Message-Based vs Video-Based Psychotherapy for Depression: A Randomized Clinical Trial.

Importance: There is a need to determine the relative effect of message-based psychotherapy (MBP), an asynchronous approach that uses emails, texts, or voice or video messages to permit therapeutic exchanges, compared with video-based psychotherapy (VBP) and whether a combination of modalities would result in better outcomes for those who do not respond to either treatment alone. Objectives: To compare MBP with VBP on a commercial digital mental health platform and test combinations of modalities for participants who did not respond to single-modality treatment. Design, Setting, and Participants: In this sequential multiple assignment randomized clinical trial, psychotherapy was delivered by therapists on a commercial digital mental health platform from January 10, 2022, to January 14, 2024, among 850 participants who were 18 years of age or older, English or Spanish speaking, living in the US in a state where the digital mental health platform had available therapists, scored 10 or more on the 9-item Patient Health Questionnaire (PHQ-9), and received a diagnosis of depression during intake assessment. Interventions: At baseline, participants were randomized to MBP or weekly VBP. At week 6, nonresponders were rerandomized to MBP with weekly or monthly VBP. Participants received treatment for 12 weeks. Main Outcomes and Measures: Primary outcomes included depression severity (measured by the PHQ-9), social functioning, response to treatment, and remission. Secondary outcomes included treatment engagement, therapeutic alliance, and indicators of treatment quality and satisfaction. Analysis was performed on an intention-to-treat basis. Results: The analytic sample included 850 participants (mean [SD] age, 33.8 [10.5] years; 562 women [66.1%]; mean [SD] PHQ-9 score, 15.0 [4.8]), with 423 randomized to MBP and 427 to VBP. Treatment disengagement by week 5 was more likely for VBP than MBP (VBP, 91 [21.3%]; MBP, 56 [13.2%]; Cramér V = 0.10; 95% CI, 0.03-0.13; P = .003). There were no significant differences on depression or social functioning score changes between MBP and VBP or on depression score changes for nonresponders randomized to MBP with weekly vs monthly VBP. At week 12, MBP and VBP did not differ in the proportion of participants who responded to treatment (MBP, 144 of 303 [47.5%]; VBP, 134 of 284 [47.2%]; Cramér V < .001; 95% CI, -0.08 to 0.09; P = .99) or who experienced remission (MBP, 95 of 303 [31.4%]; VBP, 86 of 284 [30.3%]; Cramér V = 0.01; 95% CI, -0.07 to 0.09; P = .85). Among nonresponders, VBP had a stronger initial therapeutic alliance than MBP at week 4 (P < .001; d = 0.48-0.57). Among participants assessed for rerandomization, there were no statistically significant differences among those who responded to treatment by week 5 (MBP, 105 of 363 [28.9%]; VBP, 93 of 336 [27.7%]; Cramér V = 0.01; 95% CI, -0.06 to 0.08; P = .78). Therapeutic alliance ratings increased across all conditions by week 10; however, these changes were not statistically significant. Video-based psychotherapy was more frequently recommended than MBP (VBP, 69 of 71 [97.2%]; MBP, 70 of 80 [87.5%]; odds ratio, 0.18; 95% CI, 0.04-0.88; P = .03). There were no significant differences in clinical outcomes between nonresponders randomized to weekly vs monthly VBP. Conclusions and Relevance: In this sequential multiple assignment randomized clinical trial comparing MBP with VBP, there were no differences between groups on improvement in depression or social functioning. More participants in the VBP group disengaged from treatment, while VBP also had greater therapeutic alliance early in treatment among nonresponders. There were no differential effects from rerandomizing nonresponders. Findings reinforced MBP as a viable alternative to VBP. Broader insurance reimbursement for MBP could improve access to evidence-based care. Future research should explore optimizing early alliance-building in MBP. Trial Registration: ClinicalTrials.gov Identifier: NCT04513080.