Abstract
Dialectical behavior therapy (DBT) is an evidence-based, skills-based intervention originally developed for chronic suicidality and borderline personality disorder and later adapted transdiagnostically for disorders involving emotional and behavioral dysregulation. Online and app-delivered DBT adaptations have proliferated, but their efficacy relative to in-person delivery has not been systematically quantified. This review systematically reviewed and meta-analyzed, where data permitted, randomized controlled trials (RCTs) of online or app-delivered DBT for emotional and behavioral outcomes in adults. Following a prospectively developed protocol, a search was conducted across PubMed, Cochrane CENTRAL, and PsycINFO for RCTs published between 2015 and 2026. Risk of bias was assessed with Cochrane RoB 2, and random-effects meta-analysis was conducted where two or more studies reported extractable, comparable effect sizes on a common outcome; remaining studies were synthesized narratively. Seven RCTs met inclusion criteria, spanning clinical populations including suicidality, chronic pain, disordered eating, substance use, perinatal mental health, and war-related distress. Only two studies reported comparable variance data on a shared outcome, emotion dysregulation, and their pooled effect favored online DBT with no heterogeneity between them. The remaining five studies, synthesized narratively, consistently favored online DBT on emotion dysregulation and disorder-specific outcomes, though risk of bias ranged from some concerns to high, chiefly due to attrition and unblinded self-report assessment. Online DBT shows a consistent, favorable signal across diverse populations, but the quantitative evidence base remains thin, with overall certainty rated low to very low. Larger, harmonized, multi-site trials are needed before firm clinical recommendations can be made.