One of the most transformative innovations in mental health over the past decade has been therapy delivered through text messages. This flexible approach allows individuals to engage with treatment throughout their day. Imagine waking up with pre-presentation jitters; you could send your therapist a text detailing your anxieties about a potential humiliating failure.
Hours later, a thoughtful response appears on your phone. Your therapist might guide you to label the intrusive thought, like ‘I’m feeling nervous about my presentation,’ and then work to reframe it. They might also suggest a deep breath before you assess what’s truly happening in that moment.
Later, between meetings, you read their advice. Feeling self-conscious, you might type, ‘I’m pretty sure my boss thinks I’m an idiot.’ The next morning, your therapist’s reply comes in: ‘What evidence do you have that she thinks that?’ They then instruct you to list all available evidence, weighing the pros and cons.
Text-based therapy has rapidly grown, largely due to digital mental health platforms such as BetterHelp and Talkspace. These services connect users with licensed therapists, offering both live chat and flexible, as-needed texting. A recent study, published in the journal JAMA Network Open, provides compelling early evidence that this method is effective for treating mild to moderate depression, achieving results comparable to video-based therapy.
The clinical trial involved 850 adults experiencing mild to moderate depression, who were randomly divided into two groups. One group received psychotherapy through weekly video sessions, while the other had access to unlimited, on-demand messaging or emailing with a therapist. After 12 weeks, both groups reported similar improvements in their depression symptoms.
Dr. Patricia A. Areán, a former professor at the University of Washington School of Medicine and a co-author of the study, expressed pleasant surprise at the findings. “We were pleasantly surprised to see that it was as good as weekly video therapy,” she stated. “We didn’t really find any differences in the outcomes.”
It’s important to note that this trial was designed to compare superiority, not to establish exact equivalence between the two therapy types. The study offers limited participant data, so details like depression duration, initial diagnosis methods, or concurrent treatments (such as antidepressants) during the trial are not known.
Dr. Areán explained that Talkspace initiated the collaboration for a randomized clinical trial out of a practical necessity: despite its rapid growth, text-based therapy is often not reimbursed by most insurers.
“They knew that they needed data,” she commented.
The results, she believes, support the idea that insurers should begin covering text-based therapy, which could dramatically improve access for individuals who struggle to attend scheduled video appointments.
Dr. Jane M. Zhu, an associate professor of medicine at Oregon Health & Science University, who was not involved in the study, described the new evidence as “encouraging,” but cautioned that it might not yet be sufficient to prompt widespread changes by insurers.
She highlighted that the study deliberately excluded high-risk patients, such as those with psychosis or suicidal ideation. Additionally, it did not monitor treatment variables like the therapist’s response speed or message volume.
The number of Americans seeking psychotherapy surged during the pandemic, as virtual sessions became the norm. While for decades roughly 3-4% of the population engaged with therapists, this figure rose to 8.5% by 2021. (In contrast, the percentage of Americans on psychotropic medication has remained relatively stable at around 17.5%).
Dr. Zhu, whose research focuses on healthcare accessibility, suggested that text therapy “could eventually fit into a stepped-care model,” where patients start with less intensive interventions and progress to treatments like medication or specialized care if necessary.
Dr. Mark Olfson, a professor of psychiatry at Columbia University Irving Medical Center, also not involved in the study, noted that the findings imply patients with milder depression “might reasonably be offered a choice” between text- and video-based psychotherapy.
Dr. Areán acknowledged that many in the mental health community still have reservations about text-based models, primarily concerns that therapists might miss crucial non-verbal cues or danger signs without face-to-face interaction. However, she confirmed that no adverse events occurred during the trial.
Interestingly, trial participants in the video-based therapy group were more likely to drop out compared to those in the text-based group.
Nonetheless, the researchers observed that video sessions fostered a slightly stronger bond with therapists, who were perceived as warmer and more compassionate. When some participants transitioned from text-based to video sessions in a subsequent phase, the quality of their therapeutic bond improved significantly.
Dr. Areán emphasized that this difference in therapeutic bonding warrants further investigation. “How do you build alliance when you can’t see the person?” she pondered. “How do you deal with silences when you can’t see them? Are they crying? Are they happy?”