Adherence With Online Therapy vs Face-to-Face Therapy and With Online Therapy vs Care as Usual: Secondary Analysis of Two Randomized Controlled Trials
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Abstract
Background: Adherence to internet-delivered interventions targeting mental health such as online psychotherapeutic aftercare is important for the intervention’s impact. High dropout rates limit the impact and generalizability of findings. Baseline differences may be putting patients at risk for dropping out, making comparisons between online with face-to-face (F2F) therapy and care as usual (CAU) necessary to examine. Objective: This study investigated adherence to online, F2F, and CAU interventions as well as study dropout among these groups and the subjective evaluation of the therapeutic relationship. Sociodemographic, social-cognitive, and health-related variables were considered. Methods: In a randomized controlled trial, 6023 patients were recruited, and 300 completed the baseline measures (T1), 144 completed T2 (retention 44%-52%), and 95 completed T3 (retention 24%-36%). Sociodemographic variables (eg, age, gender, marital status, educational level), social-cognitive determinants (eg, self-efficacy, social support), health-related variables (eg, depressiveness), and expectation towards the treatment for patients assigned to online or F2F were measured at T1. Results: There were no significant differences between the groups regarding dropout rates (χ21=0.02-1.06, P≥.30). Regarding adherence to the treatment condition, the online group outperformed the F2F and CAU conditions (P≤.01), indicating that patients randomized into the F2F and CAU control groups were much more likely to show nonadherent behavior in comparison with the online therapy groups. Within study groups, gender differences were significant only in the CAU group at T2, with women being more likely to drop out. At T3, age and marital status were also only significant in the CAU group. Patients in the online therapy group were significantly more satisfied with their treatment than patients in the F2F group (P=.02; Eta²=.09). Relationship satisfaction and success satisfaction were equally high (P>.30; Eta²=.02). Combining all study groups, patients who reported lower depressiveness scores at T1 (T2: odds ratio [OR] 0.55, 95% CI 0.35-0.87; T3: OR 0.56, 95% CI 0.37-0.92) were more likely to be retained, and patients who had higher self-efficacy (T2: OR 0.57, 95% CI 0.37-0.89; T3: OR 0.52, 95% CI 0.32-0.85) were more likely to drop out at T2 and T3. Additionally, at T3, the lower social support that patients reported was related to a higher likelihood of remaining in the study (OR 0.68, 95% CI 0.48-0.96). Comparing the 3 intervention groups, positive expectation was significantly related with questionnaire completion at T2 and T3 after controlling for other variables (T2: OR 1.64, 95% CI 1.08-2.50; T3: OR 1.59, 95% CI 1.01-2.51). Conclusions: While online interventions have many advantages over F2F variants such as saving time and effort to commute to F2F therapy, they also create difficulties for therapists and hinder their ability to adequately react to patients’ challenges. Accordingly, patient characteristics that might put them at risk for dropping out or not adhering to the treatment plan should be considered in future research and practice. Online aftercare, as described in this research, should be provided more often to medical rehabilitation patients. Trial Registration: ClinicalTrials.gov NCT04989842; https://clinicaltrials.gov/ct2/show/NCT04989842
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Low adherence to self-guided interventions may be due to generic and unappealing programs not addressing the particular needs of health professionals.
“This may be due to generic and unappealing programs not addressing the particular needs of these individuals”
From Effectiveness of a Web-Based Self-Guided Intervention (MINDxYOU) for Reducing Stress and Promoting Mental Health Among Health Professionals: Results From a Stepped-Wedge Cluster Randomized Trial (2025) · cites this paper as [28]
The Discussion > Limitations section (page not provided) suggests the program may have interested and suited only a small subgroup of patients and proposes testing whether tailoring affects dropout and nonadherence. It does not establish that generic or unappealing self-guided programs caused low adherence, and its participants were psychosomatic rehabilitation patients, not health professionals. (LLM, conf=0.84)
Experimental — accuracy not yet measuredLack of external guidance in self-guided interventions could contribute to higher attrition rates.
“although it has also been suggested that their lack of external guidance could contribute to higher attrition rates [26,28].”
From Effectiveness of a Web-Based Self-Guided Intervention (MINDxYOU) for Reducing Stress and Promoting Mental Health Among Health Professionals: Results From a Stepped-Wedge Cluster Randomized Trial (2025) · cites this paper as [28]
In Discussion > Comparison With Prior Work (page not available), the paper reports descriptively lower dropout in the face-to-face group, which had more human feedback. This is consistent with the suggestion that guidance may matter, but the passage does not establish that a lack of external guidance contributes to attrition in self-guided interventions specifically. (LLM, conf=0.78)
Experimental — accuracy not yet measured
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- Authors
- Lippke, S., Gao, L., Keller, F. M., Becker, P., & Dahmen, A.
- Affiliations
- Constructor University (DE)
- Corresponding author
- Lippke, Sonia
- Venue
- Journal of Medical Internet Research
- Publisher
- JMIR Publications Inc.
- Published
- 2021-11-03
- Volume
- 23
- Issue
- 11
- Pages
- e31274
- ISSN
- 1438-8871 (ISSN-L)
- PMC
- PMC8600425
- OpenAlex
- W3209165431
- Cited by
- 36
- References
- 33
- Citations by year
- 2026: 9 · 2025: 7 · 2024: 9 · 2023: 7 · 2022: 3 · 2021: 1
- FWCI
- 4.49
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- other-oa
- Locations
- Journal of Medical Internet Research (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Keywords
- online therapy, face-to-face therapy, medication adherence, treatment discontinuation, usual care, treatment satisfaction, therapeutic relationship, self-efficacy, social support, depressiveness, gender differences, marital status, online intervention, treatment expectations
- MeSH terms
- Aftercare, Female, Humans, Male, Patient Compliance, Surveys and Questionnaires, Randomized Controlled Trials as Topic
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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