Currently submitted to: JMIR Formative Research
Date Submitted: May 11, 2026
Open Peer Review Period: May 13, 2026 - Jul 8, 2026
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Routine Online Psychological Therapy in an Insurance-Based Care Setting: Retrospective Service Evaluation of Real-World Outcomes
ABSTRACT
Background:
Depression, anxiety, and stress-related difficulties represent a major global health burden, while access to timely psychological treatment remains limited for many individuals. Online psychological therapy has emerged as a promising approach to increasing access to care, yet evidence from routine, real-world clinical settings – particularly for services delivered without standardized treatment protocols – remains limited.
Objective:
This study aimed to evaluate clinical outcomes and patient-reported satisfaction associated with routine online psychological therapy delivered within an insurance-based care setting.
Methods:
A retrospective observational service evaluation was conducted using de-identified routine care data. Clients aged 15 years and older who initiated online psychological therapy and completed baseline and end-of-treatment assessments on all three outcome measures were included. Symptoms of depression, anxiety, and perceived stress were measured using the Patient Health Questionnaire--9 (PHQ-9), Generalized Anxiety Disorder--7 (GAD-7), and Perceived Stress Scale--10 (PSS-10), respectively. Changes in symptoms were examined using paired sample t-tests and within-sample effect sizes (Cohen's d with 95% confidence intervals), and reliable change indices. Clinically meaningful improvement was defined as a ≥50% reduction in symptom scores. Patient satisfaction was assessed using single-item ratings collected at treatment completion.
Results:
A total of 1,221 clients were included. Clients completed a mean of 4.7 therapy sessions over an average treatment duration of 62.7 days (SD=40.4). Significant reductions were observed across all outcome measures, with large within-sample effect sizes for depression (d=1.25, 95% CI [1.17, 1.32]), anxiety (d=1.49, 95% CI [1.41, 1.57]), and perceived stress (d=1.46, 95% CI [1.38, 1.54]). Clinically meaningful improvement was observed in 60.7% of clients for depression, 67.5% for anxiety, and 30.8% for perceived stress. At treatment completion, 80.7% of clients scored below the clinical cut-off for depression (PHQ-9 < 10) and 79.2% scored below the cut-off for anxiety (GAD-7 < 8). Reliable change analysis indicated that 56-65% of clients achieved statistically reliable improvement, with deterioration rates below 2% across all measures. Mean patient-reported satisfaction scores ranged from 8.55 to 8.96 on a 10-point scale, with a mean recommendation-likelihood score of 8.61.
Conclusions:
Routine online psychological therapy delivered within an insurance-based care setting was associated with substantial pre–post symptom reductions, high rates of clinically meaningful and reliable change, and high patient-reported satisfaction under real-world conditions. Because the evaluation used a completer-based pre–post design without a control group, observed changes cannot be attributed causally to treatment. The findings are consistent with the feasibility and acceptability of flexible online therapy models in routine mental health care; inferences about comparative effectiveness require randomized or otherwise controlled designs.
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