Therapeutic Alliance Predicts Clinical Outcomes in a Fully Virtual Telepsychiatry Practice
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Background
Given the increasing demand for accessible mental health services, fully virtual telepsychiatry has become a vital component of modern health care delivery. Therapeutic alliance, the collaborative and affective bond between patients and therapists, is a well-established predictor of clinical outcomes in traditional face-to-face psychotherapy. However, the relationship between therapeutic alliance and clinical outcomes in an outpatient telepsychiatry setting remains less understood.
Objectives
Our primary objective was to evaluate the relationship between therapeutic alliance and clinical outcomes for depression and anxiety in an outpatient telepsychiatry practice.
Methods
This retrospective cohort study analyzed data from 201 treatment seeking adults receiving outpatient telepsychiatry care. Treatments included a comprehensive psychiatric evaluation, supportive psychotherapy and medication management conducted by a psychiatrist utilizing a fully virtual platform. Anxiety and depression symptoms were assessed using the Generalized Anxiety Disorder scale (GAD-7) and Patient Health Questionnaire depression scale (PHQ-8). Eligible participants completed a baseline clinical assessment within 1 week of their first visit that revealed at least moderate baseline symptoms (PHQ-8 and/or GAD-7 ≥10). Therapeutic alliance ratings from the patients’ perspective were collected using the Working Alliance Inventory-Short Revised (WAI-SR). Follow-up clinical assessments were conducted between 8 and 16 weeks after their first visit. We used logistic regression models to assess whether therapeutic alliance was associated with clinically significant improvement, which was defined as having ≥50% improvement in depression and/or anxiety symptoms at follow-up after adjusting for demographics (age, region, sex, insurance type, urban/rural) and baseline clinical scores (PHQ-8 or GAD-7).
Results
Among 201 patients, mean baseline symptom severity scores for depression and anxiety were 14.90 (SD 3.81) and 14.64 (SD 3.39), respectively. In response to telepsychiatry treatment, patients showed significant reductions in anxiety symptoms with a 41.1% improvement in symptoms from baseline ( d =1.16, p<0.001) and a 38.8% improvement in depressive symptoms from baseline ( d =1.07, p<0.001). Importantly, after controlling for other covariates, higher therapeutic alliance scores were significantly associated with greater likelihood of clinically significant improvement for both anxiety (OR=1.08, p<0.001, 95% CI: [1.04, 1.14]) and depression (OR=1.05, p=0.01, 95% CI: [1.01, 1.09]).
Conclusion
Therapeutic alliance scores independently predicted meaningful clinical improvements in an outpatient telepsychiatry setting. These findings speak to the importance of fostering strong therapeutic relationships between patients and psychiatrists, even when treatment is delivered virtually.
