This week we will be discussing an article published in the Journal of Clinical Psychology Review titled, “Cognitive behavioral therapy for internalizing disorders in children and adolescents in routine clinical care: A systematic review and meta-analysis”, written by authors Wergeland, Riise, and Ӧst. 


Why did they do it?

Cognitive-Behavioral Therapy (CBT) is a well-known and empirically supported approach to treating psychiatric conditions, such as anxiety, depression, and others. However, as the authors highlight, due to the nature of how randomized controlled trials (RCTs) are set up, there is far less empirical research regarding the efficacy of CBT when it is delivered in a routine clinical care setting (e.g., in a typical therapist’s office). 

It is important to evaluate how efficacy data from RCTs translates to real-world practice. After all, traditional efficacy studies often implement rigorous inclusion and exclusion criteria that are not representative of “real world” clients, limiting the generalizability of findings from these studies. Thus, the authors sought to conduct a meta-analysis of the effectiveness of CBT in treating internalizing disorders in children and adolescents presenting in routine clinical care settings. 


How did they do it?

The authors conducted this meta-analysis according to PRISMA and AMSTAR 2 guidelines. Studies included in the review were identified using a systematic and comprehensive literature search of electronic databases, and scanning reference lists of articles published through October 2019. 

58 studies were included in the final meta-analysis. Using these studies, the authors aimed to first examine the effectiveness of CBT for anxiety disorders, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and depressive disorders for children and adolescents. Second, the authors sought to evaluate potential moderators of treatment outcomes. Lastly, the authors aimed to evaluate if results from CBT interventions in effectiveness studies are comparable to those found in efficacy studies.


What did they find?

With regard to study characteristics, the majority of the 58 studies were conducted in Europe (n = 29) and North America (n = 18), with fewer studies coming from Australia (n = 5), Asia (n = 4), South America (n = 1), and Africa (n = 1). In total, 4,618 participants (Mean age = 12.5 years, 58% female) were included. The authors provide in-depth details regarding their specific results, but here we will highlight the primary findings. 

Overall, nearly two-thirds of participants achieved remission at follow-up (average 10.7 months after the end of treatment). Results also revealed some specificity, such that some disorders yielded more favorable outcomes. OCD was found to have the largest effect size, while PTSD had the highest remission rate. Attrition rates across disorders averaged 12.2%, with no significant differences between disorders. While the authors note that this is lower than previously reported, these findings suggest that youth receiving CBT for internalizing disorders in routine clinical care improved significantly and substantially following treatment, and that CBT is clearly an effective intervention approach in clinical settings. 

When examining patient and treatment characteristics, the authors found that on average, being older was associated with better outcomes. Gender was identified as an additional moderator, such that a higher proportion of girls in the sample were associated with both a lower effect size and a higher remission rate. 

For more information about the results from this meta-analysis, we encourage you to go check out the article!


What does it all mean (our take)?

CBT is a robust treatment modality that certainly produces strong effects in highly controlled settings (e.g., RCT settings) and also in more typical treatment settings. The meta-analysis reviewed today shines light on an important issue - we must ensure that our interventions not only have strong efficacy, but also strong effectiveness. At the end of the day, it is the effectiveness of a treatment approach that impacts clinicians most.

We thank the authors for this fantastic review, and again we encourage you (the reader) to go have a look at this article yourself!

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