Markowitz, J.C., Milrod B., Heckman, T.G., Bergman, M., Amsalem, D., Zalman, H., Ballas, T., Neria, Y. (2020). Psychotherapy at a distance. American Journal of Psychiatry, doi: 10.1176/appi.ajp.2020.20050557.
Teletherapy was once seen as an adjunctive therapy mainly reserved for patients who lived in remote locations and who could not otherwise access psychotherapy. Now, due to public health restrictions related to COVID-19, teletherapy has become standard care. Conscientious psychotherapists who want to practice based on the best available evidence have looked to the research for some guidance. Previous PPRNet Blogs (see the May, June, and July 2020 Blogs at www.pprnet.ca) have highlighted some of the research related to teletherapy and videoconferencing psychotherapy. In this meta-review, Markowitz and colleagues in part assess the quality of some of these findings, that is – how good is this research. Quality of research often hinges on a number of factors: is the sample size large enough to make solid conclusions, are the methods used appropriate and robust (like randomized controlled trials), is there a sufficient quantity of research that can be summarized, and are patient samples in the studies similar to those typically see in clinical practice. There are thousands of studies of face to face psychotherapy for depression, but by comparison the number of studies of teletherapy are relatively sparse. Many studies of teletherapy are not randomized controlled trials in the typical sense, but rather they are a hodgepodge of studies of different interventions, patients, settings, and outcomes. Nevertheless, the outcomes are generally encouraging in terms of the efficacy of teletherapy. In a recent meta analysis, effects of videoconferenced psychotherapy appear to be equivalent to face to face therapy, but there were only 11 studies in all, only 5 of the studies were considered high quality, and 4 of the high quality studies were with military veterans with PTSD in the Veterans Administration System in the US. Regarding specific orientations, Markowitz and colleagues reported three rigorous trials showing CBT or interpersonal psychotherapy reduced depressive symptoms. There are six randomized trials of group therapy by videoconferencing or telephone, but most are of low quality and often specifically focused on patients with HIV.
Videoconferenced and telephone delivered psychotherapy are likely here to stay in some form, even after the COVID-19 pandemic. Teletherapy greatly expands access for some, though some patients including homeless, poorer, or the elderly individuals still may not have adequate access. The research evidence for the efficacy of remote therapy is encouraging, but also problematic. Most research trials are too small to draw meaningful conclusions, and few studies focus on therapeutic factors. Anecdotal reports suggest that those who are socially anxious or avoidant may prefer remote care, however it is also possible that teletherapy may exacerbate problematic avoidance behaviors among some patients. At the moment, the research lags far behind the rapid transition to remote care that has occurred in the past months.