Efficacy of cognitive bias modification interventions in anxiety and depressive disorders: a systematic review and network meta-analysis
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Background Cognitive bias modification (CBM) therapies, including attention bias modification, interpretation bias modification, or approach and avoidance training, are prototypical examples of mechanistically derived treatments, but their effectiveness is contentious. We aimed to assess the relative effectiveness of various CBM interventions for anxious and depressive symptomatology.Methods For this systematic review and network meta-analysis, we searched PubMed, PsycINFO, Embase, and Cochrane Central Register from database inception up until Feb 7, 2020. We included randomised controlled trials of CBM versus control conditions or other forms of CBM for adults aged 18 years and older with clinical or subclinical anxiety or depression measured with a diagnostic interview or a validated clinical scale. We excluded studies comparing CBM with a non-CBM active intervention. Two researchers independently selected studies and evaluated risk of bias with the Cochrane Collaboration tool. Primary outcomes encompassed anxiety and depressive symptoms measured with validated clinical scales. We computed standardised mean differences (SMDs) with a restricted maximum likelihood random effects model. This study is registered with PROSPERO, CRD42018086113.Findings From 2125 records we selected 85 trials, 65 (n=3897) on anxiety and 20 (n=1116) on depression. In a well connected network of anxiety trials, interpretation bias modification outperformed waitlist (SMD -0·55, 95% CI -0·91 to -0·19) and sham training (SMD -0·30, -0·50 to -0·10) for the primary outcome. Attention bias modification showed benefits only in post-hoc sensitivity analyses excluding post-traumatic stress disorder trials. Prediction intervals for all findings were large, including an SMD of 0. Networks of depression trials displayed evidence of inconsistency. Only four randomised controlled trials had low risk of bias on all six domains assessed.Interpretation CBM interventions showed consistent but small benefits; however heterogeneity and risk of bias undermine the reliability of these findings. Larger, definitive trials for interpretation bias modification for anxiety might be warranted, but insufficient evidence precludes conclusions for depression.Funding Romanian Ministry of Research and Innovation, The National Council for Scientific Research-The Executive Agency for Higher Education, Research, Development and Innovation Funding.
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A recent systematic review suggests antidepressant medicine-specifically fluoxetine-alone or in combination with CBT is the most efficacious treatment in moderate-to-severe depressive disorder, but the quality of the evidence is low.
“A recent systematic review 518 suggests antidepressant medicine-specifically fluoxetine- alone or in combination with CBT is the most efficacious treatment in moderate-to-severe depressive disorder. However, the quality of the evidence is low.”
From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [518]
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- Authors
- Fodor, L. A., Georgescu, R., Cuijpers, P., Szamoskozi, Ş., David, D., Furukawa, T. A., & Cristea, I. A.
- Affiliations
- Babeș-Bolyai University (RO)
- Amsterdam Public Health (NL)
- University of Pavia (IT)
- Corresponding author
- Cristea, Ioana A
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2020-06
- Volume
- 7
- Issue
- 6
- Pages
- 506-514
- ISSN
- 2215-0366 (ISSN-L)
- OpenAlex
- W3028515698
- Cited by
- 258
- References
- 40
- Citations by year
- 2026: 34 · 2025: 39 · 2024: 58 · 2023: 42 · 2022: 42 · 2021: 34 · 2020: 8
- FWCI
- 4.58
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- The Lancet Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- VU Research Portal (publishedVersion, other-oa)
- Padua Research Archive (University of Padova) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Funders
- Ontario Ministry of Research, Innovation and Science
- Unitatea Executiva pentru Finantarea Invatamantului Superior, a Cercetarii, Dezvoltarii si Inovarii (PN-III-P1-1.1-TE-2016-1054)
- Meso Scale Diagnostics
- Conseil National de la Recherche Scientifique
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- cognitive bias modification, attentional bias modification, interpretation bias modification, anxiety disorders, depressive disorders, depression, anxiety, treatment efficacy, risk of bias, heterogeneity
- MeSH terms
- Network Meta-Analysis, Adult, Anxiety Disorders, Depressive Disorder, Humans, Sensitivity and Specificity, Stress Disorders, Post-Traumatic, Reproducibility of Results, Cognitive Behavioral Therapy, Bias, Case-Control Studies, Randomized Controlled Trials as Topic, Outcome Assessment, Health Care
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