516 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JULY 2009

Cognitive-Behavioral Treatment With Adult Alcohol

and Illicit Drug Users: A Meta-Analysis of Randomized
Controlled Trials*
MOLLY MAGILL, PH.D.,† AND LARA A. RAY, PH.D.†
Center for Alcohol and Addiction Studies, Brown University, Box G S121-4, Providence, Rhode Island 02912

ABSTRACT. Objective: This meta-analysis examined 53 controlled lower at 6-9 months (g = 0.115, p < .005) and continued to diminish at
trials of cognitive-behavioral treatment (CBT) for adults diagnosed 12-month follow-up (g = 0.096, p < .05). The effect of CBT was largest
with alcohol- or illicit-drug-use disorders. The aims were to provide an in marijuana studies (g = 0.513, p < .005) and in studies with a no-treat-
overall picture of CBT treatment efficacy and to identify client or treat- ment control as the comparison condition (g = 0.796, p < .005). Meta-
ment factors predictive of CBT effect magnitude. Method: The inverse regression analyses indicated that the percentage of female participants
variance weighted effect size (Hedges’ g) was calculated for each study was positively associated and the number of treatment sessions was nega-
and pooled using fixed and random effects methods. Potential study-level tively associated with effect size. Conclusions: The findings demonstrate
moderators were assessed in subgroup analyses by primary drug, type the utility of CBT across a large and diverse sample of studies and under
of CBT, and type of comparison condition. In addition, seven client and rigorous conditions for establishing efficacy. CBT effects were strongest
treatment variables were examined in meta-regression analyses. Re- with marijuana users, when CBT was compared with no treatment, and
sults: Across studies, CBT produced a small but statistically significant may be larger with women than with men and when delivered in a brief
treatment effect (g = 0.154, p < .005). The pooled effect was somewhat format. (J. Stud. Alcohol Drugs 70: 516-527, 2009)

C OGNITIVE-BEHAVIORAL TREATMENT (CBT)

models are among the most extensively evaluated inter-
ventions for alcohol- or illicit-drug-use disorders. Based pri-
of research-based substance-use treatments. Review data to
guide such efforts, however, are needed.
CBT interventions for substance-use disorders have gen-
marily on Marlatt and Gordon’s (1985; Marlatt and Donovan, erally received empirical support, yet their effectiveness as
2005) model of relapse prevention, these treatments target a whole has not been subjected to recent systematic review.
cognitive, affective, and situational triggers for substance Meta-analysis is a promising method of research synthesis
use and provide skills training specific to coping alternatives. useful for large bodies of research that may show disparate
CBT treatment for alcohol or illicit drug use often includes results (Lipsey and Wilson, 2001). To date, qualitative re-
the following strategies: (1) identifying intrapersonal and views have concluded that CBT is more effective than no
interpersonal triggers for relapse, (2) coping-skills training, treatment but have shown mixed results regarding questions
(3) drug-refusal skills training, (4) functional analysis of sub- of implementation (Monti and Rohsenow, 2003), durability
stance use, and (5) increasing nonuse-related activities. These of effects or possible delayed effects (Carroll, 1996; Carroll
models have been manualized (e.g., Carroll, 1998; Kadden et and Onkin, 2005; Miller et al., 2005), and efficacy over other
al., 1992; Monti et al., 1989) and adapted for implementation treatments (Longabaugh and Morgenstern, 1999).
in a variety of clinical capacities. Further, CBT interventions A search of the meta-analytic literature yielded one pre-
have been tested in Stage III research to examine their utility vious review on cognitive-behavioral alcohol or illicit drug
in the “real-world” context, possible adaptations, and cost- treatment. Irvin and colleagues (1999) built on Carroll’s
effectiveness (National Institute on Drug Abuse, 1992; cited 1996 review of relapse prevention by examining 26 experi-
from Carroll and Onkin, 2005). As argued by Carroll and mental and quasi-experimental trials across drugs of abuse,
Rounsaville (2007), the addictions field would benefit from including nicotine. They reported a small overall effect size
greater and continued attention devoted to the dissemination for substance use, a medium effect for psychosocial out-
comes, and suggested that no bias resulted from inclusion of
only published research. Effect sizes were largest in quasi-
Received: June 19, 2008. Revision: February 24, 2009. experimental studies, in studies measuring outcome imme-
*This research was supported by a T32 (AA07459-22) grant awarded by diately following treatment, and in studies with self-reported
the National Institute on Alcohol Abuse and Alcoholism.
†Correspondence may be sent to Molly Magill at the above address or
outcomes. The review suggested that relapse prevention was
via email at: molly_magill@brown.edu. Lara A. Ray is now with the Depart- more effective for alcohol-use disorders than for other sub-
ment of Psychology, University of California at Los Angeles, Los Angeles, stance-use disorders and when delivered in combination with
California pharmacological intervention. The combination of pharma-

516
 MAGILL AND RAY 517

cological and psychosocial treatments has received increased (American Psychiatric Association, 1994). Finally, the stud-
attention, particularly in the field of alcoholism. The efficacy ies were English language and published between 1980 and
of relapse-prevention pharmacotherapies in combination with 2006 (inclusive).
CBT strategies warrants additional review.
Given the empirical and clinical proliferation of CBT, the Literature search
absence of an updated meta-analysis on these approaches
A literature search was conducted to identify eligible
to alcohol or illicit drug treatment is surprising. Psychoso-
studies. First was a title, abstract, keyword, and subject
cial addictions treatments, other than CBT, have received
search of treatment terms (e.g., cognitive-behavioral, relapse
relatively more attention from meta-analytic inquiry. A
prevention, coping skills) and outcome targets (e.g., alco-
review of this literature yielded four meta-analyses of brief
hol, cocaine, methamphetamine, stimulant, opiate, heroin,
motivational interventions (Burke et al., 2003; Dunn et al.,
marijuana, cannabis, illicit drug, substances) in six databases
2001; Harvard et al., 2007; Moyer et al., 2002), three on
(Campbell Collaboration, Cochrane Collaboration, PubMed,
methods based in contingency management (Griffith et al.,
PsychINFO, Social Services Abstracts, and Social Work
2000; Lussier et al., 2006; Prendergast et al., 2006), three
Abstracts). Second was a bibliographic search of qualita-
studies on marital or family-based interventions (Edwards
tive and quantitative reviews on cognitive-behavioral or
and Steinglass, 1995; Powers et al., 2008; Stanton and Shad-
general substance-dependence treatment (i.e., Carroll, 1996,
ish, 1997), and three on self-help approaches (Emrick et al.,
1999; Donovan, 2003; Irvin et al., 1999; Longabaugh and
1993; Kownacki and Shadish, 1999; Tonigan et al., 1996).
Morgenstern, 1999; Marlatt and Witkiewitz, 2005; Miller
Moreover, Butler et al. (2006) examined the current state of
et al., 2003; Monti and Rosehnow, 2003; Morgenstern and
meta-analytic evaluation across 16 studies of CBT for psy-
Longabaugh, 2000; Prendergast et al., 2002). Third was a
chiatric disorders and noted a need for meta-analysis specific
broad, all text or any field database search (PsychINFO,
to substance using populations.
PubMed) to check for studies not identified by the previous
The present meta-analysis provides a broad view of CBT
methods. Finally, there was bibliographic review of articles
efficacy for adults diagnosed with alcohol or illicit drug
derived at all search stages. Figure 1 provides a visual sum-
abuse or dependence. There are a number of promising
mary of study inclusion, which is consistent with QUOROM
CBT approaches available (McCrady, 2000) and their com-
guidelines (Moher et al., 1999). The final meta-analytic
bination with pharmacological (Carroll and Onken, 2005)
sample comprised 59 research reports, describing 52 studies,
or additional psychosocial (Longabaugh and Morgenstern,
and contributing 53 effect sizes, to result in an N of 9,308
1999) treatments may hold greater promise than either type
individuals.
of treatment alone. This meta-analysis updates previous
reviews and additionally includes research on combined Effect size calculation
cognitive-behavioral interventions. The objectives were as
follows: (1) to provide a broad picture of CBT efficacy, (2) The standardized mean difference (Hedges’ g) was used to
to clarify potential design characteristics that may inflate or measure the relative effectiveness of CBT over comparison
diminish effect size and (3) to explore client or treatment conditions for treating adult substance-use disorders. Con-
factors as moderators of outcome, which can inform future ceptually, it is an estimate of treatment effect significance
dissemination efforts. and magnitude expressed in standard deviation units. Hedg-
es’ g has sound statistical properties in samples as small as
Method 20 participants (Hedges, 1994) and includes a correction, f,
for slight upward bias in estimated population effect (a dis-
Study inclusion tinguishing property from Cohen’s d). The formulae were:
g i = M ti − M ci × [ f ]
A number of criteria were used to select studies for this ,
s pi
meta-analysis. First, studies had to be randomized controlled
trials that used psychometrically established outcome mea- where f = 1 − [3 / (4 × df − 1)]
surement. Next, the treatment delivered was identified as (nti − 1)sti2 + (nci − 1)sci2
cognitive-behavioral, relapse prevention, or coping-skills and s pi = .
nti + nci − 2
training. In addition, the CBT treatment could be either
individual or group format and delivered alone or in com- Mt and Mc are the group means for the treatment and com-
bination with one or more treatments, including pharma- parison, respectively; sp is the pooled standard deviation; and
cological treatment. The target population was adults (ages st and sc are the group standard deviations. In addition, effect
18 and older) with a primary diagnosis of alcohol or illicit sizes were inverse variance weighted before pooling, which
drug abuse or dependence as determined by the Diagnostic afforded larger studies more influence on the pooled effect
and Statistical Manual of Mental Disorders, Fourth Edition size (Hedges and Olkin, 1985).
518 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JULY 2009

FIGURE 1. Flow of primary study inclusion. aThese were primarily quasirandom procedures; bmodels included behavioral (e.g., cue exposure), integrative
behavioral (e.g., behavioral self-control training), and social skills or assertiveness training; ccomparison of two types of cognitive-behavioral therapy or
pharmacotherapy studies with cognitive-behavioral therapy held constant; dstudies targeting alcohol moderation; edual-disorder studies with alcohol or illicit
drug use as secondary diagnosis.

An effect size was calculated for each study with the studies with follow-up outcomes (n = 34), effect sizes were
exception of the outpatient and aftercare arms of Project additionally calculated at the first time-point (i.e., follow-up
MATCH (1997), which contributed two effects to the pooled between-group effect size). The outcome indicator for effect
estimate (N = 53). Most were posttreatment between-group size calculation was selected (Lipsey and Wilson, 2001; Wil-
effect sizes, but 16 studies reported only follow-up data. For son, 2000) in the following order: (1) biological measures,
 MAGILL AND RAY 519

(2) measures of use frequency, and (3) sample proportions. of between-study variability (Higgins and Thompson, 2002)
Effect sizes were reverse scored where necessary to ensure along with the pooled effect values.
consistency in effect direction across studies (e.g., number Sensitivity analysis and publication bias. Three types of
of days drank). When outcome data were not reported in sensitivity analyses were conducted. Heterogeneity and mod-
means and standard deviations, test statistics (e.g., t, F, r) erator analyses were the two primary methods for examining
were transformed into the standardized mean difference effect size validity and stability. However, trimmed estimates,
(see, e.g., Lipsey and Wilson, 2001). When dichotomous with high weight or outlier studies removed (Baujat et al.,
outcomes were presented (e.g., number of abstinent partici- 2002), were additionally provided with moderator subgroup
pants), odds ratios were calculated and similarly transformed data. Together, the Q test, fixed and random effects values as
using methods described by Chinn (2000). Finally, in stud- well as trimmed effect sizes by moderator provided a thor-
ies that involved more than two comparison groups, effect ough view of effect size stability across pooling methods.
sizes were calculated for the experimental group versus each To test for possible publication bias, two tests were con-
comparison and then averaged to obtain a single effect per ducted. First, the relationship between study precision and
study. The potential impact of type of comparison condition effect size was assessed using a rank-order correlation test
on estimate magnitude was addressed in subgroup moderator (Begg and Mazumdar, 1994). In the rank-order test, small
analyses. sample/less precise studies are assumed to be published
only when they show large effects, resulting in a significant
Moderator coding procedure and negative correlation when publication bias is present in
the meta-analytic sample. Next, the more commonly used
There were 10 variables examined as potential modera- fail-safe N (Rosenthal, 1991), an estimate of a hypothetical
tors of CBT effectiveness in subgroup and meta-regression number of null studies required to change the observed effect
analyses. These variables were coded by the first and second size to an insignificant value, was calculated.
Moderator analyses. For moderator analyses, three
authors with a 25% random selection of studies double coded
variables were examined in pooled subgroups: (1) primary
to establish rater agreement (n = 13). A minimum threshold
outcome (alcohol, marijuana, cocaine/stimulant/opiate,
of α = .70 for continuous codes (e.g., sample mean age)
or polydrug), (2) treatment type (cognitive-behavioral,
and 70% agreement for categorical codes (e.g., treatment
cognitive-behavioral combined with pharmacotherapy, or
delivery type) was required for a variable to be included in
cognitive-behavioral combined with another psychosocial
the analyses. Alpha values were in the excellent range (α
treatment), and (3) comparison type (no-treatment or wait-
= .97-1.0). Percentage agreement for categorical variables
list control, passive or usual service comparison, theoreti-
ranged from 77% to 92%, with the exception of nonsignifi-
cally active comparison, and no cognitive-behavioral adjunct
cant group differences at baseline (64% agreement), which comparison). This latter subgroup included studies of cogni-
was not included in the analyses. Variable coding guidelines tive-behavioral intervention added to another psychosocial
were outlined in a codebook available, on request, from the treatment where the comparison was that treatment alone.
first author. Given that Irvin and colleagues (1999) found larger
effects in studies with posttreatment and self-report mea-
Data analysis surement, effect size data were regressed on primary study
client and treatment characteristics, and these two design
Model of inference and heterogeneity. In calculating variables as well as posttreatment attrition rate were exam-
combined effect sizes, alcohol- and illicit-drug-use outcomes ined as covariates. Client variables were demographic and
were considered fixed effects. Specifically, it was assumed diagnostic: age, percentage female participants, inclusion of
that CBT effect sizes represented a single population or a co-occurring non-substance-related disorders, and alcohol or
distribution of populations with between-study heterogeneity illicit drug outcome. The treatment variables were delivery
that could be explained by known moderators. The signifi- (as standalone or as aftercare), format (individual or group),
cance of the Cochrane Q test for heterogeneity determined and length (number of sessions). Missing variable codes
whether this model of inference was tenable, that is, was it were mean imputed, and a predictor was removed from the
valid to combine these studies? If the null hypothesis was analysis if imputed values reached 20% of total cases (Pig-
retained (p > .05), the studies were considered homogeneous ott, 1994). Analyses were conducted using Wilson’s (2005)
and fixed effects values were the appropriate estimators. METAREG for weighted least squares and maximum likeli-
If rejected, a priori moderators were examined, and if the hood regression in SPSS Version 15 (SPSS Inc., Chicago,
Q value remained significant, random effects values were IL). Variables with significant regression coefficients were
considered the better estimates. Hedges and Vevea (1998) placed into a final predictive model and, if the model con-
describe this model of inference as conditionally random. In tained significant residual heterogeneity, maximum likeli-
addition, I2 values were provided as descriptors of proportion hood random effects analyses were conducted.
520 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JULY 2009

Results geneity could be accounted for by two trials reporting data

at 1 (Kelly et al., 2000) and 3 (Tucker et al., 2004) months
Sample descriptives following treatment. Analyses with Kelly et al. (2000) and
Tucker et al. (2004) removed showed a larger effect at 6-9
The sample for this meta-analysis consisted of 53 random- months (fixed g = 0.115, p < .005; n = 23) that diminished at
ized trials of CBT for adults diagnosed with substance-use 12 months (fixed g = 0.096, p < .05; n = 9). These analyses
disorders published between1982 and 2006. Of these studies, supported the assumption of homogeneity, suggesting that
25% were published outside of the United States. The mean time of outcome assessment was an important predictor of
sample size was 179 participants (range: 20-1,656). The between-study variance. Therefore, the subgroup values at
treatment targets were: alcohol (n = 23), cocaine/stimulants 6-9 and 12 months represent the optimal estimates of CBT
(n = 11), polydrug (n = 11), marijuana (n = 6), and opiates effect at follow-up.
(n = 2). The samples’ mean (SD) age was 38 (5.7) years.
Studies included a moderate percentage of typically under- Publication bias
represented groups such as women (mean = 29.2% [21.9%])
and ethnic or racial minorities (25.9% [27.8%]). The major- Our results did not suggest the presence of publication
ity of studies enrolled only individuals with a diagnosis of bias in the sample of studies reviewed. The rank-order cor-
alcohol or drug dependence (80.1%), whereas the remaining relation (Begg and Mazumdar, 1994) showed a negative, but
studies also allowed individuals with a diagnosis of abuse. nonsignificant, relationship between precision and effect size
Approximately 64% of studies allowed nonsubstance-related (τ = -.03, p > .10, one tailed). Moreover, the fail-safe N indi-
co-occurring diagnoses (exclusive of suicidal or homicidal cated that at an alpha level of .05, 340 unpublished null stud-
ideation and active psychosis). A slight majority of interven- ies would be required to reduce the overall observed estimate
tions were delivered in an individual format (57.7%), there to statistical nonsignificance, which lends additional support
was a mean of 18 (11.9) (range: 1-48) sessions, and these for an absence of publication bias in the present review.
treatments were evenly distributed regarding delivery as
standalone (n = 31) or aftercare following other services (n Subgroup moderators
= 22). Table 1 provides an overview of study design charac-
teristics, effect sizes and corresponding confidence intervals Table 2 presents results for subgroup moderators and
(CIs). These studies were methodologically rigorous with sensitivity analyses. First, for CBT across alcohol or other
acceptable attrition rates (mean = 19.3% [12.9%]), and high drug outcomes, pooled effect sizes were small with the
rates of both biologically validated outcomes (75% of stud- exception of CBT with marijuana use, which had a moder-
ies) and manualized treatment delivery (98% of studies). ate and homogenous effect size (fixed g = 0.513, p < .005;
n = 6). Second, studies of CBT combined with additional
Main treatment effect psychosocial treatment showed a larger effect size (random
g = 0.305, p < .005; n = 19) than for CBT combined with
Overall, the pooled CBT effect was g = 0.144 (95% CI: pharmacological treatment (fixed g = 0.208, p < .005; n =
0.094, 0.194, p < .005; N = 53), which represents a small ef- 13) and for CBT alone (random g = 0.172, p < .05; n = 21).
fect size according to guidelines suggested by Cohen (1977). Finally, a large effect size was found for CBT in comparison
The test for homogeneity was rejected at the .005 level (Q to no treatment (random g = 0.796, p < .005; n = 6). A con-
= 128.85, 52 df), and the I2 value showed that 60% of the sistent, small-sized, effect was found across other types of
variance in effect sizes could be explained by differences comparison condition (i.e., usual services, active treatment)
between studies (a moderate level of heterogeneity; Higgins with the exception of CBT adjunctive treatment. The effect
et al., 2003). The random effects estimate was slightly higher of CBT as an adjunct to a psychosocial treatment compared
(g = 0.154, 95% CI: 0.066, 0.242, p < .005) than the fixed with psychosocial treatment alone was negative and nonsig-
effects estimate but was consistent regarding overall interpre- nificant (random g = -0.054, NS; n = 7).
tation of magnitude. Because of the observed heterogeneity,
the random effects value was the better estimator of CBT Regression moderators
effect with alcohol- or other drug-use disorders.
The sample of studies reporting follow-up outcomes for Of the three methodological covariates studied—(1)
CBT showed an effect size that was slightly lower (g = 0.108, type of outcome assessment (self-report or biological), (2)
95% CI: 0.051, 0.165, p < .005; n = 34) than that reported time of follow-up assessment (posttreatment to 4 months
for the overall posttreatment sample and that was heteroge- or 6-12 months), and (3) posttreatment attrition rate—only
neous (Q = 56.95, 33 df, p < .05). Follow-up time-points outcome type and follow-up time were related to effect size
ranged from 1 to 12 months, and analyses conducted sepa- (b = -.163, p < .005; b = -.129, p < .05, respectively). Table
rately by time showed that a significant portion of hetero- 3 summarizes findings for the seven client and treatment
 MAGILL AND RAY 521

TABLE 1. Main treatment effect on substance-use reduction

Primary No.
First author N Type of treatment Type of comparison drug sess. Time Outcome g (95% CI) wi
Jones (1982) 20 CBT control discussion group alcohol 6 12 mo. days abstinent. 0.58 (-0.29, 1.44)a 0.33
Hawkins (1986) 130 + social support TAU polydrug 20 post rate abstinent 0.14 (-0.34, 0.61) 1.09
Hawkins (1989)
Donovan (1988) 31 CBT IPT alcohol 8 6 mo. days drankb 0.27 (-0.42, 0.96) 0.52
Kadden (1989) 96 CBT interactional group alcohol 26 post days abstinent -0.05 (-0.42, 0.33) 1.77
Cooney (1991)
McAuliffe (1990) 88 + social support control opiates 24 post rate abstinent 0.29 (-0.28, 0.86) 0.76
Monti (1990) 69 + relaxation CST alcohol 12 6 mo. days abstinent -0.14 (-0.79, 0.52)a 0.57
Carroll (1991) 42 CBT IPT cocaine 12 post rate abstinent 0.63 (-0.12, 1.38) 0.44
Annis (1992) 56 + calcium carbimide MM alcohol 16 6 mo. composite 0.50 (-0.09, 1.10) 0.69
O’Malley (1992) 97 + naltrexone supportive + naltrexone alcohol 12 post days drankb -0.67 (-1.35, -0.01)a,c* 0.54
Jaffe (1996) + placebo supportive + placebo
Monti (1993) 40 + cue exposure attention control alcohol 6 3 mo. rate abstinent -0.12 (-0.87, 0.63) 0.44
Carroll (1994) 139 + desipramine MM + naltrexone cocaine 12 post days abstinent -0.15 (-0.68, 0.37)a,c 0.90
+ placebo MM + placebo
Stephens (1994) 212 CBT social support group marijuana 12 post days usedb 0.29 (-0.01, 0.60) 2.67
Sobell (1995) 100 + behavioral therapy behavioral therapy alcohol 3 post days abstinent -0.37 (-0.84, 0.10) 1.11
McKay (1997) 98 CBT TAU cocaine 40 post days usedb -0.14 (-0.53, 0.25) 1.59
Monti (1997) 108 CBT relaxation training cocaine 8 3 mo. days usedb 0.51 (0.13, 0.89)* 1.70
Rohsenow (2000)
Project 1,656 CBT MI alcohol 12 post rate abstinent–o 0.08 (-0.12, 0.27)a 6.49
MATCH (1997) TSF rate abstinent–a 0.09 (-0.12, 0.31)a 5.59
Carroll (1998) 122 CBT TSF polydrug 16 post weeks abstinent -0.25 (-0.84, 0.33)a,c 0.72
Carroll (2000) + disulfiram TSF + disulfiram
supportive + disulfiram
Maude-Griffin 128 CBT TSF cocaine 48 post weeks abstinent 0.44 (0.09, 0.79)* 2.02
(1998)
Crits-Critsoph 487 + group counseling group counseling cocaine 36 post rate abstinent -0.24 (-0.55, 0.08)a 2.49
(1999) individual + group
supportive + group
Budney (2000) 40 + MI MI marijuana 14 post days usedb 0.25 (-0.36, 0.86)d 0.66
Conrod (2000) 146 + MI film polydrug 1 6 mo. no. symptomsb 0.41 (0.07, 0.75)d* 2.13
Kelly (2000) 32 + MI control alcohol 6 post no. daily useb 1.21 (0.42, 2.00)§ 0.40
Stephens (2000) 291 CBT MI marijuana 14 post days usedb 0.56 (0.25, 0.87)§ 2.59
control
Copeland (2001) 229 CBT control marijuana 6 7 mo. days abstinent 0.36 (0.04, 0.69)b* 2.38
+ MI
Heinälä (2001) 121 + naltrexone supportive + naltrexone alcohol 4 post rate abstinent 0.03 (-1.06, 1.12)a,c 0.21
+ placebo supportive + placebo
Kadden (2001) 128 CBT interactional group alcohol 26 post days abstinent 0.09 (-0.26, 0.43) 2.07
Litt (2003)
Monti (2001) 128 + cue exposure education/relaxation alcohol 14 3 mo. heavy drink daysb 0.18 (-0.17, 0.52)e 2.07
TABLE 1–Continued on next page

variables while controlling for assessment type and time. In Discussion

the client model, the percentage of female participants had
a positive association (b = .005, p < .05) and, in the treat- Across a large, diverse, and rigorous sample of random-
ment model, length of treatment had a negative association ized trials, CBT for adult substance-use disorders dem-
(b = -.008, p < .005) with effect size. The final fixed effects onstrated a small, but statistically significant, effect over
model accounted for 20.5% of the variance in CBT effect comparison conditions. Meta-analyses of other alcohol or il-
sizes, and these findings held in sensitivity analyses with licit drug treatments show effect sizes generally in the small
the two high-weight trials (Project MATCH, 1997; Anton et to moderate range (e.g., Burke et al., 2003; Prendergast et
al., 2006) removed from the analysis. However, the Q value al., 2002, 2006), and only a slightly larger effect was found
for the residual was significant, indicating that the a priori in Irvin and colleagues’ (1999) meta-analysis of relapse
moderators could not explain a fixed population effect. The prevention (four studies in this review overlap with those
final maximum likelihood model (with the random effects τ2 examined by Irvin et al.: Carroll et al., 1994; Hawkins et
estimate of .04 added to individual inverse variance weights) al., 1986; O’Malley et al., 1992; Sobell et al., 1995). Meta-
resulted in an R2 value of .169 (p < .05), thereby accounting analytic review is often late-stage evaluation research, and
for 16.9% of the variance in CBT effectiveness with adult the data provided should therefore be of practical clinical
alcohol- or illicit-drug-use disorders. and empirical value. To better illustrate the impact of CBT,
522 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JULY 2009

TABLE 1. Main treatment effect on substance-use reduction (Continued from previous page)
Primary No.
First author N Type of treatment Type of comparison drug sess. Time Outcome g (95% CI) wi
Morgenstern (2001) 168 CBT TAU polydrug 12 6 mo. days abstinent -0.08 (-0.38, 0.22)d 2.72
Rohsenow (2001) 100 + cue exposure meditation/relaxation alcohol 10 6 mo. heavy drink daysb 0.18 (-0.22, 0.57) 1.57
Schmitz (2001) 85 + naltrexone TAU + naltrexone cocaine 20 post - urine screen 0.41(-0.01, 0.84)a,c 1.35
+ placebo TAU + placebo
Brown (2002) 131 + MI TSF polydrug 10 6 mo. days usedb 0.19 (-0.15, 0.53) 2.11
Burtscheidt (2002) 120 CBT social support group alcohol 26 post rate abstinent 0.31 (-0.18, 0.80)c 1.05
Pollack (2002) 23 + cue exposure TAU polydrug 15 post - urine screen 0.03 (-1.38, 1.43) 0.13
Rawson (2002) 120 CBT CM cocaine 48 post - urine screen 0.18 (-0.44, 0.80)a,c 0.64
Messina (2003) + CM TAU
Balldin (2003) 118 + naltrexone TAU + naltrexone alcohol 9 post heavy drink daysb 0.18 (-0.33, 0.69)a,c 0.95
+ placebo TAU + placebo
Epstein (2003) 193 CBT CM cocaine 12 post no. daily useb 0.07 (-0.33, 0.47)a,c 1.57
+ CM social support group
Carroll (2004) 121 + disulfiram IPT + disulfiram cocaine 20 post - urine screen 0.27 (-0.09, 0.62)a,c 1.95
+ placebo IPT + placebo
Hammarberg (2004) 70 + acamprosate minimal + acamprosate alcohol 15 post heavy drink daysb 0.21 (-0.56, 0.97) 0.42
MTRP (2004) 450 + MI MI marijuana 9 post days usedb 0.82 (0.57, 1.07)a§ 3.91
control
Rohsenow (2004) 165 + MI relaxation + education cocaine 6 post rate abstinent 0.38 (0.01, 0.74)* 1.85
Sandahl (2004) 49 CBT IPT alcohol 15 12 mo. days abstinent -0.64 (-1.21, -0.08)* 0.77
Schmitz (2004) 80 + naltrexone TAU + naltrexone polydrug 20 post - urine screen -0.44 (-1.06, 0.17)a,c 0.65
+ placebo TAU + placebo
Tucker (2004) 97 + naltrexone TAU + naltrexone opiates 12 post days usedb 0.16 (-0.24, 0.56) 1.57
Wetzel (2004) 242 + nefazodone TAU + nefazodone alcohol 24 post days abstinent -0.07 (-0.46, 0.32)a,c 1.62
+ placebo TAU + placebo
Anton (2005) 160 + naltrexone MI + naltrexone alcohol 12 post days abstinent 0.34 (-0.08, 0.79)a,c 1.28
+ placebo MI + placebo
Bennett (2005) 124 + TAU TAU alcohol 15 12 mo. days drankb 0.36 (0.01, 0.72)* 1.91
Rosenblum (2005) 298 + MI + peer advocacy TAU + peer advocacy polydrug 48 post any substance use 0.17(-0.06, 0.40) 4.66
Rowan-Szal (2005) 61 CBT TAU polydrug 8 post rate abstinent 0.31(-0.59, 1.20)a,c 0.31
+ CM TAU + CM
Budney (2006) 90 CBT CM marijuana 14 post days abstinent 0.22(-0.32, 0.77)c 0.82
+ CM
Anton (2006) 1,383 pooled + MI pooled no CBI alcohol 20 post days abstinent 0.01(-0.10, 0.13)a,c 14.62
Gilbert (2006) 34 + domestic violence education polydrug 12 3 mo. rate abstinent 0.64(-0.31, 1.60) 0.27
intervention
Rawson (2006) 97 CBT CM stimulants 48 post rate abstinent -0.84(-1.28, -0.41)c§ 1.30
+ CM
Notes: Drug = drug outcome; no. sess. = number of sessions; time = time of outcome measurement; outcome = outcome measure; CI = confidence interval; wi
= relative weight; post = posttreatment; CBT = cognitive-behavioral treatment; mo. = month; TSF = twelve-step facilitation; TAU = treatment as usual; IPT =
interpersonal psychotherapy; CST = communication skills training; MM = medication management; MI = motivational interviewing; CM = contingency man-
agement; rate abstinent–o = abstinence rate–outpatient; rate abstinent–a = abstinence rate–aftercare; MTRP = Marijuana Treatment Project Research Group.
aEstimate with pooled comparison arms; bestimate reverse scored; cestimate with pooled treatment arms; done arm not included in analysis; efollowing 3-month

naltrexone trial.
*p < .05; §p < .005.

the U3 index was calculated. This index transforms the effect Studies of CBT combined with an additional psychosocial
size to a “success percentage,” or the percentage of treated treatment had a larger effect than either CBT combined with
participants that performed better than the median for the pharmacological treatment or CBT alone in both fixed and
comparison group (Rosenthal and Rubin, 1982). The U3 random effects estimates. Again, this is in contrast with Irvin
value for this meta-analysis indicated that 58% of patients et al. (1999), who reported greater effects for relapse preven-
receiving CBT fared better than patients in the comparison tion plus pharmacotherapy than for relapse-prevention only,
condition. but combined psychosocial treatments were not included in
Across drugs of abuse, types of CBT treatment, and types their meta-analytic sample. In general, large departures from
of comparison condition, pooled effect sizes were small and a small effect size were found only in studies of marijuana-
fell primarily within a similar range. The exception was use disorders and across comparison types, in studies that
marijuana-use disorders, which had a moderate and homo- compared CBT to no treatment. Specifically, a large effect
geneous effect, and a U3 value of 69%. Irvin and colleagues size and a corresponding U3 value suggested that 79% of
(1999) reported the highest effects for alcohol, but their individuals treated with CBT showed rates of substance-use-
review occurred when marijuana research was in its infancy. reduction above the median of those assigned to a wait-list
 MAGILL AND RAY 523

TABLE 2. Main treatment effect by primary drug, type of CBT treatment, and type of comparison condition
CBT + CBT + Vs active Vs passive Vs no Vs no
Variable Alcohol Marijuana C/S/O Polydrug CBT psychosoc. pharm. treatment treatment treatment adjunct
Fixed
effects 0.067a 0.513b§ 0.126c* 0.116 0.165d§ 0.329e* 0.208f§ 0.129g* 0.116§ 0.848§ 0.089h
95% CI -0.002, 0.136 0.375, 0.651 0.011, 0.242 -0.007, 0.239 0.085, 0.245 0.238, 0.421 0.070, 0.346 0.041, 0.217 0.052, 0.180 0.692, 1.010 -0.066, 0.244
Range -0.670, 1.209 0.225, 0.824, -0.845, 0.626 -0.442, 0.642 -0.644, 0.626 -0.239, 1.210 -0.451, 0.867 -0.644, 0.626 -0.451, 0.867 0.288, 1.210 -0.845, 0.523
N 23 6 13 11 21 19 13 17 32 6 7
Q (df) 34.20 (22)* 10.53 (5) 40.39 (12)§ 10.96 (10) 37.80 (20)* 64.23 (18)§ 18.53 (12) 20.09 (16) 34.10 (31) 18.66 (5)§ 35.21 (6)§
I2 35.67* 52.53 70.29 8.72 47.09 71.97 35.25 20.38 31.26 73.21 82.96
Random
effects 0.088 0.470§ 0.133 0.113 0.172* 0.305§ 0.199* 0.133* 0.152§ 0.796§ -0.054
95% CI -0.018, 0.194 0.259, 0.681 -0.084, 0.350 -0.020, 0.246 0.053, 0.292 0.116, 0.493 0.021, 0.376 0.029, 0.238 0.062, 0.242 0.454, 1.140 -0.455, 0.348
Notes: C/S/O = cocaine/stimulant/opiate; CBT = cognitive-behavioral treatment; psychosoc. = psychosocial; pharm. = pharmacological; CI = confidence
interval. aThe trimmed estimate with three outlying (Kelly et al., 2000; O’Malley et al., 1992; Sandahl et al., 2004) and two high weight (Anton et al., 2006;
Project MATCH, 1997) trials removed was larger, significant, and homogeneous (g = 0.14, p < .05, Q > .05); bthe estimate with one high-weight study (MTRP,
2004) removed was 0.38 (p < .005, Q > .05); cthe trimmed estimate with two outlying trials (Carroll et al., 1991; Rawson et al., 2006) removed was slightly
larger but remained heterogeneous (g = 0.19, p < .05, Q < .05); dthe trimmed estimate with one outlying trial (Sandahl et al., 2004) removed was slightly
higher (g = 0.18, p < .005, Q < .05) but remained heterogeneous; ethe trimmed estimate with two outlying studies (Kelly et al., 2001; MTRP, 2004) removed
was lower and homogeneous (g = 0.20, p < .005, Q > .05); fthe trimmed estimate with one outlying study (Heinälä et al., 2001) removed was slightly lower (g
= 0.19, p < .05, Q > .05); Anton et al. (2006) not included in analyses because it qualifies as both a psychosocial and pharmacological combined intervention;
gpositive effect comparisons include interpersonal psychotherapy (Carroll et al., 1991, 2004; Donovan and Ito, 1988), twelve-step facilitation (Brown et al.,

2002; Maude-Griffin et al., 1998), motivational interviewing (Anton et al., 2005; Stephens et al., 2000), and contingency management (Budney et al., 2006);
hthe trimmed estimate with one outlying trial (Rawson et al., 2006) removed was larger, significant but remained heterogeneous (g = 0.22, p < .05, Q < .05).

*p < .05; §p < .005.

TABLE 3. Study-level moderators of substance-use outcomes (n = 53)

or similar no-treatment control. In light of these findings, it Model β b z p
is important to note that no-treatment control studies were Client factors
a minority among those examined, and that effect size esti- Biological outcome -.191 -.118 -1.87 .061
mates were also positive and significant for both active and 6- to 12-month outcome -.170 -.102 -1.63 .104
Mean age of participants -.071 -.004 -0.58 .560
passive or treatment-as-usual comparisons. Percentage female participants .248 .005 2.66 .008
Treatment effects for CBT diminished over time, with Co-occurring disorder inclusion -.046 -.028 -0.44 .659
somewhat lower effects at 6- to 9-month follow-up and Illicit drug outcome .123 .073 0.98 .327
R2 = .186
markedly diminished effects at 12 months. This finding is QE (46) = 104.86§
consistent with previous meta-analytic research on relapse Treatment factors
prevention (Irvin et al., 1999) and does not support a de- Biological outcome -.129 -.079 -1.16 .247
6- to 12-month follow-up outcome -.228 -.134 -2.23 .026
layed emergence of treatment effects suggested by Carroll Treatment delivery .152 .096 1.61 .108
(1996). The CBT focus on ongoing coping without the use Treatment format .017 .011 0.17 .866
of substances would possibly place it among treatments Treatment length -.312 -.008 -3.00 .003
R2 = .193
suited toward longer-term outcomes, and this may be why it QE (47) = 103.52§
is often used as aftercare. This review (as well as a previous Final model–weighted least squaresa
review, Longabaugh and Morgenstern, 1999) has not found Biological outcome -.083 -.050 -0.78 .432
6- to 12-month follow-up outcome -.261 -.153 -2.57 .010
support for aftercare as a uniquely beneficial format for Percentage female participants .200 .004 2.06 .039
clinical delivery. Thus, future research will need to clarify Treatment length -.252 -.006 -2.47 .014
the mechanisms of ongoing reduction in substance use (e.g., R2 = .205
QR (4) = 26.25§
continued coping-skill use) in CBT to inform treatment ad- QE (48) = 101.95§
aptations that promote longer-term treatment gains. g = 0.144§
Among the client factors examined, women appeared Final model–maximum likelihood
Biological outcome -.048 -.037 -0.34 .732
to benefit more from CBT than men. Dumaine (2003) also 6- to 12-month follow-up outcome -.185 -.134 -1.44 .149
found a positive association between female participants Percentage female participants .226 .004 1.69 .089
and effect size in a meta-analysis of treatment with indi- Treatment length -.259 -.007 -1.76 .077
R2 = .169
viduals with co-occurring substance and other mental health QR (4) = 10.90*
disorders. Dumaine’s findings were based on bivariate cor- QE (47) = 53.52
relations, and this meta-analysis may be more conservative τ2 = .04
g = 0.155§
given that additional client and study design variables were
accounted for in the analyses. Assessment of primary stud- Notes: Attrition rate nonsignificant as a methodological covariate. aResults
held in the final weighted least squares model with the two high-weight tri-
ies with female-only samples, however, highlights additional als (Project MATCH, 1997; Anton et al., 2006) removed.
study characteristics to consider when interpreting this result. *p < .05; §p < .005.
524 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JULY 2009

Specifically, study sample size (Gilbert et al., 2006; Kelly et with contingency management. The noted findings provide
al., 2000) and strength of comparison (Conrod et al., 2000) provisional clinical guidelines and future directions for dis-
may be additional factors contributing to a positive associa- semination research.
tion between proportion of female participants and CBT ef-
fect size. Acknowledgments
This meta-analysis found no difference in effectiveness of
CBT by format (group or individual), found little evidence This meta-analysis was originally conducted in partial fulfillment of the
for its value as an adjunctive treatment, and found support requirements for Dr. Molly Magill’s doctoral degree from Boston College
for a benefit of shorter duration interventions. Given absent Graduate School of Social Work. The authors thank Drs. Thomas O’Hare
and Timothy Apodaca for their valuable guidance on this manuscript. They
differences by format, group CBT may be the most cost-ef- also thank Drs. Joseph Pedulla and Robert Dunigan for their committee
fective option for clinical delivery. CBT as an adjunct to a participation.
psychosocial treatment may not yield improved outcomes
beyond that treatment alone, but this finding may represent References
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