Dysfunctional attitudes in cognitive-behavioral therapy and antidepressant pharmacotherapy for adult depression: A systematic review and meta-analysis of individual participant data.

OBJECTIVES

Dysfunctional attitudes (DA) constitute a vulnerability factor for depression that might be most effectively targeted with cognitive-behavioral therapy (CBT), but evidence is inconclusive. This individual participant data meta-analysis examined DA change during CBT and antidepressant medication, potential pathways of change by exploring how DA were related to depressive symptoms at posttreatment, and whether baseline DA moderated CBT versus antidepressants' efficacy on depression outcomes.

METHOD: We conducted systematic literature searches up to May 1, 2024. We included randomized comparisons of CBT and antidepressants in the acute-phase treatment of adult depression, assessing the Dysfunctional Attitude Scale at baseline and posttreatment. Individual participant data were requested and analyzed with mixed-effects models and network estimation techniques.

RESULTS

Five studies totaling 734 participants met inclusion criteria. DA decreased significantly after CBT and antidepressants, with no significant difference between treatments. Regardless of treatment, posttreatment DA were positively associated with posttreatment depressive symptomatology, particularly with guilt and suicidal thoughts. Baseline DA moderated the efficacy of CBT versus antidepressants on observer-rated outcomes, with CBT more effective for participants with higher DA and antidepressants more effective for those with lower DA, but this was not replicated across individual studies nor with self-reported outcomes.

CONCLUSIONS

Change in DA and its associations with changes in depressive symptomatology do not appear specific to CBT. We found inconsistent evidence for the notion that CBT is more efficacious than antidepressants for individuals with high levels of DA. Repeated DA assessment during treatment would allow for more nuanced analysis in future studies. (PsycInfo Database Record (c) 2026 APA, all rights reserved).