Received: 9 June 2022 Revised: 2 October 2022 Accepted: 3 October 2022

DOI: 10.1002/eat.23831

REVIEW

Cognitive behavioral therapy for eating disorders: A map of the

systematic review evidence base

Milla Kaidesoja MA 1 | Zafra Cooper PhD 2 | Beth Fordham PhD 1

1
NDORMS, University of Oxford, Oxford, UK
2
Department of Psychiatry, Yale School of Abstract
Medicine, New Haven, Connecticut, USA Objective: To map and examine the systematic review evidence base regarding the

Correspondence effects of cognitive-behavioral therapy (CBT) for eating disorders (EDs), especially
Milla Kaidesoja, NDORMS, University of against active interventions.
Oxford, Oxford OX3 7LD, UK.
Email: [Link]@[Link]
Method: This systematic review is an extension of an overview of CBT for all health
conditions (CBT-O). We identified ED-related systematic reviews from the CBT-O
Action Editor: Kelly L. Klump
database and performed updated searches of EMBASE, MEDLINE, and PsychInfo in
[Correction added on 14 November 2022, April 2021 and September 2022.
after first online publication: The in-text
citation and complete reference for
Results: The 44 systematic reviews included (21 meta-analyses) were of varying qual-
“Weissman & Frank, 2017” has been replaced ity. They focused on “high intensity” CBT, delivered face-to-face by qualified clini-
with “Weissman et al., 2017” in this version.]
cians, in BN, BED and mixed, not specifically low-weight samples. ED-specific
outcomes were studied most, with little consensus on their operationalization. The,
often insufficient, reporting of sample characteristics did not allow assessment of the
generalizability of findings. The meta-analytic syntheses show that high intensity
one-to-one CBT produces better short-term effects than a mix of active controls
especially on ED-specific measures for BED, BN, and transdiagnostic samples. There
is little evidence favoring group CBT or low intensity CBT against other active
interventions.
Discussion: While this study found evidence consistent with current ED treatment
recommendations, it highlighted notable gaps that need to be addressed. There were
insufficient data to allow generalizations regarding sex and gender, age, culture and
comorbidity and to support CBT in AN samples. The evidence for group CBT and low
intensity CBT against active controls is limited, as it is for the longer-term effects of
CBT. Our findings identify areas for future innovation and research within CBT.
Public Significance: This study provides a comprehensive mapping and quality
assessment of the current large systematic review research base regarding the
effects of cognitive behavioral therapy (CBT) for eating disorders (EDs), with a focus
on comparisons to other active interventions. By transcending the more limited
scope of individual systematic reviews, this overview highlights the gaps in the cur-
rent evidence base, and thus provides guidance for future research and clinical
innovation.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.

Int J Eat Disord. 2023;56:295–313. [Link]/journal/eat 295

296 KAIDESOJA ET AL.

Resumen

n sistemática con
Objetivo: Mapear y examinar la base de evidencia de la revisio
respecto a los efectos de la terapia cognitivo-conductual (TCC) para los trastornos de
la conducta alimentaria (TCA), especialmente contra las intervenciones activas.

n sistemática es una extensio
Método: Esta revisio
n de una visio

n general de la TCC
para todas las afecciones de salud (TCC-O, Fordham et al., 2021a). Se identificaron
revisiones sistemáticas relacionadas con los TCA a partir de la base de datos TCC-O
y se realizaron búsquedas actualizadas en EMBASE, MEDLINE y PsychInfo en abril
de 2021 y septiembre de 2022.
Resultados: Las 44 revisiones sistemáticas incluidas (21 metanálisis) fueron de calidad
variable. Se centraron en la TCC de “alta intensidad”, administrada cara a cara por
clínicos calificados, en BN, TpA y muestras mixtas, no específicamente de bajo peso.
Los resultados específicos de los TCA fueron los más estudiados, con poco consenso

n. El informe, a menudo insuficiente, de las características
sobre su operacionalizacio

evaluar la generalizacio
de la muestra no permitio
n de los hallazgos. Las síntesis
metaanalíticas muestran que la TCC uno a uno de alta intensidad produce mejores

n de controles activos, especialmente en
efectos a corto plazo que una combinacio

sticas. Hay poca
medidas específicas de TCA para TpA, BN y muestras transdiagno
evidencia a favor de la TCC grupal o la TCC de baja intensidad frente a otras inter-
venciones activas.

n: Si bien este estudio encontro
Discusio
evidencia consistente con las recomenda-

las brechas notables que
ciones actuales de tratamiento de los TCA, también destaco
deben abordarse. No hubo datos suficientes para permitir generalizaciones con
respecto al sexo y el género, la edad, la cultura y la comorbilidad y para apoyar la
TCC en las muestras de AN. La evidencia para la TCC grupal y la TCC de baja intensi-
dad contra los controles activos es limitada, al igual que para los efectos a más largo

n y la
plazo de la TCC. Nuestros hallazgos identifican áreas para la innovacio

n futuras dentro de la TCC.
investigacio

KEYWORDS
anorexia nervosa, binge-eating disorder, bulimia nervosa, CBT, cognitive behavioral therapy,
eating disorder, EDNOS, OSFED, overview, systematic review

1 | I N T RO DU CT I O N CBT is now recommended by the majority of evidence-based

national guidelines (Hilbert et al., 2017) as the first line of treatment
Cognitive behavioral approaches to the understanding and treatment for bulimia nervosa (BN) and binge eating disorder (BED), and to a
of the eating disorders (EDs) were first developed in the early eighties lesser extent (due to less robust evidence) for the other specified
(Fairburn, 1981; Fairburn et al., 1986; Garner & Bemis, 1982). Since feeding and eating disorders (OSFED) (this DSM-5 diagnosis partially
this time, theory and treatment have evolved to focus on the mecha- overlaps with the previously used DSM IV category, “eating disorder
nisms proposed to maintain eating disorder psychopathology across not otherwise specified” [EDNOS]). While CBT is clearly regarded as
the full range of EDs (Cooper & Fairburn, 2011; Fairburn the treatment of choice for these latter disorders that do not involve
et al., 2003). In addition, evidence supporting cognitive behavioral significantly low weight (Weissman et al., 2017), it is one amongst a
therapy (CBT) for these disorders has accumulated from randomized number of options for the treatment of adults with anorexia nervosa
controlled trials (RCTs) and has been synthesized in a number of sys- (AN) (Mulkens & Waller, 2021). Three main approaches are currently
tematic reviews (e.g., Bulik, Berkman, Brownley, Sedway, & Lohr, recommended for the treatment of AN (e.g., National Institute for
2007; Hay, 2013; Linardon et al., 2017e). Further support has come Health and Care Excellence [NICE], 2017) specialist supportive clinical
from the use of evidence supported CBT in real world settings management (SSCM; Carter et al., 2011; McIntosh et al., 2006;
(Weissman et al., 2017). Touyz et al., 2013); the Maudsley model AN treatment for adults
KAIDESOJA ET AL. 297

(MANTRA; Schmidt et al., 2015) and CBT (CBT-E; Fairburn TABLE 1 AMSTAR-2 gradings
et al., 2013). Number of systematic
In sum, there is evidence from RCTs investigating the effective- reviews which failed to
meet this criterion (in
ness of CBT in comparison to both active (other treatment interven-
AMSTAR-2 items ascending order)
tions) and inactive control conditions in the various distinct eating
Appropriateness of meta-analytical 0/21 (0%)
disorder presentations as well as those investigating various delivery methods (item 11)
methods for CBT (e.g., group, individual, guided self-help). Individual Included studies described in 7/44 (15.9%)
systematic reviews including meta-analyses (MA) have been con- adequate detail (item 8)
ducted for different treatment intervention types and different deliv- Assessment of presence and likely 5/21 (23.8%)
impact of publication bias (item 15)
ery modes for each of the distinct eating disorder presentations. To
[if MA was performed]
our knowledge there has been no comprehensive critical synthesis or
Impact of risk of bias assessed in MA 5/21 (23.8%)
overview of this large systematic review literature to map the extent (item 12)
and strength of the available evidence and to identify gaps in the sys- Risk of bias assessed from individual 13/44 (29.5%)
tematic review evidence. Recently, an overview of CBT systematic studies being included in the review
(item 9)
reviews across all health conditions (CBT-O) was published (Fordham
Potential conflicts of interest of the 13/44 (29.5%)
et al., 2021a) that identified the large systematic review evidence base review authors reported (item 16)
for EDs. However, due to the heterogeneity of the clinical presenta- Adequacy of the literature search 16/44 (36.4%)
tions and outcomes, the overview did not focus specifically on report- (item 4)
ing the evidence for CBT for EDs. The present study addressed this Research question and inclusion 16/44 (36.4%)
omission by conducting a continuation of the CBT-O focusing exclu- criteria included components of
PICO (item 1)
sively on EDs. It aimed to provide a critical synthesis of this systematic
A satisfactory explanation and 17/44 (38.6%)
review evidence to identify the extent and strength of the evidence discussion of any heterogeneity
for CBT, to identify gaps in the evidence drawn from individual sys- observed (item 14)
tematic reviews and examine the quality of the reviews from which it Consideration of risk of bias when 18/44 (40.9%)
interpreting the results of the
is drawn. Critically synthesizing and evaluating the evidence at this
review (item 13)
higher level of generalization allows a meta-perspective of all the sys-
Study selection performed in 21/44 (47.7%)
tematic review evidence free of the more limited scope of any individ- duplicate (item 5)
ual systematic review. An overview of systematic reviews also Data extraction performed in 29/44 (65.9%)
highlights the focus of the majority of past research in the area. duplicate (item 6)
The present synthesis of evidence from systematic reviews Justification for excluding individual 31/44 (70.5%)
studies (item 7)
regarding the effects of CBT for EDs aimed to examine:
Selection of included study designs 32/44 (72.7%)
explained (item 3)
1. the comparative effects of CBT in relation to other active
Sources of funding reported for the 37/44 (84.1%)
treatments individual included studies (item 10)
2. the effects of different forms and delivery of CBT Protocol registered before 38/44 (86.4%)
3. whether CBT is transdiagnostic, achieving similar effects on the full commencement
of the review (item 2)
range of eating disorder presentations
4. the populations (in terms of age, sex and gender, ethnic/cultural
contexts and those with comorbid health conditions) for whom
there are data regarding the effects of CBT
5. the longer-term effects of CBT ED focused study. One author (MK) identified systematic reviews
6. the range of outcomes reported for CBT with ED related outcomes as part of the original search conducted for
the CBT-O study, and we subsequently conducted two updated
searches, in April 2021 and September 2022, of EMBASE, MEDLINE
2 | METHODS and PsychInfo using the same search strategy as the original with
these two additional search queries: (1) restricted to EDs and (2) publi-
2.1 | Search strategy cation dates of January 2019 to April 2021 and April 2021 to
September 2022 respectively. Only systematic reviews were included
The present study is an extension of an overview of CBT for all health since they are widely considered the gold standard method for evi-
conditions (CBT-O), (Fordham et al., 2021a; Fordham et al., 2021b). dence synthesis. Only papers written in English were included due to
The full methods of the CBT-O study have been previously published the authors' limited proficiency in other languages. A list of excluded
(Fordham, Suganvam, et al., 2021a). Where applicable, we adhered to papers with reasons for their exclusion (S1) and the details of the
the CBT-O protocol and did not produce a separate protocol for this search strategy (S4) are provided in the Supplementary material.
298 KAIDESOJA ET AL.

2.2 | Inclusion criteria 2.4 | Quality assessment

Inclusion criteria were those used in the CBT-O study with minor As in the CBT-O study, the quality of the systematic reviews was
modifications in line with our research questions. The criteria were as assessed using the widely accepted AMSTAR-2 (Shea et al., 2017).
follows: The individual item descriptions are provided in Table 1 in the Results.
Reviews included in the original study had been previously assessed
1. As in the CBT-O study, reviews fulfilled at least four of the five cri- by the CBT-O study authors (one of whom was BF), and reviews
teria outlined by the widely accepted Centre for Reviews and Dis- added to the present review were assessed by the authors (MK, ZC,
semination (CRD), as part of the Database of Abstracts of Reviews and BF) with each paper being assessed by two reviewers. Any dis-
of Effects (DARE). These are: reporting of inclusion/exclusion cri- agreements were resolved through discussion.
teria; adequacy of search; synthesis of included studies; assess-
ment of quality of included studies and presentation of sufficient
details about the individual studies (Khan et al., 2001). 2.5 | Data synthesis
2. Interventions studied were CBT treatments (excluding CBT in
combination with other treatments, and prevention interventions). The qualitative data describing the study details extracted from the
“Third-wave” therapies (e.g., dialectical behavior therapy) were not reviews are displayed in a PICO table (population, interventions,
included as CBT interventions. comparison type, outcome [types of outcome assessed in the MAs])
3. CBT treatments were compared to non-CBT control conditions. to demonstrate the extent of the current evidence and any possible
4. Participants studied met full or subthreshold criteria for an ED gaps. All outcomes were included, and categorized into eight
(excluding the newly recognized feeding disorders). outcome groups (ED behaviors, ED psychopathology, remission/
5. Outcomes of the RCTs included in the reviews were qualitatively abstinence, weight/BMI, depression, other psychological outcomes,
or quantitatively summarized. quality of life and percentage of dropouts). The definitions of
6. Reviews were in English. “remission” and “abstinence” varied between the systematic
reviews, and were often overlapping; thus, these two types of out-
comes were grouped in one category.
2.3 | Data extraction The MA syntheses extracted from the included systematic
reviews are presented in data tables, including information about
We based our data extraction template on a pre-designed set of data the type of MA comparison, the sample studied and the results (sta-
tables from the CBT-O study and amended it to better answer our tistical significance, effect sizes when the results are statistically sig-
research questions (see Supplementary material S3 for the amend- nificant [p-value ≤ .05], and the number of included RCTs/
ments). The following data were extracted by one author (MK): demo- synthesis). The emphasis of the reporting is on MAs that compared
graphic details (age group, sex and gender, ethnicity, comorbidity, CBT against active controls. Summary tables of the syntheses
diagnostic status [as reported in the systematic review], country), including inactive controls are presented in the Supplementary
intervention details (type of CBT [high intensity/low intensity; ED- material (S2).
specific or generic; individual or group, CBT protocol]), comparison
details (active/inactive control, description of control), length of
follow-up (short = <12 months/long = ≥12 months), possible harms 3 | RE SU LT S
related to treatment, and data from MAs when provided (number of
RCTs, type of comparison, outcomes studied, results and whether 3.1 | Included reviews
poor quality RCTs were excluded from the review). If a MA provided a
synthesis at both end-of-treatment (EOT) and at short term follow-up, As can be seen in Figure 1, we included 44 systematic reviews,
in interests of parsimony only the EOT time point analysis was 37 from the original study and 7 further reviews from the updated
extracted since this was reported more often than the short follow-up searches. For a list of the included reviews, please see the References.
timepoint. CBT delivery was categorized as high or low intensity, The included reviews are presented in Table 2 together with a brief
based on Roth and Pilling (2007) with high-intensity CBT defined as description of their characteristics using PICO criteria.
face-to-face, individual or group therapy, delivered by a trained CBT
therapist and low-intensity as delivered via media (internet, written,
telephone), or face-to-face, individual or group CBT interventions 3.2 | Quality of the reviews
delivered by a non-CBT therapist (paraprofessional or layperson). Self-
help (including guided self-help) was categorized as a low intensity Of the 44 reviews, 18 (40.9%) were graded as of high/moderate qual-
intervention. If the review did not report the intensity of the interven- ity while 26 (59.1%) were graded as of low/critically low quality.
tion, it was assumed to be high intensity CBT. Also, if length of Table 1 presents the AMSTAR-2 items (Shea et al., 2017) and the
follow-up was not clearly reported, it was assumed to be short. number of reviews that failed to meet each criterion. The most
KAIDESOJA ET AL. 299

FIGURE 1 Flow chart of the article selection process

common items that reviews failed to meet were: publishing a protocol Inter-rater reliability (calculated as % of agreement on individual
prior to conducting the review, reporting the sources of funding and AMSTAR items) was 74.5% between ZC and MK, and 81.3% between
reporting the reason for the study designs selected for inclusion. BF and MK.
TABLE 2 Description of the systematic reviews presented using their PICO criteria
300

Type of ED Type of CBT Comparison Outcomes in the MA

Review IDa RCTs
High
and ED- Not Other ED ED Abstinence/ Weight/ Other Quality
BED BN AN Other High Low low Generic specific specified Psychotherapy Pharmacotherapy active Inactive psychopathology behaviors remission BMI Depression psychological of life Dropouts

Allen and 3 x x x x x x
Dalton
(2011)
Atwood 8 x x x x x x x x x
and
Friedman
(2019)
Beumont 2 x x x x x x
et al.
(2004)
Berkman 25 x x x x x x x x x x x
et al.
(2006)

Berkman 11 x x x x x x x x
et al.
(2015)
Dahlenburg 5 x x x x x x x x
et al.
(2019)

Datta et al. 4 x x x x x x x x
(2022)

De-Bacco 3 x x x x x x x x
et al.
(2017)
de Jong 4 x x x x x x x
et al.
(2018)
Flament 1 x x x x
et al.
(2012)
Ghaderi 7 x x x x x x x
and
Andersson
(1999)
Ghaderi 19 x x x x x x x x x x x x
et al.
(2018)
Giel et al. 2 x x x x x
(2021)
KAIDESOJA ET AL.
TABLE 2 (Continued)

Type of ED Type of CBT Comparison Outcomes in the MA

Review IDa RCTs
High
and ED- Not Other ED ED Abstinence/ Weight/ Other Quality
KAIDESOJA ET AL.

BED BN AN Other High Low low Generic specific specified Psychotherapy Pharmacotherapy active Inactive psychopathology behaviors remission BMI Depression psychological of life Dropouts

Grenon 22 x x x x x x x x x x x x x
et al.
(2017)
Grenon et al. 28 x x x x x x x x x x x x x x
(2018)

Hay et al. 5 x x x x x x x x x x x
(2001)

Hay et al. 39 x x x x x x x x x x x x x x x x
(2009)
Hay and 10 x x x x x x x x
Claudino
(2010)
Hay et al. 1 x x x x
(2012)

Hay (2013) 18 x x x x x x x x x x
Hay et al. 1 x x x x
(2014)
Hay et al. 4 x x x x x x x x x x x x x
(2015)
Hilbert 29 x x x x x x x x x x x x x
et al.
(2019)
Keel and 28 x x x x x x x x x x
Haedt
(2008)

Linardon 24 x x x x x x x x x x x
& Brennan
(2017)
Linardon, 3 x x x x x x x x x x
Fairburn,
et al.
(2017)
Linardon 78 x x x x x x x x x x x x x x
et al.
(2017a)

Linardon 23 x x x x x x x x x
et al.
(2017b)

(Continues)
301
 302

TABLE 2 (Continued)

Type of ED Type of CBT Comparison Outcomes in the MA

Review IDa RCTs
High
and ED- Not Other ED ED Abstinence/ Weight/ Other Quality
BED BN AN Other High Low low Generic specific specified Psychotherapy Pharmacotherapy active Inactive psychopathology behaviors remission BMI Depression psychological of life Dropouts

Linardon, 98 x x x x x x x x x x x x
Hindle,
&
Brennan
(2017)

Linardon 28 x x x x x x x x x x
(2018)

Linardon 23 x x x x x x x x x
et al.
(2019)
Loucas 6 x x x x x x x x x x
et al.
(2014)

Miniati 21 x x x x x x x x x x
et al.
(2018)
Palavras 10 x x x x x x x x x x x
et al.
(2017)
Pittock 4 x x x x x x
and Mair
(2010)
Pittock 3 x x x x x x
et al.
(2018)
Polnay 8 x x x x x x x x x
et al.
(2014)

Reas 1 x x x x
and Grilo
(2008)
Solmi 5 x x x x x x x x x x
et al.
(2021)

Svaldi 28 x x x x x x x x x x x
et al.
(2019)
KAIDESOJA ET AL.
TABLE 2 (Continued)

Type of ED Type of CBT Comparison Outcomes in the MA

Review IDa RCTs
High
and ED- Not Other ED ED Abstinence/ Weight/ Other Quality
KAIDESOJA ET AL.

BED BN AN Other High Low low Generic specific specified Psychotherapy Pharmacotherapy active Inactive psychopathology behaviors remission BMI Depression psychological of life Dropouts

Thompson 16 x x x x x x
Brenner
et al.
(2003)
Van den 4 x x x x x x x x x x
Berg et al.
(2019)
Vogel 16 x x x x x x x x x
et al.
(2021)
Watson 4 x x x x x
and Bulik
(2013)

Abbreviations: High, high intensity; low, low intensity; other, most often this was EDNOS; RCT, number of RCTs extracted from the review.
a
The reviews rated as moderate or high quality are bolded.
303
304 KAIDESOJA ET AL.

TABLE 3 Summary table of MA syntheses comparing CBT to a variety of active controls pooled together

Outcomes
CBT intensity Control ED type
ED behaviors ED psychopathology Abstinence/remission Weight

High Various active BED Y (9 RCTs, g= .18), N(2 RCTs) Y (8 RCTs, g=.17), N(2 RCTS) N (1‐5 RCTs)
controls
BN Y (20‐25 RCTs, g=.21) Y (16‐18 RCTs, g=.20) Y (15 RCTs, OR=1.49), N (14 RCTs)1

AN N (2‐10 RCTs) N (2 RCTs) N (2 RCTs)

Mixed Y (15 RCTs, g=.18‐.33)X

CBT‐E BN Y (3 RCTs, g=.52) Y (4 RCTs, g=.52) N (3 RCTs)

AN N (3 RCTs) N (3 RCTs)
X
Mixed N (5 RCTs)

CBT‐BN BN N (4 RCTs) Y (3 RCTs, g=.53) N (4 RCTs)

X
Mixed Y (17 RCTs, g=.23‐.27)

CBT‐BN/E BED N (1 RCT) N (1 RCT) N (1 RCT)

BN Y (7 RCTs, g=.42) Y (7 RCTs, g=.53) Y (7 RCTs, OR=2.08)

“adapted” BED N (2 RCTs) N (2 RCTs) N (2 RCTs)

CBT‐BN BN N (11 RCTs) N (10 RCTs) N (7 RCTs)

group CBT BED N (6 RCTs) N (7 RCTs) N (4 RCTs)

BN N (5 RCTs) N (2 RCTs) N (1 RCT)

High and low BED N (5 RCTs) Y (6 RCTs, g=.27), N (4 RCTs)X 2 N (2 RCTs)

BN N (7 RCTs) Y (12 RCTs, g= .21‐.27)X, N(1‐12 RCTs)X 3 N (1 RCT)

Mixed Y (18 RCTs, g=.29)X Y (22 RCTs, g=.24‐.31)X

Low BED N (4 RCTs) N (5 RCTs) N (4 RCTs)

X X4
Mixed Y (7 RCTs, g= .34, .39) , N (7 RCTs)

Outcomes
CBT intensity Control ED type
Depression Other psychological Quality of life Dropouts

High Various active BED N (10 RCTs)

controls
BN N (23 RCTs)
5
AN N (1 RCT) N(1 RCT) N (3 RCTs, CBT‐E) N (9 RCTs)

Mixed N (44 RCTs)

High and low BED N (6 RCTs) 6

BN N (8 RCTs) 7
Mixed Y (9 RCTs, g=.36), N (3 RCTs) 8

Note: Where the results are difficult to interpret, the differences between the syntheses are explained, and the outcomes categorized under “Other psychological” are
specified (see numbers 1–8). The number of RCTs reported in parentheses refers to the number of RCTs in the synthesis/‐es in question. The statistically significant
results (Y) are bolded. Y = a statistically significant result in favor of CBT, N = no statistically significant difference. SMD = standardized mean difference. g = Hedge's
g. OR = risk ratio. For a detailed definition of “adapted CBT‐BN”, please see Linardon et al. 2017a. (1) Many overlapping RCTs in the comparisons; Y: individual and
group, N: only individual, close to statistical significance (p = .062), see Linardon et al. 2017a. (2) N: dietary restraint, shape concern, weight concern, Y: cognitive
symptoms. (3) Y: weight concern, dietary restraint, N: shape concern (12 RCTs), cognitive symptoms (1 RCT). (4) Y: shape concern, weight concern; N: dietary
restraint. (5) Outcome: general psychiatric score. (6) Outcome: self‐esteem. (7) Outcome: self‐esteem. (8) Y: subjective QoL, N: health‐related QoL. XThe result is from
a low/critically low quality review.

3.3 | Qualitative synthesis of the reviews EDNOS). Five (11.4%) included reviews were conducted exclusively
with BED populations, seven (15.9%) exclusively with BN populations
3.3.1 | Participants and eight (18.2%) exclusively with AN populations.
Twenty-nine (65.9%) reviews included data from adult popula-
Most reviews (n = 24, 54.5%) combined data collected from partici- tions, whereas two (4.5%) reviews focused solely on young people
pants with different EDs (i.e., at least partly transdiagnostic samples, (<18 years old) and none on older adults (≥65 years old). Eight (18.1%)
referred to as “mixed” from here on), and of these 18 (40.9%) included reviews did not report the age of participants, and 19 (43.2%) reviews
participants with eating disorder not otherwise specified (DSM IV did not report the sex or gender of the participants. Eleven (44% of
TABLE 4 Summary table of MA syntheses comparing CBT to particular active control interventions individually (ED‐specific outcomes)

Outcomes
CBT intensity Control ED type
ED behaviors ED psychopathology Abstinence/remission Weight
X
KAIDESOJA ET AL.

High Behavioral weight loss treatment BED Y (4 RCTs, MD= 2.04 , SMD=.31) N (2 RCTs) N (4 RCTs)
Mixed Y (5 RCTs, g=.30) N (5 RCTs) N (4 RCTs)
Supportive therapy Mixed N (6 RCTs) N (4 RCTs) N (2 RCTs)
Pharmacological BED N (2 RCTs) Y (2 RCTs, g=.73)
BN N (1 ‐ 4 RCTs) N (4 RCTs) N (3‐5 RCTs)
Various psychotherapies BED Y (2 RCTs, SMD=.21)X, N (1 RCTs) 1 N (3 RCTs) X N (1‐3 X RCTs) N (1‐3 RCTs)
2
BN Y (15 RCTs, g=.33), N (8‐15 RCTs) Y (7 RCTs, RR= .83) N (5 RCTs)
AN N (2 RCTs) N (2 RCTs) N (2 RCTs)
EDNOS N (1 RCT)
Mixed Y (15 RCTs, SMD=.21), N (5X RCTs) 3 Y (7‐11 RCTs, g=.31) X N (7 X‐10 RCTs) control (11 RCTs, SMD=.18)
X X X
Interpersonal psychotherapy BED N (1 RCT) N (1 RCT) N (1 RCT) N (1 RCT)X
Mixed Y (6 RCTs, g=.24) Y (6X‐7 RCTs, g=.32) N (6 RCTs)
Behavioral psychotherapy Mixed N (8 RCTs) N (7 RCTs) N (5 RCTs)
Psychodynamic psychotherapy BED N (1 RCT)X N (1 RCT)X N (1 RCT)X N (1 RCT)X
X X
Humanistic psychotherapy BED N (1 RCT) Y (1 RCT) N (1 RCT)X
Group psychotherapy BED N (3 RCTs) N (3 RCTs)
BN N (1 RCT) N (1 RCT)
Mixed N (4 RCTs)
Thirdwave psychotherapies BED N (2 RCTs) Y (1 RCT), N (2 RCTs) 4 N (1 RCT)
Mixed N (3 RCTs) N (2‐3 RCTs) N (3 RCTs)
High and low Behavioral weight loss treatment BED Y(4 RCTS, SMD=.27) N (4 RCTs) N (4 RCTs)
Various psychotherapies BN Y (13 RCTs, g=.30), N (17 RCTs) 5
Interpersonal psychotherapy BED N (2 RCTs) N (2 RCTs) N (2 RCTs)
Low Bibliotherapy BN N (1 RCT)X N (1‐2 RCTs)X N (1‐2 RCTs)X
Self‐compassion training BED N (1 RCT)X N (1 RCT)X N (1 RCT)X
Various psychotherapies BN N (2‐3 RCTs)

Note (for Tables 4 and 5): Where the results are difficult to interpret, the differences between the syntheses are explained, and the outcomes categorized under “Other psychological” are specified (see numbers
1–7 in Table 4, and numbers 1–6 in Table 5). The syntheses that excluded poor quality RCTs are underlined. The number of RCTs reported in parentheses refers to the number of RCTs in the synthesis/‐es in
question. The statistically significant results (Y) are bolded. Y = a statistically significant result in favor of CBT, N = no statistically significant differences, control = a statistically significant result in favor of
control group. g = Hedge's g. MD = mean difference. RR = risk ratio. SMD = standardized mean difference. (1) Y = binge‐eating days, N = mean bulimic symptoms (2) Y = binge frequency, N = purge frequency
(15 RCTs), mean bulimic symptoms (8 RCTs), (3) Y = mean bulimic symptoms, N = binge/purge frequency, (4) Y & N: both studied similar ED psychopathology outcomes, (5) Y = binge frequency, N = purge
frequency. X = the result is from a low/critically low quality review.
305
306 KAIDESOJA ET AL.

TABLE 5 Summary table of MA syntheses comparing CBT to particular active control interventions individually (non-ED-specific outcomes)

Outcomes
CBT intensity Control ED type
Depression Other psychological Dropouts
High Behavioral weight loss treatment BED N (4 RCTs) N (1 RCT)1 N (3 RCTs)
Pharmacological BN N (3 RCTs) Y (4 RCTs, RR = -2.18)
X 2
Various psychotherapies BED N (1-2 RCTs) N (1 RCT) N (1–4 X RCTs)
BN Y (15 RCTs, g = .25), N (7 RCTs)) 3 4 5
N (4 -5 RCTs) N (1–8 RCTs)
6
AN N (1 RCT) N (1 RCT) N (2 RCTs)
Mixed N (1–13 RCTs) N (4X-7 RCTs) 7 N (14 RCTs)
Interpersonal psychotherapy BED N (1 RCT)X
MANTRA AN N (NR RCTs)
X
Psychodynamic BED N (1 RCT) N (1 RCT)X
AN Y (NR RCTs, OR = .54)
Familybased psychoterapy AN N (NR RCTs)
Humanistic therapy BED Y (1 RCT)X N (1 RCT)X
High and low Behavioral weight loss treatment BED N (3 RCTs)
Various psychotherapies BN N (18 RCTs)
Low Self-compassion training BED N (1 RCT)X N (1 RCT)X
Mixed psychotherapy BN N (1-2RCTs)

Note: (1) outcome = interpersonal functioning, (2) outcome = interpersonal functioning and general psychiatric score, (3) N (7 RCTs) close to statistical
significance (see Hay et al., 2009; Linardon et al. 2017b), (4) outcome = interpersonal functioning, (5) outcome = general psychiatric score, (6)
outcome = general psychiatric score, (7) outcome = interpersonal functioning, self-concept, general psychiatric score. X = the result is from a low/critically
low quality review.
Abbreviation: NR, not reported.

the reviews that reported sex) reviews included only female partici- 3.3.3 | Comparison interventions
pants. Where men were included (n = 14, 56% of the reviews that
reported sex), the percentage of men in the samples studied ranged Most reviews (n = 34, 77.3%) combined data from RCTs that com-
between 2% and 41%. Other gender identities were not addressed in pared CBT to both active and inactive control groups (Table 2). Eight
any of the reviews. Two reviews reported the ethnicity of some par- (18.1%) reviews included RCTs with only active comparisons and two
ticipants, but also included RCTs that did not report ethnicity. Partici- reviews (4.5%) compared CBT exclusively with inactive comparators.
pants in these two reviews were 57%–98% White ethnic groups. The active comparator interventions included other forms of psycho-
Sixteen reviews were high middle income countries (HMIC), while logical treatments (e.g., interpersonal psychotherapy, behavioral treat-
others did not report these data. Fifteen reviews mentioned comorbid ment, supportive psychotherapy, or psychodynamic psychotherapy)
conditions, but only four reviews reported and/or included any analy- and pharmacotherapy (most often antidepressant medication)
sis of these conditions. amongst other active interventions.

3.3.2 | Interventions 3.3.4 | Types of outcome reported in the MAs

Twenty-two (50%) reviews combined data from both high and low The most common outcome studied in the MAs was ED behaviors
intensity CBT interventions (see Table 2). Nineteen (43.2%) included (16 MAs, 76.1% of all MAs), most commonly binge eating and/or
only high intensity (individual or group CBT). The three (6.8%) reviews purging. Abstinence and/or remission was reported in 13 (61.9%) MAs,
studying exclusively low intensity CBT combined guided and unguided operationalized as abstinence from key behavioral symptoms or remis-
self-help. sion from ED symptoms or ED diagnosis. The time frame for abstinence
Often reviews did not explicitly state whether the CBT interven- varied between the reviews and RCTs. ED psychopathology outcomes
tion was ED-focused or generic CBT, and this had to be inferred. Ten were studied in 10 (47.6%) MAs; most often as assessed by the Eating
(22.7%) reviews only included ED-focused CBT interventions. The Disorder Examination Questionnaire EDE( Q) (Fairburn & Beglin,
remainder included both ED-focused and generic CBT or provided no 2008) or Eating Disorder Inventory (EDI) (Garner, 2004; Garner
information regarding CBT type. et al., 1983). Weight-related outcomes (weight or BMI) were studied in
 KAIDESOJA ET AL.

TABLE 6 A summary table of MA syntheses conducted at long follow-up (1 year or over)

CBT intensity Control ED type ED behaviors ED psychopathology Abstinence/remission Weight/BMI Depression Other psychological Dropouts
High Various active BED N (4 RCTs) N (4 RCTs) N (4 RCTs)
BN Y (10 RCTs, g = .31) N (9 RCTs) N (6 RCTs)
AN N (2–6 RCTs) N (1 RCT) N (2 RCTs) N (1 RCT) N (1 RCT) 1
X X
Behavioral weight BED N (3 RCTs) N (3 RCTs) N (4 RCTs)X
loss treatment
Pharmacological BED N (2 RCTs) Y (3 RCTs, g = .99) Y (1 RCT)
BN N (1 RCT) N (1 RCT) N (1 RCT)
Various AN N (2 RCTs) N (1 RCT) N (2 RCTs) N (1 RCT) N (1 RCT) 2
psychotherapies
Family-based AN N (NR RCTs) N (NR RCTs)
psychotherapy
MANTRA AN N (NR RCTs) N (NR RCTs)
Psychodynamic AN N (NR RCTs) N (NR RCTs)
psychotherapy
Treatment as usual AN N (NR RCTs) N (NR RCTs)
High and low Interpersonal BED N (2 RCTs) N (2 RCTs) N (2 RCTs)
psychotherapy
Behavioral weight BED Y (3 RCTs, SMD = .24) Y (3 RCTs, RD = .13) N (3 RCTs) N (2 RCTs)
loss treatment

Note: The outcomes categorized under “Other psychological” are specified (see numbers 1–2). The syntheses that excluded poor quality RCTs are underlined. The number of RCTs reported in parentheses refers to
the number of RCTs in the synthesis/ es in question. The statistically significant results (Y) are bolded. Y = a statistically significant result in favor of CBT, N = no statistically significant differences. g = Hedge's
g. SMD = standardized mean difference. RD = risk difference. (1) outcome: general psychiatric score, (2) outcome: general psychiatric score. X = the result is from a low/ critically low quality review. NR = not
reported.
307
308 KAIDESOJA ET AL.

seven (33.3%) MAs. Depressive symptoms were studied in nine (42.9%) 3.3.7 | Summary of results
MAs, dropout in eight (38.1%) MAs, other psychological outcomes
(self-esteem, self-concept, general psychiatric functioning or interper- CBT compared to active controls
sonal functioning) in four (19.0%) MAs and quality of life in two High intensity CBT was more effective compared to mixed active
(9.5%) MAs. controls in reducing ED behaviors and psychopathology (see
Potential harms related to treatment were addressed in nine Table 3). It was also more effective than behavioral weight loss in
reviews but the lack of details in the RCTs prevented the synthesis reducing ED behaviors, and more effective than interpersonal psy-
and analysis of these. chotherapy in reducing ED behaviors and psychopathology. The
Almost half of the reviews (n = 19, 43.2%) reported short and results are mixed when CBT was compared against pharmacologi-
long term outcomes with only three (6.8%) reviews reporting exclu- cal interventions and a mixed group of various psychotherapies.
sively on studies of long-term outcome. Meta-analytic syntheses at CBT has not been shown to be more effective than behavioral or
long term follow up were performed in five (23.8% of all MAs) supportive therapy on any of the outcomes. Comparisons against
reviews, all on high or mixed intensity CBT compared to active con- other forms of psychotherapy have included few RCTs. (see
trol conditions. Tables 4,5). Aside from ED specific outcomes, the only effects
favoring CBT against active controls were for depression and num-
ber of dropouts and only against certain specific control interven-
3.3.5 | Quantitative results from the meta-analytic tions (see Table 5).
syntheses In syntheses that pooled active and inactive controls (not in the
data tables), high intensity CBT was effective in increasing self-esteem
Of the 44 reviews 21 (47.7%) included at least one meta-analytic syn- (9–14 RCTs per synthesis). There was also some support for high and
thesis comparing CBT with a non-CBT intervention or an inactive con- low intensity CBT leading to improvements in quality of life outcomes
trol. Tables 3–6 present the findings from the MAs including active in both those with BN and in mixed ED samples (3–13 RCTs/synthe-
controls. Effect sizes are reported for the syntheses with statistically sis), but no significant effect for those with BED (3–4 RCTs/
significant effects that included more than 1 RCT in comparison with synthesis).
an active control. If more than one synthesis studied a similar type of
comparison, the effect size is reported for the synthesis that included Effects of different forms of CBT
more RCTs, or if syntheses included a similar number of RCTs, effect Low and high intensity CBT. We identified a large evidence base for
sizes from both are reported. The effect sizes are presented as they high intensity CBT. Low intensity CBT (pure self-help or guided
were reported in the original paper. self-help) MAs with active controls did not include the following:
Table 3 presents the data from reviews comparing CBT to any the study of AN populations, reports on long term outcomes and
active control group. Tables 4 and 5 present the data comparing CBT an examination of the effect of the quality of the RCTs. One MA
to specific active controls groups and Table 6 presents the MAs of synthesis found an effect in favor of low intensity CBT on certain
long-term follow-up data. Data from reviews which compared CBT to ED psychopathology features (see Table 3). In MA syntheses
inactive control groups are presented in Tables 7a and 7b in the Sup- where active and inactive controls were pooled, the only signifi-
plementary material. Of the reviews with a MA, 16 (76.1%) were rated cant favorable effects of low intensity CBT were on quality of life
as moderate or high quality. Results extracted from the critically (3–5 RCTs/synthesis).
low/low quality reviews are marked in the tables. Group-based CBT. We found evidence that group CBT is more
The results from MA syntheses that compared CBT to active and effective than inactive control conditions but not more effective than
inactive controls pooled together are reported in the summary of active control conditions for BN and BED populations (see Table 3).
results but not in the tables. There are no data for AN. No effect favoring group CBT was found
when compared to active and inactive interventions pooled together
(quality of life, three RCTs/synthesis).
3.3.6 | Quality of RCTs in the MAs Specific CBT protocols. The data support CBT-BN (Fairburn
et al., 1993) and its enhanced transdiagnostic form (CBT-E)
Only three of the MAs (14.2%) were conducted solely with RCTs (Fairburn et al., 2008) as more effective than active and inactive
rated as having low or moderate risk of bias. Ten (47.6%) reviews control conditions for mixed diagnostic and BN populations with
assessed the moderating effect of higher and lower quality RCTs and regard to ED behavior and psychopathology, although not all syn-
reported that the quality of the RCTs did not moderate effects theses produced consistent results. CBT-BN was not favored when
reported. Six (28.6%) reviews assessed RCT quality but neither ana- it was described as “adapted” (see Linardon et al. 2017a, see
lyzed nor discussed its effects on their reported results. Four (19.0%) Table 3). CBT-BN/E has shown a favorable effect on reported
reviews did not assess RCT quality. quality of life (six RCTs/synthesis) but no effect on health-related
KAIDESOJA ET AL. 309

quality of life (two RCTs/synthesis) in syntheses that pooled active First, the current evidence base shows statistically significant
and inactive control interventions. effects for individually delivered high intensity CBT over a mixed
group of active control interventions (as well as over certain specific
Effects across various eating disorder presentations psychological and psychotherapeutic approaches) with regard to cer-
As we have seen, benefits for CBT have been reported on a variety of tain ED-specific outcomes, although the effect sizes are small. How-
outcomes in those with BED, BN, and for mixed diagnostic groups, ever, overall, the current evidence base does not fully support CBT as
but no significant effects have been demonstrated for CBT as com- generally more effective than other specific psychotherapeutic treat-
pared to other active treatments in those with AN, other than one ments. Further investigation of, for whom and under what circum-
MA synthesis that found a statistically significant effect in favor of stances, this form of CBT might be the treatment of choice has the
CBT in the percentage of dropouts from treatment. potential to greatly enhance clinical benefit for patients.
Second, as regards the form of CBT, our overview of systematic
Effects across various demographic groups reviews shows that low intensity CBT has received significantly less
The systematic review data is almost exclusively generated from attention than high intensity CBT. The evidence supporting low inten-
adults, predominantly women, who are white and live in HMI coun- sity CBT, as well as group CBT, was relatively weak as there was only
tries. Comorbid conditions, with the exception of depression, have support for these forms of CBT when compared to inactive control
received relatively little attention in the MA syntheses. There are a interventions. A possible exception was for a particular form of low
lack of data to explore whether sex and gender, ethnicity, country of intensity CBT, guided self-help, which has the potential to be made
origin or age moderates the effectiveness of CBT on ED outcomes. much more widely available with the possibility of helping to bridge
the well-documented treatment gap in EDs (Kazdin et al., 2017). CBT
Longer term effects in guided self-help form produced benefits for certain features of ED
The effectiveness of CBT at follow up of 12 month or longer is psychopathology even when compared to active interventions, and
unclear (see Table 6) with some reviews finding positive effects on ED benefits to quality of life in comparison to active and inactive controls
behaviors and psychopathology in BED and BN populations, while pooled together.
others did not. The MA syntheses studying specific manualized approaches sup-
ported CBT-BN (Fairburn et al., 1993) and CBT-E (Fairburn
Range of outcomes et al., 2008), but not the “adapted” approaches. However, the data is
In comparison to active control conditions, the strongest evidence for limited and not all syntheses produce consistent results. Further data
CBT has been found for the outcomes of ED behaviors and ED on whether some approaches are more potent than others for all
psychopathology. patients, or for particular subgroups of patients would provide poten-
tially valuable evidence to guide clinicians about how to help patients
gain the most from CBT.
4 | DISCUSSION Third, there was very limited evidence supporting CBT for those
who are significantly low weight and generally receive a diagnosis of
The current overview of the evidence supporting CBT for EDs aimed AN, and no evidence to support it as more effective than other active
to provide a critical synthesis of the large and growing systematic ED focused psychological treatments. Thus, while CBT in its present
review literature in the field. It was undertaken with the explicit aim form can be used transdiagnostically, its effects for those who are low
of synthesizing evidence drawn from previously conducted systematic weight are less positive than for some groups with EDs. This finding
reviews to identify the extent and strength of the evidence for CBT, points to a pressing need for further treatment innovation to improve
identify any gaps in the evidence and to examine the quality of the outcomes for this group.
systematic reviews from which it is drawn. By undertaking a review of Fourth, the insufficient reported data concerning the age, sex and
the evidence at this higher level of generalization, we aimed to tran- gender, culture or country of residence of those being treated,
scend the more limited scope of individual systematic reviews. calls into question the generalizability of the effects of CBT across
Consistent with current guidelines (Hilbert et al., 2017), our various populations. Also, considering the high levels of comorbid
review confirmed that CBT produces benefits for people with symp- conditions in those with EDs, the lack of data on the effects of
toms of binge eating and/or purging (generally those with BED, BN CBT on those with EDs and comorbid conditions limits generaliz-
and EDNOS/OSFED). More particularly, it made clear that CBT is ability to the full range of clinical presentations. These gaps in the
most effective in producing good outcomes for these groups on both data limit the evidence-based guidance that can be provided to cli-
ED behavior and psychopathology and, to a lesser extent, abstinence/ nicians and point to a need to examine the effectiveness of CBT in
remission, when delivered face-to-face on an individual basis. The a wider group of patients. One recent systematic review did con-
review with its explicit aims to assess systematic review evidence sider a variety of demographic and comorbid conditions as moder-
guided by a number of specific research aims also highlighted signifi- ators of the effect of CBT (Linardon, de la Piedad Garcia, &
cant gaps in the evidence that need to be addressed in future Brennan, 2017) but the findings were inconclusive, and the review
research. author identified the need for more research on the mediators and
310 KAIDESOJA ET AL.

moderators of the effectiveness of CBT for EDs. Further under- CBT for certain ED presentations, an important finding was that there
standing of the moderators of treatment effects would allow bet- are major gaps in the current evidence that need to be addressed in
ter matching of treatments and perhaps highlight the need for the future. One of the most important and pressing concerns is the
further treatment development for some sub-groups. limited data on those who receive a diagnosis of AN. Although cur-
Fifth, the longer-term effects of CBT beyond 12 month follow up rently there are three main approaches recommended by the clinical
are not clear. This is because of the relatively few studies of longer guidelines (e.g., NICE, 2017), there is limited evidence to support CBT
term follow up and the inconsistency of the existing results. as the treatment of choice and there is an urgent need to address the
Sixth, our review highlighted the limited range of outcomes reported relatively poor outcomes to date of treatment for this group
for CBT, and the lack of consensus on how they are operationalized in (Mulkens & Waller, 2021). In addressing the gaps in the existing evi-
the syntheses. Other than ED specific outcomes, there is relatively little dence, there is a need to ensure that future research is conducted in
evidence of any other effects produced by CBT for EDs. For example, careful alignment with quality criteria to produce RCTs with low risk
there is limited data on impairment of functioning—an important omis- of bias and systematic reviews of high quality. We have identified that
sion when considering that impairment is often a key factor in making a the quality of the synthesized evidence base to date has not been
diagnosis of a disorder and in patients seeking treatment. uniformly high.
An important strength of our study was that we assessed the It is important to note that while our overview highlights limited
quality of the reviews being synthesized using AMSTAR, a widely evidence or the absence of certain evidence, it does not constitute
used instrument for critically appraising systematic reviews. We found evidence against CBT, but rather points to areas for future innovation
that the quality of the reviews included varied, as did the quality of and research. Target areas for future high quality research should
the RCTS included in these reviews. The most common shortcomings include: a better understanding of the potential generalizability of
of the systematic reviews were not registering a protocol before com- CBT by studying the moderating effects of age, sex and gender, eth-
mencing the review, not reporting the funding sources of the RCTs nicity, culture country of origin and the presence of comorbid condi-
included and, importantly, not providing an explanation for the selec- tions upon the effectiveness of CBT for EDs and assessing a wider
tion of studies reviewed. Most of the reviews did not exclude poor range of outcomes for CBT by including a systematic study of clinical
quality RCTs from their MA syntheses, although many did study the impairment and quality of life. Further targets for innovation are the
moderating effect of their quality. development and testing of new approaches to benefit those groups,
A limitation of our report is that we have only provided the main particularly those who are significantly low in weight, where outcome
quantitative results and have left out some of the more detailed infor- to date has been relatively poor and the further development, imple-
mation that is usually included when reporting a MA. Data were only mentation and testing of potentially more widely available low inten-
extracted at the review level and so some data from relevant RCTs sity interventions that might bridge the well documented treatment
were not explicitly represented. We excluded reviews not published gap in EDs.
in English (n = 10), which might have addressed one of the evidence
gaps identified, namely few RCTs performed in settings outside of AUTHOR CONTRIBU TIONS
Western cultures. We also excluded consideration of the newly recog- Milla Kaidesoja: Conceptualization; data curation; investigation; meth-
nized feeding disorders in DSM 5, and studies that directly compare odology; project administration; visualization; writing – original draft;
different forms of CBT, limiting our ability to draw conclusions about writing – review and editing. Zafra Cooper: Conceptualization; inves-
the treatment of these feeding disorders and the efficacy of different tigation; methodology; supervision; writing – original draft; writing –
forms of CBT. The MAs studied various outcome variables and diag- review and editing. Beth Fordham: Conceptualization; investigation;
nostic groups, and the operationalization of definitions of variables methodology; resources; supervision; writing – original draft; writing
and subthreshold disorders was not always explicit and varied – review and editing.
between the systematic reviews. This was particularly an issue with
the outcome of abstinence/remission as noted earlier. To synthesize a CONFLIC T OF INT ER E ST
large amount of sometimes disparate data, we had to combine out- No conflicts of interest. No specific funding was received for
comes in a way that may obscure some finer grained details. Lastly, a this work.
single researcher performed the data extraction and synthesis.
In assessing the qualitative and meta-analytic syntheses in our DATA AVAILABILITY STAT EMEN T
overview it is important to remember that many include the same The data that support the findings of this study are available from the
RCTs; i.e. certain RCTs are “recycled” and studied in different synthe- corresponding author upon reasonable request.
ses. We suggest further study of the quality and generalizability of
any possible RCTs that might play a key role in determining the statis- OR CID
tical significance of the various MA syntheses. Milla Kaidesoja [Link]
In summary, while the results of our current overview of the sys- Zafra Cooper [Link]
tematic review evidence provide support for some particular forms of Beth Fordham [Link]
KAIDESOJA ET AL. 311

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