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Health Technology Review
The rate of mental illnesses, such as major depressive disorder and generalized anxiety disorder, has significantly increased among people aged 15 and older living in Canada.
In Canada, more than 1 in 3 of those with mental illnesses do not receive adequate mental health (MH) services, with notable geographic disparities in the availability and quality of services. Specialized MH services remain particularly scarce in remote and rural areas.
Providing MH counselling through virtual platforms has the potential to enhance the accessibility of MH services and reduce the stigma associated with in-person services.
A review of the clinical effectiveness and evidence-based guidelines is required to help understand the potential role of virtual MH counselling in clinical practice.
To inform decisions regarding the use of virtual MH counselling for people with depression, anxiety, obsessive-compulsive disorder (OCD) or posttraumatic stress disorder (PTSD), we conducted a rapid review and summarized evidence that compared the clinical effectiveness of MH counselling provided in a virtual setting versus in person. We also sought to identify evidence-based guidelines regarding the use of virtual MH counselling for these populations.
We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2019. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.
We found 6 systematic reviews (SRs) relevant to the present review that evaluated the clinical effectiveness of MH counselling provided through virtual versus in-person settings. Most SRs and their included randomized controlled trials (RCTs) reported results on the reduction of depression and anxiety, followed by PTSD and OCD.
For depression, PTSD and specific anxiety outcomes (generalized anxiety disorder, social anxiety disorder, and panic disorder), the effectiveness of virtual MH counselling in improving these outcomes was comparable to in-person settings. For OCD, results were inconsistent, suggesting virtual MH counselling can be an alternative treatment where in-person MH counselling is not readily available.
We found 5 evidence-based guidelines that provide recommendations on the use of virtual MH counselling for adults with depression, anxiety, and PTSD, based mostly on low-quality evidence or expert opinion. We did not find any evidence-based guidelines or relevant recommendations regarding the use of virtual MH counselling for people of any age with OCD nor children and youth with depression, anxiety, and PTSD.
Virtual MH counselling is recommended as a first-line intervention for adults with mild depression and for reducing symptoms of anxiety in older adults.
Virtual MH counselling is recommended as second-line adjunctive or alternative intervention for adults with moderate-severe depression, certain anxiety disorders, and PTSD.
Virtual MH counselling may improve clinical outcomes for people with depression, anxiety, OCD, or PTSD and can be used as a comparable or alternative treatment to in-person MH counselling.
Virtual MH counselling may address equity issues regarding access to evidence-based MH services where in-person MH counselling is not readily available.
Clinicians and health care decision-makers can use the evidence summarized in this review to inform decisions regarding the implementation of virtual MH counselling for adults with depression, anxiety, OCD, or PTSD.
What is the comparative clinical effectiveness of MH counselling (i.e., psychotherapy or clinical counselling) provided in a virtual setting versus in person for people with depression, anxiety, OCD, or PTSD?
What are the evidence-based guidelines regarding the use of MH counselling (i.e., psychotherapy or clinical counselling) in a virtual setting for people with depression, anxiety, OCD, or PTSD?
MH is a state of well-being in which individuals can cope with the normal stresses of life, work productively, and contribute to their community.1 In contrast, mental illness can be defined as a range of conditions that significantly affect a person’s thinking, mood, behaviour, and ability to function in daily life.2 Four of the most prevalent mental illnesses include depressive disorders, anxiety disorders, OCD, and PTSD.2
The rate of mental illnesses, such as major depressive disorder (MDD) and generalized anxiety disorder, has significantly increased among people aged 15 and older living in Canada.3 More than 1 in 3 (36.6%) of people living in Canada with mental illnesses do not receive adequate MH services, with notable geographic disparities in the availability and quality of services.3 Specialized MH services remain particularly scarce in remote and rural areas.4 The COVID-19 pandemic further affected access to MH services in Canada as well as other countries.3
In-person MH counselling is widely recognized as the standard of care, offering a structured, face-to-face environment that fosters trust, rapport, and effective communication between clients and therapists.5,6 In-person setting allows for real-time observation of nonverbal cues, immediate feedback, and personalized interventions tailored to the client’s unique needs.6 In-person MH counselling ensures access to a controlled and confidential space which is critical for addressing sensitive issues.5 Services offered may include individual therapy, group therapy and support groups, family and couples counselling, crisis intervention and suicide prevention, and psychoeducation.7
Cognitive behavioural therapy (CBT) has been the most studied approach of psychotherapy.7 However, the effectiveness of other psychotherapy approaches such as behavioural activation (BA), prolonged exposure (PE) therapy, psychodynamic approaches, interpersonal psychotherapy, and acceptance and commitment therapy has also been explored.7
In an effort to increase access, many health care systems and organizations developed platforms to deliver MH services virtually.8 Virtual MH counselling refers to providing psychological support and therapy services through digital platforms, allowing individuals to access MH services remotely.8 These services can be delivered synchronously or asynchronously and differ based on the timing of communication between the client and the therapist.8 Synchronous counselling refers to real-time communication between a client and a therapist whereby both parties are actively engaging in the session at the same time (e.g., video calls, phone calls, or live chat).9 In contrast, asynchronous counselling does not require real-time interaction; clients and therapists communicate at their convenience through written messages, audio recordings, or video clips.10 For this review, virtual MH counselling delivered synchronously is of particular interest as it mirrors the dynamic of traditional in-person therapy; the therapist and client can engage in immediate dialogue, allowing the therapist to respond to the client’s concerns as they are expressed, enabling instant clarification and emotional support.9 Moreover, the use of verbal and nonverbal cues, especially in video sessions, helps build rapport and fosters a sense of connection.
Virtual MH counselling offers several benefits. It increases accessibility, especially for people in rural areas, individuals with disabilities, or those with demanding schedules.11 It is also more affordable than in-person therapy.12 Virtual MH counselling can also reduce stigma by providing a private space for seeking help and reducing concerns about being seen visiting a therapist's office.13 Finally, it can help individuals with mental illnesses to maintain therapy even when travelling or during public health emergencies like the COVID-19 pandemic.14 Despite these benefits, MH counselling delivered via virtual settings has challenges such as technical barriers, the need for reliable internet access and familiarity with digital tools, which might exclude some populations.15,16 In addition, ensuring the confidentiality of sensitive information is critical and may depend on the platform's security measures.16 Therapists may find it harder to observe body language or subtle emotional cues, particularly in telephone-based formats.17 Finally, the effectiveness of virtual MH counselling in some conditions, such as severe psychiatric disorders, may be limited.18
Virtual MH counselling is a rapidly evolving field. Conducting a review of clinical studies and guidelines on virtual MH is crucial for several reasons, as it helps establish a robust foundation for understanding its effectiveness, limitations, and best practices. A review helps evaluate the effectiveness of virtual MH interventions. By analyzing existing studies, practitioners and policy-makers can determine whether these services are as effective as in-person MH counselling for different populations and conditions. Understanding these findings is critical to building trust in virtual MH services and guiding clinicians and clients in their decision-making. Reviewing guidelines ensures adherence to ethical standards and best practices. A review of the available evidence is essential for adapting to changing client needs and emerging technologies. Evaluating these treatment modalities through rigorous studies ensures that their adoption is based on evidence. Moreover, as client expectations evolve, it may help ensure that services remain relevant and client-centred.
The purpose of this rapid review is to identify, summarize, and critically appraise evidence on clinical effectiveness of MH counselling (i.e., psychotherapy or clinical counselling) provided in a virtual setting versus in-person for people with depression, anxiety, OCD, or PTSD. The second objective of this rapid review is to identify, summarize, and critically appraise the evidence-based guidelines regarding the use of MH counselling in a virtual setting for people with depression, anxiety, OCD, or PTSD.
An information specialist conducted a customized literature search, balancing comprehensiveness with relevancy, of multiple sources and grey literature on November 15, 2024. One reviewer screened citations and selected studies and guidelines based on the inclusion criteria presented in Table 1, and critically appraised included publications and guidelines using established critical appraisal tools. Appendix 1 presents a detailed description of methods and selection criteria for included studies.
Selection Criteria.
This report includes 6 SRs19-24 and 5 evidence-based guidelines.18,25-28 Appendix 1 presents the PRISMA29 flow chart of the study selection. Additional references of potential interest are provided in Appendix.
Summaries of study characteristics are organized by research question. Additional details regarding the characteristics of included publications are provided in Appendix 2.
We identified 6 SRs,19-24 4 of them20,22-24 with meta-analyses (MAs) that addressed this research question. These 4 SRs20,22-24 included data from 42 unique primary RCTs; however, there was considerable overlap among their included primary studies. As a result, the pooled effect estimates from separate reviews are based on some of the same data, although not all reviews reported the same outcomes. A citation matrix illustrating the degree of primary study overlap is presented in Appendix 5.
All SRs except for 121 limited their search to RCTs; the 6 SRs19-24 searched for studies published from inception, with the last search date being reported as March 2024.22
One SR19 included studies on children and adolescents, aged 0 to 19 years old, 1 SR22 included studies with participants aged over 5 years, and 4 SRs20,21,23,24 included studies on adults (aged ≥ 18 yr). Four SRs19,21-23 provided information on the age of participants from their included primary studies. Three SRs19,21,23 provided information on the sex of participants from their included primary studies; however, they did not report how sex was defined or measured. Authors of the SRs included number or percentage of female and/or male participants; other sexes or genders were not reported.
Four SRs20-22,24 included studies on any form of psychotherapies, such as CBT, BA, cognitive therapy, psychodynamic psychotherapy, PE therapy, or family therapy, which was delivered by a provider via videoconferencing technology (audio and/or video). Two SRs19,23 limited the included studies to CBT delivered via videoconferencing technology by a provider (therapist-guided). One SR21 focused on online group treatments that involved the presence or mediation of a therapist within the group and required active participation of group members. Two SRs22,24 included individual psychotherapy delivered via videoconferencing technology. Three SRs19,20,23 included a mix of individual and group therapies. One SR24 specified a duration of 6 sessions or longer for the length of interventions. Length of follow-up was reported in 4 SRs,19,21-23 which ranged from 0 to 6 months.
The included 6 SRs19-24 assessed several clinical outcomes to address research question 1. Four SRs20,22-24 included eligible MAs on various depression outcomes (e.g., depressive symptoms and severity), and 1 SR22 included eligible MA on anxiety symptoms. One SR24 conducted 2 MAs on depressive symptoms; the first 1 was based on posttreatment scores of 11 RCTs on depressive symptoms measures of all participants with a variety of primary diagnoses (PTSD [n = 5], depression [n = 3], insomnia [n = 1], bulimia nervosa [n = 1], and a combination of mood and anxiety disorders [n = 1]). The second 1 was focused on depressive symptoms measures of 3 RCTs of participants with depression.
Four SRs19-21,23 included eligible RCTs on depression (depressive symptoms or episodes and MDD), anxiety (generalized anxiety disorder, social anxiety disorder, panic disorder, and specific phobia), OCD outcomes (e.g., OCD symptoms and severity), and PTSD outcomes (e.g., PTSD symptoms and severity). One SR24 was limited to studies reporting depressive symptoms as the clinical outcome, 2 SRs19,22 reported on depression and anxiety symptoms, and 3 SRs reported on a mix of various clinical outcomes (e.g., anxiety, obsessive-compulsive, and trauma-related disorders).20,21,23 A variety of additional clinical outcomes were evaluated across the included SRs,20,21 including quality of life, satisfaction with treatment, therapeutic alliance (refers to the strength of the relationship between a therapist and a client), anger, and psychiatric and social functioning.
The 5 included guidelines18,25-28 all had specific sections providing recommendations on virtual MH counselling or psychotherapy. There were no guidelines that exclusively focused on virtual MH counselling or psychotherapy.
Two guidelines18,25 provide recommendations for adults with depression: 1 guideline was commissioned by the Canadian Network for Mood and Anxiety Treatments (CANMAT; an academic group)25 and 1 guideline was commissioned by the German National Disease Management Guideline Group (NDGM; in German: Nationale VersorgungsLeitlinie, a national medical association).18 Two guidelines26,27 provide recommendations for older adults and adults with anxiety, which were conducted by the Canadian Coalition for Seniors’ Mental Health (CCSMH; a not-for-profit organization)26 and the German Guidelines for Anxiety Disorders (GGAD) (an academic group).27 The final guideline was commissioned by the Phoenix Australia Centre for Posttraumatic Mental Health (a not-for-profit public company),28 and provides recommendations for children and adults with trauma-related symptoms and PTSD (virtual MH recommendations were specific to adults). No guidelines were found regarding virtual psychotherapy or counselling for OCD.
The guidelines considered and included recommendations on the use of several types of virtual MH interventions, including CBT (4 guidelines),25-28 trauma-focused CBT (1 guideline),28 psychodynamic therapy (1 guideline),27 and internet-based BA (iBA) (1 guideline).25 One guideline18 provides recommendations on internet- and mobile device–based interventions broadly.
Critical appraisal summaries are organized by study design. Additional details regarding the strengths and limitations of included publications are provided in Appendix 3.
The authors of all 6 SRs19-24 clearly defined their objectives and eligibility criteria, conducted comprehensive literature searches across multiple databases, and provided details on key search terms and search dates. They also included flow charts illustrating study selection, along with reasons for excluding studies. These methodological strengths increase the reproducibility of the SRs. The review methods for all 6 SRs were established before conducting the reviews (e.g., they were documented in published protocols), reducing the risk of reporting bias. In all 6 SRs,19-24 at least 2 independent reviewers conducted study selection and quality assessment. The quality of the included primary studies was assessed using transparent and satisfactory techniques in all 6 SRs. In 3 SRs,20,21,23 subject matter experts were consulted to ensure the search captured relevant studies. Four SRs19-21,23 reported the characteristics of included studies in sufficient detail (e.g., study design, number of participants, intervention). Five SRs19,20,22-24 conducted MAs; all used appropriate statistical methods for the MA. Publication bias was assessed by the authors of 3 SRs.20,23,24 Three SRs19,20,23 used appropriate methods for the statistical combination of results and assessing statistical heterogeneity (e.g., the I2 statistic). The authors of all 6 SRs stated their potential conflicts of interest and the sources of funding.19-24
As for methodological limitations, 3 SRs19,21,24 did not conduct a grey literature search, increasing the risk of missing relevant studies that are not published commercially and that may be inaccessible by bibliographic databases (i.e., non-indexed studies). Although the types of study designs included in the reviews are stated, none of the 6 SRs19-24 provided an explanation for including them. Three SRs19,20,24 limited included studies to those published in English, potentially introducing language bias and omitting relevant data from non-English studies. In 2 SRs,19,21 the data extraction was conducted by a single reviewer or was unclear, creating a risk for inaccuracies in these processes. Two SRs22,24 did not report adequate details on characteristics of included studies (e.g., study design, number of participants, study location, follow-up). One SR21 did not conduct a MA without providing an explanation. Two SRs19,22 did not assess the potential impact of risk of bias on MA findings or adequately investigate publication bias or discussed its likely impact on the results. In 1 SR,22 the authors did not provide an explanation for the considerable statistical heterogeneity observed in the MAs. Not all findings relevant to this review reported relative effects21,23 and actual P values.19,20,22-24 Finally, none of the 6 SRs19-24 reported funding sources for the included primary studies. Although reasons for exclusion were provided, none of the 6 SRs provided a list of excluded studies after full-text review.
All 5 guidelines18,25-28 reported seeking views and preferences of the target population. Three guidelines25,26,28 clearly outlined their scope and purpose. The target users and intended population of the guideline were clearly stated for 4 guidelines.18,25,26,28 All guidelines18,25-28 conducted SRs and had a grading system for assessing the quality of evidence used to make recommendations. Two guidelines conducted additional SRs and/or a rapid review where no recent high-quality SR was available,26,28 and 2 guidelines conducted literature searches of RCTs and other methods of searching (e.g., cross-referencing bibliographies, handsearching pre-existing international guidelines).25,27 Four guidelines25-28 presented each recommendation in an easily identifiable way (e.g., recommendation statements separated from explanatory text, tables within body of guideline to organize statements).
Two guidelines did not specifically describe the health questions.18,25 One guideline did not clearly define their target users.27 For 1 guideline, the methods for formulating the recommendations (e.g., voting, consensus) and an explicit link between the recommendations and the supporting evidence were not clearly described.18 Three guidelines18,27,28 were not externally reviewed by experts before their publication. Two guidelines18,27 did not report supporting documents or tools to aid readers in understanding or implementing recommendations. For 3 guidelines,18,25,27 it is unclear whether the views of the funding body have not influenced the content of the guideline. For 1 guideline, the conflicts of interest in guideline development were not recorded.28 None of the guidelines provided a procedure for updating the guideline.18,25-28
Appendix 4 presents the main study findings.
Evidence regarding the clinical effectiveness of MH counselling provided through virtual versus in-person settings were available from 6 SRs,19-24 4 of them20,22-24 with MAs relevant to the present review. There was considerable overlap in the primary studies that were included in these SRs; the pooled estimates from separate reviews thus contain much of the same data (refer to Appendix 5 for details regarding overlap). Most SRs and their included RCTs reported results on reduction of depression and anxiety, followed by PTSD and OCD. In general, the effectiveness of MH counselling in the reduction of depression, PTSD and various anxiety outcomes was similar in both virtual and in-person settings. However, the results on OCD were inconclusive across intervention modalities.
Five SRs19,20,22-24 evaluated the effectiveness of MH counselling provided through virtual versus in-person settings on reduction of depression.
The results from 3 SRs, including 4 MAs,22-24 indicated that virtual MH counselling demonstrates comparable efficacy to in-person interventions in reducing the symptoms of depression.
Two SRs with MAs22,23 on depressive symptoms showed no difference in effectiveness of CBT delivered either virtually or in-person.
One SR conducted 2 MAs24 on RCTs comparing multiple video-based versus in-person MH counselling modalities (e.g., CBT and PE) in reducing depressive symptoms for people with various primary diagnoses (11 RCTs) and a subgroup of participants specifically based on depressive diagnoses (3 RCTs). Both MAs showed no evidence that video-based psychotherapy is inferior to in-person psychotherapy in the reduction of depressive symptoms. There was no significant difference between the pooled efficacy effect size estimate of the primary depression subgroup and the pooled estimate of the studies with primary diagnoses of other psychological diagnoses. Prespecified subgroup analyses assessing whether video-based MH counselling might be more effective than in-person counselling for people with a diagnosis of depression found no evidence of differences between the 2 approaches in reducing depressive symptoms or in the risk of participants’ attrition.
Results from 1 SR20 with MAs of 2 RCTs, including veterans and active-duty military participants, indicated that for those with symptoms or diagnosis of depression, in-person delivery was associated with better outcomes compared to video teleconference. The quality of evidence for this comparison was rated as low because of study-specific risk of bias and imprecision.
Results from 1 SR20 that included 1 RCT on telephone-based versus in-person CBT indicated a comparable reduction in depressive symptoms in both groups.
One SR19 including 2 relevant RCTs indicated that virtual CBT was not inferior to in-person CBT in terms of its effectiveness for reducing depressive symptoms in children and youth populations.
Two SRs22,23 evaluated the effectiveness of MH counselling provided through virtual versus in-person settings on reduction of anxiety. All RCTs included in these 2 SRs focused on CBT.
One SR with MA22 indicates that virtual CBT was comparable to in-person CBT in reducing symptoms of anxiety with a follow-up of more than 12 weeks.
One SR23 evaluated the effectiveness of therapist-guided virtual versus in-person CBT on various anxiety outcomes, including health anxiety (1 RCT), social anxiety disorder (1 RCT), panic disorder (4 RCTs) and social phobia (1 RCT). Results of these RCTs indicated that both forms of CBT were comparable and equally effective in improving these various anxiety outcomes of participants.
Two SRs19,23 including 3 RCTs described the clinical effectiveness of virtual MH counselling, with a focus on CBT, versus in-person counselling for OCD.
One SR19 included 1 RCT on the effectiveness of telephone-based CBT for adolescents (aged 11 to 18 years old) with OCD compared to standard clinic-based, in-person CBT. The results indicated that telephone-based CBT was not inferior to in-person CBT at posttreatment, 3-month, and 6-month follow-up and was similarly effective in reducing OCD symptoms.
One SR23 included 2 RCTs on the effectiveness of telephone-based CBT and therapist-guided internet-based CBT (iCBT) versus in-person CBT for adults with OCD. The clinical outcomes including reduction in OCD symptoms and level of satisfaction with treatment were equivalent for telephone-based CBT and in-person CBT. However, the findings on therapist-guided internet-based CBT versus in-person CBT for adults with OCD were less conclusive, as the primary noninferiority results favoured in-person CBT. SR authors concluded that the therapist-guided iCBT could be an alternative to in-person CBT for adults with OCD where traditional in-person CBT is not readily accessible.
Two SRs20,21 including 12 RCTs provided results for the use of virtual MH counselling on PTSD. Two RCTs were included in both SRs.
Moderate quality of evidence from 1 SR,20 which included 10 relevant RCTs on the use of various interventions for PTSD, indicated that video teleconference is comparable to in-person delivery for people with PTSD. However, this body of literature is mostly focused on evaluating PE (in 3 RCTs) and cognitive processing therapy (CPT and CPT- cognitive only version in 5 RCTs).
One SR,21 including 4 RCTs (2 overlapping with other SR)20 explored the efficacy of online group therapies on PTSD and found evidence supporting the efficacy of video teleconference group therapies for populations with PTSD. These interventions included CPT-C in 2 RCTs and CBT and anger management therapy in the other 2 RCTs. In all 4 RCTs, both video teleconference and in-person group therapies showed significant reductions in PTSD. No significant differences were reported between the groups.
Three SRs20,21,23 reported on the effectiveness of virtual MH counselling versus in-person counselling on other clinical outcomes. They included studies investigating quality of life (1 RCT), satisfaction with treatment (5 RCTs), therapeutic alliance (5 RCTs), anger (1 RCT) and psychiatric and social functioning (1 RCT each). In general, participants who received virtual versus in-person MH counselling reported comparative degrees of therapeutic alliance and satisfaction with treatment. However, the results were inconclusive for other types of functioning and quality of life. Further, participants who received virtual MH counselling showed a similar reduction of anger symptoms as those who received in-person MH counselling.
Based on limited, low to moderate level quality or unclear evidence, NDGM (2022)18 and CANMAT (2023)25 guidelines provide recommendations for the use of MH counselling through a virtual setting for the treatment of depression. Both guidelines18,25 include recommendations based on the severity of depressive symptoms and/or MDD in adults. The CANMAT (2023)25 guideline provides recommendations on specific types of internet-based psychotherapy (i.e., guided iCBT and guided iBA). The NDGM (2022)18 guideline includes recommendations on the use of internet- and mobile device-based interventions. The NDGM (2022)18 and CANMAT (2023)25 guidelines recommend virtual MH counselling as first-line intervention for mild depression in adults. The NDGM (2022)18 recommends that it is embedded in an overall therapeutic plan. The NDGM (2022)18 guideline recommends virtual MH counselling as second-line adjunctive intervention for moderate-severe depression in addition to other psychotherapy or antidepressants and for adults with moderate depressive episodes who refuse both psychotherapy and antidepressants.
Based on limited and low-quality evidence, the CCSMH (2024)26 and GGAD (2022)27 guidelines include strong or positive recommendations for the use of MH counselling through virtual settings for the treatment of anxiety. The CCSMH (2024)26 guideline provides strong recommendations on the use of remote CBT for reducing symptoms of anxiety in older adults. The GGAD (2022)27 guideline provides positive recommendations on the use of virtual MH counselling for adults with 3 types of anxiety disorders, as an adjunctive intervention to other standard treatments or for adults waiting for initiation of in-person psychotherapy.27 This includes internet-based CBT for adults with generalized anxiety disorder, social anxiety disorder (SAD) or panic disorder with or without agoraphobia (PDA) (refers to an anxiety disorder characterized by recurrent unexpected panic attacks with or without a fear of being in situations where escape might be difficult), and virtual psychodynamic therapy for people with SAD.27
No guideline or recommendation on the use of virtual MH counselling was found for OCD.
The Phoenix Australia (2021) guideline28 provides recommendations on the use of MH counselling through virtual setting for treatment of trauma-related symptoms and PTSD in adults.28 Based on insufficient evidence, the guideline28 does not recommend internet-based CBT for treatment of PTSD symptoms in adults within the first 3 months of trauma. Based on low-quality evidence, the guideline28 also includes conditional recommendations for use of trauma-focused iCBT and trauma-focused CBT delivered via telehealth (videoconferencing) for adults with PTSD, where face-to-face trauma-focused CBT or Eye Movement Desensitization and Reprocessing (EMDR) are unavailable or unacceptable. Based on insufficient evidence, the Phoenix Australia (2021) guideline28 was not able to make a recommendation on telephone-based CBT for adults within the first 3 months of trauma. Similarly, the guideline28 was not able to make recommendations on BA, Therapeutic Exposure, or group non–trauma-focused CBT delivered via telehealth (videoconferencing) for adults with PTSD.28
Across the 6 SRs,19-24 significant gaps in evidence were identified. Mental illnesses such as OCD, or specific types of anxiety and depressive disorders were either included in very few studies or not studied at all. Similarly, virtual group counselling for common conditions were notably limited, restricting our understanding of their potential scalability and effectiveness. There is also a lack of long-term follow-up data to assess the sustained efficacy of these interventions. Most studies focused on immediate or short-term outcomes, leaving a critical knowledge gap about the durability of treatment effects over time. Furthermore, site-specific differences in virtual settings (e.g., home-based versus clinic-based delivery) were not adequately explored, even though such factors may influence treatment outcomes and people’s experiences.
Another critical gap involves the range of interventions studied under virtual CBT. Reviews often grouped diverse modalities, such as telephone-based, therapist-guided internet-based, and video-based therapy, under a broad umbrella. Still, there was insufficient evidence to clarify the differences in effectiveness among these approaches. For example, while therapist-guided, internet-based CBT showed comparable outcomes to in-person therapy, findings for telephone-based CBT were inconclusive, suggesting a need for further investigation.
Several limitations related to the risk of bias were apparent across SRs. A common issue was the potential for publication bias, as some reviews excluded unpublished data, which may overestimate the effectiveness of interventions. Moreover, a heavy reliance on self-reported measures for assessing MH symptoms was noted. Self-report tools can introduce bias, as they may not fully capture the clinical outcomes compared to clinician-rated assessments, which are typically more rigorous.
The narrow inclusion criteria in some reviews also restricted the diversity of studies analyzed. For example, some MAs focused exclusively on direct comparison RCTs, excluding studies with other relevant control conditions. While this approach reduced between-study heterogeneity, it also limited the scope of the analysis and potentially excluded valuable insights. Another significant concern was the unexplained heterogeneity in the pooled estimates, such as compliance rates. In some cases, subgroup analyses were hindered by the small number of trials available for specific conditions, such as anxiety or depression.20,22 This limitation may obscure clinically meaningful effects within subgroups, further complicating interpretations of the data.
The generalizability of findings from these SRs was a recurring challenge. Most of the studies included were conducted in high-income, developed countries and involved participants from relatively affluent and well-educated backgrounds. This demographic profile limits the applicability of findings to low- and middle-income countries or populations with fewer resources. Similarly, populations who may face additional barriers to using technology, such as people with disabilities, were underrepresented in the studies, raising concerns about whether the findings extend to this group. One SR23 was conducted in Canada. However, of the 4 SRs19,21-23 that reported country of study for the included RCTs, 2 RCTs were conducted in Canada. The lack of studies from Canada may limit the generalizability of the evidence to health care settings in Canada.
Other limitations were the age range and sex and gender of participants, with adolescents or younger children (under 12 years old) rarely studied and sex and gender-diverse groups often not specified or included, making it difficult to generalize the results to these populations. However, 2 guidelines25,26 developed by organizations in Canada (i.e., CCSMH (2024) and CANMAT (2023) guidelines) may enhance their relevance to the health care context in Canada. In addition, the reviews grouped diverse delivery methods under broad terms, such as “technology-assisted CBT,” without addressing whether interventions like telephone-based therapy or internet-based therapy provide equivalent outcomes. This lack of distinction undermines the ability to generalize findings across different modalities. Furthermore, the variability in virtual delivery settings — such as home-based versus supervised environments like clinics — was not adequately addressed, even though these factors may significantly influence treatment outcomes.
The limitations of the guidelines for virtual MH counselling primarily relate to the quality and scope of the evidence used to inform their recommendations, as well as gaps in addressing specific populations (i.e., children and youth, sex and gender-diverse groups) and conditions (e.g., OCD). Many recommendations were based on limited, low-quality, or unclear evidence, reducing the confidence in their generalizability and applicability. Some guidelines provided broad recommendations without specifying the strength of the evidence or detailing the optimal conditions for intervention.
The guidelines were based on evidence largely derived from studies in high-income countries, limiting their applicability to low- and middle-income settings and culturally diverse populations. Children, adolescents, and individuals in remote or underserved areas were underrepresented in the evidence base. While virtual MH counselling is recommended as an adjunctive or alternative treatment for moderate-to-severe conditions, the guidelines do not provide detailed guidance on how to effectively integrate these interventions with existing treatments (e.g., medication or in-person psychotherapy).
This review includes 6 SRs,19-24 with 4 including MAs,20,22-24 regarding the effectiveness of MH counselling provided through virtual versus in-person settings. It also includes 5 evidence-based guidelines18,25-28 with specific recommendations on the use of virtual MH counselling for people with depression, anxiety, or PTSD. The evidence summarized in this report is drawn from SRs with substantial overlap in primary studies, meaning that data from the same participants were included in more than 1 SR (refer to Appendix 5 for a citation matrix illustrating the degree of primary study overlap). As a result, some evidence may be disproportionally represented in the overall conclusions.
The evidence summarized in this report indicates virtual MH counselling showed comparable clinical effectiveness to in-person counselling for PTSD and depressive and anxiety disorders. However, findings for OCD, specific clinical settings or subpopulations presented mixed results, highlighting areas where virtual counselling may serve as an alternative to in-person therapy when traditional services are unavailable. Virtual MH counselling may be especially valuable in settings where access to in-person services is limited, though further research is needed to explore long-term outcomes and applicability to diverse populations and contexts. Variability in results may have been due to differences in included populations in studies, study designs, and the specific MH intervention used. For example, 3 SRs with MAs,22-24 which included a large number of participants of diverse backgrounds with depressive symptoms, showed no difference in effectiveness of CBT delivered either virtually or in-person. In contrast, the SR by Kelber et al.,20 which included data from 2 RCTs on veterans and active-duty military participants in their MA, indicated that in-person delivery was associated with better depression outcomes compared to virtual delivery, highlighting certain populations may experience different outcomes than others.
The guidelines for virtual MH counselling provide recommendations for its use across conditions such as depression, anxiety, and PTSD, while no specific guidelines were identified for OCD. Overall, the recommendations reflect limited but generally positive evidence supporting virtual counselling, with suggestions for its use either as a first-line intervention for mild conditions or as an adjunctive or alternative treatment for moderate-to-severe cases or specific conditions when in-person therapy is not feasible.
More studies are needed to evaluate the efficacy of virtual interventions for conditions such as OCD and co-occurring psychiatric or medical conditions to assess the utility of virtual MH counselling in managing these conditions. It is also needed to evaluate the long-term effectiveness of virtual MH counselling, including symptom recurrence, maintenance of therapeutic gains, and functional outcomes. Future research may consider comparing different virtual delivery methods (e.g., telephone-based, internet-based, video teleconferencing) to identify which approaches work best for specific conditions, populations, and settings. Additional research will benefit from adopting consistent, validated clinical and functional outcome measures, including clinician-rated tools, to improve comparability across studies. In addition, larger and adequately powered trials are needed to strengthen the evidence base. Future research is needed to assess the effectiveness of blended MH counselling models, combining virtual and in-person interventions, and integration with other treatments (e.g., pharmacological treatment) to optimize flexibility and accessibility.
Additional research is needed to address the generalizability of findings to diverse populations and settings. Future studies may include underrepresented groups, such as children and adolescents, culturally diverse populations, and individuals in low- and middle-income countries. Few RCTs included in SRs were conducted on veterans from living in rural areas. Additional research is needed with other groups living in areas where access to in-person services is limited.
The guidelines reflect the evolving state of evidence on virtual MH counselling and its growing role in clinical practice. However, their limitations underscore the need for more robust and inclusive research, particularly in areas like long-term outcomes, diverse populations, and underrepresented conditions (e.g., OCD). Addressing these gaps will enhance future guidelines' relevance, specificity, and strength.
The integration of virtual interventions into clinical practice and policy frameworks requires addressing various practical, systemic, and person-centred considerations. Virtual MH counselling has demonstrated comparable effectiveness to in-person therapy for conditions such as depression, anxiety, PTSD, and some forms of OCD. This emerging evidence suggests that it may be a valuable option for expanding access to MH counselling, particularly in underserved areas (e.g., rural and remote communities) and underserved populations, such as individuals with mobility issues or transportation constraints. Notwithstanding, assessing people’s preferences, comfort with technology, and specific MH needs are important considerations when determining the appropriateness of virtual versus in-person counselling.30 For conditions such as OCD or PTSD, where virtual therapy may be less effective in some modalities (e.g., internet-based CBT), it will be helpful to consider hybrid or stepped-care approaches.31 While virtual counselling has shown high levels of satisfaction and therapeutic alliance in people who received these services, clinicians may consider strategies to build rapport in virtual settings.32 Techniques may include maintaining regular contact through video or telephone check-ins, and ensuring a supportive environment for group therapies, which have shown comparable effectiveness for PTSD and other conditions.32 Virtual therapy delivery may necessitate clinicians requiring training to navigate technology and maintain engagement.33 This points to the consideration of policy-makers and organizations developing standardized training programs for delivering evidence-based virtual MH counselling and providing technical and psychological support for clinicians to reduce burnout in virtual MH delivery.33
behavioural activation
cognitive behavioural therapy
health technology assessment
mental health
internet-based behavioural activation
internet-based cognitive behavioural therapy
meta-analysis
major depressive disorder
obsessive-compulsive disorder
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
posttraumatic stress disorder
randomized controlled trial
systematic review
Please note that this appendix has not been copy-edited.
An information specialist conducted a literature search on key resources including MEDLINE, PsycInfo, the Cochrane Database of Systematic Reviews, the International HTA Database, the websites of health technology assessment agencies in Canada and major international HTA agencies, as well as a focused internet search. The search approach was customized to retrieve a limited set of results, balancing comprehensiveness with relevancy. The search strategy comprised both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. Search concepts were developed based on the elements of the research questions and selection criteria. The main search concepts were virtual or remote care, psychotherapy or counselling, and anxiety, depression, posttraumatic stress disorder, or obsessive-compulsive disorder. Search filters were applied to limit retrieval to health technology assessments, systematic reviews, meta-analyses, indirect treatment comparisons, or guidelines. The search was completed on November 15, 2024, and limited to English-language documents published since January 01, 2019.
One reviewer screened citations and selected studies: the reviewer screened the health technology assessments, systematic reviews (SRs), and meta-analyses (MAs) from the past 3 years (published since November 15, 2021) and screened the guidelines from the past 5 years (published since January 1, 2019). In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1.
Articles were excluded if they met any of the following criteria:
did not meet the selection criteria outlined in Table 1
were SRs in which all relevant studies were captured in other more recent or more comprehensive SR
were guidelines with unclear methodology.
In addition, articles with a focus on the following criteria were excluded:
people receiving counselling for neurodevelopmental conditions (e.g., autism)
psychotherapy or clinical counselling provided by other health care providers not listed in Table 1 (e.g., psychiatrists, medical doctors)
facilities-based or residential-based addictions treatment
non-clinical counselling (e.g., life skills coaching, vocational coaching)
asynchronous communication (text, email, secured messaging) and AI-based software, apps or bots.
The included publications were critically appraised by 1 reviewer using the following tools as a guide: A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2)34 for SRs, and the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument35 for guidelines. Summary scores were not calculated for the included studies; rather, the strengths and limitations of each included publication were described narratively.
Selection of Included Studies.
Characteristics of Included Systematic Reviews.
Characteristics of Included Guidelines.
Please note that this appendix has not been copy-edited.
Strengths and Limitations of SRs Using AMSTAR 234.
Strengths and Limitations of Guidelines Using AGREE II.
Summary of Findings by Outcome — Depression.
Summary of Findings by Outcome — Anxiety.
Summary of Findings by Outcome — OCD.
Summary of Findings by Outcome — PTSD.
Summary of Findings by Outcome — Additional Clinical Outcomes.
Summary of Recommendations in Included Guidelines — Depression.
Summary of Recommendations in Included Guidelines — Anxiety.
Summary of Recommendations in Included Guidelines — PTSD.
Please note that this appendix has not been copy-edited.
Overlap in Relevant Primary Studies Between Included Systematic Reviews.
Please note that this appendix has not been copy-edited.
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