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Pre-post effect sizes should be avoided in meta-analyses
Open accessAbstract
Aims: The standardised mean difference (SMD) is one of the most used effect sizes to indicate the effects of treatments. It indicates the difference between a treatment and comparison group after treatment has ended, in terms of standard deviations. Some meta-analyses, including several highly cited and influential ones, use the pre-post SMD, indicating the difference between baseline and post-test within one (treatment group). Methods: In this paper, we argue that these pre-post SMDs should be avoided in meta-analyses and we describe the arguments why pre-post SMDs can result in biased outcomes. Results: One important reason why pre-post SMDs should be avoided is that the scores on baseline and post-test are not independent of each other. The value for the correlation should be used in the calculation of the SMD, while this value is typically not known. We used data from an ‘individual patient data’ meta-analysis of trials comparing cognitive behaviour therapy and anti-depressive medication, to show that this problem can lead to considerable errors in the estimation of the SMDs. Another even more important reason why pre-post SMDs should be avoided in meta-analyses is that they are influenced by natural processes and characteristics of the patients and settings, and these cannot be discerned from the effects of the intervention. Between-group SMDs are much better because they control for such variables and these variables only affect the between group SMD when they are related to the effects of the intervention. Conclusions: We conclude that pre-post SMDs should be avoided in meta-analyses as using them probably results in biased outcomes.
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“Furthermore, single-arm pre-post studies may constitute a low quality with the perceived overestimated effect size compared to randomised trials.42”
From Mindfulness-based interventions for psychological wellbeing and quality of life in men with prostate cancer: A systematic review and meta-analysis (2021) · cites this paper as [42]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
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“Furthermore, between-group SMDs provide better control over covariates compared with within-group SMDs.41”
From Drug Efficacy in the Treatment of Antipsychotic-Induced Akathisia: A Systematic Review and Network Meta-Analysis (2024) · cites this paper as [41]
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“As it is not recommended to analyze pre-post standardized mean differences within a metaanalysis (Cuijpers et al., 2017), the findings of pre-post studies were summarized in a narrative synthesis.”
From A Systematic Review and Meta-Analysis Exploring Effects of Third-Wave Psychological Therapies on Hearing-Related Distress, Depression, Anxiety, and Quality of Life in People With Audiological Problems. (2022) · cites this paper as Cuijpers et al., 2017
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“Cuijpers et al. (2017, p. 367) argued that “insofar as possible pre-post SMDs (standardized mean differences) should be avoided because they can contribute to biased outcomes and do not give reliable information about treatment effects”.”
From The effect of internet-delivered cognitive behavioral therapy for depression and anxiety on quality of life: A meta-analysis of randomized controlled trials (2023) · cites this paper as Cuijpers et al. (2017)
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“What is even more important with regard to pre-post SMD, is that “it only calculates the change within one group. That means that the pre-post SMD is uncontrolled and it is impossible to disentangle which proportion of the SMD is caused by the intervention and which by natural recovery and other processes” (Cuijpers et al., 2017, p. 365).”
From The effect of internet-delivered cognitive behavioral therapy for depression and anxiety on quality of life: A meta-analysis of randomized controlled trials (2023) · cites this paper as Cuijpers et al., 2017
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“We also conducted sensitivity analyses for correlations set to 0.00, 0.75, and 0.99 to examine the robustness of our findings [42].”
In the citing paper
“most patients favor psychotherapyoverpharmacotherapy.”
From Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders: A Systematic Review and Meta-analysis (2020) · cites this paper as [14]
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Self-citation
Metadata
- Authors
- Cuijpers, P., Weitz, E., Cristea, I. A., & Twisk, J.
- Affiliations
- Amsterdam Public Health (NL)
- Babeș-Bolyai University (RO)
- Corresponding author
- Cuijpers, P.
- Venue
- Epidemiology and Psychiatric Sciences
- Publisher
- Cambridge University Press (CUP)
- Published
- 2016-10-28
- Volume
- 26
- Issue
- 4
- Pages
- 364-368
- ISSN
- 2045-7960 (ISSN-L)
- 2045-7979
- PMC
- PMC6998624
- OpenAlex
- W2539720341
- Semantic Scholar
- a0bf02bc67c2e6ba75bcb6ba79dab587e691fc75
- Cited by
- 432
- References
- 14
- Citations by year
- 2026: 51 · 2025: 48 · 2024: 61 · 2023: 66 · 2022: 61 · 2021: 55 · 2020: 42 · 2019: 28 · 2018: 12 · 2017: 7 · 2016: 1
- FWCI
- 14.95
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Epidemiology and Psychiatric Sciences (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion, other-oa)
- VU Research Portal (publishedVersion, other-oa)
- Amsterdam UMC (VU Amsterdam) - Institutional Repository (submittedVersion)
- Padua Research Archive (University of Padova) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Funders
- National Authority for Scientific Research and Innovation
- Autoritatea Natională pentru Cercetare Stiintifică
- Unitatea Executiva pentru Finantarea Invatamantului Superior, a Cercetarii, Dezvoltarii si Inovarii
- Topics
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Clinical Trials
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
- Keywords
- standardized mean difference, effect size bias, individual patient data meta-analysis, cognitive behavioral therapy, antidepressants, depression treatment
- MeSH terms
- Antidepressive Agents, Depression, Humans, Reference Standards, Meta-Analysis as Topic, Cognitive Behavioral Therapy
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