Therapist-guided remote versus in-person cognitive behavioural therapy: a systematic review and meta-analysis of randomized controlled trials

Abstract

Background: Cognitive behavioural therapy (CBT) has been shown to be effective for several psychiatric and somatic conditions; however, most randomized controlled trials (RCTs) have administered treatment in person and whether remote delivery is similarly effective remains uncertain. We sought to compare the effectiveness of therapistguided remote CBT and inperson CBT. Methods: We systematically searched MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to July 4, 2023, for RCTs that enrolled adults (aged ≥ 18 yr) presenting with any clinical condition and that randomized participants to either therapistguided remote CBT (e.g., teleconference, videoconference) or inperson CBT. Paired reviewers assessed risk of bias and extracted data independently and in duplicate. We performed randomeffects model metaanalyses to pool patientimportant primary outcomes across eligible RCTs as standardized mean differences (SMDs). We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance to assess the certainty of evidence and used the Instrument to Assess the Credibility of Effect Modification Analyses (ICEMAN) to rate the credibility of subgroup effects. Results: We included 54 RCTs that enrolled a total of 5463 patients. Seventeen studies focused on treatment of anxiety and related disorders, 14 on depressive symptoms, 7 on insomnia, 6 on chronic pain or fatigue syndromes, 5 on body image or eating disorders, 3 on tinnitus, 1 on alcohol use disorder, and 1 on mood and anxiety disorders. Moderatecertainty evidence showed little to no difference in the effectiveness of therapistguided remote and inperson CBT on primary outcomes (SMD -0.02, 95% confidence interval -0.12 to 0.07). Interpretation: Moderatecertainty evidence showed little to no difference in the effectiveness of inperson and therapistguided remote CBT across a range of mental health and somatic disorders, suggesting potential for the use of therapistguided remote CBT to facilitate greater access to evidencebased care.