Key findings

Effectiveness and safety

The evidence relating to the clinical effectiveness of remote digital delivery of psychotherapies consisted of five systematic reviews, two of which incorporated meta-analyses. Cognitive behaviour therapy (CBT) was the most common psychotherapy modality reported in the literature. Only one review discussed patient safety.

There was overlap in the studies that were included in the systematic reviews. The small number of robust comparative primary studies included in the reviews, and the heterogeneity across participant groups and outcome measures, leads to low confidence in the quality of the evidence.

Key points are presented below by psychological condition:

Anxiety

A systematic review including seven comparative studies in patients with a range of diagnoses found no statistically significant differences in anxiety measures between videoconferencing psychotherapy (VCP) and face-to-face therapy (FTFT).

Post-traumatic stress disorder (PTSD)

One well-conducted meta-analysis based on seven studies found that, when compared with FTFT, videoconference therapy did not result in statistically significantly different PTSD outcomes post-treatment, but led to inferior outcomes at 3-6 months follow up.

A systematic review discussed patient safety and noted that a cautious approach should be taken when conducting exposure tasks via tele-therapy in the PTSD population due to the potential effects of high levels of emotional arousal.

Depression

A high quality systematic review with meta-analysis reported that, compared with FTFT, telephone-administered CBT was not statistically significantly different in its effectiveness in reducing depressive symptoms.

A systematic review included 14 controlled studies comparing the effects of VCP and FTFT on depressive symptoms, and found no statistically significant differences between the delivery methods.

Therapeutic alliance

A narrative systematic review reported the therapeutic alliance developed between patient and therapist during VCP to be non-inferior to FTFT, for people with anxiety disorders, depression, or PTSD. In an associated meta-analysis of five trials in patients with mixed mental health conditions, therapeutic alliance in VCP was found to be inferior to FTFT.

In one primary study, people with generalised anxiety disorder who underwent VCP rated the therapeutic alliance significantly higher compared with patients who underwent FTFT.

Patient and social aspects

Acceptability

Based on seven randomised controlled trials (RCTs) within a systematic review, the weighted average percentage of completed sessions of telephone-administered psychotherapy for depression was 73% (range 37% to 86%).

A network meta-analysis (NMA) did not find any statistically significant differences in acceptability/drop-out risk between telephone-administered CBT and individual or group therapy for depression.

Evidence from two primary studies conducted in military veteran populations showed that although the retention rate between FTFT and VCP for treating PTSD may not be significantly different, patients undergoing VCP drop out earlier in the programme compared to FTFT.

Acceptability: provider attitudes

One systematic review of 38 studies found that providers’ attitudes to using VCP were largely positive, with providers describing it as an important and acceptable mode of treatment delivery. Important negative attributes included concern around patient acceptability and safety.

Satisfaction

Across seven RCTs, a systematic review found no statistically significant differences in satisfaction when comparing VCP with FTFT for treatment of depression. High levels of patient and provider satisfaction with VCP were frequently reported.

A primary study (n=115) found no significant effects of treatment modality (video tele-health versus FTFT) on any measure of perception of service quality or satisfaction in patients treated for PTSD.

Cost effectiveness

No systematic reviews of economic evidence on remote digital delivery of psychotherapy were identified.

What were we asked to look at?

We were asked to review the published evidence on the effectiveness of remote digital psychotherapy for adult patients with depression or anxiety (including post-traumatic stress disorder), compared with face-to-face therapy. Remote digital psychotherapy can be delivered via telephone, the internet, video, or online messaging.  Our assessment included whether clinical staff can build an effective therapeutic relationship with clients during psychotherapy via digital media. We also assessed the literature relating to patient satisfaction and acceptability of remote digital delivery of psychotherapy.

Why is this important?

This report will support an update of the NES matrix of psychological therapies that are commissioned in NHSScotland. Depression and anxiety disorders are common and it is likely that there have been rapid advances in interactive technologies and changes in digital skills in society since the NES matrix was last published in 2015.

Referred by

NHS Education for Scotland (NES)