CHATBOT-DELIVERED COGNITIVE BEHAVIOURAL THERAPY: A STRUCTURED REVIEW OF EFFICACY, USER ENGAGEMENT, AND EQUITY OF ACCESS
DOI:
https://doi.org/10.31435/ijitss.4(52).2026.6374Keywords:
Conversational Agents, Cognitive Behavioural Therapy, Digital Mental Health, Health Equity, User Engagement, Artificial IntelligenceAbstract
Background: Chatbots are increasingly used to deliver cognitive behavioural therapy (CBT) via mobile and web applications. Many mental health systems cannot meet demand with face-to-face care alone. CBT chatbots have therefore been introduced in app form, but data on outcomes, dropout, and unequal uptake remain limited.
Objective: This review evaluates whether CBT chatbots reduce anxiety and depression symptoms, which user- and design-related factors are linked to engagement and dropout, and which structural barriers limit who can practically use these tools.
Methodology: Peer-reviewed studies from 2018 to 2026 were identified through searches in PubMed/MEDLINE and Google Scholar. Included studies examined automated CBT chatbots (e.g., Woebot, Wysa, Youper, Limbic Care) and reported clinical outcomes, engagement or dropout, and/or access-related findings. Twenty-four publications were synthesised thematically.
Results: Short-term trials and observational studies reported reductions in anxiety and depression symptoms, with small-to-moderate effects1. Generative conversational designs were linked to higher engagement than static digital programmes in at least one RCT, which reported roughly 2.4 times the use frequency of a generative CBT app relative to workbook controls3. Attrition remained notable; one meta-analysis estimated intervention-arm dropout at 21.84%5. Unequal access persisted because of connectivity, device availability, and digital literacy, despite the privacy and round-the-clock availability of app-based care23.
Conclusion: CBT chatbots may serve as useful low-intensity interventions, but their public health value depends on improved retention and fairer access. Implementation should address digital literacy, culturally appropriate design, and governance that does not restrict validated tools to already advantaged users.
References
Feng, X., Tian, L., Ho, G. W. K., Yorke, J., & Hui, V. (2025). The effectiveness of AI chatbots in alleviating mental distress and promoting health behaviors among adolescents and young adults: Systematic review and meta-analysis. Journal of Medical Internet Research, 27, e79850. https://doi.org/10.2196/79850
Fitzpatrick, K. K., Darcy, A., & Vierhile, M. (2017). Delivering cognitive behavior therapy to young adults with symptoms of depression and anxiety using a fully automated conversational agent (Woebot): A randomized controlled trial. JMIR Mental Health, 4(2), e19. https://doi.org/10.2196/mental.7785
McFadyen, J., Habicht, J., Dina, L.-M., Harper, R., Hauser, T. U., & Rollwage, M. (2026). Increasing engagement with cognitive-behavioral therapy (CBT) using generative AI: A randomized controlled trial (RCT). Communications Medicine, 6, 132. https://doi.org/10.1038/s43856-025-01321-8
Oewel, B., Areán, P. A., & Agapie, E. (2024). Approaches to tailoring between-session mental health therapy activities. Proceedings of the 2024 CHI Conference on Human Factors in Computing Systems, 1–19. https://doi.org/10.1145/3613904.3642856
Jabir, A. I., Lin, X., Martinengo, L., Sharp, G., Theng, Y.-L., & Tudor Car, L. (2024). Attrition in conversational agent–delivered mental health interventions: Systematic review and meta-analysis. Journal of Medical Internet Research, 26, e48168. https://doi.org/10.2196/48168
Smith, K. A., Davenport, T., Ospina-Pinillos, L., Guille, C., Arroll, B., Patel, V., & Torous, J. (2025). Engagement and attrition in digital mental health: Current challenges and potential solutions. npj Digital Medicine, 8(1), 398. https://doi.org/10.1038/s41746-025-01778-w
Palmer, A., & Schwan, D. (2025). Digital mental health tools and AI therapy chatbots: A balanced approach to regulation. Hastings Center Report, 55(3), 15–29. https://doi.org/10.1002/hast.4979
Habicht, J., Viswanathan, S., Carrington, B., Hauser, T. U., Harper, R., & Rollwage, M. (2024). Closing the accessibility gap to mental health treatment with a personalized self-referral chatbot. Nature Medicine, 30(2), 595–602. https://doi.org/10.1038/s41591-023-02766-x
van der Schyff, E. L., Ridout, B., Amon, K. L., Forsyth, R., & Campbell, A. J. (2023). Providing self-led mental health support through an artificial intelligence–powered chat bot (Leora) to meet the demand of mental health care. Journal of Medical Internet Research, 25, e46448. https://doi.org/10.2196/46448
Agrawal, A., Weiss, H. A., Gupta, R., Pednekar, S., Wilkinson, T., Kirk, K., & Patel, V. (2025). A conversational agent (PracticePal) to support the delivery of a brief behavioral activation treatment for depression in rural India: Development and pilot-testing study. JMIR Formative Research, 9, e73563. https://doi.org/10.2196/73563
Birk, M. N., Darcy, A. M., & Chen, E. (2021). Acceptability and effectiveness of artificial intelligence therapy for anxiety and depression (Youper): Longitudinal observational study. Journal of Medical Internet Research, 23(6), e26771. https://doi.org/10.2196/26771
Im, C.-H., & Woo, M. (2025). Clinical efficacy, therapeutic mechanisms, and implementation features of cognitive behavioral therapy–based chatbots for depression and anxiety: Narrative review. JMIR Mental Health, 12, e78340. https://doi.org/10.2196/78340
Zhong, W., Luo, J., & Zhang, H. (2024). The therapeutic effectiveness of artificial intelligence-based chatbots in alleviation of depressive and anxiety symptoms in short-course treatments: A systematic review and meta-analysis. Journal of Affective Disorders, 356, 371–380. https://doi.org/10.1016/j.jad.2024.04.057
Beatty, C., Malik, T., Meheli, S., & Sinha, C. (2022). Evaluating the therapeutic alliance with a free-text CBT conversational agent (Wysa): A mixed-methods study. Frontiers in Digital Health, 4, 847991. https://doi.org/10.3389/fdgth.2022.847991
Wang, Y., Li, X., Zhang, Q., Yeung, D., & Wu, Y. (2025). Effect of a cognitive behavioral therapy–based AI chatbot on depression and loneliness in Chinese university students: Randomized controlled trial with financial stress moderation. JMIR mHealth and uHealth, 13, e63806. https://doi.org/10.2196/63806
Karkosz, S., Szymański, R., Sanna, K., & Michałowski, J. (2024). Effectiveness of a web-based and mobile therapy chatbot on anxiety and depressive symptoms in subclinical young adults: Randomized controlled trial. JMIR Formative Research, 8, e47960. https://doi.org/10.2196/47960
MacNeill, A. L., Doucet, S., & Luke, A. (2024). Effectiveness of a mental health chatbot for people with chronic diseases: Randomized controlled trial. JMIR Formative Research, 8, e50025. https://doi.org/10.2196/50025
Chang, C. L., Sinha, C., Roy, M., & Wong, J. C. M. (2024). AI-led mental health support (Wysa) for health care workers during COVID-19: Service evaluation. JMIR Formative Research, 8, e51858. https://doi.org/10.2196/51858
Xu, Z., Lee, Y.-C., Stasiak, K., Warren, J., & Lottridge, D. (2025). The digital therapeutic alliance with mental health chatbots: Diary study and thematic analysis. JMIR Mental Health, 12, e76642. https://doi.org/10.2196/76642
Yoon, S. C., An, J. H., Choi, J., Chang, J. H., Jang, Y. J., & Jeon, H. J. (2025). Digital psychiatry with chatbot: Recent advances and limitations. Clinical Psychopharmacology and Neuroscience, 23(4), 542–550. https://doi.org/10.9758/cpn.25.1346
Khosravi, M., & Izadi, R. (2026). Mental health chatbots and their technical features: A systematic review of reviews and a thematic analysis. Global Mental Health, 13, e10144. https://doi.org/10.1017/gmh.2026.10144
Hou, J., Lin, S., Teng, P., Han, Y., Luo, Y., & He, G. (2026). Application of chatbots in chronic disease management: A scoping review. Digital Health, 12, 20552076251411287. https://doi.org/10.1177/20552076251411287
Yesha, R., Orezzoli, M. C. E., Sims, K., & Landau, A. Y. (2026). Digital mental health through an intersectional lens: A narrative review. Healthcare, 14(2), 211. https://doi.org/10.3390/healthcare14020211
Bendig, E., Erb, B., Schulze-Thuesing, L., & Baumeister, H. (2022). The next generation: Chatbots in clinical psychology and psychotherapy to foster mental health—a scoping review. Verhaltenstherapie, 32(2), 64–76. https://doi.org/10.1159/000501812
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Krzysztof Konopka, Michalina Justyna Kozłowska, Eliza Zofia Kabat, Maryan Liasota, Zuzanna Julia Komin, Mateusz Lis, Jakub Juskowiak, Alicja Kwiatkowska, Faustyna Magdalena Kołodziej, Maciej Kamil Majchrzak
This work is licensed under a Creative Commons Attribution 4.0 International License.
All articles are published in open-access and licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). Hence, authors retain copyright to the content of the articles.
CC BY 4.0 License allows content to be copied, adapted, displayed, distributed, re-published or otherwise re-used for any purpose including for adaptation and commercial use provided the content is attributed.
