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Background: Many patients with depressive disorders demonstrate resistance to psychological therapy. A frequent finding is hypothalamic-pituitary-adrenal (HPA) axis alterations. As cortisol is known to modulate cognitive processes, those patients may be less likely to profit from psychological therapy.Aims: To conduct a systematic review and meta-analysis on cortisol as a predictor of psychological therapy response.Method: The Cochrane Library, EMBASE, MEDLINE and PsycINFO databases were searched. Records were included if they looked at patients with any depressive disorder engaging in psychological therapy, with a pre-treatment cortisol and a post-treatment symptom measure.Results: Eight articles satisfied our selection criteria. The higher the cortisol levels before starting psychological therapy, the more symptoms patients with depression experienced at the end of treatment and/or the smaller their symptom change.Conclusions: Our findings suggest that patients with depression with elevated HPA functioning are less responsive to psychological therapy. [ABSTRACT FROM AUTHOR]