In an online world, we’re used to comparing pros and cons before making a decision. We read reviews before booking a hotel, compare specifications before buying a phone, and check star ratings before watching a film. But with mental health support, the stakes are higher than a disappointing meal or boring movie. Therapy requires time, effort, vulnerability, and often money, so it’s reasonable to ask: is one type of therapy better than another?
Depression is one of the most common mental health conditions worldwide and is often treated with cognitive behavioural therapy (CBT). CBT is a structured talking therapy that helps people notice and change patterns of thinking and behaviour that can keep them feeling low (Blane et al., 2013; Salkovskis et al., 2023). CBT is often considered the ‘gold standard’ psychological treatment for depression due to extensive research (David et al., 2018) and is recommended by NICE guidelines (2022). However, while most research supporting CBT comes from specialist mental health settings like community mental health teams or mental health hospital wards, most people with depression are treated in primary care settings, like GP practices and hospitals (Jackson et al., 2022), making it vital to study CBT in this setting.
As the name suggests, CBT involves cognitive and behavioural techniques, including cognitive therapy (CT; which challenges negative thinking patterns) and behavioural activation (BA; which encourages activities that improve mood). These approaches can be used together or separately, so it’s important to understand what approach works best in primary care, and whether factors such as patient group or outcome measure influence results. Carey and colleagues (2025) undertook a systematic review and meta-analysis to investigate this.
Do people need the whole CBT toolbox for depression, or could one element of it be just as effective?
Methods
The authors searched three major databases for peer-reviewed randomised controlled trials (RCTs) which included adults with major depressive disorder (MDD) recruited through primary care settings, and compared CBT (including CT, BA, or a combination of the two) with a control group. Studies were excluded if they were not written in English or focused on third-wave CBT approaches like mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), or dialectical behaviour therapy (DBT).
Titles and abstracts were first screened by one author, and full texts were screened by two before data was extracted and a random effects meta-analysis was conducted. When there was lots of heterogeneity between studies, meta-regressions were carried out to explore possible reasons for these differences. Study quality was assessed using an adapted version of the Cochrane risk-of-bias tool 2.0, with 82% of included studies rated as high risk of bias.
Results
Forty-four studies were included in the meta-analysis, including over 10,000 participants. Most studies took place in Europe (n = 30) and reported use of psychotropic medication (i.e., antidepressants; n = 36). Thirty-three studies used CBT, nine used BA, and two used CT, and most (n = 22) were in an individual format. Most studies used inactive controls, including treatment as usual (n = 29), enhanced care as usual (n = 6), and waitlist control (n = 5). The most common active comparator was different types of psychological therapy (n = 7). Duration of treatment varied between one and 30 weeks, and duration of follow-up ranged from one to 52 weeks.
CBT works better than inactive controls, but the effects are small
The first key finding across 40 studies was that CBT, BA, or CT all successfully reduced depressive symptoms more than inactive control groups (p = <.001), with a small effect (g = 0.44). This means that the treatments were helpful, but not considerably.
CBT not clearly better than other active treatments
Nine studies compared CBT to other active treatments and found that CBT did not clearly outperform them. People improved by similar amounts whether they received CBT, other talking therapies, antidepressants, or exercise (g = 0.06, p = .24).
Which formats of CBT work?
Twenty studies found that individual face-to-face CBT, BA or CT all reduced depressive symptoms more than inactive controls (p < .001), although the effect size was small (g = 0.47). In contrast, seven studies found that individual face-to-face CBT was no more effective than other active comparators (g = 0.01, p =.92.).
Twelve studies found that computerised CBT or BA also worked better than inactive control groups (g = 0.39, p < .001), demonstrating that both in-person and online CBT seem promising ways of reducing depressive symptoms. Although the two formats were not directly compared in this review, their effect sizes were similar, which is consistent with the literature that digital and face-to-face CBT can be comparably effective (Hedman-Lagerlöf et al., 2023). However, one study did find no significant differences between computerised CBT and the active comparator of exercise, again indicating that while it can be effective, it’s not necessarily better than other treatments.
Finally, five studies found that self-help CBT did not perform better than inactive controls (g = 0.21, p = .086). However, moderator analyses found that length of therapy and analytic strategy significantly influenced the effect size, with shorter therapies reporting larger effect sizes, and intention-to-treat analyses reporting smaller effect sizes.
In-person CBT and computerised CBT in primary care settings are both more effective than inactive controls, but self-help CBT is not.
Conclusions
- Overall, the findings from this systematic review and meta-analysis suggest that in primary care settings, CBT, CT and BA were all more effective than inactive control conditions at reducing depressive symptoms.
- However, CBT did not clearly outperform other active treatments such as alternative talking therapies, antidepressants, or exercise.
- This challenges the idea that CBT is uniquely better than alternative approaches; CBT may be a good option, but it isn’t the only option.
- The results also raise questions about the use of self-help CBT, which may be less effective in primary care, yet is recommended by NICE guidelines for milder cases of depression.
Does CBT deserve to be the gold standard? Other active comparators appear to be equally effective, suggesting CBT may be one strong option among several, rather than uniquely superior.
Strengths and limitations
There are many strengths to this systematic review, including its focus on primary care as a setting, which is where most people with depression are treated (Jackson et al., 2022); as such, this evidence synthesis was very much necessary. The way the authors approached the review was also rigorous, including pre-registering the study protocol and following PRISMA guidelines, increasing the transparency and reliability of findings.
Another strength is the inclusion of a broad range of participants in terms of age and comorbidities, and including studies where participants either had a formal diagnosis of depression or reported symptoms above a clinical threshold. This reflects real-world care, where patients often have multiple health conditions and treatment may be based on symptom severity rather than diagnosis. Furthermore, the authors focused on papers where treatment was delivered in primary care settings, rather than recruiting primary care patients and treating them elsewhere. By including a sample that reflects the kinds of patients seen in everyday care, the findings are more likely to generalise to everyday practice. We can better trust that results are not limited to a specific group but are relevant to the variety of patients that clinicians treat.
However, there are also several limitations to this review, including:
- While the methodology of this review was generally rigorous, the explanation for the screening process was brief and rather vague, meaning it is unclear whether the studies were double-screened or not. At title/abstract stage, it seems like only one author reviewed the papers, increasing the likelihood that relevant studies were missed.
- 82% of included studies were rated as high risk of bias, reducing the reliability of the data within this review. This was partly due to participants reporting their own outcomes in studies where they knew which group they had been randomised to, which could have influenced their answers; this is something that future trials could reduce by using independent assessors.
- There was also considerable heterogeneity between the studies being compared, including trial design, comparison groups, and participant characteristics. For example, some participants were also taking antidepressant medication, which may have affected outcomes. This makes it hard to compare studies and come to comprehensive conclusions.
- Most studies only evaluated CBT in the short term, with no included studies following up after 1 year; this limits the conclusions that can be drawn about how effective these treatments are over the long-term.
By including studies where interventions were delivered in primary care settings (as opposed to just recruiting patients from primary care), the findings of this review are more applicable to real-world practice.
Implications for practice
In general, the findings of this systematic review align with previous research indicating that CBT, BA and CT are effective for treating depression within primary care, but have a smaller effect size than studies carried out in research or specialist settings (Bortolotti et al., 2008; Cuijpers et al., 2019; Mavranezouli et al., 2024). Findings also supported the effectiveness of online CBT, which is a cost-effective and convenient form of the treatment that works in real-world settings (read Natalia’s Mental Elf blog to learn more). With the NHS planning to continually increase the use of digital tools in healthcare over the next 10 years, these findings are encouraging to see.
However, CBT does not seem to outperform other active treatments like exercise or medication, which is reflected in the wider literature (Cuijpers et al., 2019; Linde et al., 2015). This does not mean CBT is ineffective, but that multiple treatments work equally well at reducing the severity of depressive symptoms. This has several implications for practice:
- For patients, it suggests there may be several effective options for treating depression in primary care. Choices could be guided by availability, personal suitability and practical considerations like time and cost. If CBT doesn’t work for someone, or if they are dealing with difficult-to-treat depression, this does not mean that all approaches won’t work.
- For clinicians, this suggests a flexible approach to treatment may be most important. Rather than assuming CBT is always the best option, clinicians may benefit from drawing on a range of approaches and tailoring treatment to the individual’s needs. Many clinicians already work in this person-centred, flexible way, but some talking therapy services operate within structured frameworks that can limit the extent that treatment can be adapted to the individual; this is something that needs to be considered at a policy level.
- For researchers, it is important that treatment outcomes are followed up across the longer term and beyond one year. Researchers should also consider focusing efforts on comparing CBT with other active treatments, including different formats of CBT. This will help us to better understand if CBT is really the gold standard, or if alternative treatments need further consideration.
There may be more than one effective path to recovery. CBT is one option, but other treatments may work just as well for some people.
Statement of interests
Harry Oldridge has no conflicts of interest to declare. The author used AI tools to support proofreading. All analysis, interpretation, and final text were completed and reviewed by the author.
Edited by
Dr Nina Higson-Sweeney.
Links
Primary paper
Miriam Carey, Jess Kerr-Gaffney, Rebecca Strawbridge, Fredrik Hieronymus, Robert A. McCutcheon, Allan H. Young, & Sameer Jauhar (2025). Are cognitive behavioural therapy, cognitive therapy, and behavioural activation for depression effective in primary care? A systematic review and meta-analysis. Journal of Affective Disorders, 382, 215-226. https://doi.org/10.1016/j.jad.2025.04.070
Other references
Blane, D., Williams, C., Morrison, J., Wilson, A., & Mercer, S. (2013). Cognitive behavioural therapy: Why primary care should have it all. The British Journal of General Practice, 63(607), 103–104. https://doi.org/10.3399/bjgp13X663235
Bortolotti, B., Menchetti, M., Bellini, F., Montaguti, M. B., & Berardi, D. (2008). Psychological interventions for major depression in primary care: A meta-analytic review of randomized controlled trials. General Hospital Psychiatry, 30(4), 293–302. https://doi.org/10.1016/j.genhosppsych.2008.04.001
Cuijpers, P., Noma, H., Karyotaki, E., Cipriani, A., & Furukawa, T. A. (2019). Effectiveness and Acceptability of Cognitive Behavior Therapy Delivery Formats in Adults With Depression: A Network Meta-analysis. JAMA Psychiatry, 76(7), 700–707. https://doi.org/10.1001/jamapsychiatry.2019.0268
David, D., Cristea, I., & Hofmann, S. G. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Frontiers in Psychiatry, 9, 4. https://doi.org/10.3389/fpsyt.2018.00004
Hedman-Lagerlöf, E., Carlbring, P., Svärdman, F., Riper, H., Cuijpers, P., & Andersson, G. (2023). Therapist-supported Internet-based cognitive behaviour therapy yields similar effects as face-to-face therapy for psychiatric and somatic disorders: An updated systematic review and meta-analysis. World Psychiatry, 22(2), 305–314. https://doi.org/10.1002/wps.21088
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