Are all psychotherapies equally effective in the treatment of adult depression? The lack of statistical power of comparative outcome studies
Open accessAbstract
More than 100 comparative outcome trials, directly comparing 2 or more psychotherapies for adult depression, have been published. We first examined whether these comparative trials had sufficient statistical power to detect clinically relevant differences between therapies of d=0.24. In order to detect such an effect size, power calculations showed that a trial would need to include 548 patients. We selected 3 recent meta-analyses of psychotherapies for adult depression (cognitive behaviour therapy (CBT), interpersonal psychotherapy and non-directive counselling) and examined the number of patients included in the trials directly comparing other psychotherapies. The largest trial comparing CBT with another therapy included 178 patients, and had enough power to detect a differential effect size of only d=0.42. None of the trials in the 3 meta-analyses had enough power to detect effect sizes smaller than d=0.34, but some came close to the threshold for detecting a clinically relevant effect size of d=0.24. Meta-analyses may be able to solve the problem of the low power of individual trials. However, many of these studies have considerable risk of bias, and if we only focused on trials with low risk of bias, there would no longer be enough studies to detect clinically relevant effects. We conclude that individual trials are heavily underpowered and do not even come close to having sufficient power for detecting clinically relevant effect sizes. Despite this large number of trials, it is still not clear whether there are clinically relevant differences between these therapies.
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In major depressive disorder, CBT, interpersonal psychotherapy, and behavioural activation display similar efficacies.
“In MDD, CBT, interpersonal psychotherapy (IPT) and behavioural activation have been explored in multiple RCTs and in general display similar efficacies.92”
From Canadian Network for Mood and Anxiety Treatments ( <scp>CANMAT</scp> ) and International Society for Bipolar Disorders ( <scp>ISBD</scp> ) 2018 guidelines for the management of patients with bipolar disorder (2018) · cites this paper as [92]
The Introduction says CBT, IPT and behavioural activation have been studied in randomised trials for adult depression and that therapies seem about equally effective. The Discussion and Conclusion caution that comparative trials are underpowered and the evidence is insufficient to establish whether one therapy is more effective than another. Thus, the source supports apparent similar efficacy, but not an unqualified conclusion that their efficacies are similar. (LLM, conf=0.87)
Experimental — accuracy not yet measuredThe existing data suggest that screening programs generally increase the likelihood of remission and treatment response in general adult populations but only in the presence of subsequent treatment offers.
“However, the existing data do suggest that screening programs generally increase the likelihood of remission and treatment response in general adult populations but only in the presence of subsequent treatment offers.”
From Major depressive disorder (2016) · cites this paper as [125]
The Introduction and Discussion address the statistical power of trials comparing psychotherapies for adult depression, not depression-screening programs. Searches for screening programs, remission or treatment response, and subsequent treatment offers found no passage addressing the claimed effect. (LLM, conf=0.76)
Experimental — accuracy not yet measuredPrevious studies suggested that a certain level of cognitive maturity is required for successful engagement in CBT, which children may not yet have acquired.
“Previous studies33,34 suggested that a certain level of cognitive maturity is required for successful engagement in CBT, which children may not yet have acquired.”
From Different Types and Acceptability of Psychotherapies for Acute Anxiety Disorders in Children and Adolescents: A Network Meta-analysis (2019) · cites this paper as [34]
The comparative-outcome-trials section discusses CBT for adult depression and the statistical power of trials, not the cognitive maturity needed to engage in CBT. Searches for cognitive maturity and children's developmental capacity found no passage addressing the claim; page numbers were unavailable in our copy. (LLM, conf=0.75)
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Farley, K., Copsey, B. J., Wright-Hughes, A. M., Farrin, A., Bojke, C., McMillan, D., Graham, C. D., Mattock, R., Brennan, C. A., Gates, C., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26943225
Farley, K., Copsey, B. J., Wright-Hughes, A. M., Farrin, A., Bojke, C., McMillan, D., Graham, C. D., Mattock, R., Brennan, C. A., Gates, C., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26839120
Farley, K., Copsey, B. J., Wright-Hughes, A. M., Farrin, A., Bojke, C., McMillan, D., Graham, C. D., Mattock, R., Brennan, C. A., Gates, C., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26943237
Farley, K., Copsey, B. J., Wright-Hughes, A. M., Farrin, A., Bojke, C., McMillan, D., Graham, C. D., Mattock, R., Brennan, C. A., Gates, C., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26943234
Farley, K., Copsey, B. J., Wright-Hughes, A. M., Farrin, A., Bojke, C., McMillan, D., Graham, C. D., Mattock, R., Brennan, C. A., Gates, C., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26943240
Farley, K., Copsey, B. J., Wright-Hughes, A. M., Farrin, A., Bojke, C., McMillan, D., Graham, C. D., Mattock, R., Brennan, C. A., Gates, C., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26943231
Carniel, B. P., Claudino, F. C. D. A., Bristot, G., & da Rocha, N. S. (2026) · Acta Psychologica · doi:10.1016/j.actpsy.2026.106524
Practice-Based Evidence as a Cornerstone for Learning Health Systems
Barkham, M., Saxon, D. R., Firth, N., & Delgadillo, J. (2026) · Oxford University Press eBooks · doi:10.1093/9780197748336.003.0002
Swamy, D. S. V., Ibrahim, F. M., Murad, A. A., Tia, M. M. G., Moreljwab, M. H., Alharbi, S. A., Mahallawi, H. A., & Fadlalmola, H. A. (2026) · Journal of Psychosocial Nursing and Mental Health Services · doi:10.3928/02793695-20260417-02
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Mundorf, A., Peterburs, J., & Ocklenburg, S. (2026) · Springer eBooks · doi:10.1007/978-3-662-73259-5_2
Riper, H. M., Kleiboer, A. M., Hoogendoorn, A. W., Bosmans, J. E., Schulte, M. H. J., Mathiasen, K., Hazo, J., Holtzmann, J., Chevreul, K., Ebert, D. D., et al. (2026) · Interactive Journal of Medical Research · doi:10.2196/72866
Self-citation
- Authors
- Cuijpers, P.
- Affiliations
- Amsterdam Public Health (NL)
- Corresponding author
- Cuijpers, Pim
- ORCID
- Cuijpers, Pim
- Venue
- Evidence Based Mental Health
- Publisher
- BMJ
- Published
- 2016-03-16
- Volume
- 19
- Issue
- 2
- Pages
- 39-42
- ISSN
- 1362-0347 (ISSN-L)
- 1468-960X
- PMC
- PMC10699414
- OpenAlex
- W2297553235
- Cited by
- 86
- References
- 21
- Citations by year
- 2026: 6 · 2025: 3 · 2024: 12 · 2023: 4 · 2022: 2 · 2021: 12 · 2020: 6 · 2019: 9 · 2018: 13 · 2017: 10 · 2016: 8
- FWCI
- 17.85
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Evidence-Based Mental Health (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- VU Research Portal (publishedVersion, other-oa)
- HighWire Press Open Archive (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- adult depression, psychotherapy, statistical power, cognitive behavioral therapy, interpersonal psychotherapy, non-directive counseling, meta-analysis, risk of bias, effect size, trial size
- MeSH terms
- Adult, Depressive Disorder, Humans, Psychotherapy, Outcome Assessment, Health Care
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