Research desk · How therapy is delivered
Asynchronous messaging used to be the thing clients did between sessions. Now some platforms sell it as the therapy itself. Three randomized trials have compared it with video for depression. The results are more interesting than either side of the argument usually admits.
In these trials, message-based psychotherapy (MBP) means the client and therapist exchange text, voice, or video messages asynchronously, on an agreed schedule, as the main treatment. It is not a chatbot, and it is not a therapist answering scheduling texts. A licensed clinician is on the other end, delivering an evidence-based approach such as cognitive behavioral therapy, just not in real time. [1],[3]
The comparison is video therapy, which itself now has a solid evidence base. A 2021 meta-analysis of 47 between-group studies found live video psychotherapy differed negligibly from in-person treatment in outcomes. [4] Another meta-analysis of 18 studies found no significant difference in therapeutic alliance between video and in-person therapy, whether clients or therapists did the rating. [5] So the question these trials ask is whether going asynchronous costs anything compared with a format already shown to hold up.
The largest study, published in JAMA Network Open in 2025, ran from January 2022 to January 2024 on a commercial digital mental health platform. [1] It enrolled 850 adults in the US with a diagnosis of depression and a PHQ-9 of 10 or more; the average starting PHQ-9 was 15.0. Participants were randomized to messaging (423) or weekly video sessions (427). At week 6, people who had not responded were randomized again to messaging plus either weekly or monthly video. Treatment lasted 12 weeks.
The main results:
The authors concluded that message-based therapy is a viable alternative to video, and that future work should focus on building alliance early in messaging care.
Two earlier trials from overlapping research teams found the same shape of result.
A 2023 RCT in the Journal of Medical Internet Research randomized 83 people with moderate depression to messaging or once-weekly 45-minute video sessions. [2] The messaging group improved substantially in depression (d = 1.04), anxiety, and functioning, and those changes were noninferior to video. There were no significant differences in alliance, treatment credibility, or engagement.
A 2024 trial in Psychiatric Services randomized 215 adults with depression. [3] People who started with messaging stayed engaged with their therapist for more weeks (7.8 vs 4.9). Rates of change in depression, anxiety, disability, and global improvement did not meaningfully differ at 6 or 12 weeks. Neither format produced adverse events.
Three things should temper enthusiasm.
Who ran the studies. All three trials list co-authors affiliated with Talkspace. The 215-person trial delivered care on Talkspace, and the 850-person trial ran on a commercial platform with Talkspace employees among its authors, as its conflict-of-interest statement discloses. [1],[3],[2] That doesn’t make the results wrong. It does mean independent replication matters.
Who was in them. Participants were adults with depression who signed up for digital care. People at high risk, with complex presentations, or who would never choose text-based care are not well represented. Messaging that works for a 34-year-old with moderate depression may not suit a client with active suicidal thinking or psychosis.
What alliance looks like in text. Alliance still matters in digital formats, but it may matter differently. A 2024 meta-analysis of teletherapy by video or phone (31 studies, 4,862 participants) found a small alliance-outcome association, somewhat weaker than in in-person care. [6] A 2026 meta-analysis of internet-based interventions found an overall correlation of r = .21, with agreement on tasks (r = .25) and goals (r = .19) predicting outcome more than the emotional bond (r = .12). [7] In text, being clear about what you are working on together may carry more of the relationship than warmth alone.
Plenty of clinicians already message clients between sessions without calling it a treatment format. Either way, the risks are the same: unclear expectations, missed crisis signals, and unpaid hours. Decide these before the first message, and put them in writing.
Write it into informed consent, and say it out loud:
“You can message me here any time, and I’ll read and reply once a day on weekdays. If you’re ever in danger or can’t wait, call or text 988 or go to the nearest emergency room. Messages aren’t watched at night.”
The trial data suggest one more practice: if a messaging client isn’t improving by week 4 to 6, check the alliance directly rather than assuming the format is neutral. [1] A short video session to re-agree on goals and tasks fits the evidence above.
If you practice in California, our guides on telehealth and insurance in California and online therapy in California cover related ground.
Each card links to the PubMed record. Numbers are reported the way the authors reported them. Read the abstract before you quote any of them.
Pullmann MD, Rouvere J, Raue PJ et al.
850 US adults with depression, commercial platform, 12 weeks. Response 47.5% vs 47.2%, remission 31.4% vs 30.3% (messaging vs video). Week-5 disengagement 13.2% vs 21.3%. Weaker early alliance with messaging among non-responders. Co-authors included platform employees.
Song J, Litvin B, Allred R et al.
83 adults with moderate depression. Messaging produced large depression improvement (d = 1.04) and was noninferior to weekly 45-minute video sessions. No differences in alliance or engagement.
Areán PA, Pullmann MD, Griffith Fillipo IR et al.
215 adults with depression. Messaging clients engaged over more weeks (7.8 vs 4.9). No meaningful differences in clinical outcomes at 6 or 12 weeks; no adverse events in either arm.
Fernandez E, Woldgabreal Y, Day A et al.
Video vs in-person psychotherapy. 47 between-group studies (N = 3,564). Video outcomes differed negligibly from in-person; strongest pre-post effects for CBT targeting anxiety, depression, and PTSD.
Seuling PD, Fendel JC, Spille L et al.
Alliance in video vs in-person therapy, 18 publications. No significant difference by patient rating (SMD −0.09) or therapist rating (SMD 0.04).
Aafjes-van Doorn K, Spina DS, Horne SJ et al.
Alliance and outcome in teletherapy by video or phone. 31 studies, 4,862 participants. Small association (0.15), somewhat weaker than in-person estimates.
Flückiger C, Schweizer AM, Boehme MS et al.
Alliance in internet-based interventions. 40 samples, 2,864 participants. Overall r = .21; task .25 and goal .19 predicted outcome more than bond .12.
Education for clinicians, not medical or legal advice. This page summarizes published research for licensed mental health professionals. It is not a treatment recommendation for any individual, and it does not replace your own clinical judgment, your licensing board’s rules, or consultation with a prescriber or attorney. Evidence reviewed through October 24, 2026. Spot an error? Tell us and we will fix it.
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