Telemental health services

There is some evidence that telemental health services improve mental health^{5, 6, 7, 8, 9} at least as effectively as in-person treatment for a range of conditions^{3, 10}, especially when provided synchronously³. Telemental health services appear to improve access to care^{3, 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 conditions^{3, 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 depression^{6, 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) symptoms^{8, 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 conditions^{3, 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 contact^{12, 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 travel^{3, 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 emissions^{3, 4, 18, 19}.

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.