This review concluded that remotely communicated therapist-delivered psychotherapy had the potential to be clinically effective, but the available evidence was limited in quantity and quality and restricted any definitive conclusions from being drawn. This was a well-conducted review. The authors conclusion is likely to be reliable.

To determine the effectiveness of remotely communicated therapist-delivered psychotherapy.

MEDLINE, PsychINFO, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDAN-CTR) were searched for English-language publications from inception up to July 2006. Search terms were reported. Authors of published and ongoing trials were contacted, and references of relevant papers were searched, to identify any additional studies.

Randomised controlled trials (RCTs) of a treatment that incorporated a psychological intervention (defined as any treatment with an explicit psychological orientation) mediated by remote communication in any group seeking treatment for a mood disorder or functional mental health problem were eligible for inclusion. Mood disorders and functional mental health problems were as defined by criteria from ICD-10 (International Classification of Diseases and Related Health Problems, 10th edition) or DSM (Diagnostic and Statistical Manual of Mental Disorders).

Any treatment in which all or most treatment was delivered by a therapist to a patient on a scheduled one-to-one basis through a remote technology (not face-to-face) was accepted as being mediated by remote communication.

There was a number of exclusion criteria. Therapy involving more than one client simultaneously. Trials examining telephone helplines. Trilas of the efficacy of medication management programs in the absence of psychotherapy. Interventions in which the majority of therapy was delivered outside of client-therapist interaction or via technology with little or no therapist contact. Studies in which changes in mental health symptoms were measured as a by-product of counselling for physical illness. Studies involving therapy for substance misuse or addictions. And trials that examined remote therapy for healthy populations at risk of mental health difficulties.

Most included studies assessed psychotherapy mediated by telephone. Other methods included internet and video conference. Where reported, psychotherapy included problem-solving therapy, cognitive behavioural therapy or exposure therapy. Comparators included face-to-face psychotherapy or an alternative remote psychotherapy (stress management, supportive emotion focused therapy and relaxation therapy). Duration and frequency of interventions varied between studies. Follow-up duration ranged from six weeks to 12 months. Study populations included primary and secondary care patients with depression (including one study of children) and individuals with obsessive compulsive disorder (OCD), agoraphobia with panic disorder and post traumatic stress disorder (PTSD). Outcome measures varied between studies and included a number of different rating scales and symptom checklists.

Two reviewers independently selected papers for inclusion in the review. Disagreements were resolved through discussion with other team members.

Methodological quality was assessed using a modified version of a checklist developed by the Cochrane Collaboration for Depression, Anxiety and Neurosis (CCDAN). Two criteria relating to blinding (patients) and the recording of pharmacological side-effects were omitted. The maximum quality score that could be assigned was 42. Two reviewers independently assessed the methodological quality of the included studies. Any disagreements were resolved by discussion.

Continuous and dichotomous measures were translated into standardised effect sizes (Cohen's d). Dichotomous outcomes were first estimated as odd ratios (OR) and then converted into standardised effect sizes. Two reviewers independently extracted data from the included studies onto a standardised data form; any disagreements were resolved by discussion.

Studies were combined in a meta-analysis using a fixed-effect model. Summary estimates were reported as standardised mean difference (SMD) with 95% confidence intervals (CIs). Three main comparison groups were analysed: remote communication therapy versus a control group; remote communication therapy versus conventional face-to-face therapy; and different types of remotely communicated therapy. Studies were further categorised into anxiety-related disorders or depression. Statistical heterogeneity was assessed using the I² statistic. Values up to 25 per cent were considered to have low variation. Values of 50 per cent were of moderate variation. Values of 75 per cent or above were classed as high variation.

Thirteen studies were included in the review (n=1,567, range 23 to 600): 11 RCTs; and two quasi-RCTs. Rates of withdrawal ranged from nine per cent to 73 per cent. The mean CCDAN score was 23 (SD 7.33, range 13 to 38).

A statistically significant effect in favour of remotely delivered therapy compared to control was found for depressive disorders (SMD 0.44, 95% CI: 0.29, 0.59, seven studies, n=726) and for anxiety-related disorders (SMD 1.15, 95% CI: 0.81, 1.49, three studies, n=168). No evidence of statistical heterogeneity was found (I²=0%).

Other comparisons were evaluated only in single studies and no overall conclusions could be drawn.

Remotely delivered psychotherapies had the potential to overcome many of the barriers to conventional (face-to-face) psychological therapy services. But, the available evidence was limited in both quantity and quality, which restricted any definitive conclusions from being drawn. More rigorous trials were needed to confirm the preliminary estimates.

The review question was supported by clear inclusion criteria in terms of study design, intervention and population. Several databases were searched and some attempts to locate unpublished material were made. The search was restricted by language, raising the possibility of language bias. In general the methodology was reported clearly and the use of multiple independent reviewers for each stage of the review was likely to minimise risks of reviewer error and bias. The quality of the included studies was assessed using specified criteria and the results were reported. Appropriate methods were used to pool results and investigate statistical heterogeneity. Overall, this was a well-conducted review. The authors' conclusion is likely to be reliable.

Practice: The authors did not state any implications for practice

Research: The authors stated that more rigorous trials were needed to confirm the findings. Studies should compare remote psychotherapy with conventional face-to-face therapy and consider levels of patient and therapist satisfaction, as well as the impact of different modes of communication on outcome and the quality of the therapeutic alliance.

None reported

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.