Abstract
Mental health chatbots have proliferated rapidly, yet their effectiveness remains unclear. This systematic review and meta-analysis included randomized controlled trials comparing chatbots with any control condition for depressive and/or anxiety outcomes. PubMed, Embase, PsycINFO, Scopus and Web of Science were searched from January 2017 to October 2025. Risk of bias was assessed using the revised Cochrane tool. Pooled effect sizes (Hedges’ g) were calculated using random-effects models. Of the 39 eligible studies, 38 (n = 7,401) were analyzed for depression and 34 (n = 7,621) for anxiety. Chatbots produced statistically significant reductions in depressive (g = 0.31, 95% CI [0.17, 0.46]) and anxiety symptoms (g = 0.28, 95% CI [0.05, 0.51]) compared with controls. Subgroup analyses for depressive symptoms showed larger effects in clinical and subclinical than in nonclinical samples (p = 0.001). Contemporary chatbots thus appear to alleviate depressive and anxiety symptoms, especially in individuals with greater depressive severity. (PROSPERO registration: CRD42024598761).
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References
Institute of Health Metrics and Evaluation. Global Health Data Exchange (GHDx). https://vizhub.healthdata.org/gbd-results. (2025).
Santomauro, D. F. et al. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet. 398, 1700–712 (2021).
Mongelli, F., Georgakopoulos, P. & Pato, M. T. Challenges and Opportunities to Meet the Mental Health Needs of Underserved and Disenfranchised Populations in the United States. Focus (Am. Psychiatr. Publ.) 18, 16–24 (2020).
Tal, A. & Torous, J. The digital mental health revolution: Opportunities and risks. Psychiatr. Rehabil. J. 40, 263–265 (2017).
Jabir, A. I. et al. Attrition in Conversational Agent-Delivered Mental Health Interventions: Systematic Review and Meta-Analysis. J. Med Internet Res 26, e48168 (2024).
Tudor Car, L. et al. Conversational Agents in Health Care: Scoping Review and Conceptual Analysis. J. Med Internet Res. 22, e17158 (2020).
Laymouna, M. et al. Roles, Users, Benefits, and Limitations of Chatbots in Health Care: Rapid Review. J. Med Internet Res. 26, e56930 (2024).
Mnasri, M. Recent advances in conversational NLP: Towards the standardization of Chatbot building. arXiv preprint arXiv:1903.09025 (2019).
Fitzpatrick, K. K., Darcy, A. & Vierhile, M. 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 Ment. Health. 4, e19 (2017).
Inkster, B., Sarda, S. & Subramanian, V. An Empathy-Driven, Conversational Artificial Intelligence Agent (Wysa) for Digital Mental Well-Being: Real-World Data Evaluation Mixed-Methods Study. JMIR Mhealth Uhealth. 6, e12106 (2018).
Veroniki, A. A. et al. Methods to estimate the between-study variance and its uncertainty in meta-analysis. Res Synth. Methods 7, 55–79 (2016).
Achiam, J. et al. Gpt-4 technical report. arXiv preprint arXiv:2303.08774 (2023)..
Team, G. et al. Gemini: a family of highly capable multimodal models. arXiv preprint arXiv:2312.11805 (2023).
Demszky, D. et al. Using large language models in psychology. Nat. Rev. Psychol. 2, 688–701 (2023).
Peretz, G., Taylor, C. B., Ruzek, J. I., Jefroykin, S. & Sadeh-Sharvit, S. Machine Learning Model to Predict Assignment of Therapy Homework in Behavioral Treatments: Algorithm Development and Validation. JMIR Form. Res 7, e45156 (2023).
Tanana, M. J. et al. How do you feel? Using natural language processing to automatically rate emotion in psychotherapy. Behav. Res Methods 53, 2069–2082 (2021).
Chen, Y. et al. Structured Dialogue System for Mental Health: An LLM Chatbot Leveraging the PM+ Guidelines. Springer, Singapore. 15170, 262–271 (2025).
Koh, J., Tng, G. Y. Q. & Hartanto, A. Potential and Pitfalls of Mobile Mental Health Apps in Traditional Treatment: An Umbrella Review. J. Pers. Med. 12, https://doi.org/10.3390/jpm12091376.(2022).
Abd-Alrazaq, A. A. et al. An overview of the features of chatbots in mental health: A scoping review. Int J. Med Inf. 132, 103978 (2019).
Shiferaw, M. W., Zheng, T., Winter, A., Mike, L. A. & Chan, L.-N. Assessing the accuracy and quality of artificial intelligence (AI) chatbot-generated responses in making patient-specific drug-therapy and healthcare-related decisions. BMC Med. Inform. Decis. Mak. 24, 404 (2024).
He, Y. et al. Conversational Agent Interventions for Mental Health Problems: Systematic Review and Meta-analysis of Randomized Controlled Trials. J. Med Internet Res 25, e43862 (2023).
Li, H., Zhang, R., Lee, Y. C., Kraut, R. E. & Mohr, D. C. Systematic review and meta-analysis of AI-based conversational agents for promoting mental health and well-being. NPJ Digit Med 6, 236 (2023).
Villarreal-Zegarra, D. et al. Self-Administered Interventions Based on Natural Language Processing Models for Reducing Depressive and Anxiety Symptoms: Systematic Review and Meta-Analysis. JMIR Ment. Health. 11, e59560 (2024).
Page, M. J. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372, n71 (2021).
Sabour, S. et al. A chatbot for mental health support: exploring the impact of Emohaa on reducing mental distress in China. Front Digit Health 5, 1133987 (2023).
Yasukawa, S. et al. A chatbot to improve adherence to internet-based cognitive-behavioural therapy among workers with subthreshold depression: a randomised controlled trial. BMJ Ment. Health 27, https://doi.org/10.1136/bmjment-2023-300881.(2024).
Ulrich, S., Lienhard, N., Künzli, H. & Kowatsch, T. A Chatbot-Delivered Stress Management Coaching for Students (MISHA App): Pilot Randomized Controlled Trial. JMIR Mhealth Uhealth 12, e54945 (2024).
Prochaska, J. J. et al. A randomized controlled trial of a therapeutic relational agent for reducing substance misuse during the COVID-19 pandemic. Drug Alcohol Depend. 227, 108986 (2021).
Danieli, M. et al. Assessing the Impact of Conversational Artificial Intelligence in the Treatment of Stress and Anxiety in Aging Adults: Randomized Controlled Trial. JMIR Ment. Health 9, e38067 (2022).
Ogawa, M. et al. Can AI make people happy? The effect of AI-based chatbot on smile and speech in Parkinson’s disease. Parkinsonism Relat. Disord. 99, 43–46 (2022).
Nicol, G., Wang, R., Graham, S., Dodd, S. & Garbutt, J. Chatbot-Delivered Cognitive Behavioral Therapy in Adolescents With Depression and Anxiety During the COVID-19 Pandemic: Feasibility and Acceptability Study. JMIR Form. Res 6, e40242 (2022).
Fitzsimmons-Craft, E. E. et al. Effectiveness of a chatbot for eating disorders prevention: A randomized clinical trial. Int J. Eat. Disord. 55, 343–353 (2022).
Kleinau, E. et al. Effectiveness of a chatbot in improving the mental wellbeing of health workers in Malawi during the COVID-19 pandemic: A randomized, controlled trial. PLoS One 19, e0303370 (2024).
MacNeill, A. L., Doucet, S. & Luke, A. Effectiveness of a Mental Health Chatbot for People With Chronic Diseases: Randomized Controlled Trial. JMIR Form. Res 8, e50025 (2024).
Karkosz, S., Szymański, R., Sanna, K. & Michałowski, J. Effectiveness of a Web-based and Mobile Therapy Chatbot on Anxiety and Depressive Symptoms in Subclinical Young Adults: Randomized Controlled Trial. JMIR Form. Res 8, e47960 (2024).
Vereschagin, M. et al. Effectiveness of the Minder Mobile Mental Health and Substance Use Intervention for University Students: Randomized Controlled Trial. J. Med Internet Res 26, e54287 (2024).
Oh, J., Jang, S., Kim, H. & Kim, J. J. Efficacy of mobile app-based interactive cognitive behavioral therapy using a chatbot for panic disorder. Int J. Med Inf. 140, 104171 (2020).
Hunt, M., Miguez, S., Dukas, B., Onwude, O. & White, S. Efficacy of Zemedy, a Mobile Digital Therapeutic for the Self-management of Irritable Bowel Syndrome: Crossover Randomized Controlled Trial. JMIR Mhealth Uhealth 9, e26152 (2021).
Romanovskyi, O., Pidbutska, N. & Knysh, A. in International Conference on Computational Linguistics and Intelligent Systems.
Liu, I., Chen, W., Ge, Q., Song, D. & Ni, S. in Proceedings of the Tenth International Symposium of Chinese CHI 216–221 (Association for Computing Machinery, Guangzhou, China and Online, China, 2024).
Suharwardy, S. et al. Feasibility and impact of a mental health chatbot on postpartum mental health: a randomized controlled trial. AJOG Glob. Rep. 3, 100165 (2023).
Bird, T., Mansell, W., Wright, J., Gaffney, H. & Tai, S. Manage Your Life Online: A Web-Based Randomized Controlled Trial Evaluating the Effectiveness of a Problem-Solving Intervention in a Student Sample. Behav. Cogn. Psychother. 46, 570–582 (2018).
He, Y. et al. Mental Health Chatbot for Young Adults With Depressive Symptoms During the COVID-19 Pandemic: Single-Blind, Three-Arm Randomized Controlled Trial. J. Med Internet Res 24, e40719 (2022).
Jang, S. et al. Mobile app-based chatbot to deliver cognitive behavioral therapy and psychoeducation for adults with attention deficit: A development and feasibility/usability study. Int J. Med Inf. 150, 104440 (2021).
Gong, E. et al. My Diabetes Coach, a Mobile App-Based Interactive Conversational Agent to Support Type 2 Diabetes Self-Management: Randomized Effectiveness-Implementation Trial. J. Med Internet Res 22, e20322 (2020).
Maeda, E. et al. Promoting fertility awareness and preconception health using a chatbot: a randomized controlled trial. Reprod. Biomed. Online 41, 1133–1143 (2020).
Greer, S. et al. Use of the Chatbot “Vivibot” to Deliver Positive Psychology Skills and Promote Well-Being Among Young People After Cancer Treatment: Randomized Controlled Feasibility Trial. JMIR Mhealth Uhealth. 7, e15018 (2019).
Liu, H., Peng, H., Song, X., Xu, C. & Zhang, M. Using AI chatbots to provide self-help depression interventions for university students: A randomized trial of effectiveness. Internet Inter. 27, 100495 (2022).
Ulrich, S. et al. Development and Evaluation of a Smartphone-Based Chatbot Coach to Facilitate a Balanced Lifestyle in Individuals With Headaches (BalanceUP App): Randomized Controlled Trial. J. Med Internet Res. 26, e50132 (2024).
Chan, W. S. et al. Assessing the Short-Term Efficacy of Digital Cognitive Behavioral Therapy for Insomnia With Different Types of Coaching: Randomized Controlled Comparative Trial. JMIR Ment. Health 11, e51716 (2024).
Chua, J. Y. X. et al. The effectiveness of Parentbot - a digital healthcare assistant - on parenting outcomes: A randomized controlled trial. Int J. Nurs. Stud. 160, 104906 (2024).
Reilly, E. D. et al. Virtual Coach-Guided Online Acceptance and Commitment Therapy for Chronic Pain: Pilot Feasibility Randomized Controlled Trial. JMIR Form. Res 8, e56437 (2024).
Chen, C. et al. Comparison of an AI Chatbot With a Nurse Hotline in Reducing Anxiety and Depression Levels in the General Population: Pilot Randomized Controlled Trial. JMIR Hum. Factors 12, e65785 (2025).
de Graaff, A. M. et al. Evaluation of a Guided Chatbot Intervention for Young People in Jordan: Feasibility Randomized Controlled Trial. JMIR Ment. Health 12, e63515 (2025).
Heinz, M. V. et al. Randomized Trial of a Generative AI Chatbot for Mental Health Treatment. NEJM AI 2, AIoa2400802 (2025).
Sharp, G., Dwyer, B., Randhawa, A., McGrath, I. & Hu, H. The Effectiveness of a Chatbot Single-Session Intervention for People on Waitlists for Eating Disorder Treatment: Randomized Controlled Trial. J. Med Internet Res 27, e70874 (2025).
Six, S., Schlesener, E., Hill, V., Babu, S. V. & Byrne, K. Impact of Conversational and Animation Features of a Mental Health App Virtual Agent on Depressive Symptoms and User Experience Among College Students: Randomized Controlled Trial. JMIR Ment. Health 12, e67381 (2025).
Tong, A. C. Y., Wong, K. T. Y., Chung, W. W. T. & Mak, W. W. S. Effectiveness of Topic-Based Chatbots on Mental Health Self-Care and Mental Well-Being: Randomized Controlled Trial. J. Med Internet Res 27, e70436 (2025).
Xu, S. & Ma, T. Depression intervention using AI chatbots with social cues: a randomized trial of effectiveness. J. Affect Disord. 389, 119760 (2025).
Ye, X., Shan, X., Tu, Y. & Zhang, Y. Examining the Efficacy of Large Language Models for Mitigating Depression and Anxiety Among Chinese Students: A Randomized Controlled Trial. Comput Inform. Nurs. 43, https://doi.org/10.1097/cin.0000000000001349. (2025).
Yokotani, K., Ito, M., Ihara, N. & Shigeeda, Y. A unified protocol chatbot reduces anxiety by encouraging university students’ negative emotional expressions: A randomized controlled trial. Computers Hum. Behav. Rep. 19, 100770 (2025).
Zhao, Y. et al. Effect of an AI agent trained on a large language model (LLM) as an intervention for depression and anxiety symptoms in young adults: A 28-day randomized controlled trial. Appl Psychol. Health Well Being 17, e70067 (2025).
Higgins JPT et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.5 (Cochrane, 2024). www.cochrane.org/handbook.
Barnett, A. G., van der Pols, J. C. & Dobson, A. J. Regression to the mean: what it is and how to deal with it. Int J. Epidemiol. 34, 215–220 (2005).
Morton, V. & Torgerson, D. J. Regression to the mean: treatment effect without the intervention. J. Eval. Clin. Pr. 11, 59–65 (2005).
Blease, C. & Rodman, A. Generative Artificial Intelligence in Mental Healthcare: An Ethical Evaluation. Curr. Treat. Options Psychiatry 12, 5 (2024).
Abd-Alrazaq, A. A., Rababeh, A., Alajlani, M., Bewick, B. M. & Househ, M. Effectiveness and Safety of Using Chatbots to Improve Mental Health: Systematic Review and Meta-Analysis. J. Med Internet Res 22, e16021 (2020).
van Aert, R. C., Wicherts, J. M. & van Assen, M. A. Conducting Meta-Analyses Based on p Values: Reservations and Recommendations for Applying p-Uniform and p-Curve. Perspect. Psychol. Sci. 11, 713–729 (2016).
Sohn, J.-S., Lee, E., Kim, J.-J., Oh, H.-K. & Kim, E. Implementation of generative AI for the assessment and treatment of autism spectrum disorders: a scoping review. Front. Psychiatr. 16, 1628216 (2025).
Denecke, K. & May, R. Developing a Technical-Oriented Taxonomy to Define Archetypes of Conversational Agents in Health Care: Literature Review and Cluster Analysis. J. Med Internet Res 25, e41583 (2023).
Chiu, Y. H., Lee, Y. F., Lin, H. L. & Cheng, L. C. Exploring the Role of Mobile Apps for Insomnia in Depression: Systematic Review. J. Med Internet Res 26, e51110 (2024).
Sterne, J. A. C. et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. Bmj 366, l4898 (2019).
Egger, M., Davey Smith, G., Schneider, M. & Minder, C. Bias in meta-analysis detected by a simple, graphical test. Bmj 315, 629–634 (1997).
Pustejovsky, J. E. & Rodgers, M. A. Testing for funnel plot asymmetry of standardized mean differences. Res Synth. Methods 10, 57–71 (2019).
Acknowledgements
This research was supported by a grant of the Research and Development (R&D) project funded by the National Center for Mental Health (grant number: MHER25C04). The funder had no role in the study design; data collection, analysis, or interpretation; manuscript preparation; or decision to submit the manuscript for publication. We thank Dr. Vincent Kipkorir for feedback on the original draft and methodological insights regarding systematic reviews.
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Conceptualization: J.-S.S., H.-K.O., S.L., and E.K.; Methodology: J.-S.S., S.L., and S.P.; Data curation and investigation: J.-S.S., B.-G.H., and E.K.; Writing-original draft: J.-S.S.; Writing-review and editing: J.-S.S., B.-G.H., S.P., J.-J.K., E.L., H.-K.O., S.L., and E.K.; Supervision: J.-J.K., S.L., and E.K.; All authors have read and approved the final manuscript.
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Sohn, JS., Ha, BG., Park, S. et al. Systematic review and meta analysis of chatbots in the management of depressive and anxiety symptoms. npj Digit. Med. (2026). https://doi.org/10.1038/s41746-026-02566-w
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DOI: https://doi.org/10.1038/s41746-026-02566-w


