A total of 3956 references were identified through searching databases of published papers. medRxiv was the only preprint database where included papers were found (n=10); 1 more relevant paper was identified by a member of the research team and a further paper was found through reference searching of included studies.
A PRISMA flow diagram [
PRISMA diagram showing screening and included studies.
The quality of included primary research studies was moderate to high: 23 out of 48 studies appraised using the MMAT met above 80% of quality criteria, whereas 21 out of 48 met between 50% and 79%. The quality of included service evaluations or audits was generally high: 27 out of 29 studies appraised using the AACODS met at least 4 out of the 6 quality criteria assessed. These include being written by recognized experts; including reference lists; having a clear aim; stating details such as date, location, and limitations; and making a meaningful contribution to the research literature.
Of the 77 studies which were eligible for inclusion in the review (
Of the 45 primary research studies, 32 involved staff and 9 involved service users. The remaining 4 analyzed service use data (3 evaluated contacts with hotlines and 1 evaluated service use in 1 UK National Health Service [NHS] service provider).
Most studies were conducted in services that worked with people with mixed psychiatric diagnoses (n=30), although we also found studies conducted with groups with a single diagnosis (eg, dementia or eating disorders). Studies could include more than 1 service type, the most commonly studied being community mental health teams (CMHTs) or outpatient settings (n=39), followed by psychology or psychotherapy services (n=17). Inpatient or residential services were included in 15 studies, while 12 included general hospitals. Eight studies included private hospitals or clinics, while 4 explored telemental health use in helplines, voluntary sector services, crisis teams, or veterans’ health services, respectively. Five studies did not report any specific setting.
The aims of most studies were either a description of changes made due to the pandemic, new services set up because of the pandemic, or an evaluation of the impact of the pandemic on either staff or service users. The descriptions of changes either focused specifically on the move to telemental health or were wider descriptions of changes to services including the use of telemental health. The characteristics of each of the included studies are shown in
Study characteristics.
| Study | Aim of study | Modality used | Mental health problem/diagnosis | Participants |
| Aafjes-van Doorn et al [ |
Survey of therapists’ experiences of video therapy during the pandemic | Va | Not stated | Staff (n=144) |
| Anton et al [ |
Description of transition to telemedicine | V, Pb, TMc, Ed, Me | Depression, posttraumatic stress disorder | Staff |
| Barney et al [ |
Description of transition to telemedicine | V | Mixed | Staff |
| Békés et al [ |
Survey of psychotherapists’ attitudes toward online psychotherapy | V | Mixed | Staff (n=145) |
| Békés et al [ |
Survey of psychoanalytical therapists’ experiences of videoconference therapy during the pandemic | V, P | Mixed | Staff (n=190) |
| Benaque et al [ |
Description of service changes due to the pandemic | V, P, TM | Dementia | Staff |
| Berdullas Saunders et al [ |
Description of the use of a psychological helpline | P | Mixed | General population (15,170 calls) |
| Bhome et al [ |
Survey of staff perspectives on delivery of services to older adults during the pandemic | NAf | Dementia | Staff (n=158) |
| Bierbooms et al [ |
Interviews with health professionals on the sustainability of online treatment after the pandemic | V, TM, Og | Mixed | Staff (n=11) |
| Boldrini et al [ |
Survey of psychotherapists’ experience with telepsychotherapy during the pandemic | V, P, M | Mixed | Staff (n=308) |
| Burton et al [ |
Interviews with people with mental health conditions on their experience during the pandemic | NA | Mixed | Service users (n=22) |
| Carpiniello et al [ |
Survey to explore the impact of the pandemic on the functioning of mental health services | NA | Mixed | Staff (n=71) |
| Cheli et al [ |
Evaluation of a crisis intervention for patients diagnosed with psychosis | V | Psychosis and bipolar | Service users (n=6) |
| Chen et al [ |
Description of changes made to mental health services due to the pandemic | V, P | Mixed | NA (description of service change) |
| Childs et al [ |
Description of changes made in an outpatient psychiatric service due to the pandemic | V, P | Mixed | Service users |
| Colle et al [ |
Evaluation of teleconsultation during the pandemic | V, P | Mixed | Service users |
| Connolly et al [ |
Description of changes to services during the pandemic | V, P | Mixed | NA (description of service change) |
| Datta et al [ |
Description of transition to telehealth during the pandemic | V | Eating disorders | NA (description of service change) |
| Dores et al [ |
Exploration of mental health professionals’ attitudes regarding information and communications technology use | V, P, O, E | Mixed | Staff (n=108) |
| Erekson et al [ |
Exploration of use of telehealth in a student counseling service during the pandemic | V | Mixed | Staff |
| Feijt et al [ |
Exploration of staff experiences of online treatment during the pandemic | V, P, O, E | Mixed | Staff (n=51) |
| Fernandez et al [ |
Survey on the impact of the pandemic for people diagnosed with an eating disorder | NA | Eating disorders | Service users (n=121) |
| Foye et al [ |
Exploration of the impact of the pandemic on mental health nurses | V, P | Mixed | Staff |
| Gaddy et al [ |
Exploration of the impact of the pandemic on music therapy professionals | V, P | NA | Staff (n=1196) |
| Gillard et al [ |
Exploration of the experiences of people with mental health problems during the COVID-19 pandemic | V, P, TM | Mixed | Service users |
| Gomet et al [ |
Description and review of the implementation of remote working in an addiction outpatient service | P | Substance abuse | Service users |
| Graell et al [ |
Exploration of the impact of the pandemic on a child and adolescent eating disorders service | V, P, M | Child and adolescent eating disorders | Service users (n=365) |
| Grover et al [ |
Evaluation of the monitoring of patients with schizophrenia on clozapine during the pandemic | P, TM | Psychosis and bipolar | Service users |
| Grover et al [ |
Evaluation of the impact of the pandemic on mental health services in India | V, P | Mixed | Staff (n=396) |
| Grover et al [ |
Evaluation the impact of the pandemic on mental health services in India | V, P | Mixed | Staff (n=109) |
| Haxhihamza et al [ |
Evaluation of the satisfaction of patients with telepsychiatry due to the pandemic | M | Mixed | Service users (n=28) |
| He et al [ |
Evaluation of a psychological intervention program | V, P, M, O | General population | NA |
| Hom et al [ |
Description of the development of a virtual program for an acute psychiatric population | V | Mixed | Staff and service users |
| Humer et al [ |
Survey of psychotherapists’ views on working during the pandemic | V, P, E, M | NA | Staff (n=338) |
| Humer et al [ |
Survey of psychotherapists view on the use of the internet during the pandemic | V | NA | Staff (n=1547) |
| Izakova et al [ |
Survey of the impact of the pandemic on mental health experts | V, P | NA | Staff (n=157) |
| Johnson et al [ |
Survey of the experiences of mental health staff during the pandemic | V, P, M | Mixed | Staff (n=2180) |
| Jurcik et al [ |
Exploration of how the pandemic affected mental health services | V, P, M | Mixed | Staff (n=8) |
| Khanna et al [ |
Description of services changes in a trauma service during the pandemic | V, P, M | Posttraumatic stress disorder | Staff (n=21) |
| Kopec et al [ |
Description of the transition to telehealth in a community mental health service | V, P | Mixed | NA (description of service change) |
| Lai et al [ |
Evaluation of the benefits of telehealth to people with dementia and their carers | V, P | Dementia | Service users (n=60) |
| Lakeman and Crighton [ |
Exploration of providing dialectical behavior therapy using telehealth technology | V, P, M | Personality disorder | Staff (n=28) |
| Lin et al [ |
Evaluation of psychological hotline services set up during the pandemic | P, TM | General population | NA (evaluation of a new service) |
| Looi et al [ |
Evaluation of the use of psychiatry telehealth in smaller states | V, P, M | Mixed | Staff |
| Looi et al [ |
Evaluation of the use of psychiatry telehealth in larger states | V, P, M | Mixed | Staff |
| Lynch et al [ |
Description of change to telehealth in a service for people with psychosis | V | Psychosis and bipolar | Service users (n=64) |
| McBeath et al [ |
Exploration of the experiences of psychotherapists working remotely during the pandemic | V, P, TM, E | Mixed | Staff (n=335) |
| Medalia et al [ |
Description of the change to telehealth in a service for people with serious mental illness | V | Mixed | NA (description of service change) |
| Miu et al [ |
Evaluation of the engagement with telehealth of people with severe mental illness during the pandemic | V, P | Mixed | Staff (n=24) |
| Olwill et al [ |
Survey of psychiatrists’ experience of remote consultations | P | Mixed | Staff (n=26) |
| Patel et al [ |
Analysis of health record data on the impact of remote consultation during the pandemic | NA | Mixed | NA (description of whole service) |
| Peralta et al [ |
Evaluation of the effectiveness of teleconsultation use during the pandemic | V, P, TM | General population | NA (6800 interventions) |
| Pierce et al [ |
Survey of the impact of telepsychology use by psychologists before and during the pandemic | V, P | Mixed | Staff (n=2619) |
| Probst et al [ |
Investigation of changes to psychotherapy compared with the months before the pandemic | P | Mixed | Staff (n=1547) |
| Reilly et al [ |
Survey to understand change in practice by health care staff during the pandemic | NA | Mixed | Staff (n=903) |
| Roach et al [ |
Interviews to understand the experience of people with dementia during the pandemic | NA | Dementia | Service users (n=21) |
| Roncero et al [ |
Description of the response of a mental health network to the pandemic | V, P, M | Mixed | NA (description of service change) |
| Rosen et al [ |
Description of transition to telemental health services | V, P | Mixed | NA (description of service change) |
| Sasangohar et al [ |
Description of implementation of telepsychiatry in a psychiatric practice | V, P, E | Mixed | NA (description of service change) |
| Scharff et al [ |
Description of changes made by a psychological service during the pandemic | V | Mixed | NA |
| Schlegl et al [ |
Survey to investigate the impact of the pandemic on patients with bulimia nervosa | NA | Eating disorders | Service users (n=55) |
| Sciarrino et al [ |
Description of providing trauma-focused treatment using telehealth during the pandemic | V, O | Posttraumatic stress disorder | NA |
| Sequeira et al [ |
Description of change to services for people with obsessive compulsive disorder during the pandemic | V | OCD | Service users (n=5) |
| Severe et al [ |
Survey of patients using a mental health service to explore decisions to accept or decline telepsychiatry | V, P | Mixed | Service users (n=244) |
| Sharma et al [ |
Description of the implementation of a home-based telemental health service during the pandemic | V, P | Child and adolescent services | Staff (n=105) |
| Sheehan et al [ |
Survey of the experiences of staff working with people with intellectual and other developmental disabilities | NA | Intellectual disabilities | Staff (n=648) |
| Sklar et al [ |
Exploring the impact of the pandemic on mental health services in Indiana | NA | NA | Staff |
| Termorshuizen et al [ |
Survey to evaluate the impact of the pandemic on people with eating disorders | NA | Eating disorders | Service users (n=1021) |
| Uscher-Pines et al [ |
Interviews with psychiatrists to understand how change in delivery has affected mental health care | V, P | Mixed | Staff (n=20) |
| Uscher-Pines et al [ |
Interviews with clinicians to understand the experience of using telemedicine for opiate use disorder | V, P | Opiate use disorder | Staff (n=18) |
| van Dijk et al [ |
Description of transforming a day-treatment program for older people into an online program | V | Mixed | Staff |
| Wang et al [ |
Survey to compare Chinese and US practitioners’ attitudes toward teletherapy during the pandemic | V, P | Mixed | Staff (n=329) |
| Wilson et al [ |
Survey to explore staff perceptions of the impact of the pandemic on perinatal services | V, P, M | Perinatal services | Staff (n=363) |
| Wood et al [ |
Description of the implementation of group teletherapy for people with first-episode psychosis | V | Psychosis and bipolar | Service users (n=7) |
| Wyler et al [ |
Exploration of the experience of therapy sessions for people with attention deficit hyperactivity disorder and their therapists during the pandemic | V, P | Attention deficit hyperactivity disorder | Staff and service users (n=60 therapist/service user dyads) |
| Yellowlees et al [ |
Description of the rapid conversion of an outpatient psychiatric clinic to a telepsychiatry clinic | V, P | Mixed | NA (description of service change) |
| Zulfic et al [ |
Audit to understand the move to telephone support for people using a community mental health team | P | Mixed | Service users (n=314) |
aV: video.
bP: phone.
cTM: text message.
dE: email.
eM: mobile.
fNA: not applicable/not stated.
gO: other.
Implementation barriers and facilitators were categorized using a condensed version of the CFIR framework (see
Implementation barriers and drivers for telemental health grouped according to condensed CFIRa domains.
| CFIR domain | Findings | Example references |
|
Remote care had advantages over face-to-face, for example, making therapy more accessible for certain groups such as service users in remote locations; saving users money on travel; helping therapists get a better idea about the service users’ home environment; some users benefitted from the distance, found it easier to communicate openly, and became more independent. The main barriers for clinicians to deliver quality therapy were picking up on nonverbal cues, assessing mental health symptoms, keeping service users engaged. Video and phone calls were the most common modalities; however, studies also reported the use of emails, instant messaging services, apps, videos, and forums. Duration of telemental health appointments were shorter than face-to-face; clinicians reported it required more concentration and was more tiring. In some cases, studies have reported using shorter but more frequent appointments to deal with challenges in remote working (eg, some service users struggling to stay focused). This was also used as a method to increase flexibility. Frequent contacts between sessions helped to build the therapeutic relationship. |
[ |
|
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Implementation was commonly due to “stay at home” orders or national lockdowns, or a high level of COVID-19 cases in that area resulting in social distancing requirements. In the United States, health insurers did not always cover telemental health care, whereas in some European countries, insurance cover for telemental health terminated at the end of the first wave of infections. Telehealth service delivery was eased by the relaxation of policy and billing reimbursements during this time. Professional bodies facilitated transition to telehealth by posting guidelines on their websites to assist clinicians. Platform developers worked rapidly to increase capacity. Clinicians identified the need for a video tool that adheres to privacy standards and links with a technical helpdesk. There were also concerns over the reduction in services to support the physical health needs of mental health service users. |
[ |
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Overall, all settings had sufficient capacity to shift to some delivery of telemental health in a short period. |
[ |
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There was some variation in acceptability of remote ways of working for staff depending on their therapeutic approaches. Telemental health take-up was dependent on perceived experience of patient (positive or negative), comfort with online platform, previous clinical experience. Some staff felt less confident about professional skills during online compared with in-person consultations, especially those with less clinical experience and those who perceived their patients disliked remote care. |
[ |
|
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The transition to telemental health occurred usually over a short period. Training staff to use platforms was mentioned frequently, as was phoning service users to let them know about the transition to telemental health and how care would be provided going forward. Methods of staff training included courses, shadowing or observing senior colleagues, discussion within clinical teams, facility-level telehealth coordinators, clinical champions providing training, and webinars. Sources of information for staff: colleagues, government guidelines, prepared consent forms, posts on listservs, American Psychological Association, and other official guidelines. New workflows had to be developed to allow staff to access patient records remotely. Despite some training, staff reported lack of support and identified training needs across several studies regarding how to use online platforms and meeting privacy regulations. |
[ |
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A commonly reported issue was access to technology, particularly among service users with diagnoses such as schizophrenia, service users with a lower socioeconomic status, and older adults (one study mentioned that older adults often lacked access to video software, so preferred phone calls). Concerns around privacy and confidentiality, and forming a therapeutic relationship may be more difficult when using remote care. Difficulties for service users to concentrate within a digital environment. Several studies mention the need for an agreed “Zoom etiquette” for service users, including attire, audio/visual setup, and reducing background distractions. Stable internet connection was a problem for some service users. Some clients benefitted from the distance created by online treatment, as they became less inhibited and less dependent on therapist. |
[ |
aCFIR: Consolidated Framework for Implementation Research.
Video and phone calls were the most common modalities used for remote care; studies also reported the use of emails, instant messaging services, apps, prerecorded videos and forums (further details about the modality used in each study can be found in
When comparing remote care with traditional face-to-face settings, studies identified advantages for both methods. Benefits for remote care included being more convenient (for both staff and service users), making care more accessible to groups who may previously have been excluded, reducing travel (resulting in both time and cost savings), and helping clinicians understand more about the service user, as they had more insight into their home lives. A further benefit is that more family members were readily able to attend family therapy or family education sessions since care was moved online (eg, [
Services commonly implemented remote methods of working due to “stay at home” orders or national lockdowns, or due to a high level of cases in their local area. Overall, all settings described in papers had sufficient capacity to make a rapid shift to remote forms of care. Several studies in the United States in particular mentioned the impact of health insurance regarding uptake of telemental health (eg, [
Enablers for clinician uptake included supporting clinicians by ensuring supervision, supportive leadership, clear communication, keeping track of clinicians’ needs, optimizing physical space for comfort and privacy (eg, using headphones or ergonomic seating), and arranging times away from the computer.
However, staff in several studies reported a lack of initial training for telemental health, and therefore identified training needs regarding the use of online platforms and meeting privacy regulations in particular. In some studies, having no previous experience with telemental health was also found to be associated with higher anxiety [
As telemental health was not commonly used in most services before COVID-19, staff had to rapidly adjust to a new way of working. Several studies discussed the training which was put in place for staff, which included training courses, shadowing, or observing senior colleagues; discussion within clinical teams’ facility-level telehealth coordinators and clinical champions providing training; webinars; and checking official guidelines. New workflows also had to be developed to allow staff to access patient records remotely, and service users had to be informed about the transition to telemental health.
In addition to the needs of staff, service users also identified certain needs and resources to enable them to effectively transition to telemental health care. A commonly reported issue was access to technology, particularly among service users with diagnoses such as schizophrenia (eg, [
Outcomes of the implementation of telemental health have been summarized below using Proctor et al’s [
Implementation outcomes summary findings for telemental health.
| Implementation outcome | Findings | Example studies |
| Acceptability |
Remote methods of care are acceptable to most service users and ”exceeded expectations” in terms of satisfaction, but are not viewed as a substitute for face-to-face care. Clinicians and service users consider the intimacy and connection of face-to-face care are not reproducible on virtual platforms, especially for treatments involving nonverbal communication. Beyond the pandemic: further data are needed about longer-term acceptability, observance, quality of care, and satisfaction. Clinician burnout due to more appointments per day and requiring more concentration. |
[ |
| Adoption |
Remote working was generally well adopted (most service users switched to remote working). A few studies also mentioned lower levels of cancellations/no shows, likely due to not having to travel to the service and the removal of other barriers (eg, difficulty fitting care around school or work). Remote working also had the potential to result in reduced waiting times. Productivity was generally maintained, or in some cases even increased. Some studies showed no decrease, just change in modality and need to modify psychological treatment. |
[ |
| Appropriateness |
Difficulties managing medication prescription during online consultations. Concerns around user engagement and assessing new patients. Harder to assess mental status markers such as hygiene or eye contact, or physical symptoms (eg, of opioid withdrawal). Although it allows to know more about home environment and behavior outside of clinic. Does not capture the richness of in-person interaction. Online felt safer for clinicians providing care to service users at risk for violence and behavioral dysregulation. Not appropriate for patients with auditory or visual impairments, or with conditions such as migraines. |
[ |
| Feasibility |
Links with service user and staff needs and resources, in particular problems accessing technology/private space/stable internet connection. All studies reported good feasibility at least for the short-term emergency response during the pandemic. However, it was not possible to use for specific therapies that require physical presence (role play, collaborative models). Telemental health was less suitable for treating trauma, for clients with severe anxiety, children, and clients with cognitive impairment. Insurance coverage and legal aspects affected feasibility of implementation in some countries. However, most health insurances caught up and started covering costs. |
[ |
| Fidelity |
No studies explored this area. |
|
| Implementation cost |
Limited information about cost of intervention, suggested to be “cost effective” without any presentation of costs. Reduced travel costs. |
[ |
| Penetration |
Prior to the pandemic, few services used telemental health and for those that did, uptake was low. After the first few weeks, most or all of services were conducted remotely. |
[ |
| Sustainability |
Rates of telemental health use fell as COVID-19 rates declined in the summer of 2020. Links with findings that not all staff and service users would want to continue using remote methods of care after the pandemic ends. Flexibility is a key advantage of telemental health versus face-to-face care. There are some aspects of remote working that services would like to keep, as they provide benefits such as being more efficient and enabling access for certain groups. Some barriers to remote working (such as lack of experience with online methods of care) have been reduced, making it more likely telemental health will continue to some extent. |
[ |
Remote care was seen as satisfactory by the majority of clinicians and service users in most studies in the context of the pandemic. A number of studies also reported that telemental health enabled some groups to access care who found it difficult to engage with face-to-face support (eg, [
Telemental health services were acceptable to people during the pandemic as a way of continuing their treatment; however, findings from several studies also indicated that participants wanted at least some appointments to be face-to-face once restrictions on in-person contact had loosened.
Levels of acceptability of telemental health during the COVID-19 pandemic.
| Author | Type of service | Service location | Acceptability data |
| Aafjes-van Doorn et al [ |
Psychology/psychotherapy/counseling service | United States, Canada, Europe (Hungary, Italy, United Kingdom, Germany, Norway, Sweden, Switzerland, Latvia, Ireland) |
Clinician views: Mainly positive attitudes toward video therapy were reported (mean 3.42 [SD 0.50]; range: 2.31-4.69). Views on video therapy had become more positive since the pandemic (t140=2.06, Service user and carer views (reported by clinicians): Only 7% (n=10) thought their patients experienced video therapy negatively. The majority perceived patient experience as either positive (N=88, 63.8%) or neutral (N=40, 28.4%). |
| Békés et al [ |
Psychology/psychotherapy/counseling service; private hospital/clinic; CMHTa and outpatient services | Canada, United States, Europe (countries not stated) |
Service user and carer views (reported by clinicians): Psychotherapists reported that their patients had an extremely positive (N=20, 13.8%), positive (N=71, 49%), or neutral (N=40, 27.6%) experience with online psychotherapy. About 7.6% of the psychotherapists thought that their patients experienced online psychotherapy somewhat negatively and none of the psychotherapists reported an extremely negative patient experience. |
| Békés et al [ |
CMHT and outpatient services; psychology/psychotherapy/counseling service; private hospital/clinic | Canada, United States, Europe (countries not stated) |
Clinician views: Challenges included technical/internet problems (64.7%), patients not having a private space (46.8%), risk of patient (44.7%) or therapist (26.3%) getting distracted, difficulty feeling connected to patients (29.5%) or reading their emotions (27.4%), difficulty keeping professional boundaries (23.2%), and confidentiality concerns (16.3%). About 64.2% (n=122) reported their relationships with service users felt as authentic to before COVID-19, 46% felt as emotionally connected, and 64% reported no change to the therapeutic relationship. Service user and carer views (reported by clinicians): Most therapists reported a positive (n=101, 53.2%) or neutral (n=55, 28.9%) patient experience, with only 34 reporting a somewhat negative online therapy experience for their patients (25.8%). |
| Benaque et al [ |
Voluntary sector/nonprofit | Spain |
Clinician views: 81% of clinical staff considered the quality of telemedicine consultations to be either good or excellent; 75% viewed telemedicine visits as equal or better than face-to-face consultations. |
| Colle et al [ |
CMHT and outpatient services | France |
Clinician views: 94.1% of psychiatrists were satisfied with teleconsultations in this context. Service user and carer views: 89.5% of patients were satisfied and 73.3% of patients spontaneously expressed their gratefulness for remote care. |
| Dores et al [ |
Psychology/psychotherapy/counseling service | Portugal |
Clinician views: 21 (out of 71) psychologists (29.6%) considered their experiences to be neither negative nor positive. Most of the respondents considered their experience with digital technologies to be either positive (n=37, 52.1%) or very positive (n=13; 18.3%). None reported their experiences as negative. |
| Grover et al [ |
CMHT and outpatient services | India |
Service user and carer views: 75.5% of patients and family members were satisfied they could remain in touch with the treating doctor. A quarter of patients had difficulty in procuring clozapine, with clozapine not being available in their locality in 15% of cases and 3.4% having to switch their brand. 25% were able to get the absolute neutrophil count done in the previous month. |
| Grover et al [ |
CMHT and outpatient services; inpatient mental health service; private hospital/clinic | India |
Service user and carer views (as reported by clinicians): 21% reported that non-HCWsb in quarantine were dissatisfied, 19.9% reported that HCWs in quarantine were dissatisfied, and 13.5% reported that HCWs working with patients with COVID-19 were dissatisfied. Clinician views: Participants rated their satisfaction with the services they were currently providing to their patients with a mean of 45.8% (SD 28.6) on a Likert scale from 0 to 100. |
| Grover et al [ |
Medical colleges, government-funded institutes, general hospital psychiatry units | India |
Clinician views: Overall satisfaction with the mental health services being catered; the participants rated their mean level of satisfaction as 46.6% (SD 27.6). |
| Haxhihamza et al [ |
Day hospital | Macedonia |
Service user and carer views: 20/28 strongly agreed/agreed that the medical care received was just about perfect; 4 patients agreed that they were dissatisfied with some things about their medical care (1 strongly agreed and 3 agreed); 20 (strongly) agreed that they can get medical care whenever they need it; 20 (strongly) agreed that they have easy access to medical specialists; 4 (strongly) agreed that the wait for emergency treatment was too long. |
| He et al [ |
Helplines; online media programs | China |
Service user and carer views: Feedback from clients demonstrated that more than 50% felt their negative emotions, such as anxiety and depression, were relieved. |
| Hom et al [ |
Private hospital/clinic | United States |
Service user and carer views: Patients who have been discharged thus far (n=10) have also expressed confidence in their aftercare plans; 2 patients who completed the exit survey reported very positive experiences and both rated their care as 9/10. |
| Izakova et al [ |
CMHT and outpatient services; inpatient mental health service | Slovakia |
Clinician views: 69.4% of them have considered it as an adequate form for diagnostics and therapy in the common clinical practice; 51.6% want to use it at a limited level with the defined guidelines in future. |
| Johnson et al [ |
All service settings, including inpatient, CMHTs, voluntary sector | United Kingdom |
Clinician views: A majority (n=818, 74.0% of respondents) agreed/strongly agreed that video calls were suitable to assess progress of existing service users, but only 39.8% (n=442) agreed/strongly agreed that they were suitable for making the initial assessments. A majority (n=725, 65.8%) agreed/strongly agreed that use of remote care had resulted in not having contact with some service users who had not engaged with remote appointments. |
| Lakeman and Crighton [ |
Psychology/psychotherapy/counseling service | Australia |
Clinician views: 32% (n=7) stated they were not confident at all in delivering online DBTc, 50% (n=11) reported being “a little” confident and 4 reported feeling confident doing so; 14 respondents identified limited access to the internet, appropriate devices, or internet blackspots as being significant obstacles to engagement. |
| Lynch et al [ |
CMHT and outpatient services | United States |
Service user and carer views: The telehealth acceptance rates of the CPd subsample indicated that 90% (n=18) enrolled at the time of conversion agreed to telehealth sessions within 10 days of the service transition. |
| Olwill et al [ |
CMHT and outpatient services | Ireland |
Clinician views: 92% of respondents (n=24) (and 100% consultants [n=12]) reported lower confidence in making a diagnosis. 96% (n=25) agreed that the lack of visual cues affected their assessment of the patient; 70% agreed that they found it more difficult to consider discharging a patient; 88% agreed they found it more difficult to establish a therapeutic alliance with new patients. |
| Sheehan et al [ |
CMHT and outpatient services | United Kingdom |
Clinician views: 53.3% reported concerns of having to adapt too quickly to new ways of working; 37.9% reported having to learn new technologies too quickly or without sufficient training or support; 45.3% raised concerns around engaging patients with learning difficulties or autism; 23.7% had concerns around safeguarding or risk management; 27.9% reported greater workload than usual. |
| Wang et al [ |
Not stated/unclear | United States and China |
Clinician views: Before COVID-19, 25% of US psychoanalytic practitioners felt mainly negative about teletherapy and 36% felt mainly positive, as compared with only about 9% and 47% of CAPAe practitioners, respectively; during the pandemic about 23% of US psychoanalytic practitioners felt mainly negative about teletherapy and about 37% felt mainly positive, compared with about 2% and about 58% of CAPA practitioners, respectively. |
| Wilson et al [ |
CMHT and outpatient services; crisis and emergency mental health services; inpatient mental health service | United Kingdom |
Clinician views: Staff reported feeling less able to assess women attending the perinatal mental health service using telemedicine, particularly their relationship with their baby (43.3%, 90/208), and to mobilize safeguarding procedures (29.4%, 62/211). |
aCMHT: community mental health team.
bHCW: health care worker.
cDBT: dialectical behavior therapy
dCP: complex psychosis
eCAPA: China American Psychoanalytic Alliance.
Adoption rates were relatively high across studies, with most services or clinicians moving their appointments to remote methods. Rates of adoption of telemental health for service users who were already receiving care at the start of the pandemic ranged from 48% [
While most studies reported high adoption rates, a few studies reported a decrease in attendance: for example, Erekson et al [
There was also evidence to indicate that adoption rates of telemental health fell as COVID-19 cases decreased (eg, [
Levels of adoption and coverage of telemental health during the COVID-19 pandemic.
| Author | Type of service | Service location | Adoption/coverage data |
| Anton et al [ |
General hospital/physical health service | United States | 77% (n=20) of those approached via telephone enrolled in the program, higher than the observed in-person rates of 61%. 80% of patients who were contacted by phone in the hospital agreed to be enrolled, lower than the 98% success rate when staff approaches patients in person at the bedside. |
| Barney et al [ |
CMHTa and outpatient services | United States | The percentage of provider telemedicine visits increased from 0% to 97%. The number of overall clinic visits did not decline when compared with that a year before (337 visits in March 2019 vs. 332 visits in March 2020), |
| Békés et al [ |
CMHT and outpatient services; psychology/psychotherapy/counseling service; private hospital/clinic | Canada, United States, Europe (countries not stated) | Before COVID-19 an average of 23 sessions (SD 10.58) per week were conducted in person, 3 sessions (SD 2.28) by phone, and 1 session (SD 2.84) online via videoconferencing. |
| Benaque et al [ |
Voluntary sector/nonprofit organization | Spain | Initially, average weekly visits dropped from 657 to 254 in the first week after the state of alarm was declared. This drop was of 44% for follow-up visits and 40% for on-demand consultations. |
| Boldrini et al [ |
CMHT and outpatient services; psychology/psychotherapy/counseling service; private hospital/clinic | Italy | 42.1% (SD 28.9) of their psychotherapy treatments were interrupted during the lockdown. |
| Carpiniello et al [ |
CMHT and outpatient services; inpatient mental health service | Italy | 75% of appointments were switched to remote. Telehealth modalities used were mainly phone calls (100% of the Italian Departments of Mental Health), videocalls (67%), or emails (19%), with 41% of units adopting all these means of contact. |
| Chen et al [ |
General hospital/physical health service | United States | The outpatient psychiatry division switched from under 5% virtual visits in March 2019 to over 97% in March 2020. Productivity was maintained at about 95% of previous levels, with 9206 virtual visits in March 2020. |
| Childs et al [ |
CMHT and outpatient services | United States | Before COVID-19, 100% of care was delivered in person. In the first week after shutdown, telehealth comprised 65.45% of visits (100% over the telephone). In the second week, 91.6% of visits were conducted using telehealth (83.49% over the telephone and 15.6% video). By the third week 99% of appointments used telehealth (30% using video). The percentage of appointments using video increased weekly, peaking at 69.9% |
| Colle et al [ |
CMHT and outpatient services | France | After 2 weeks of teleconsultations, 376 (91.0%) out of the 413 previously planned appointments were performed. |
| Connolly et al [ |
CMHT and outpatient services; Veterans Affairs service | United States | Daily TMH-Vb encounters rose from 1739 on March 11 to 11,406 on April 22 (556% growth, 222,349 total encounters). Between March 11 and April 22, 114,714 patients were seen via TMH-V. A total of 88,908 (77.5%) were first-time TMH-V users. |
| Dores et al [ |
Psychology/psychotherapy/counseling service | Portugal | During the lockdown period, 17 (15.7%) of the 108 psychologists discontinued therapy and counseling; 53 (58.2%) continued to provide services to most or all of their clients; 23 psychologists (25.3%) decreased the number of clients they saw to a range of between 0% and 25%, and for another 15 psychologists (16.5%) that number diminished to a range of between 26% and 50%. |
| Erekson et al [ |
Psychology/psychotherapy/counseling service | United States | Attendance rates for individual therapy temporarily dropped by about 35% but climbed to previous levels within 2 weeks. Group therapy attendance dropped by about 30% but did not fully recover, remaining about 15% lower after 2 weeks. The number of clients receiving individual therapy in 2020 dropped by 43%. Between March 22 and April 4, 2020, the service had fewer than half the intakes of any other recent year. |
| Gaddy et al [ |
Music therapy service | United States | Of the 869 respondents indicating current contact hours, 70.54% reported that they were providing alternative services, including telehealth services (54.81%), virtual music lessons (17.01%), prerecorded songs/playlists (16.98%), and prerecorded video sessions (16.00%). |
| Gomet et al [ |
General hospital: addiction service | France | 100% of service users took part in remote care |
| Graell et al [ |
CMHT and outpatient services; inpatient mental health service | Spain | During the study period, a total of 1818 outpatient consultations were carried out: 1329 (73.10%) by telephone or videoconferencing and 489 (26.9%) face-to-face. |
| Grover et al [ |
CMHT and outpatient services | India | The majority of the patients reported that they were in touch with their treating doctor (81.5%), with contact initiated by the treating team in 79% of patients. |
| Grover et al [ |
CMHT and outpatient services; inpatient mental health service; private hospital/clinic | India | Use of teleservices almost doubled during the lockdown period: 206 (52%) participants provided telecommunication services during the lockdown period, 186 (47%) provided free tele-consultation to the general public, and 269 (67.9%) provided free tele-consultation to their patients; 132 (33.3%) were using both voice and video calls (combination of free and paid services), 31 (7.8%) were using only voice calls (combination of free and paid services), and 31 (7.8%) were using only voice calls (combination of free and paid services). |
| Grover et al [ |
Medical colleges, government-funded institutes mental hospital setting, general hospital psychiatry units | India | Around 25% of institutes began offering telemental health services; 45.9% of institutes reported that telecommunication services continued during lockdown. |
| Humer et al [ |
Psychology/psychotherapy/counseling service | Czech Republic, Germany, Slovakia | Among all countries, the combined (personal contact + telephone + internet) number of patients treated on average per week during COVID-19 (mean 18.32 [SD 12.86]) did not differ from the combined (personal contact + telephone + internet) number of patients treated on average per week in the months before the COVID-19 situation (mean 19.35 [SD 13.73]), t337=−1.506; |
| Humer et al [ |
Psychology/psychotherapy/counseling service | Austria | During the COVID-19 pandemic, face-to-face psychotherapy remained the most abundant treatment modality. |
| Khanna et al [ |
CMHT and outpatient services | Australia | There was a 3% increase in appointment bookings compared with the same period in 2019. Cancellation/nonattendance rate dropped from an average of 19% last year to 12% for 2020 |
| Kopec et al [ |
CMHT and outpatient services | United States | Prior to COVID-19, Network180 served an average of 2390 patients/month, which decreased to an average of 1921 patients/month during the pandemic. This decrease was noted most significantly in crisis services (averaging 822 patients/month before COVID-19 and 640 patients/month during COVID-19). |
| Looi et al [ |
Psychiatrist telehealth service | Australia | Percentage of consultations conducted using telemental health—ACT: 62% (April), 58% (May); NT: 53% (April), 51% (May); SA: 69% (April), 58% (May); Tasmania: 38% (April), 40% (May) |
| Looi et al [ |
Psychiatrist telehealth service | Australia | The majority of private practice was conducted by telehealth in April but was lower in May as new COVID-19 case rates fell. Percentage of consultations conducted using telemental health—NSW: 56% (April), 52% (May); QLD: 63% (April), 53% (May); VIC: 61% (April), 59% (May); WA: 51% (April), 36% (May) |
| Lynch et al [ |
CMHT and outpatient services | United States | The service continued providing all services except community-based coaching via telehealth. 90% of patients with complex psychosis accepted telehealth sessions and maintained their specific treatment plans. 2 opted out of telemental health. |
| Medalia et al [ |
CMHT and outpatient services | United States | Tracking the number of RS enrollees with active participation indicated that in the week before telehealth conversion, when shelter-in-place recommendations commenced, participation dropped from 94% to 52%; after telehealth conversion, participation rose from 67% in the first 4 days to 79% after 1 week and to 84% after 2 weeks. |
| Miu et al [ |
CMHT and outpatient services | United States | A total of 816 participants comprised the analytic sample. A total of 400 converted to telehealth and of those 64 were SMIc. The conversion rates from in-person psychotherapy to teletherapy were similar for SMI (n=64, 51.6%) and non-SMI (n=334, 48.3%) groups. |
| Patel et al [ |
All National Health Service Trust services | United Kingdom | From March 2020, in‐person contacts reduced substantially from around 9000 per week to 3000 per week in early April 2020. Over the same period there was an increase in remote contacts from around 2500 per week in early March 2020 to around 8000 per week by the end of April 2020. |
| Pierce et al [ |
Variety of MH service settings | United States | Psychologists estimated that telepsychology comprised 85.53% of their clinical work during the pandemic, compared with the prepandemic context when only 7.07% of their clinical work was conducted remotely. |
| Probst et al [ |
Psychology/psychotherapy/counseling service | Austria | Face-to-face psychotherapies in personal contact were reduced and remote psychotherapies (via telephone or internet) were increased in the early weeks of the COVID-19 lockdown as compared with the months before. Although average increases in psychotherapies via telephone (979%) or via internet (1561%) were dramatic, there was an undersupply of psychotherapy in Austria in the early weeks of the COVID-19 lockdown as the total number of patients treated on average per week was lower in COVID-19 lockdown than in the months before. |
| Reilly et al [ |
Various service types | United States | There was uptake of telemental health by approximately 80% of respondents by late March or early April 2020. |
| Rosen et al [ |
VHAd mental health services | United States | VHA provided nearly 1.2 million telephone and video encounters to veterans in April 2020 and reduced in-person visits by approximately 80% when compared with the October 2019 to February 2020 period before the pandemic. |
| Scharff et al [ |
Community-based training clinic providing therapy | United States | The Psychological Services Centre saw an initial retention rate of 82% in the first week of teletherapy, with more clients resuming services in the weeks that followed. |
| Schlegl et al [ |
Inpatient mental health service | Germany | More than 80% of patients with bulimia nervosa received face-to-face therapy before the COVID-19 pandemic (81.8%) compared with 36.4% during the pandemic (ie, a decrease by 55.5%). Use of videoconference-based therapy increased from 3.6% to 21.8% and use of telephone contacts from 18.2% to 38.2%, whereas the use of additional online interventions decreased from 3.6% to 0%. |
| Sciarrino et al [ |
Veterans Healthcare Administration | United States | Approximately 76% of veterans engaged in posttraumatic stress disorder treatment chose to continue despite the COVID-19 pandemic via telehealth. |
| Sequeira et al [ |
Residential services | United States | After transition to teletherapy, the average daily virtual program census from March 19, 2020, to April 18, 2020, was 3.3 intensive outpatient program patients and 22.4 outpatients. These numbers indicate a slight decrease in intensive outpatient program patients (−0.3/per day) and an increase in outpatients seen per day (+2.7/per day). |
| Severe et al [ |
CMHT and outpatient services | United States | Take up for remote care was over 95%; 82.8% (n=202) initially chose to receive psychiatric care through video visits, whereas 13.5% (n=33) chose telephone visits; 1.2% (n=3) decided to postpone care until in-person visit availability. |
| Sharma et al [ |
General hospital/physical health service | United States | By March 20, 2020, 67% of all outpatient appointments were conducted at home. Most of these appointments were conducted by phone with some TMH sessions. By March 27, 2020, 90% of all outpatient appointments were done at home, predominantly by phone (59%) but increasingly by HB-TMHe (31%). One week later (April 3, 2020), these rates were 48% versus 45%, respectively. |
| Sheehan et al [ |
CMHT and outpatient services | United Kingdom | 64% were spending at least some time working from their workplace (either solely or in combination with home working); 33.9% were working from home only. Just over a third were at the workplace (n=178, 35.1%) and the remainder (n=147, 28.9%) worked from both home and at the workplace. |
| Termorshuizen et al [ |
CMHT and outpatient services | The Netherlands and United States | Most transitioned to telehealth care (United States 45%; Netherlands 42%), with fewer still receiving face‐to‐face care (United States 3%; Netherlands 6%), or not having been able to engage with their provider at all (United States 6%; Netherlands 5%). |
| Uscher-Pines et al [ |
CMHT and outpatient services and private hospital/clinic | United States | Most of the psychiatrists had transitioned to fully virtual practices. Only a quarter of the participants were seeing any patients in person. |
| Uscher-Pines et al [ |
CMHT and outpatient services; private hospital/clinic; general hospital/physical health service | United States | Telemedicine use: None (in-person only), 1 (5.6%); phone only, 2 (16.7%); video only, 0 (0.0%); combination of video and phone, 15 (83.3%). |
| van Dijk et al [ |
CMHT and outpatient services; psychology/psychotherapy/counseling service | The Netherlands | Treatment adherence was 100%. |
| Yellowlees et al [ |
General hospital/physical health service | United States | By the second day after shutdown, only 8% (n=52) of our appointments were in-person clinic visits, compared with our baseline average of 98%. By the third business day, 100% (n=73) of appointments were conducted virtually, with 92% (n=67) via videoconference and 8% (n=6) by phone. |
| Zulfic et al [ |
CMHT and outpatient services | Australia | Some patients still required regular face-to-face reviews, including the 91 patients (29%) who are treated with depot medications and 71 (23%) taking clozapine. |
aCMHT: community mental health team.
bTMH-V: telemental health: video.
cSMI: serious mental illness.
dVHA: Veterans Health Administration.
eHB-TMH: home-based telemental health.
There were some concerns raised over the appropriateness of remote care, for example, studies reported difficulties managing medication (eg, [
Staff reported concerns around the management of risk and safeguarding of service users when using remote methods of care (eg, [
In general, all studies reported good feasibility, at least for the short-term emergency response during the pandemic. However, some studies reported that telemental health is not suitable for all types of therapy, for example, those that require a physical presence (exposure therapy, role play, collaborative models; eg, [
There was limited information about costs of implementation of remote care in the included studies and no actual costs of telemental health were reported in the papers. However, initial evidence suggests remote care is not a costly intervention, with 1 paper stating that telemental health is “cost-effective” [
There was widespread penetration (the extent to which telemental health was integrated into mental health services) of remote methods of care delivery due to the COVID-19 pandemic, despite few services utilizing telemental health previously. Services were able to rapidly adapt to this new way of working, with the majority of appointments conducted remotely after the first few weeks of “stay at home” orders.
The sustainability of telemental health cannot be completely determined from the included studies, as they present data mostly from the early stages of the COVID-19 pandemic. However, there was some indication that although remote working was widely accepted as a necessity, once restrictions loosened, rates of telemental health use declined (corresponding with the drop in cases in Europe in summer 2020). This correlates with findings that not all staff and service users would want to continue using remote methods of care after the pandemic ends. However, there are some aspects of remote working that both clinicians and service users would like to keep in the future in combination with face-to-face care (eg, [
Comparing the clinical outcomes of face-to-face and remote care using quantitative measures indicated that telemental health approaches could be as effective as face-to-face care (eg, [
Although the quality of therapeutic relationships reported by studies was generally good, clinicians reported problems reading patients’ emotions (eg, [
Studies which reported clinical outcomes of telemental health.
| Item | Type of service | Country | Clinical outcomes |
| Cheli et al [ |
Psychology/psychotherapy/counseling service | Italy |
5/6 patients reported a reliable change index (≥1.96) in the primary outcome (Symptoms Checklist 90 [SCL-90] total score), and 1 reported a stable symptomatology. All the patients reported a significant decreasing trend in the Depression, Anxiety and Stress Scale (DASS-21) total score (secondary outcome), as determined by Kendall τ ( |
| Dores et al [ |
Psychology/psychotherapy/counseling service | Portugal |
Comparing remote to in-person care (psychologists): 65 (71.6%) considered the results to be more of less the same, 4 (4.4%) reported obtaining better results with at-distance sessions, and 22 (24.2%) considered that at-distance sessions have yielded worse results than in-presence sessions. Comparing remote with in-person care (service users): Remote and in-person sessions were more or less the same (n=71; 78.0%). Six (6.6%) of the respondents reported receiving better feedback (ie, the clients preferred the online sessions), and 1 (1.1%) received much better feedback. Even so, 13 (14.3%) psychologists received worse feedback from their clients about this type of intervention. |
| Erekson et al [ |
Psychology/psychotherapy/counseling service | United States |
Comparing current students (who received telemental health) with those in previous years (who received face-to-face care) found that students in previous years were not significantly different in their achievement of reliable improvement compared with those in 2020 (χ23=10.43, However, students in previous years were significantly more likely to deteriorate than those in 2020 (χ23=8.48, |
| Gomet et al [ |
General hospital/physical health service (addictions service) | France |
13 out of the 16 patients did not relapse during the data collection period. |
| Lai et al [ |
Day center (dementia service) | Hong Kong |
The MoCAa scores in the intervention group (who received additional services using video conference, rather than telephone only) remained largely stable, whereas the MoCA scores for the control group fell after the 4-week study period ( Quality of life scores were higher for the intervention group by the end of the study period ( Scores on behavioral and psychological problems remained stable for both groups. Improvement in both physical and mental status of the caregivers was identified—( |
| Lynch et al [ |
CMHTb and outpatient services | United States |
During the 12-week study timeframe, the subsample of participants with complex psychosis remained psychiatrically stable; there were no psychiatric decompensations or referrals to a higher level of care. |
| Medalia et al [ |
CMHT and outpatient services | United States |
There were no psychiatric decompensations after conversion to telehealth. |
| Sequeira et al [ |
Residential services (obsessive compulsive disorder) | United States |
There were overall trends in reductions of scores of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), The Centre for Epidemiologic Studies Depression Scale (CES-D), The 7-item General Anxiety Disorder-7 (GAD-7), and Distress Intolerance Index (DII) across all patients, indicating that the telemental health program was effective in reducing symptoms of obsessive compulsive disorder, anxiety, and depression. |
| Wyler et al [ |
Mental health team and outpatient services | Switzerland |
For about 1 in 3 cases, therapists reported that they felt the sessions were at least fairly comparable to pre-COVID-19 sessions or that the restrictions were not particularly problematic. |
aMoCA: Montreal Cognitive Assessment.
bCMHT: community mental health team.
One study [
Improved communication was noted between staff when using telemental health when compared with traditional face-to-face care, as the use of online file sharing or discussion platforms facilitated communication between staff (eg, [