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Research · Therapies

Cognitive behavioral therapy

Across 409 trials, CBT lowered depression more than waiting list or usual care, about as much as antidepressants at treatment end, and about as much as other psychotherapies. It eased anxiety disorders more than placebo and improved insomnia, including online. Chronic pain benefits were small. Symptoms worsened in about 4% of patients, fewer than in control groups.

Checked 2026-11-13
Status
Most psychotherapy is delivered one-on-one or in groups by a licensed mental health professional. There is no FDA approval process for psychotherapies as there is for medications, and web programs and apps deliver some therapy without a therapist [1]. The American College of Physicians advises CBT for insomnia as the initial treatment for chronic insomnia disorder in adults [2].
Also called
CBT, cognitive behavioural therapy, cognitive therapy, behavioral therapy, CBT-I, CBT for insomnia, cognitive behavioral therapy for insomnia, iCBT, internet CBT, digital CBT, online therapy, exposure therapy, talk therapy, psychotherapy
Used for
depression, anxiety, panic attacks, social anxiety, obsessive compulsive disorder, PTSD, worry, insomnia, sleep, chronic pain, back pain, fibromyalgia, stress, coping, PMS, PMDD

Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on

Shown to help8

Reported risks2

What it is used for, and what was found

Shown to help8

Strong

Depression, compared with waiting list or usual care

Shown to lower depression moderately to largely against waiting list and usual care, with effects still present 6 to 12 months later.

Compared with care as usual and waiting list [3]; control groups [4]

The numbers and sources
Effect
Across 409 trials, CBT outperformed control conditions such as care as usual and waiting list (g 0.79, 95% CI 0.70 to 0.89), and the effect was still significant at 6 to 12 months. As unguided self-help it gave g 0.45, and in children and adolescents g 0.41 [3]. An earlier analysis of 75 studies found g 0.71 (number needed to treat 2.6), which was 0.53 after adjusting for publication bias and 0.53 in higher-quality studies [4].
Population
52,702 patients in 409 trials (518 comparisons) [3]. 115 studies of adults with depression [4].
Sources
[3], [4]
Caveats
Waiting-list controls inflate effects, and the earlier analysis found strong signs of publication bias [4]. Both analyses come from the same research group and share trials.
Strong

Anxiety disorders, compared with placebo

Shown to ease anxiety disorder symptoms moderately against pill or psychological placebo, with nearly three times the odds of responding.

Compared with psychological placebo [6][7]; pill placebo [6][7]; waiting list [7]

The numbers and sources
Effect
Against psychological or pill placebo, CBT reduced target disorder symptoms (Hedges' g 0.56), other anxiety symptoms (g 0.38), depression (g 0.31) and improved quality of life (g 0.30). The odds of responding were 2.97 times those on placebo. Effects were large for obsessive compulsive disorder, generalized anxiety disorder and acute stress disorder, and small to moderate for PTSD, social anxiety and panic disorder [6]. In a second analysis, individual CBT outperformed waiting list, psychological placebo and pill placebo [7].
Population
2,843 patients in 41 placebo-controlled trials [6]. 37,333 patients in 234 trials of panic disorder, generalized anxiety disorder and social phobia [7].
Sources
[6], [7]
Caveats
Effects were larger in completers than in intention-to-treat samples [6]. Patients know they are receiving therapy, which a pill placebo cannot match.
Moderate

Anxiety disorders, long-term

Shown to keep anxiety lower than control conditions for up to 12 months, and past 12 months for generalized anxiety, social anxiety and PTSD, in mostly low-quality trials.

Compared with care as usual, relaxation, psychoeducation, pill placebo, supportive therapy or waiting list [8]

The numbers and sources
Effect
CBT was associated with better outcomes at treatment end and at 1 to 6 and 6 to 12 months for generalized anxiety disorder (g 0.07 to 0.40), panic disorder (g 0.22 to 0.35), social anxiety disorder (g 0.34 to 0.60), specific phobia (g 0.49 to 0.72), PTSD (g 0.59 to 0.72) and OCD (g 0.70 to 0.85). At 12 months or more, effects remained for generalized anxiety (g 0.22), social anxiety (g 0.42) and PTSD (g 0.84), and not for panic disorder [8].
Population
4,118 adult outpatients in 69 trials [8].
Sources
[8]
Caveats
Trials were mainly of low quality, and relapse rates of 0% to 14% came from only 6 trials [8].
Strong

Insomnia

Shown to cut time to fall asleep by about 19 minutes and time awake at night by about 26 minutes against inactive comparisons, with little change in total sleep time.

Compared with inactive comparators [9]; no treatment [10]

The numbers and sources
Effect
After face-to-face CBT for insomnia, sleep onset latency improved by 19.03 minutes (95% CI 14.12 to 23.93), wake after sleep onset by 26.00 minutes, and sleep efficiency by 9.91%. Total sleep time rose 7.61 minutes, a change that was not significant (95% CI -0.51 to 15.74) [9]. Across 87 trials, insomnia severity improved (g 0.98), as did sleep efficiency (g 0.71) and sleep quality (g 0.40). The smallest effect was on total sleep time (g 0.16) [10].
Population
1,162 adults with chronic insomnia, 64% women, mean age 56, in 20 trials [9]. 3,724 treated patients and 2,579 controls in 87 trials [10].
Sources
[9], [10]
Caveats
Sleep was mostly measured by diary. The first analysis excluded insomnia alongside other medical, sleep or psychiatric disorders [9].
Moderate

Insomnia, online CBT

Shown to improve insomnia severity, sleep efficiency and sleep onset when delivered over the internet, by amounts similar to those reported for face-to-face CBT.

Compared with control conditions the source abstract does not describe [12]

The numbers and sources
Effect
Internet-delivered CBT for insomnia improved insomnia severity, sleep efficiency, sleep quality, wake after sleep onset, sleep onset latency, total sleep time and night awakenings, with effect sizes from g 0.21 to 1.09, generally maintained at 4 to 48 weeks. Longer programs and more clinician support were associated with larger effects [12].
Population
1,460 participants in 11 trials [12].
Sources
[12]
Caveats
The comparison with face-to-face CBT sets results from different trials side by side [12].
Strong

Depression and anxiety, online or computer CBT

Shown to lower depression and anxiety disorder symptoms against control conditions, with guided programs ahead of unguided ones right after treatment.

Compared with control treatments [13]; care as usual, waiting list, information control, psychological placebo or pill placebo [14]; face-to-face CBT [14]

The numbers and sources
Effect
In individual data from 39 trials, guided and unguided internet CBT lowered depression scores more than control treatments in the short and long term. Guided programs were ahead of unguided ones after treatment (PHQ-9 mean difference -0.8, 95% CI -1.4 to -0.2) and not at 6 or 12 months [13]. Across 64 trials in major depression, panic disorder, social anxiety and generalized anxiety, computer or internet CBT outperformed control groups (g 0.80, number needed to treat 2.34). Nine trials comparing it with face-to-face CBT found them equally beneficial [14].
Population
9,751 people with depression in 39 trials [13]. 64 trials in adults meeting diagnostic criteria [14].
Sources
[13], [14]
Caveats
Few trials compared online CBT with medication [14].
Moderate

Chronic pain

Shown to ease chronic pain, disability and distress slightly more than usual treatment. Against other active treatments the benefit was very small and did not last.

Compared with treatment as usual [15]; active control treatments [15]

The numbers and sources
Effect
Against treatment as usual, CBT lowered pain (SMD -0.22, 95% CI -0.33 to -0.10, 29 trials), disability (SMD -0.32) and distress (SMD -0.34) at treatment end, effects largely maintained at follow-up. Against active controls, benefits were very small for pain (SMD -0.09, 95% CI -0.17 to -0.01, 23 trials), disability (SMD -0.12) and distress (SMD -0.09), and not maintained at follow-up [15].
Population
59 CBT trials among 75 studies with 9,401 adults, mostly with fibromyalgia, chronic low back pain, rheumatoid arthritis or mixed chronic pain [15].
Sources
[15]
Caveats
Evidence quality ranged from moderate to low, and most trials were at high or unclear risk of bias. Headache was excluded [15].
ModerateStudied in women

PMS and PMDD, compared with waiting list or no treatment

Shown in several trials to ease PMS and PMDD symptoms more than a waiting list or no treatment. A 2009 review had found little evidence.

Compared with waiting list [20][22][23]; no intervention [21]

The numbers and sources
Effect
In women with PMDD, 8 weeks of therapist-guided internet CBT improved functional and psychological impairment, interference with everyday life, symptom intensity and symptom disability more than waiting, and the gains held at 6 months [20]. In university students with moderate to severe PMS, internet CBT over 2 cycles lowered total symptom scores to 10.4 against 20.2 with no intervention (adjusted difference -9.9, 95% CI -13.3 to -6.6) and raised quality of life around periods [21]. One-to-one and couple CBT lowered total premenstrual symptoms and distress more than a waiting list [22]. Twelve weekly sessions of cognitive therapy improved symptoms and functioning more than a waiting list [23]. A 2009 review of 7 reports, 3 of them RCTs, found few statistically significant effects [24], while a 2021 review of 32 studies reported symptom reductions in all of them [25].
Population
174 women with PMDD [20]; 92 university students aged 18 to 35 [21]; 83 women with premenstrual disorders, 63 completing [22]; women with PMS referred by doctors [23]; 7 reports [24]; 32 studies [25].
Sources
[20], [21], [22], [23], [24], [25]
Caveats
Waiting-list and no-treatment controls can inflate effects, and no trial here compared CBT with an attention control or with medication. The 2021 review called for more high-quality research [25].

Mixed results3

Strong

Depression, compared with antidepressant medication

Not shown to differ from antidepressants at the end of treatment. A few trials favored CBT 6 to 12 months later, and CBT plus medication outperformed medication alone.

Compared with antidepressant medication [3][4][5]; medication alone, against CBT plus medication [3][4]

The numbers and sources
Effect
CBT did not differ from pharmacotherapy in the short term, and was larger at 6 to 12 months (g 0.34, 95% CI 0.09 to 0.58), from a small number of trials and not in all sensitivity analyses. CBT plus medication outperformed medication alone in the short term (g 0.51) and long term (g 0.32), and did not differ from CBT alone [3]. An earlier analysis found no difference between CBT and medication, and combined treatment ahead of medication alone (g 0.49) [4]. Across 67 head-to-head trials of psychotherapy and antidepressants for depressive and anxiety disorders, the overall difference was g 0.02 (95% CI -0.07 to 0.10) [5].
Population
52,702 patients [3]. 115 studies [4]. 5,993 patients in 67 trials, 40 in depressive disorders [5].
Sources
[3], [4], [5]
Caveats
The head-to-head analysis covers all psychotherapies, not CBT alone [5]. The long-term advantage rests on few trials [3].
Moderate

Anxiety disorders, compared with medication

Mixed results: head-to-head trials found psychotherapy and antidepressants similar overall, while a broader analysis found larger before-and-after improvements with medication.

Compared with antidepressant medication in head-to-head trials [5]; medication arms in separate trials, before and after treatment in the same people [7]

The numbers and sources
Effect
In 67 head-to-head trials, psychotherapy and antidepressants did not differ overall (g 0.02). Psychotherapy outperformed medication for obsessive compulsive disorder (g 0.64) [5]. Across 234 trials, average improvement from before to after treatment was larger with medication (d 2.02) than with psychotherapy (d 1.22), with individual CBT at d 1.30 and pill placebo at d 1.29 [7].
Population
27 head-to-head trials in anxiety disorders, among 5,993 patients [5]. 37,333 patients in 234 trials [7].
Sources
[5], [7]
Caveats
The before-and-after comparison sets arms of different trials side by side, which is weaker than a head-to-head trial [7]. The head-to-head analysis covers all psychotherapies [5].
Limited

Insomnia, compared with sleep medication

Limited evidence: five trials suggested CBT for insomnia outlasts sleep drugs in the long term, while benzodiazepines gave better short-term results.

Compared with benzodiazepine and non-benzodiazepine sleep drugs [11]

The numbers and sources
Effect
Low to moderate-grade evidence suggested CBT for insomnia gave better long-term results than benzodiazepine and non-benzodiazepine drugs. Very low-grade evidence suggested benzodiazepines gave better short-term results [11].
Population
Adults with primary or comorbid insomnia in 5 trials [11].
Sources
[11]
Caveats
Only 5 trials, with evidence graded low to very low [11].

Not shown to help1

Strong

Depression, compared with other psychotherapies

Not shown to differ meaningfully from other psychotherapies for depression. A tiny edge in one analysis disappeared in most sensitivity checks.

Compared with other psychotherapies [3][4]

The numbers and sources
Effect
CBT was ahead of other psychotherapies by g 0.06 (95% CI 0 to 0.12), a difference that became non-significant in most sensitivity analyses [3]. An earlier analysis found no indication that CBT differed from other psychotherapies [4].
Population
52,702 patients in 409 trials [3]. 115 studies [4].
Sources
[3], [4]
Caveats
Both analyses come from the same research group.

Protocols studied

CBT for insomnia trials combined at least 3 of cognitive therapy, stimulus control, sleep restriction, sleep hygiene and relaxation [9]. Face-to-face treatments of at least 4 sessions showed larger effects than self-help or fewer sessions [10]. One trial gave 6 sessions of CBT for insomnia or 2 sessions of sleep restriction with phone contact [16]. Internet programs with more clinician support and longer duration showed larger effects [12].

Depression trials delivered CBT individually, in groups, as guided or unguided self-help, in institutions, and to children and adolescents [3]. Online depression programs were guided by a coach or therapist, or unguided [13]. Anxiety trials used exposure-based, cognitive, or combined techniques, individually or in groups [6].

Risks

Reported risks1

ModerateVery common

Dropping out of treatment for PTSD

Shown in placebo-controlled PTSD trials, where 29.0% left CBT against 17.2% on placebo. No difference in dropout appeared for other anxiety disorders.

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
In PTSD studies, dropout rates were 29.0% with CBT and 17.2% with placebo. No difference in dropout was found across the other disorders [6].
Population
Patients with PTSD among 41 placebo-controlled trials [6].
Sources
[6]
Caveats
Dropout is not a measure of harm, and the abstract does not give reasons for leaving [6].

Mixed results1

LimitedHow often is not known

Daytime sleepiness during sleep restriction

Mixed results: one uncontrolled study found sleepiness and slower reactions in the first weeks of sleep restriction, while a trial found no rise in excessive sleepiness afterward.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
In 16 patients, measured total sleep time fell by 91 minutes on the first night of sleep restriction, 78 minutes on night 8 and 69 minutes on night 22. Attention lapses and sleepiness scores rose during treatment and returned to baseline by 3 months [19]. In 150 postmenopausal women, the odds of being excessively sleepy after sleep restriction (OR 0.94) or CBT for insomnia (OR 0.62) did not differ from the odds of not being sleepy [16].
Population
16 patients, 10 of them women, no control group [19]. 150 postmenopausal women with insomnia [16].
Sources
[19], [16]
Caveats
The first study was small and uncontrolled. The trial measured sleepiness after treatment, not during the first weeks [16].

Checked, no increase found1

Moderate

Symptoms getting worse during treatment

Not shown to raise the risk of worsening. Depression worsened in a median 4% of therapy patients, a lower risk than in control groups.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
Across 23 comparisons, patients in psychotherapy for depression were 61% less likely to deteriorate than control patients (RR 0.39, 95% CI 0.27 to 0.57). The median deterioration rate in therapy groups was 4%, and above 10% in some studies [17]. With self-guided internet CBT, 5.8% deteriorated against 9.1% in control groups (OR 0.62) [18].
Population
18 trials of psychotherapy for adult depression [17]. 3,805 adults with depressive symptoms in 13 trials [18].
Sources
[17], [18]
Caveats
Only 6% of trials reported deterioration, defined in different ways [17]. The first analysis covers several psychotherapies, not CBT alone.

Claims tested and not found

  1. That CBT outperforms other psychotherapies for depression. The difference was g 0.06 and became non-significant in most sensitivity analyses [3].
  2. That CBT for insomnia adds much total sleep time. Total sleep time rose 7.61 minutes, a change that was not significant [9].
  3. That CBT gains for panic disorder hold past a year. At 12 months or more, the effect against control was not significant [8].

Sources

  1. National Institute of Mental Health. Psychotherapies. 2024. https://www.nimh.nih.gov/health/topics/psychotherapies
  2. Qaseem A, Kansagara D, Forciea MA, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2016. https://doi.org/10.7326/m15-2175
  3. Cuijpers P, Miguel C, Harrer M, et al. Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry. 2023. https://doi.org/10.1002/wps.21069
  4. Cuijpers P, Berking M, Andersson G, et al. A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. The Canadian Journal of Psychiatry. 2013. https://doi.org/10.1177/070674371305800702
  5. Cuijpers P, Sijbrandij M, Koole SL, et al. The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisons. World Psychiatry. 2013. https://doi.org/10.1002/wps.20038
  6. Carpenter JK, Andrews LA, Witcraft SM, et al. Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and Anxiety. 2018. https://doi.org/10.1002/da.22728
  7. Bandelow B, Reitt M, Röver C, et al. Efficacy of treatments for anxiety disorders: a meta-analysis. International Clinical Psychopharmacology. 2015. https://doi.org/10.1097/YIC.0000000000000078
  8. van Dis EAM, van Veen SC, Hagenaars MA, et al. Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2020. https://doi.org/10.1001/jamapsychiatry.2019.3986
  9. Trauer JM, Qian MY, Doyle JS, et al. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Annals of Internal Medicine. 2015. https://doi.org/10.7326/M14-2841
  10. van Straten A, van der Zweerde T, Kleiboer A, et al. Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis. Sleep Medicine Reviews. 2018. https://doi.org/10.1016/j.smrv.2017.02.001
  11. Mitchell MD, Gehrman P, Perlis M, et al. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Family Practice. 2012. https://doi.org/10.1186/1471-2296-13-40
  12. Zachariae R, Lyby MS, Ritterband LM, et al. Efficacy of internet-delivered cognitive-behavioral therapy for insomnia: A systematic review and meta-analysis of randomized controlled trials. Sleep Medicine Reviews. 2016. https://doi.org/10.1016/j.smrv.2015.10.004
  13. Karyotaki E, Efthimiou O, Miguel C, et al. Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis. JAMA Psychiatry. 2021. https://doi.org/10.1001/jamapsychiatry.2020.4364
  14. Andrews G, Basu A, Cuijpers P, et al. Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. Journal of Anxiety Disorders. 2018. https://doi.org/10.1016/j.janxdis.2018.01.001
  15. Williams ACdC, Fisher E, Hearn L, et al. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews. 2020. https://doi.org/10.1002/14651858.CD007407.pub4
  16. Cheng P, Kalmbach D, Fellman-Couture C, et al. Risk of excessive sleepiness in sleep restriction therapy and cognitive behavioral therapy for insomnia: a randomized controlled trial. Journal of Clinical Sleep Medicine. 2020. https://doi.org/10.5664/jcsm.8164
  17. Cuijpers P, Reijnders M, Karyotaki E, et al. Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates. Journal of Affective Disorders. 2018. https://doi.org/10.1016/j.jad.2018.05.050
  18. Karyotaki E, Kemmeren L, Riper H, et al. Is self-guided internet-based cognitive behavioural therapy (iCBT) harmful? An individual participant data meta-analysis. Psychological Medicine. 2018. https://doi.org/10.1017/S0033291718000648
  19. Kyle SD, Miller CB, Rogers Z, et al. Sleep restriction therapy for insomnia is associated with reduced objective total sleep time, increased daytime somnolence, and objectively impaired vigilance: implications for the clinical management of insomnia disorder. Sleep. 2014. https://doi.org/10.5665/sleep.3386
  20. Weise C, Kaiser G, Janda C, et al. Internet-Based Cognitive-Behavioural Intervention for Women with Premenstrual Dysphoric Disorder: A Randomized Controlled Trial. Psychotherapy and Psychosomatics. 2019. https://doi.org/10.1159/000496237
  21. Borji-Navan S, Mohammad-Alizadeh-Charandabi S, Esmaeilpour K, et al. Internet-based cognitive-behavioral therapy for premenstrual syndrome: a randomized controlled trial. BMC Women's Health. 2022. https://doi.org/10.1186/s12905-021-01589-7
  22. Ussher JM, Perz J. Evaluation of the relative efficacy of a couple cognitive-behaviour therapy (CBT) for Premenstrual Disorders (PMDs), in comparison to one-to-one CBT and a wait list control: A randomized controlled trial. PLOS ONE. 2017. https://doi.org/10.1371/journal.pone.0175068
  23. Blake F, Salkovskis P, Gath D, et al. Cognitive therapy for premenstrual syndrome: a controlled trial. Journal of Psychosomatic Research. 1998. https://doi.org/10.1016/s0022-3999(98)00042-7
  24. Lustyk MK, Gerrish WG, Shaver S, Keys SL. Cognitive-behavioral therapy for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review. Archives of Women's Mental Health. 2009. https://doi.org/10.1007/s00737-009-0052-y
  25. Kancheva Landolt N, Ivanov K. Short report: cognitive behavioral therapy, a primary mode for premenstrual syndrome management: systematic literature review. Psychology, Health & Medicine. 2021. https://doi.org/10.1080/13548506.2020.1810718

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