 32,968 adults (mean age 43.4 years; 68% women) with clinically diagnosed mental disorders.

The disorders included major depression, four anxiety disorders (panic disorder, social anxiety disorder, generalized anxiety disorder, specific phobia), post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), psychotic disorder, bipolar disorder, bulimia nervosa, and binge eating disorder. Only RCTs that used uniform criteria for data extraction, risk of bias assessment, and statistical analysis were included.

The authors followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines—a widely recognised set of standards designed to ensure transparency, completeness, and reproducibility in systematic reviews and meta-analyses. Searches were conducted on PubMed, PsycINFO, and Embase up to January 2024 for randomised controlled trials (RCTs) comparing CBT with cognitive restructuring as a core component to inactive controls in adults with a clinical diagnosis established via interview. Only adults with clinically diagnosed mental disorders (via structured or unstructured clinical interview) were included, excluding self-report diagnoses. CBT was strictly defined as interventions with cognitive restructuring as a core component, excluding exposure-only or mindfulness-based treatments.

For quality assessment purposes, two independent reviewers conducted screening, data extraction, and risk of bias assessment using the revised Cochrane RoB 2 tool across five domains. Random effects models were used given expected heterogeneity, with standardised mean differences (Hedges’ g) as the primary outcome. However, substantial heterogeneity was observed (I² often >75%), and publication bias was detected in several disorder groups. Sensitivity analyses, subgroup analyses and meta-regressions were conducted to explore sources of variation.

The authors also rated the strength of evidence using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation), which assesses the overall confidence in effect estimates for each important outcome across studies, not just individual studies.

Results

  • CBT showed significant benefits across all disorders compared to inactive controls, but effect sizes varied substantially
    • Effect sizes (Hedges’ g) were largest for PTSD and specific phobia,
    • moderate to large for depression, anxiety disorders (generalised anxiety disorder, social anxiety disorder and panic disorder), obsessive-compulsive disorder and eating disorders (bulimia nervosa and binge eating disorder),
    • and small for psychotic and bipolar disorders.
  • Control condition type drastically influenced results
    • When CBT was compared to waitlist controls, all effect sizes exceeded g = 0.94, suggesting very large benefits.
    • However, when compared to care-as-usual controls, arguably more representative of real-world practice, effects were more modest, ranging from g = 0.22 to 1.13.
  • The Number Needed to Treat (NNT) ranged from 2.5 patients for PTSD to 16 patients for psychotic disorders, meaning between 3-16 people would need to receive CBT for one additional person to benefit compared to control conditions.
  • Dropout rates within CBT arms ranged from 8% (specific phobia) to 24% (PTSD), with most disorders between 13% and 19%. Dropout rates in control groups were similar, except for higher rates in bipolar disorder (27%) and bulimia nervosa (24%). The relative risk (RR) of dropping out from CBT compared to controls was significantly higher in PTSD (RR 1.72, 95% CI 1.32 to 2.25) and binge eating disorder (RR 1.90, 95% CI 1.39 to 2.60), but not in other disorders.
  • Study quality concerns emerged from the risk of bias analyses, with only 10% of the 375 included studies achieve low risk of bias overall, with 56% rated as high risk. When high-risk studies were excluded, some findings became non-significant, particularly for OCD and bipolar disorder.
  • The strength of evidence (GRADE) was moderate for panic disorder, OCD, and bulimia nervosa; low or very low for most other disorders, including depression and bipolar disorder. Heterogeneity was high (I² > 75%) for most disorders except bipolar disorder and OCD.
  • Publication bias was detected in several disorder groups, and adjustment for bias reduced effect sizes but did not eliminate significance.
CBT showed the strongest effects for PTSD and specific phobia, but benefits were smaller and less certain for psychotic and bipolar disorders.

CBT showed the strongest effects for PTSD and specific phobia, but benefits were smaller and less certain for psychotic and bipolar disorders.

Conclusion

Cuijpers et al. (2025) unified meta-analysis provides the most comprehensive evidence to date that cognitive behavior therapy (CBT) is probably effective for treating a wide range of adult mental disorders including major depression, anxiety disorders, PTSD, OCD, and eating disorders, and is possibly effective for psychotic and bipolar disorders.

Effect sizes were large for PTSD and specific phobia, moderate for most anxiety, depressive, and eating disorders, and small for psychotic and bipolar disorders, but were notably larger in trials using waitlist controls compared to care as usual.

As the authors concluded:

CBT was probably effective in the treatment of mental disorders …  however, the effect sizes depended on the type of control condition.

These findings reinforce CBT’s central role in mental health care, while highlighting the importance of study quality and control group selection in interpreting results.

CBT is broadly effective across mental disorders, but effect sizes, dropout rates, and study quality vary widely, highlighting important limitations in the evidence base.

CBT is broadly effective across mental disorders, but effect sizes, dropout rates, and study quality vary widely, highlighting important limitations in the evidence base.

Strengths and limitations

Strengths

  • Scope and Consistency: This is the largest meta-analysis of CBT to date, synthesising results from 375 RCTs and nearly 33,000 adults across 11 major mental disorders using uniform methods for data extraction, risk of bias assessment, and analysis, which greatly enhances comparability across conditions and addresses a key limitation of prior umbrella reviews.
  • Comprehensive and Up-to-date Evidence: The study used systematic searches across multiple major databases up to January 2024, ensuring inclusion of recent and relevant trials, and applied living systematic review methodology for ongoing updates.
  • Rigorous Methodology: Dual independent review for study selection and risk of bias, random-effects meta-analyses, and extensive sensitivity, subgroup, and meta-regression analyses were performed, aligning with best practice in evidence synthesis.
  • Focus on Diagnosed Disorders: Only studies with clinical diagnoses were included, not just self-report, enhancing the study’s clinical relevance and generalisability to real-world practice.
  • Examination of Moderators and Dropout: The unified approach allowed for direct comparison of effect sizes, dropout rates, and effect modifiers across disorders, which presents an advantage over previous reviews.

Limitations

  • High Risk of Bias and Heterogeneity: Only 10% of included studies were rated low risk of bias, while 56% were high risk. High heterogeneity (I² often >75%) across most disorders undermines the precision and reliability of pooled estimates. Similar concerns have been raised in other recent CBT meta-analyses.
  • Inflated Effect Sizes Due to Control Conditions: The predominance of waitlist controls (especially in anxiety, eating disorders, PTSD, and OCD) likely overstates CBT’s effectiveness compared to care as usual or active controls, a limitation highlighted in previous research and meta-analyses. This study purposefully only focused on studies using inactive controls. The lack of active controls generally can be seen as a bit of a problem in therapy research.
  • Publication Bias: Evidence suggests that up to 20% of relevant studies may be missing, potentially leading to overestimation of CBT’s effects.
  • Limited Assessment of Long-term Outcomes: The review focused on post-treatment effects, omitting longer-term follow-up, relapse rates, or functional outcomes, which are crucial for understanding the durability and real-world impact of CBT.
  • Clinical and Methodological Diversity: The broad definition of CBT where the inclusion only required cognitive restructuring means interventions pooled may differ substantially; introducing clinical heterogeneity. Differences in delivery format, session number, and therapist expertise were not always accounted for, which could have confounded the results.
  • Selection and Observer Bias: There was variability in recruitment settings with only 34% being clinical samples. Variability was also present in outcome measurement, and reporting practices across studies, which may introduce selection and observer bias, as seen in other psychotherapy research.
The review offers unprecedented scope and rigour, but is limited by high bias and reliance on inactive controls.

The review offers unprecedented scope and rigour, but is limited by bias and reliance on inactive controls.

Implications for practice

This is a rather impressive piece of work, the implications of which span over clinical practice, policy, and future research.

Clinical implications

For clinicians, the evidence reinforces CBT as a first-line treatment for a broad range of adult mental disorders, including depression, anxiety disorders, PTSD, OCD, and eating disorders, for which effect sizes were moderate to large or very large. This should give practitioners confidence in recommending and delivering CBT for these diagnoses, especially in outpatient and community settings. For psychotic and bipolar disorders, the benefits of CBT appear more modest, suggesting that it should be considered as part of a broader, multimodal treatment plan rather than a standalone intervention. Clinicians should also be aware of dropout rates, which are higher in some populations (notably PTSD and binge eating disorder), and consider strategies to enhance engagement and retention.

Policy implications

In terms of policy implications, continued investment in high-quality CBT training, supervision, and service provision, particularly for common mental health conditions continues to be worthwhile. Additionally, the findings point to the value of supporting research and service development for under-studied conditions and populations, such as those with psychotic or bipolar disorders. In the study, the number of clinical trials varied greatly across disorders, with very few studies on anorexia nervosa and over 120 on depression. Perhaps we have reached a point where further trials comparing therapies to control groups add little value for certain conditions, like depression. Instead, future research efforts might be better directed toward exploring the less researched conditions, new questions and strategies that could more meaningfully improve treatment outcomes.

The study highlights that effect sizes are smaller when CBT is compared to care as usual rather than waitlist controls, serving as a reminder that research settings may not always reflect real-world effectiveness. There is a strong need in therapy research more broadly to use active controls and care as usual as comparators instead of waitlist controls to ensure that effect sizes are not artificially inflated. There is also a need for studies that examine the effectiveness of different CBT delivery formats, such as digital or group-based interventions, and for research that explores the reasons behind treatment dropout and how to mitigate it. Furthermore, recent work on CBT for transdiagnostic processes like repetitive negative thinking shows that personalising CBT to target specific mechanisms may further improve treatment outcomes, so moving towards research that improves our mechanistic understanding of CBT will also be valuable.

While CBT remains a cornerstone of treatment, it is not a panacea. Patients’ experiences, preferences, and the context in which therapy is delivered all matter. This meta-analysis provides reassurance about the broad utility of CBT, but also a timely reminder to consider areas for improvement and future directions for research.

The findings reinforce CBT’s role as a first-line treatment for common disorders while urging clinicians to tailor approaches for complex cases and address dropout challenges.

The findings reinforce CBT’s role as a first-line treatment for common disorders while urging clinicians to tailor approaches for complex cases and address dropout challenges.

Statement of interest

No conflicts to declare.

Links

Primary Paper

Cuijpers, P., Harrer, M., Miguel, C., Ciharova, M., Papola, D., Basic, D., … & Furukawa, T. A. (2025). Cognitive behavior therapy for mental disorders in adults: A unified series of meta-analyses. JAMA psychiatry.

Other References

Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev. 2006;26(1):17-31. doi:10.1016/j.cpr.2005.07.003

Hofmann SG, Asnaani A, Vonk IJJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36 (5):427-440. doi:10.1007/s10608-012-9476-1

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