Table 2.
Clinical effectiveness outcomes.
Main diagnosis | Study | Intervention (number of studies) | Comparator (number of studies) | Results | Data |
Anxiety | |||||
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Berryhill et al (2019b) [23] | Video-based CBTa (n=12); video-based behavioral activation (n=3); video-based ACTb (n=1); video-based exposure therapy (n=2); video-based problem-solving therapy (n=1); video-based metacognitive therapy (n=1); multiple modality (n=1) | Face-to-face psychotherapy (n=20); no control (n=1) | In total, 66% (14/21) of studies found statistically significant improvement on validated anxiety measures when videoconferencing psychological therapy was involved. A total of 52% (11/21) of studies reported clinically significant improvements among participants. Controlled study designs comparing face-to-face and videoconferencing psychological therapy sessions (7/10, 70%) found no statistical difference between them. | No combined data were available |
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Coughtrey and Pistrang (2018) [26] | Telephone-based CBT (n=2); telephone-based exposure response prevention therapy (n=1); telephone-based behavioral therapy (n=1) | Face-to-face exposure response therapy (n=1); waitlist (n=3) | All 3 RCTsc on anxiety reported significant reductions in anxiety symptoms following telephone-delivered intervention (OCDd: comparable reductions with face-to-face treatment, maintained over 6-month follow-up. Panic disorder: significant reductions in panic and gains maintained over 3-month follow-up. Transdiagnostic intervention: significant reductions in anxiety sensitivity, panic, social phobia and PTSDe). One quasiexperimental study found significant reductions in OCD symptoms as compared with controls maintained at 12-week follow-up. | RCTs: Cohen d range 0.34-1.07 (median 0.69; n=2); uncontrolled: Cohen d=1.07 (n=1) |
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Olthuis et al (2016a) [35] | Internet CBT with therapist email or telephone support (n=37); internet behavioral therapy with exposure (n=1) | Waitlist or attentional control (n=20); face to face (n=7); other internet-based therapy (n=6); multiple control groups (n=5) | Versus control: therapist-supported iCBTf showed significantly larger improvements in anxiety (n=12), disorder-specific anxiety symptom severity (n=30), and general anxiety symptom severity (n=19) at posttreatment as compared with waiting list, attentional control, information only or internet-based discussion group only controls. Versus unguided iCBT: therapist-supported iCBT showed no difference in improvements in anxiety at posttreatment (n=1), disorder-specific anxiety symptom severity at posttreatment (n=5), and general anxiety symptom severity (n=2) at posttreatment compared with unguided self-help iCBT. Versus face-to-face: therapist-supported iCBT showed no difference in improvements in anxiety at posttreatment (n=4) and 6- to 12-month follow-up (n=3), disorder-specific anxiety symptom severity at posttreatment (n=7) and 6- to 12-month follow-up (n=6) and general anxiety symptom severity (n=6) at posttreatment and at 6- to 12-month follow-up (n=5) as compared with face-to-face CBT. | Waitlist, attentional control, information only or internet-based discussion group–only controls at posttreatment: SMDg=–1.06 (95% CI –1.29 to –0.82), P<.001; face-to-face CBT at posttreatment: SMD=0.06 (95% CI –0.25 to 0.37); P=.36 (no difference between iCBT and face-to-face sessions) |
PTSD | |||||
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Turgoose et al (2018, veterans) [38] | Video-based exposure (n=10); video-based cognitive processing therapy (n=6); video-based CBT (n=5); mixed interventions (n=11); telephone mindfulness (n=1); video-based behavioral activation (n=2); video-based eye movement desensitization and reprocessing (n=1); video-based anger management (n=2); video-based general coping and psychoeducation interventions (n=3) | Face-to-face (n=41) | In total, 18 studies looked at the clinical effectiveness of teletherapy interventions. All of these studies reported that teletherapy was associated with significant reductions in PTSD symptoms, regardless of the type of intervention used, except one study that only measured anger in veterans with PTSD. Of those studies that used follow-up measures, all but one found these changes to be present at 3 or 6 months following treatment. In total, 67% (12/18) of studies compared teletherapy with in-person interventions. In all, 9 studies concluded that teletherapy was as effective as in-person therapy. Two suggested in-person therapy produced significantly greater reductions in PTSD symptoms (though neither were randomized), and 1 study found that teletherapy was more effective than in-person therapy. | No combined data available |
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Olthuis et al (2016b) [36] | Video-based CBT (n=3); video-based cognitive processing therapy (n=3); internet CBT with therapist email or telephone support (n=9); video-based prolonged exposure (n=2); telephone mindfulness (n=1); video-based behavioral activation and exposure (n=1) | Face-to-face (n=8); internet-based supportive counseling (n=1); treatment as usual (n=2); telephone (n=1); self-help iCBT (n=1); waiting list (n=6) | Overall, telehealth interventions showed significant improvement in PTSD symptoms postintervention (n=18), at 3- to 6-month follow-up (n=11), and at 7- to 12-month follow-up (n=3); videoconferencing: in total, 9 studies examined videoconferencing interventions for PTSD. Results showed a significant improvement in PTSD symptoms at postintervention. There was no difference in improvements in PTSD symptoms between telehealth and face-to-face interventions at posttreatment (n=7); however, face-to-face interventions showed a significantly greater improvement at 3- to 6-month follow-up (n=5). Internet-based therapy delivered with telephone or email support: in total, 8 studies examined internet-delivered interventions with telephone or email support. Results showed significant improvements in PTSD symptoms at postintervention. Furthermore, telehealth interventions were found to show a significantly greater improvement in PTSD symptoms as compared with waitlist controls (n=6). There were no data comparing these interventions with face-to-face treatments. No follow-up data were available. | Total: within group: pre- and postintervention: g=0.81 (95% CI 0.65 to 0.97), n=18 (favors telehealth); preintervention to 3- to 6-month follow-up: g=0.78 (95% CI 0.59 to 0.97), n=11 (favors telehealth) preintervention to 7- to 12-month follow-up: g=0.75 (95% CI 0.25 to 1.26), n=3 (favors telehealth); Between group: as compared with waitlist control postintervention: g=0.6 (95% CI 0.51 to 0.86), n=6 (favors telehealth) compared with face-to-face treatment for PTSD postintervention: g=–0.05 (95% CI –0.31 to 0.20), n=7 (no difference) compared with face-to-face treatment for PTSD 3- to 6-month follow-up: g=–0.25 (95% CI –0.44 to –0.07), n=5 (favors face-to-face). Videoconferencing: within group: pre- and postintervention: g=0.71 (95% CI 0.47 to 0.96), n=8 (favors telehealth). Between group: compared with waitlist control postintervention: No data compared with face-to-face treatment for PTSD postintervention: g=–0.05 (95% CI –0.31 to 0.20), n=7 (no difference). Internet-delivered interventions with telephone or email support. Within group: pre- and postintervention: g=0.94 (95% CI 0.69 to 1.20), n=8 (favors telehealth). Between group: compared with waitlist control postintervention: g=0.73 (95% CI 0.56 to 0.91), n=5 (favors telehealth) compared with face-to-face treatment for PTSD postintervention (no data) |
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Bolton and Dorstyn (2015) [24] | iCBT with therapist support via telephone calls, introductory face-to-face meetings, or emails (n=6); video-based CBT (n=5) | Face-to-face (n=5); supportive counseling (n=1); waitlist (n=1); no control (n=4) | Therapist-assisted internet programs. Statistically significant reductions in the severity of depression and anxiety symptoms (including PTSD) were associated with therapist-assisted internet programs in five studies, including significant large reductions in fear reactions, suicidal ideation, social functioning, and insomnia. Treatment effects 1-6 months posttelepsychology were mixed, with both deterioration and continued improvement found in psychological functioning. This included an increased risk of alcohol consumption over time but also a decline in PTSD and depression symptoms in participants using internet programs. Videoconferencing: video-based interventions also produced short-term reductions in affective symptoms; however, face-to-face therapy demonstrated slightly higher treatment gains. The longer-term effectiveness of videoconferencing was reported in only two studies which showed nonsignificant effect sizes at follow-up. | No useful synthesis of data |
Depression | |||||
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Harerimana et al (2019, older adults) [20] | Telephone-based (n=3); video-based (n=2); web based (n=1) | Waiting list (n=NRh) treatment as usual (n=NR) | Telephone: three studies examined a telephone-based intervention. One study found that a home electronic messaging service reduced emergency room and hospital visits. Another study found that older adult veterans given a combined telephone-based psychotherapy and long-term illness management intervention showed significant reductions in depression as compared with usual care. However, a third study found that adding telecoaching to a web intervention did not significantly improve symptoms compared with providing only the web intervention. Videoconferencing: two studies examined Skype-based videoconferencing interventions with inconsistent results. One study found that depression scores improved significantly from baseline but got worse at the 2-month follow-up. Another found that face-to-face and Skype-based intervention were not significantly different at postintervention and shorter follow-ups, but at 36 months, the telehealth intervention showed significantly larger improvements in symptoms. Web-based CBT: one web-based CBT intervention was effective in reducing depression symptoms (P=.04), even with high rates of attrition. | No combined data available |
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Berryhill et al (2019a) [22] | Video-based CBT (n=12); video-based behavioral activation (n=5); video-based acceptance and behavioral therapy (n=1); video-based exposure (n=3); video-based metacognitive therapy (n=1); video-based problem-solving therapy (n=2); video-based therapy in multiple modalities (n=9) | Face-to-face psychotherapy (n=16); face-to-face or telephone (n=2); no control (n=15) | In total, 67% (22/33) of studies included reported statistically significant reductions in depressive symptoms following videoconference-based psychotherapy. Most controlled studies reported inconsistent results while comparing face-to-face and video-based psychotherapy. | No combined data available |
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Coughtrey and Pistrang (2018) [26] | Telephone-based CBT (n=10) | Telephone emotion-focused therapy (n=1); treatment as usual (n=5); no control (n=4) | In total, 83% (5/6) of RCTs on depression reported a significant reduction in depression symptoms following telephone-delivered CBT (n=3) or IPTi (n=2). These studies included people with recurrent depression (n=1), HIV (n=1), multiple sclerosis (n=1), and people from rural Latino communities (n=1). Two RCTs reported follow-up: only one of these found the maintenance of reductions in depressive symptoms. One RCT found that depression symptoms were not significantly reduced in veterans. One quasiexperimental study found significant reductions in depression following telephone-delivered CBT, with similar patterns of change found in the comparison group. Three uncontrolled studies reported statistically significant reductions in depression following telephone-delivered CBT, including people with Parkinson disease (n=1), HIV (n=1), and veterans with depression (n=1). | RCTs: Cohen d range: 0.25-1.98 (median 0.58), n=5; uncontrolled: Cohen d range: 1.13-1.90 (median 1.25), n=2 |
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Dorstyn et al (2013; minority ethnicity communities) [21] | Telephone CBT (n=2); telephone supportive counseling (n=1); telephone structural ecosystems therapy (n=1); internet-based CBT with weekly individual sessions (n=2); internet telepsychiatry (n=1); internet supportive counseling and personalized email correspondence (n=1) | Face-to-face (n=1); treatment as usual (n=3); minimal support control or waitlist (n=2); no control (n=2) | Telephone- and internet-mediated services were associated with significant improvements in the measurements of depression, anxiety, quality of life and psychosocial functioning. The review also found that two studies demonstrated similar effects on depression ratings (CES-Dj) in telephone and face-to-face psychotherapy. Three studies reported longer-term effects of telecounseling, with conflicting findings. | No combined data available |
Carers of people with dementia (for depressive symptoms) | Lins et al (2014) [31] | Telephone counseling (n=9) | Friendly calls (n=3); treatment as usual (n=6) | Telephone counseling without any additional intervention showed significant reductions in depressive symptoms in three studies; however, two additional studies showed no differences between groups. A study of telephone counseling with video sessions showed reductions in depressive symptoms in the intervention group but these did not significantly differ from the control group. One study found that telephone counseling with video sessions and a workbook showed significant reductions in depressive symptoms. Burden, distress, anxiety, quality of life, satisfaction, and social support outcomes were inconsistent. Results show that it is still unclear whether telephone counseling can reduce caregiver burden. | Telephone counseling only: depressive symptoms: n=3, SMD=0.32 (95% CI 0.01 to 0.63), P=.04; burden: n=4, SMD=0.45 (95% CI –0.01 to 0.90), P=.05 |
Substance use disorders | Lin et al (2019) [30] | Video or telephone-based psychotherapy (n=10); remote medication management (n=3; patient presents at local clinic with nurse and is connected to a physician at a distant site via videoconference) | Face-to-face psychotherapy (n=7); telephone (n=2); treatment as usual (n=1); no control (n=3) | Tobacco: videoconferencing interventions were not significantly better than in-person (n=1) or telephone (n=2) conditions in terms of abstinence. Alcohol: no significant difference in alcohol use outcomes as compared with usual treatment (n=1), but lower dropout was reported in the telemental health intervention (n=1). Opioid: no significant difference in abstinence between videoconference-based psychotherapy and in-person psychotherapy for methadone patients (n=2), and no difference in time to abstinence (n=1). Notably, none of the included studies described a noninferiority design that specifically assessed whether the intervention was not significantly worse than usual in-person delivered care. Overall, most studies suggested telemental health interventions were an effective alternative, especially when access to treatment is otherwise limited. | No combined data available |
Nonspecific | |||||
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Hassan and Sharif (2019, refugee populations) [29] | Not specified videoconferencing treatment intervention (n=2); video-based CBT (n=7); video-based psychoeducation (n=2); video-based relapse prevention (n=1); video-based treatment management (n=1); video-based evaluation of competency to stand trial (n=1) | Face-to-face (n=14) | Five studies compared remote and face-to-face interventions in symptom reduction. Two reviews found greater improvement in the remote intervention, whereas 3 found no significant difference between the intervention and control groups. | No combined data available |
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Norwood et al (2018) [34] | Video-based CBT (n=10) | Face-to-face CBT (n=10) | All 10 studies showed that video-based CBT improved symptom severity. Eight studies offered follow-up data, and the postintervention improvement was maintained in all of them. Symptom reduction in video-based CBT was noninferior to face-to-face sessions across all six studies which offered a face-to-face comparison. | No combined data available |
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Drago et al (2016) [27] | Videoconferencing (n=24) | Face-to-face (n=23). No comparator (n=1) | In total, 14 RCTs focused on efficacy of remote psychiatric counseling. There was no difference between treatment outcomes in remote and face-to-face settings. | Videoconferencing versus face-to-face therapy: SMD=–0.11 (95% CI –0.41 to 0.18) |
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Garcia-Lizana and Munoiz-Mayorga (2010) [28] | Videoconferencing for diagnosis and follow-up (n=3); video-based evaluation of competency to stand trial (n=1); nonspecific video-based CBT (n=5); video-based psychoeducation and counseling (n=1) | Face-to-face (n=10) | Across seven studies, there was no statistically significant difference between telepsychiatry and face-to-face interventions in symptom reduction. Across three studies, there was no statistically significant difference between telepsychiatry in improvements in quality of life. | No combined data available |
aCBT: cognitive behavioral therapy.
bACT: acceptance and commitment therapy.
cRCTs: randomized controlled trials.
dOCD: obsessive-compulsive disorder.
ePTSD: posttraumatic stress disorder.
fiCBT: internet-based cognitive behavioral therapy.
gSMD: standardized mean difference.
hNR: not reported.
iIPT: interpersonal psychotherapy.
jCES-D: Center for Epidemiological Studies-Depression Scale.