Symptom Trajectories and Attendance in Face-to-Face and Online Psychiatric Follow-Up for Major Depressive Disorder and Anxiety Symptoms: Prospective Observational Cohort Study

BACKGROUND Major depressive disorder is a leading cause of disability, and access to specialist psychiatric follow-up remains limited in many settings. Telepsychiatry may reduce logistical barriers to care, but data on video-based follow-up under routine outpatient conditions in Türkiye are scarce, and comparisons of delivery modalities are frequently limited by baseline imbalance between self-selected groups. OBJECTIVE The aim of the study is to describe symptom trajectories and attendance over 6 months of routine psychiatric follow-up delivered either face-to-face or online and to examine whether outcomes differed between modalities after adjustment for baseline severity. METHODS In this prospective, nonrandomized observational cohort study, 120 adults with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) major depressive disorder were followed for 6 months at a university hospital psychiatry department in Ankara, Türkiye (September 2021 to May 2022). Participants entered face-to-face (n=60) or online (n=60) follow-up according to their own preference. Seven sessions were scheduled at approximately 4-week intervals; the Hamilton Depression Rating Scale (HAM-D; primary outcome), the Hamilton Anxiety Rating Scale, and DSM-5 Level 1 and Level 2 measures were administered at baseline and at sessions 1, 2, 4, and 6. Attendance was recorded at all sessions. Between-group comparisons used analysis of covariance adjusted for the corresponding baseline score and for prespecified covariates. Linear mixed models incorporating a group-by-time interaction were fitted to all available observations, and multiple imputation (m=20) was performed as a sensitivity analysis. RESULTS Depressive symptoms decreased substantially in both groups: mean HAM-D fell from 26.6 to 5.0 in the face-to-face group (81.2% reduction; Cohen d=4.86; P<.001; n=43) and from 24.1 to 3.3 in the online group (86.3% reduction; Cohen d=6.06; P<.001; n=49). Response rates were 41 of 43 (95.3%) and 48 of 49 (98%; P=.60), and remission rates were 32 of 43 (74.4%) and 43 of 49 (87.8%; P=.11). Unadjusted between-group differences at sessions 4 and 6 did not persist after adjustment for baseline severity (session 4: –0.47, 95% CI –1.71 to 0.77; P=.46; session 6: –0.79, 95% CI –2.22 to 0.65; P=.28), and the group-by-time interaction was not significant (χ23=1.9; P=.59). Anxiety scores did not differ at any time point. Findings were unchanged under multiple imputation, and prescribing patterns were comparable. Attendance across all 7 scheduled sessions was higher in the online group overall (373/420, 88.8% vs 319/420, 76%; P<.001), with differences at sessions 2 through 5. CONCLUSIONS Both modalities were followed by large reductions in depressive symptoms, and between-group differences did not persist after adjustment for baseline severity. The study was not designed as an equivalence trial and cannot establish equivalence. The most consistent difference favoring online follow-up was attendance, although its reasons could not be determined. These findings characterize online psychiatric follow-up as a feasible means of maintaining continuity of routine care rather than as a more effective one.