Study Examines Prognostic Risk Factors of Face-to-Face vs Internet-Based Therapy for Depression


A new analysis was unable to provide conclusive comparisons between the 2 methods of psychotherapy delivery, despite robust data.

Study Examines Prognostic Risk Factors of Face-to-Face vs Internet-Based Therapy for Depression

Credit: ResearchGate

While face-to-face therapy (FTF) had been the traditional treatment type for depression, internet-based therapy (IBT) has been growing for the past 2 decades—and according to a new study, internet-based therapy may have less prognostic risk factors (PRF) than face-to-face.1

Previous studies support the effectiveness of internet-based therapy, with cognitive behavior therapy (CBT) proving to be effective for treating depressive symptoms when delivered online.2

Led by Mariia Merzhvynska, MSc, of the department of psychology at University of Zurich, the new systematic review and meta-regression compared face-to-face therapy and internet-based therapy and both therapy’s association with PRF. The investigators performed the study because previous research found that severe symptoms, comorbidity, and sociodemographic characteristics including low education and unemployment are associated with poorer prognosis in adults treated for depressive symptoms.1

The data was from 2000 – 2021, and the primary outcome was the standardized mean difference in depressive symptoms at the treatment end date. A positive standardized mean difference signified larger improvements in treatment compared to those in the control group.

The prognostic risk index (PROG) calculated the sum of 12 individual indicators, with scores ranging from 0 - 12. The higher the score, the more the indicator that a sample of patients had poorer prognoses.

The study identified 105 eligible randomized controlled trials (RCTs). Less than half of studies examined face-to-face therapy (46%; n = 4073) and 54% of studies examined internet-based therapy (n = 14,290).

The team found that the PROG was significantly higher in the RCTs of face-to-face therapy (mean [SD], 3.55 [1.75]; median [IQR], 3.5 [2.0 - 4.5]) than internet-based therapy (mean [SD], 2.27 [1.66]; median [IQR], 2.0 [1.0-3.5]. The z score was −3.68 (P < .001; Hedges g, 0.75; 95% CI, 0.36 - 1.15).

Thus, the research suggests the RCTs of face-to-face and internet-based therapy differ regarding PRFs.

The investigators found the following were significantly more prevalent in face-to-face therapy than in internet-based therapy:

1. Comorbid personality disorders (FTF, 8.3% vs IBT 0%; P = .04)

2. Clinical diagnosis of depression (FTF, 72.9% vs IBT 31.6%; P < .001)

3. Severe depressive symptoms (FTF, 35.4%vs IBT 3.5%; P < .001)

4. Lower education (FTF, 39.6% vs IBT 15.8%; P = .008)

Investigators reported that 9 - 88% of data was not assessed or reported for each of the 12 PRFs. Not-reported PRF data was more common in internet-based therapy (mean [SD], 6.91 [1.97]) than in face-to-face therapy (mean [SD], 5.67 [1.84]; z, 2.97; P = .003).

Ultimately, the association of PROG and the primary outcome are inconclusive, and the investigators pointed out that this could be due to study design, sample size, or the composition of the PROG.

“The reporting quality of PRFs was poor in most trials, particularly in IBT trials,” the investigators wrote. “This renders the translation of trial results difficult in clinical practice, where most patients present with complex conditions.”

The investigators continued by saying comparing different depression treatments are tricky because trial samples are not taken from the same clinical population.

“To improve, reporting guidance is needed about which PRFs are deemed relevant, and adherence to guidelines should be encouraged by grant providers and scientific journals,” the investigators wrote.


  1. Merzhvynska, M, Wolf, M, Krieger, T, et al. Prognostic Risk Factors in Randomized Clinical Trials of Face-to-Face and Internet-Based Psychotherapy for Depression. JAMA Psychiatry. 2023. doi:10.1001/jamapsychiatry.2023.3861.
  2. Neuman, L. Internet-Based Cognitive Behavior Therapy Found to Be Effective. HCPLive. May 21, 2017. Assessed October 11, 2023.
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