Telemental health services

Evidence Rating  
Evidence rating: Some Evidence

Strategies with this rating are likely to work, but further research is needed to confirm effects. These strategies have been tested more than once and results trend positive overall.

Disparity Rating  
Disparity rating: Inconclusive impact on disparities

Strategies with this rating do not have enough evidence to assess potential impact on disparities.

Health Factors  
Date last updated
Community in Action

Telemental health services are mental health care services provided via telephone or videoconferencing technology. Services are sometimes referred to as telepsychiatry or telepsychology and can include psychotherapy, counseling, supplemental support services accompanying in-person therapy such as medication management, and self-directed services such as online cognitive behavioral therapy1, 2. Patients can receive care on their personal device via a service which uses a secure platform1 or be hosted at clinics or hospitals with telemedicine equipment. Direct real time services, or synchronous services, are the most common3 and are generally provided by psychiatrists, clinical psychologists, clinical social workers, and psychiatric nurse practitioners2. Supplemental or self-directed services such as cognitive behavioral therapy programs may or may not involve direct interaction with a practitioner. Telemental health services can supplement or provide services to individuals in areas with limited access to mental health care professionals, such as rural communities or other Health Professional Shortage Areas (HPSAs), and in emergency situations, such as disasters1, 4.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Improved mental health

  • Reduced post-traumatic stress

  • Increased access to mental health services

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Reduced suicide

  • Reduced vehicle miles traveled

  • Reduced emissions

What does the research say about effectiveness?

There is some evidence that telemental health services improve mental health5, 6, 7, 8, 9 at least as effectively as in-person treatment for a range of conditions3, 10, especially when provided synchronously3. Telemental health services appear to improve access to care3, 10 though additional evidence is needed to confirm effects on access among different patient groups, as well as on using telemental health to treat understudied mental health conditions3, 5. Studies of audio-only, hybrid in-person and digital11, and longer treatments are also needed10.

Telepsychiatry can be more effective than in-person treatment for depressive disorders, especially over a longer treatment period, and for mild cognitive impairments10, while telecounseling appears to be as effective as in-person psychotherapy for treating depression6, 7, 8, 9. Telemental health treatment for families, where parental depression is the focus, may be more effective than in-person treatment11. Telemental health services may be appropriate for individuals with autism spectrum disorders or social anxiety as it reduces stimuli, stress about social interactions, and the need for eye contact3.

Telemental health treatments can reduce post-traumatic stress disorder (PTSD) symptoms8, 9, but appear to be less effective than face-to-face interventions8. Telemental health services may be less appropriate for individuals with schizophrenia and psychosis disorders, who report feeling monitored or recorded; some may refuse care3. Telemental health services appear less effective at treating patients with eating disorders and those with substance use disorders, who may be more likely to discontinue treatment10. More research is also needed regarding telemental health services use by patients at risk for suicide or violence3.

Synchronous and asynchronous care. Telemental health services for treatment and assessment, provided synchronously, appear to be as effective as in-person treatment for many conditions3, 5, and videoconferencing appears to be acceptable to patients, at least in the short-term5. Most patients report that synchronous telemental health services improve their access to care as well as feelings of independence and self-expression3. Asynchronous care, in which the patient and provider communicate when they have time – usually not directly – is recommended for activities like sending patient reminders and offering support to reduce a patient’s risk of relapse, but is not recommended as a sole means of telemental health care3. Experts note possible limitations with audio-only telemental health services, such as a lack of non-visual verbal cues, and that more research is needed which compares audio-only, or audio-only plus in-person treatment, with standard in-person treatments11.

Recommendations. Overall, telemental health programs and services which offer a combination of care approaches12, for example, including some contact with a therapist for feedback and follow-up, appear to be more effective than less comprehensive programs and those that do not involve therapist contact12, 13. Telemental health services may be more effective when treating mild or moderate symptoms, rather than more severe symptoms13. Providers should also use informed consent and follow guidance to ensure their practice offers a standard of care equivalent to in-person treatment and meets the same ethical and professional standards. Guidance includes assessing patients’ suitability for telemental health care as well as whether both patient and provider have adequate privacy, technology, and knowledge about the nearest emergency health care facility11. Experts also recommend providers be trained in prevention and reporting of adverse events for clients during assessment and care, and note that additional monitoring and reporting of such events in telemental health practices is needed14.

Best practices for providing telemental health services via videoconferencing include using platforms with security and confidentiality features and through which recording is not possible1. Experts also recommend that providers offer initial free consultations to help patients determine if the provider is a good fit, which can be more difficult to tell in a virtual environment1. Providers appear to be able to develop as effective of therapeutic relationships using telemental health technology as in-person. Experts suggest that treating patients while they are in their homes may allow providers to see and better understand patients’ home environments, which may make treatment approaches more effective10, while the geographic distance between providers and patients reduces providers’ risk of physical confrontation3.

Costs. Synchronous forms of telemental health care, such as videoconferencing telepsychiatry, appear favorable, with potential savings in time, costs, and patient travel3, 15. One study of telephone care management and cognitive behavioral therapy found only a modest increase in the cost of services compared to usual primary care16, although additional study is needed to confirm effects on cost17.

Environmental benefits. Telemental health services have the potential to reduce the carbon footprint of the health care industry, primarily by reducing vehicle miles traveled (VMT) and greenhouse gas emissions from patients driving to appointments. Telemental health appointments generate some carbon emissions and those amounts vary based on the length of the appointment, type of teleconferencing platform used, energy used to support the virtual connection, and different broadband capacities. In general, telemental health appointments that replace a car trip of a few kilometers or more reduce carbon emissions3, 4, 18, 19.

How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.

It is unclear what impact telemental health services have on disparities in mental health conditions and access to health care among individuals who experience barriers to care. More research is needed to confirm what telemental health services are most effective and appropriate for those who experience marginalization or other barriers to accessing digital health interventions3, 26, 27, including for individuals accessing care at federally qualified health centers (FQHCs)27.

Available evidence suggests that prior to the COVID-19 pandemic, telemental health service use appeared to be increasing among Medicare beneficiaries in rural areas and among populations with the most barriers. However, as with telemedicine generally, telemental health use varies by geography, socioeconomic status, and among those with minoritized backgrounds, as well as between urban, rural, and suburban settings11. Although telemedicine overall is a suggested strategy to decrease geographic disparities in access to health care between rural and urban areas21 by improving access for rural populations and in areas with medical provider shortages28, telemedicine use appears to differ significantly by patients’ race, household income, insurance status, and whether the household has high-speed internet21, 29. Adults without health insurance are least likely to use telemedicine29 and video-enabled visits in particular appear to be used more by younger, higher income, urban, white adults, and less by those with lower incomes, adults with less than a high school degree, individuals who identify as Black, Latino/a, or Asian, and adults over age 6529, even with significant increases in use in 2020 and 2021 when barriers were removed due to the COVID-19 pandemic21, 29.

Disparities in mental health outcomes exist in the U.S. within racially, ethnically, and gender-diverse civilian populations, as well as among service members and veterans, compared with those at less risk because of their identity or military service status30. Participation in telecounseling can reduce depression and anxiety, and improve quality of life among groups who are racially or ethnically minoritized, at least in the short-term7. For veterans, both videoconferencing and audio-only treatment appear comparable to in-person treatment for anxiety and depression, and videoconferencing is as effective for a wider range of conditions, but in-person treatment may be modestly more helpful for trauma treatment11. Telemental health services may also be effective among individuals experiencing homelessness or unstable housing31. However, women who are Black and experiencing poverty are least likely to use telehealth -- even as advances have been made among other populations and across a broad range of conditions32.

A California-based study finds that rates of audio-only telehealth appointments remain high, even after the COVID-19 pandemic, especially among individuals with lower incomes and clients of FQHCs27; it is unclear whether wide use of audio-only among these groups is appropriate27.

An Australia-based review suggests telemental health care may reduce disparities in mental health status experienced by Indigenous individuals, increase access to specialist care for individuals in geographically remote areas, and offers cost savings from reduced travel33. However, such outcomes are possible only if providers are educated about and if services reflect Indigenous values and local needs26. More research is needed to confirm which telemental health services are most effective and appropriate for patients who are from Indigenous backgrounds26, who often experience less availability of and access to mental health services34.

Experts recommend creating services which are culturally safe, meaning care that is adapted or designed especially for individuals from a specific minoritized background34. For example, components to establish a culturally safe telepsychiatry practice in an Indigenous community include, as a first step, directly consulting and involving local community members and organizations in order to identify needs and initial adaptations; pilot testing with feedback from multiple sources and further adaptation; and trial provision of care, with the understanding that adaptation is an ongoing process34. Challenges can include technical considerations, like broadband service or internet access and speed, suitable devices, and geographic distance34. For some people, including some individuals with Indigenous backgrounds, in-person mental health treatment will always be preferable35. Some principles of culturally safe care overlap with initiatives for patient-centered care35.

What is the relevant historical background?

Telemedicine was initially used for acute conditions, such as strokes or traumatic injuries, to connect specialist providers with clinicians treating patients in emergency departments. Telemedicine programs have also historically focused on rural populations, as well as those in the military and individuals who are incarcerated36. Before March 2020 and the onset of the COVID-19 pandemic in the U.S., provider-patient telemedicine use was increasing but was a tiny proportion of overall care21, especially video-enabled visits36. Most patients in the U.S. who used telemedicine did so through large academic medical centers, the Veterans Administration (VA) health systems, or purchased access if their health care provider offered direct-to-consumer services. Barriers to internet access and use prevented patients in rural areas, those with lower household incomes, disabilities21, and older adults from accessing care via telemedicine36. Legal barriers and differing state rules, such as whether medication could be prescribed over the internet also restricted use36.

In March 2020, to support access to care and financial solvency for health care systems, Congress adjusted telemedicine restrictions for Medicare, which included removing some restrictions for reimbursement, geography, and platform, as well as including telephone-only visits, and addressed interstate barriers to practice and privacy related to states’ differing rules, with state and private health insurance payors following this example21. A study of private and Medicare health care claims estimates that telehealth claims increased from 0.1% in 2019 to 5% of overall claims as of 202121. Barriers in access to care for mental illness are a problem worldwide, and estimates for the U.S. suggest that less than half of individuals with mental illness receive treatment11.

Equity Considerations
  • Who has access to mental health services in your community and who does not? How could telemental health help remove barriers (e.g., health insurance coverage, internet access) so more people can access services?
  • Who is choosing which types of telemental health services to offer patients and how are those decisions being reached? Which health needs are the focus? Which patient groups?
  • How are health care providers, as well as community members, engaged in efforts to expand telemental health use? What local or state laws and regulations restrict its use?
Implementation Examples

As of January 2023, all 50 states and Washington, D.C. provide Medicaid reimbursement for live video telehealth services (which may include telemental health), and 43 states and Washington, D.C. have telehealth private payer laws and also reimburse for audio-only telephone services, which is a significant increase since 202120. As of 2018, 76% of U.S. hospital systems use telemedicine in some form, most often for radiology, cardiology, and psychiatry21. The U.S. Department of Health and Human Services National Institute of Mental Health (NIMH) has information about finding a health care provider that offers telemental health services1. Comprehensive guidelines and toolkits for telemental health care provision are available from organizations including the American Psychological Association, American Psychiatric Association, American Telemedicine Association (ATA), the World Psychiatric Association (WPA), and the American Academy of Child and Adolescent Psychiatry (AACAP)11.

The U.S. has an interstate compact which makes telepsychology services (and temporary in-person services) from licensed psychologists available across state boundaries, called the Psychology Interjurisdictional Compact (PSYPACT)22. The PSYPACT Commission, with representatives from multiple states, authorizes psychologists’ interstate practice22. As of 2024, nearly all states participate, with only a handful of states and territories lacking active legislation to join the compact (Alaska, Guam, Iowa, Hawaii, Louisiana, Montana, New Mexico, Oregon, Puerto Rico, and the U.S. Virgin Islands)23.

Legislation has been introduced in some states which would allow providers not approved by the PSYPACT Commission to practice across state lines24. Such legislation was vetoed in Wisconsin in 2024, citing the existing compact and concerns that consumers would have difficulty filing complaints against providers in other states, where consumers’ home state agencies for credentialing and safety have no jurisdiction25.

Implementation Resources

Resources with a focus on equity.

NIMH-Telemental - National Institute of Mental Health (NIMH): What is telemental health? U.S. Department of Health and Human Services (U.S. DHHS), National Institutes of Health (NIH).

HRSA-HHS Telehealth licensing - Health Resources & Services Administration (HRSA). Licensing across state lines.

PSYPACT-Map - Psychology Interjurisdictional Compact (PSYPACT). Participating states.

CCHP - Center for Connected Health Policy (CCHP).

LawAtlas-Telehealth - LawAtlas. Telehealth and primary care provider laws map.

APA-Telepsychiatry - American Psychiatric Association (APA). APA Work Group on Telepsychiatry: Telepsychiatry Toolkit.

AACAP-Telepsychiatry - The American Academy of Child and Adolescent Psychiatry (AACAP). The Child and Adolescent Telepsychiatry Toolkit.


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1 NIMH-Telemental - National Institute of Mental Health (NIMH): What is telemental health? U.S. Department of Health and Human Services (U.S. DHHS), National Institutes of Health (NIH).

2 Lambert 2013 - Lambert D, Gale J, Hansen AY, Croll Z, Hartley D. Telemental health in today’s rural health system. Portland, ME: Maine Rural Health Research Center, University of Southern Maine Muskie School of Public Service. 2013:PB-51.

3 Philippe 2022 - Philippe TJ, Sikder N, Meng AJ, et al. Digital health interventions for delivery of mental health care: Systematic and comprehensive meta-review. JMIR Mental Health. 2022;9(5):e35159.

4 Yellowlees 2022 - Yellowlees P. Climate change impacts on mental health will lead to increased digitization of mental health care. Current Psychiatry Reports. 2022;24:723-730.

5 Barnett 2021 - Barnett P, Goulding L, Casetta C, et al. Implementation of telemental health services before COVID-19: Rapid umbrella review of systematic reviews. Journal of Medical Internet Research. 2021;23(7):e26492.

6 Osenbach 2013 - Osenbach JE, O’Brien KM, Mishkind M, Smolenski DJ. Synchronous telehealth technologies in psychotherapy for depression: A meta-analysis. Depression and Anxiety. 2013;30(11):1058-67.

7 Dorstyn 2013 - Dorstyn DS, Saniotis A, Sobhanian F. A systematic review of telecounselling and its effectiveness in managing depression amongst minority ethnic communities. Journal of Telemedicine and Telecare. 2013;19(6):338-346.

8 Sloan 2011 - Sloan DM, Gallagher MW, Feinstein BA, Lee DJ, Pruneau GM. Efficacy of telehealth treatments for posttraumatic stress-related symptoms: A meta-analysis. Cognitive Behaviour Therapy. 2011;40(2):111-25.

9 Hailey 2008 - Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: A review. Canadian Journal of Psychiatry. 2008;53(11):769-78.

10 Hagi 2023 - Hagi K, Kurokawa S, Takamiya A, et al. Telepsychiatry versus face-to-face treatment: Systematic review and meta-analysis of randomised controlled trials. British Journal of Psychiatry. 2023;223(3):407-414.

11 Sugarman 2023 - Sugarman DE, Busch AB. Telemental health for clinical assessment and treatment. BMJ. 2023;380:e072398.

12 Appleton 2023 - Appleton R, Barnett P, San Juan NV, et al. Implementation strategies for telemental health: A systematic review. BMC Health Services Research. 2023;23(78):1-24.

13 Penate 2012 - Peñate W. About the effectiveness of telehealth procedures in psychological treatments. International Journal of Clinical and Health Psychology. 2012;12(3):475-487.

14 Martiniuk 2023 - Martiniuk A, Toepfer A, Lane-Brown A. A review of risks, adverse effects and mitigation strategies when delivering mental health services using telehealth. Journal of Mental Health. 2023:1-24.

15 Pesamaa 2004 - Pesamaa L, Ebeling H, Kuusimaki ML, et al. Videoconferencing in child and adolescent telepsychiatry: A systematic review of the literature. Journal of Telemedicine and Telecare. 2004;10(4):187-192.

16 Simon 2009 - Simon GE, Ludman EJ, Rutter CM. Incremental benefit and cost of telephone care management and telephone psychotherapy for depression in primary care. Archives of General Psychiatry. 2009;66(10):1081-9.

17 RAND-Brown 2015 - Brown RA, Marshall GN, Breslau J, et al. Access to behavioral health care for geographically remote service members and dependents in the U.S. Santa Monica: Rand Corporation; 2015.

18 Dacones 2021 - Dacones I, Cave C, Furie GL, Ogden CA, Slutzman JE. Patient transport greenhouse gas emissions from outpatient care at an integrated health care system in the Northwestern United States, 2015–2020. The Journal of Climate Change and Health. 2021;3.

19 Holmner 2014 - Holmner Å, Ebi KL, Lazuardi L, Nilsson M. Carbon footprint of telemedicine solutions - Unexplored opportunity for reducing carbon emissions in the health sector. PLoS ONE. 2014;9(9).

20 CCHP-Telehealth glance - Center for Connected Health Policy (CCHP). State telehealth laws and reimbursement policies at-a-glance. Fall 2023.

21 Shaver 2022 - Shaver J. The state of telehealth before and after the COVID-19 pandemic. Primary Care: Clinics in Office Practice. 2022;49(4):517-530.

22 PSYPACT-About - Psychology Interjurisdictional Compact (PSYPACT). Overview.

23 PSYPACT-Map - Psychology Interjurisdictional Compact (PSYPACT). Participating states.

24 WI AB 541 - Representatives Gustafson, Dittrich, Kitchens, et al. Wisconsin State Legislature. 2023 Assembly Bill (AB) 541.

25 WI AB 541-Veto - Wisconsin State Legislature. Assembly Bill (AB) 541. Governor’s veto message. March 29, 2024.

26 Hensel 2019 - Hensel JM, Ellard K, Koltek M, Wilson G, Sareen J. Digital health solutions for indigenous mental well-being. Current Psychiatry Reports. 2019;21:68.

27 RAND-Uscher Pines 2023 - Uscher-Pines L, McCullough CM, Sousa JL, et al. Changes in in-person, audio-only, and video visits in California’s federally qualified health centers, 2019-2022. Santa Monica: RAND Corporation; 2023.

28 Shigekawa 2018 - Shigekawa E, Fix M, Corbett G, Roby DH, Coffman J. The current state of telehealth evidence: A rapid review. Health Affairs. 2018;37(12):1975-1982.

29 US DHHS-Karimi 2022 - Karimi M, Lee EC, Couture SJ, et al. National survey trends in telehealth use in 2021: Disparities in utilization and audio vs. video services. Washington, D.C.: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services (U.S. DHHS); 2022.

30 Sharifian 2024 - Sharifian N, Kolaja C, LeardMann CA, et al. Racial and ethnic mental health disparities in U.S. military veterans: Results from the National Health and Resilience in Veterans Study. American Journal of Epidemiology. 2024;193(3):500-515.

31 DeLaCruz-Jiron 2023 - DeLaCruz-Jiron EJ, Hahn LM, Donahue AL, Shore JH. Telemental health for the homeless population: Lessons learned when leveraging care. Current Psychiatry Reports. 2023;25:1-6.

32 Saeed 2021 - Saeed SA, Masters RM. Disparities in health care and the digital divide. Current Psychiatry Reports. 2021;23:61.

33 Caffery 2017 - Caffery LJ, Bradford NK, Wickramasinghe SI, Hayman N, Smith AC. Outcomes of using telehealth for the provision of healthcare to Aboriginal and Torres Strait Islander people: A systematic review. Australian and New Zealand Journal of Public Health. 2017;41(1):48-53.

34 Ruiz-Consignani 2024 - Ruiz-Cosignani D, Chen Y, Cheung G, et al. Adaptation models, barriers, and facilitators for cultural safety in telepsychiatry: A systematic scoping review. Journal of Telemedicine and Telecare. 2024;30(3):466-474.

35 Terrill 2023 - Terrill K, Woodall H, Evans R, et al. Cultural safety in telehealth consultations with Indigenous people: A scoping review of global literature. Journal of Telemedicine and Telecare. 2023.

36 Dorsey 2016 - Dorsey ER, Topol EJ. State of telehealth. New England Journal of Medicine. 2016;375(2):154-161.