How Much Engagement Really Matters in Online Therapy for Anxiety and Depression
As mental health treatment increasingly moves online, researchers are trying to understand what makes digital therapy most effective. A comprehensive study examining over 500 patients who received internet-based cognitive behavioural therapy for anxiety and depression has revealed important insights about how patient engagement relates to treatment success.
The Digital Therapy Landscape - CBT
Internet delivered CBT has become increasingly popular, especially since the pandemic accelerated the adoption of digital mental health services. These programs typically consist of structured modules that patients work through over several weeks, often with support from a therapist through chat or video calls. The appeal is clear: reduced waiting times, lower costs, and greater accessibility compared to traditional face to face therapy.
However, just like with in person therapy, not everyone who starts an online program completes it or benefits equally. This has led researchers to examine what factors influence success in digital mental health interventions.
Understanding Patient Engagement
The study tracked multiple aspects of how patients interacted with their online therapy platform. Researchers looked at how many modules patients started, how many activities they completed, how much time they spent logged into the system, how often they logged in, and how much they communicated with their therapists through written messages.
On average, patients started about 65% of their assigned modules and completed about 63% of assigned activities. They logged in an average of 34 times throughout treatment and spent roughly 10 hours total on the platform. Most patients exchanged regular messages with their therapists, with patients sending about 14 messages and receiving 19 messages on average.
What Really Drives Success
The most significant finding was that persistence in engaging with treatment content mattered most for outcomes. Patients who started more modules and completed more activities showed greater improvements in their anxiety and depression symptoms. This relationship held true regardless of whether patients started treatment with mild or more severe symptoms.
Interestingly, other measures of engagement proved less important than expected. The total time patients spent on the platform and how frequently they logged in were not strongly associated with better outcomes. In fact, for anxiety treatment, spending more time logged in was sometimes associated with slightly worse outcomes, possibly because patients who were struggling more needed to spend additional time navigating the platform or seeking help.
The amount of written communication between patients and therapists also did not predict treatment success. This finding surprised researchers, though they note that the quality of communication, rather than quantity, might be more important. The study also could not separate time spent in video calls with therapists from other platform activities, which limits conclusions about different types of therapist support.
Early Signs of Improvement
One unexpected discovery was that patients showed symptom improvement even before they began working through the therapy modules. This was particularly striking for anxiety symptoms, where patients experienced significant improvements between their initial assessment and starting the first treatment module.
This early improvement may result from several factors, including the relief of finally seeking help, the therapeutic effect of completing detailed assessments of their mental health, or the hope generated by receiving a personalized treatment recommendation. Understanding this phenomenon better could help optimize the early stages of digital therapy programs.
The Role of Initial Severity
Patients who started treatment with more severe symptoms tended to show greater improvements over the course of therapy. This pattern appeared for both depression and anxiety treatment. However, the researchers note that even patients classified as having "clinical level" symptoms had moderate rather than severe levels of distress, so this finding might partly reflect statistical tendencies rather than true differences in treatment responsiveness.
Implications for Patients and Providers
These findings offer practical guidance for both people considering online therapy and the professionals who provide it. For patients, the research suggests that consistently working through treatment modules and activities is more important than spending excessive time on the platform or communicating frequently with therapists.
This doesn't mean that therapist support is unimportant, but rather that the key is steady progress through the structured treatment content. Patients shouldn't worry if they're not spending hours each day on the platform or sending multiple messages to their therapist. What matters more is showing up consistently and completing the assigned work.
For therapy providers, the findings suggest that efforts to improve engagement should focus on helping patients complete modules and activities rather than simply increasing time spent on the platform. This might involve making content more accessible, providing clearer instructions, or offering targeted support when patients get stuck.
This research contributes to growing understanding of how digital mental health interventions work in real world settings. Unlike controlled research studies that often exclude patients with multiple conditions or mild symptoms, this study examined patients receiving routine clinical care, providing insights that are more likely to apply to typical treatment scenarios.
The effectiveness of internet delivered CBT in this naturalistic setting, while modest, was consistent with previous research. Both patients with mild and more severe initial symptoms experienced meaningful improvements, though those with higher initial distress showed greater absolute changes.
The study opens several avenues for improving online therapy. A better understanding of why early symptom improvement occurs could help optimize the initial stages of treatment. Research into how different types of therapist communication affect outcomes could guide decisions about when to use chat versus video calls.
The findings also suggest that treatment platforms could be designed to better promote the type of engagement that matters most: consistent completion of therapeutic activities. This might involve gamification elements, progress tracking, or personalized reminders that encourage steady participation.
As digital mental health services continue to evolve, this research provides valuable evidence that quality engagement matters more than quantity. For the millions of people who might benefit from online therapy, these insights suggest that effective treatment is achievable through consistent, focused participation rather than intensive time commitments.
The study reinforces that online CBT can be an effective treatment option for anxiety and depression when delivered thoughtfully and when patients engage meaningfully with the content. As our understanding of digital therapy engagement continues to develop, these findings offer a foundation for creating more effective and accessible mental health care.
Hammerfald, K., Jahren, H. H., & Solbakken, O. A. (2025). The association between patient engagement and treatment outcome in guided internet-delivered CBT for anxiety and depression. Frontiers in Psychology, 16, 1494729.
