Spotlight Research 13 - Message-based Psychotherapy Is as Effective as Video-based Psychotherapy in Reducing Depression Outcomes: A Large-scale Sequential Multiple Assignment Randomized Trial

There is limited research on the effectiveness of message-based psychotherapy (MBP) compared to video-chat psychotherapy (VCP). Insurance companies typically cover only VCP despite emerging evidence that timely therapeutic interventions with more frequent contact are more effective than the standard once a week hourly session. We review a 12-week sequential multiple assignment randomized trial (SMART) implemented in a real-world, large telehealth company examining the effectiveness of MBP compared to VCP.

A racially diverse and large pool of participants were randomly assigned to receive daily MBP (n=422) or weekly VCP (n=426). Those who did not respond to treatment were re-randomized to MBP+monthly VCP or MBP+weekly VCP at week 6. 3-level longitudinal mixed effects regression models were used to measure change in PHQ-9 scores at 6 and 12 weeks compared to baseline. Chi-square tests were conducted to compare response to treatment and remission between the treatment conditions.

There were no significant differences on PHQ-9 scores at each timepoint between the treatment modalities. Participants using MBP were slightly more likely (24.6%) to respond to treatment than those assigned to VCP (21.6%) at week 6, but not at week 12. Within participants initially assigned to MBP, response to treatment at 12 weeks was not significantly different between MBP+monthly VCP and MBP+weekly VCP. Participants initially assigned to VCP and re-assigned to MBP+monthly VCP were more likely to respond at 12 weeks compared to those re-assigned to weekly VCP+MBP.

This was the first large-scale study examining the effectiveness of MBP compared to VCP in a real-world telehealth company. These findings can have a profound impact on the modality of psychotherapy covered by insurance providers, as we found no differences in outcomes between MBP and VCP. Asynchronous text therapy offers many benefits for both therapists and clients. It can be delivered on demand, at the patient’s convenience, and in the privacy of the text environment, making MBP a treatment modality that may be more acceptable to clients than VCP. The study’s findings may impact insurance coverage decisions such that clients might be reimbursed for text-based therapy.