Comparing Video-Based and Face-to-Face Psychotherapy: Systematic Review and Multilevel Meta-Analysis Across Mental Disorders.

Background: Video-based psychotherapy (VBT) is increasingly used to expand access to mental health care. Review studies generally report symptom outcomes similar to those achieved with face-to-face (F2F) psychotherapy. However, these studies often analyze VBT alongside other remote modalities, and it remains unclear what portion of the effects can be attributed to the video-based setting itself. Objective: The objective of this systematic review is to compare VBT and F2F psychotherapy in terms of symptom reduction, using strict methodological inclusion criteria, to maximize comparability between the delivery formats while also considering therapy duration. Methods: We searched bibliographic databases (MEDLINE via PubMed, PsycINFO, and Embase) from inception to May 20, 2025, supplemented by reference checking. The search was updated on March 10, 2026. We conducted a systematic review of randomized controlled trials (RCTs) comparing synchronous VBT with F2F psychotherapy in adults and reporting symptom severity. Trials had to meet a minimum treatment dose (≥500 min) and limited hybrid exposure (≤1/3 of sessions delivered F2F). Interventions had to be delivered by health professionals. We excluded interventions delivered solely via telephone or asynchronous platforms, blended formats, or unstructured counseling or group settings. Risk of bias was assessed following Metapsy (RoB2) guidelines, and certainty of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Standardized mean differences (Hedges g) of posttreatment symptom severity were synthesized using a 3-level correlated and hierarchical effects (CHE) random-effects model to account for dependent outcomes. Results: Out of 11,386 identified records, 87 articles underwent full-text review; 12 RCTs (465/900, 51.7% female; mean age 40.21, SD 14.52 y) met the inclusion criteria. Diagnoses included posttraumatic stress disorder, depression, obsessive-compulsive disorder, bulimia nervosa, generalized anxiety disorder, and somatoform pain. Across 41 effect sizes, no significant differences in symptom reduction emerged between VBT and F2F psychotherapy (Hedges g=-0.09, 95% CI -0.52 to 0.33; SE=0.19; P>.99). Between-study heterogeneity was substantial; the 95% prediction interval was -1.65 to 1.46. No moderating effects were detected. The Akaike information criterion favored the 3-level model over conventional approaches. Conclusions: The evidence base was limited in size and scope (predominantly Western settings, posttraumatic stress disorder diagnoses, and cognitive behavioral interventions). Study limitations, heterogeneity, and few noninferiority trials reduced the certainty of the evidence. This review is innovative in isolating synchronous VBT from other remote delivery formats to understand the specific impact of the setting. Unlike previous reviews, this one provides a more specific estimate of the effects of the delivery setting. This is achieved by isolating synchronous video delivery, applying dose/setting restrictions, and focusing on RCTs. Results refine the current evidence base and support offering VBT as a pragmatic delivery option to extend access to mental health care. Adequately powered noninferiority trials across diverse diagnoses, cultures, and longer-term treatments are needed.