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Cited by 108Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychotherapy Techniques and ApplicationsTreatment of Major Depression

Predictors of depression relapse and recurrence after cognitive behavioural therapy: a systematic review and meta-analysis

Wojnarowski, Caroline, Firth, Nick, Finegan, Megan, Delgadillo, Jaime·2019·Behavioural and Cognitive Psychotherapy
DOI 10.1017/s1352465819000080
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Abstract

Background: Cognitive behavioural therapy (CBT) is an effective psychological treatment for major depressive disorder, although some patients experience a return of symptoms after finishing therapy. The ability to predict which individuals are more vulnerable to deterioration would allow for targeted interventions to prevent short-term relapse and longer-term recurrence. Aim: This systematic review and meta-analysis aimed to identify factors associated with an increased risk of relapse and/or recurrence (RR) after CBT for depression. Method: We reviewed 13 relevant papers, of which a small set of unique samples were eligible for meta-analysis (k= 5,N= 369). Twenty-six predictor variables were identified and grouped into seven categories: residual depressive symptoms; prior episodes of depression; cognitive reactivity; stressful life events; personality factors; clinical and diagnostic factors; demographics. Results: Meta-analyses indicated that residual depressive symptoms (r= 0.34 [0.10, 0.54],p= .01) and prior episodes (r= 0.19 [0.07, 0.30],p= .002) were statistically significant predictors of RR, but cognitive reactivity was not (r= 0.18 [−0.02, 0.36],p= .08). Other variables lacked replicated findings. On average, 33.4% of patients experienced RR after CBT. Conclusions: Patients with the above risk factors could be offered evidence-based continuation-phase interventions to enhance the longer-term effectiveness of CBT.

Verified 2026-10-10 · 2 references not checked yet

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and meta-analysis found that residual depressive symptoms and prior episodes of depression significantly predicted relapse and/or recurrence (RR) after acute-phase CBT, whereas cognitive reactivity did not. On average, 33.4% of patients experienced RR after CBT.

Key findings

  • In random-effects meta-analyses, residual depressive symptoms were a moderate predictor of RR (r = 0.34 [0.10, 0.54], p = .01) and prior episodes were a small predictor (r = 0.19 [0.07, 0.30], p = .002); cognitive reactivity was not statistically significant (r = 0.18 [−0.02, 0.36], p = .08).
  • Reported RR rates ranged from 18.5% to 46.5% after acute-phase CBT, with an average of 33.4% events within a maximum follow-up of 36 months; CBT-alone studies had a mean RR rate of 29.1%, and studies grouping treatments had a mean of 28.6%.
  • Other predictors were mostly single-study findings: childhood maltreatment (OR = 2.89), dependent chronic stressors (OR = 1.34), severe independent life event post-treatment (OR = 1.03), intake anxiety (OR = 1.08), subclinical psychotic experiences (OR = 3.85), and subthreshold bipolar symptoms (OR = 1.16).
  • Heterogeneity was high for residual depressive symptoms (I² = 85.3%) but not for prior episodes (I² = 0.0%); fail-safe N values were 72 for residual symptoms, 9 for prior episodes, and 7 for cognitive reactivity.

Methods

  • Systematic review and random-effects meta-analysis; protocol registered in PROSPERO. Searches of Web of Science, PubMed, PsycINFO, and Scopus (January 1990–March 2017) returned 275 unique titles/abstracts; 59 full texts were assessed, and 13 articles were included (9 RCTs, 4 longitudinal cohort studies; total pooled sample N = 1219).
  • Eligible studies included adults with unipolar major depressive disorder who completed acute-phase CBT without continuation-phase interventions, were published in peer-reviewed English-language journals, had follow-up of at least 6 months, and investigated predictors of RR.
  • Meta-analysis was restricted to predictors examined in two or more studies with sufficient statistics; inferential statistics were converted to correlation coefficients (r), with heterogeneity assessed using Q and I², publication bias examined via funnel plot asymmetry tests, and fail-safe N calculated. The meta-analysis included k = 5, N = 369.

Limitations

  • The paper states that at least half of the reviewed studies used arbitrary or unconventional operational definitions of relapse, making it impossible to clearly disentangle predictors of relapse versus recurrence.
  • The paper states that most primary studies were underpowered: the largest number of RR events was 40 and the mean was 19, whereas detecting a medium effect would require 212 participants (64 RR cases) and a small effect 1310 participants (393 RR cases); over half of studies only reported significant results, suggesting possible selective reporting.
  • The paper states that exclusions of grey literature, non-English publications, children and young people, and continuation-phase studies limit the review, and the small number of included studies precluded subgroup and moderator analyses; evident from the text, the meta-analyses rested on only five studies and high heterogeneity was present for residual depressive symptoms.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1017/s1352465819000080

Cites

69 of 71 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 40 cited sources checked · 0 supported · 0 flagged

  • Findingown data
    § Study characteristics · p. 6

    No single or consistent cut-off was used across studies to demarcate relapse and recurrence events.

    “An important discrepancy is that no single or consistent cut-off was used across studies to demarcate relapse and recurrence events.”
    Quote in the paperSubstantial claim
  • Findingown data
    § Study characteristics · p. 6

    There was no significant association between relapse/recurrence rates and follow-up duration (r = 0.46, p = 0.16).

    “However, after conducting a Pearson ' s correlation between RR rates and follow-up duration, we found no significant association ( r = 0.46, p = 0.16).”
    Quote in the paperNot a substantial claim
  • Findingown data
    § Study characteristics · p. 6

    The cut-off period to define relapse events varied from 4 up to 24 months across different studies.

    “As shown in Table 1, the cut-off period (from the time of remission of symptoms) to define ' relapse ' events varied from 4 up to 24 months across different studies, thus blurring the boundaries between these clinical phenomena.”
    Quote in the paperSubstantial claim
  • Findingown data
    § Cognitive reactivity · p. 9

    Cognitive reactivity is not a statistically significant predictor of relapse/recurrence after CBT (r = 0.18, 95% CI −0.02-0.36, p = .08).

    “The pooled effect was not statistically significant; r = 0.18 ( -0.02, 0.36), p = .08.”
    Quote in the paperNot a substantial claim
  • Findingown data
    § Residual depressive symptoms · p. 9

    Residual depressive symptoms are a statistically significant predictor of relapse/recurrence after CBT, with a moderate pooled correlation (r = 0.34, 95% CI 0.10-0.54, p = .01).

    “The pooled effect was statistically significant, denoting a moderate correlation between residual depressive symptoms and RR; r = 0.34 (95% CI 0.10, 0.54), p = .01.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 20
  • The quote only partly states this claim. 4
  • May combine two claims. 18

  • Classified as probably not a substantial claim.

    Findingown data
    § Selection of articles · p. 4

    Thirteen articles were identified as eligible for inclusion in the review.

    “Thirteen articles were identified as eligible for inclusion in the review.”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data
    § Discussion · p. 12

    Residual depressive symptoms have a statistically significant moderate correlation with risk of relapse/recurrence after CBT for depression (r = 0.34).

    “Our meta-analytic results indicated statistically significant and moderate correlations ( r = 0.34 and r = 0.19) between each of these variables and the risk of RR.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Discussion · p. 12

    The majority of significant predictors of relapse/recurrence after CBT for depression were tested in only single studies and lacked replicated findings.

    “Several significant predictors were identified across studies; however, the majority were only tested in single studies and lacked replicated findings.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Discussion · p. 12

    Heterogeneity was high for residual depressive symptoms (I2 = 85.3%) but not for prior episodes (I2 = 0%) in the meta-analyses.

    “Indices of heterogeneity were high (I 2 = 85.3%) for residual depressive symptoms but not for prior episodes (I 2 = 0%).”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data
    § Discussion · p. 12

    Three variables (residual depressive symptoms, prior episodes, cognitive reactivity) were examined across multiple studies with sufficient data for meta-analysis.

    “Three variables, however, were examined across multiple studies that reported sufficient data to enable meta-analysis.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given
    § Future research · p. 13

    Many studies deemed ineligible for this review were well-designed controlled trials with adequate longitudinal follow-up periods but did not quantify relapse/recurrence events or rates at follow-up.

    “Many studies that were deemed ineligible for this review were well-designed controlled trials with adequate longitudinal follow-up periods; however, these did not quantify RR events or rates at follow-up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Limitations · p. 12

    Over half of the reviewed studies only reported significant results, with no mention of non-significant predictors in most studies.

    “Furthermore, over half of the reviewed studies only reported significant results -there was no mention of variables that were non-significant predictors of RR in most of the studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Future research · p. 13

    Personality factors (e.g., neuroticism, hopelessness, perceived pleasure) predicted relapse/recurrence most frequently in the included studies, albeit in single studies.

    “Personality factors (e.g. neuroticism, hopelessness, perceived pleasure) predicted RR most frequently in the included studies, albeit in single studies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § Limitations · p. 12

    The largest number of subjects experiencing a relapse/recurrence event in the reviewed studies was 40, and the mean was 19.

    “The largest number of subjects that experienced a RR event in the reviewed studies was 40 (Gollan et al. , 2006), whilst the mean was only 19.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data
    § Study protocol · p. 4

    The systematic review protocol was registered and published in PROSPERO ahead of conducting the review.

    “The systematic review protocol was registered and published in the International Prospective Register of Systematic Reviews (PROSPERO) ahead of conducting the review (protocol ID: PROSPERO 2017:CRD42017057747).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data
    § Selection of articles · p. 4

    Fifty-nine full-text articles were assessed for eligibility independently by two reviewers, with disagreements resolved by consensus.

    “Fifty-nine full-text articles were then assessed for eligibility independently by two reviewers; any disagreements were discussed and resolved by consensus.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Introduction · p. 3

    Some patients are prone to relapse/recurrence after CBT, with rates between studies ranging from 10 to 49%.

    “However, some patients are prone to RR after CBT as described in a review by Paykel (2007), where rates between studies ranged from 10 to 49%.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Paykel (2007)

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data
    § Quality assessment · p. 4

    There were no disagreements in risk-of-bias results between the two independent reviewers.

    “There were no disagreements in results between the two independent reviewers.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Data extraction and synthesis · p. 4

    Two reviewers extracted the data independently.

    “Two reviewers extracted the data independently.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Introduction · p. 3

    CBT is an effective psychological treatment for major depressive disorder.

    “Cognitive behavioural therapy (CBT) is an increasingly available and effective psychological intervention, recommended as a first-line treatment in clinical guidelines for the management of depression (American Psychiatric Association, 2000b; National Institute for Health and Care Excellence, 2010).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites American Psychiatric Association, 2000b

      Not checked in the free run.

    • cites National Institute for Health and Care Excellence, 2010

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data
    § Prior episodes of depression · p. 9

    Tests for funnel plot asymmetry were not statistically significant and the fail-safe N was 9 for the prior depression episodes meta-analysis.

    “The regression ( t = -0.8810, d.f. = 2, p = 0.47) and rank correlation tests (Kendall ' s tau = -0.33, p = 0.75) for funnel plot asymmetry were not statistically significant and the fail-safe N was 9.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data
    § Cognitive reactivity · p. 9

    Tests for funnel plot asymmetry were not statistically significant and the fail-safe N was 7 for the cognitive reactivity meta-analysis.

    “The regression ( t = 1.40, d.f. = 2, p = 0.30) and rank correlation tests (Kendall ' s tau = 0.33, p = 0.75) for funnel plot asymmetry were not statistically significant and the fail-safe N was 7.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given
    § Other sources of bias · p. 8

    In Evans et al. (1992) and Forand and DeRubeis (2013), the authors of the paper were also the therapists, potentially leading to researcher allegiance effects.

    “In Evans et al. (1992) and Forand and DeRubeis (2013), the authors of the paper are also the therapists within the study, potentially leading to researcher allegiance effects.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Evans et al., 1992

      Not checked in the free run.

    • cites Forand and DeRubeis, 2013

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Incomplete outcome data · p. 8

    There were high rates of attrition in the included longitudinal studies.

    “As is common in longitudinal studies, there were high rates of attrition.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Demographics · p. 11

    Age, gender, race, employment status, education, socioeconomic status, and intelligence are not associated with relapse/recurrence after CBT for depression (Evans et al., 1992).

    “Other demographic characteristics that were not associated with RR included age, gender, race, employment status, education, socioeconomic status, and intelligence (Evans et al. , 1992).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Evans et al. , 1992

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

    Premisecitation
    § Demographics · p. 11

    Unmarried participants are more likely to experience relapse/recurrence after CBT for depression (Thase et al., 1992).

    “Thase et al. (1992) found that unmarried participants were more likely to experience RR; however, Evans et al. (1992) did not find marital status to be a significant predictor.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Thase et al. (1992) source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based). May combine two claims. The quote only partly states this claim.

    Premisecitation
    § Other clinical and diagnostic factors · p. 11

    A range of diagnostic and clinical history features (age at onset, duration of current episode, insidiousness of onset, presence of precipitant, previous treatment with tricyclics, history of hospitalization, suicidal ideation, history of suicide attempts, history of alcoholism, history of substance abuse, RDC depressive sub-type, double depression, family history of depression, general level of功能

    “Non-significant diagnostic and clinical history features included: age at onset of disorder; duration of current episode; insidiousness of onset; presence of precipitant; previous treatment with tricyclics; history of hospitalization; suicidal ideation; history of suicide attempts; history of alcoholism; history of substance abuse; Research Diagnostic Criteria (RDC) depressive sub-type; double dep”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Evans et al. , 1992

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation
    § Discussion · p. 12

    Cognitive reactivity as measured by the DAS following a mood induction procedure is a commonly cited predictor of depressive relapse/recurrence (Segal et al., 1999, 2006).

    “A third commonly cited predictor of depressive RR is cognitive reactivity as measured by the DAS following a mood induction procedure (Segal et al. , 1999, 2006).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Segal et al. , 1999, 2006

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data
    § Conclusions · p. 14

    Depression is a refractory condition, particularly for patients with prior episodes and with residual depressive symptoms at the end of treatment.

    “In summary, at least 30% of patients were found to experience RR (relapse and/or recurrence) after acute-phase CBT, confirming that depression is a refractory condition, particularly for patients with prior episodes and with residual depressive symptoms at the end of treatment.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data
    § Limitations · p. 13

    The present review conducted quantitative meta-analyses of available data.

    “The present review had several strengths including the pre-registration of the study protocol; searches across multiple databases, reference lists and direct requisition to corresponding authors; double rating of included studies; and quantitative meta-analyses of available data.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Clinical implications · p. 14

    Adjunctive and continuation-phase interventions are costly, but gains in prevention tend to outweigh the costs of future episodes of care for people who experience relapse/recurrence (Scott et al., 2003).

    “As others have argued (Scott et al. , 2003), adjunctive and continuation-phase interventions are costly, but gains in prevention tend to outweigh the costs of future episodes of care for people that experience RR, who are often more severely impaired with each subsequent episode.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Scott et al. , 2003

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Limitations · p. 13

    The present review used double rating of included studies.

    “The present review had several strengths including the pre-registration of the study protocol; searches across multiple databases, reference lists and direct requisition to corresponding authors; double rating of included studies; and quantitative meta-analyses of available data.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Limitations · p. 13

    The present review had a pre-registered study protocol.

    “The present review had several strengths including the pre-registration of the study protocol; searches across multiple databases, reference lists and direct requisition to corresponding authors; double rating of included studies; and quantitative meta-analyses of available data.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Clinical implications · p. 14

    Continuation-phase CBT and MBCT are well-established relapse prevention interventions for depression (Vittengl et al., 2007; Piet and Hougaard, 2011).

    “There are also well-established relapse prevention interventions that should be offered after patients have completed an acute-phase treatment, such as continuation-phase CBT (Vittengl et al. , 2007) and MBCT (Piet and Hougaard, 2011).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Vittengl et al. , 2007

      Not checked in the free run.

    • cites Piet and Hougaard, 2011

      Not checked in the free run.

  • May combine two claims.

    Study design and conductnone given
    § Limitations · p. 13

    The present review excluded grey literature, publications in languages other than English, studies in children and young people, and studies including a continuation-phase procedure or intervention.

    “However, this review was limited by the exclusions imposed on grey literature, publications in languages other than English, studies in children and young people, and studies which included a continuation-phase procedure or intervention.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given
    § Limitations · p. 13

    The present review searched multiple databases, reference lists, and directly requisitioned corresponding authors.

    “The present review had several strengths including the pre-registration of the study protocol; searches across multiple databases, reference lists and direct requisition to corresponding authors; double rating of included studies; and quantitative meta-analyses of available data.”
    Quote in the paperNot a substantial claim
31 of 31

  • The paper relies on this without support.

    No prior systematic review and quantitative synthesis of predictors of relapse/recurrence after CBT for depression exists.

    “This study presents the first systematic review and quantitative synthesis of the literature on predictors of RR (relapse and/or recurrence) after CBT for depression.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • A fifth predictor was assessed in multiple studies

    Minor

    The paper says only four variables were assessed as predictors in more than one study, but it also reports that attributional style was assessed in two studies.

  • Reported minimum RR rate exceeds a rate in Table 1

    Minor

    The stated range begins at 18.5%, whereas Table 1 reports 2/22 (9%) for the CBT subjects in Harkness et al. (2014).

  • Conflicting counts of predictor variables

    Minor

    The abstract says 26 predictor variables were identified, but the results say the included studies investigated 62 variables as potential predictors.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 7

  1. Eysenck, 1968, Eysenck Personality Inventory Manual
  2. 2009, Systematic Reviews: CRD’s Guidance for Undertaking Reviews in Healthcare
  3. 2000, Practice guideline for the treatment of patients with major depressive disorder (revision), American Journal of Psychiatry, 157, 1
  4. Möller, 2011, Relapse or recurrence in depression: why has the cutoff been set at 6 months, Medicographia, 33, 125
  5. Spitzer, 1985, Research Diagnostic Criteria (RDC) for a Selected Group of Functional Disorders
  6. National Institute for Health and Care Excellence (NICE) (2010). Depression: The Treatment and Management of Depression in Adults (updated edition). London, UK: The British Psychological Society and The Royal College of Psychiatrists.
  7. 2000, DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders

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Related

Authors
Wojnarowski, C., Firth, N., Finegan, M., & Delgadillo, J.
Affiliations
University of Sheffield (GB)
Corresponding author
Wojnarowski, Caroline
ORCID
Venue
Behavioural and Cognitive Psychotherapy
Publisher
Cambridge University Press (CUP)
Published
2019-03-21
Volume
47
Issue
5
Pages
514-529
ISSN
  • 1352-4658 (ISSN-L)
  • 1469-1833
DOI
10.1017/s1352465819000080
OpenAlex
W2906420156
Semantic Scholar
1e09ba2efd15d1e8d6e17722669310f81e5613bc
Cited by
108
References
69
Citations by year
2026: 13 · 2025: 16 · 2024: 11 · 2023: 20 · 2022: 12 · 2021: 22 · 2020: 10 · 2019: 4
FWCI
1.79
Type
journal article
Language
en
Open access
closed
Licence
www.cambridge.org/core/terms (unspecified)
Locations
  • Behavioural and Cognitive Psychotherapy (publishedVersion)
  • PubMed (publishedVersion)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
  • Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
Keywords
cognitive behavioral therapy, major depressive disorder, depression relapse, depression recurrence, predictors of relapse, residual depressive symptoms, cognitive reactivity, life events, personality factors
MeSH terms
Depression, Major Depressive Disorder, Humans, Prognosis, Recurrence, Risk Factors, Cognitive Behavioral Therapy, Treatment Outcome

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