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Barriers to Use of Telepsychiatry: Clinicians as Gatekeepers
Open accessAbstract
Telepsychiatry is effective and has generated hope and promise for improved access and enhanced quality of care with reasonable cost containment. Clinicians and organizations are informed about clinical, technological, and administrative telepsychiatric barriers via guidelines, but there are many practical patient and clinician factors that have slowed implementation and undermined sustainability. Literature describing barriers to use of telepsychiatry was reviewed. PubMed search terms with date limits from January 1, 1959, to April 25, 2019, included telepsychiatry, telemedicine, telemental health, videoconferencing, video based, Internet, synchronous, real-time, two-way, limitations, restrictions, barriers, obstacles, challenges, issues, implementation, utilization, adoption, perspectives, perceptions, attitudes, beliefs, willingness, acceptability, feasibility, culture/cultural, outcomes, satisfaction, quality, effectiveness, and efficacy. Articles were selected for inclusion on the basis of relevance. Barriers are described from both patient and clinicians' perspectives. Patients and clinicians are largely satisfied with telepsychiatry, but concerns about establishing rapport, privacy, safety, and technology limitations have slowed acceptance of telepsychiatry. Clinicians are also concerned about reimbursement/financial, legal/regulatory, licensure/credentialing, and education/learning issues. These issues point to system and policy concerns, which, in combination with other administrative concerns, raise questions about system design/workflow, efficiency of clinical care, and changing organizational culture. Although telepsychiatry service is convenient for patients, the many barriers from clinicians' perspectives are concerning, because they serve as gatekeepers for implementation and sustainability of telepsychiatry services. This suggests that solutions to overcome barriers must start by addressing the concerns of clinicians and enhancing clinical workflow.
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“However, in addition to external barriers, mental health clinicians report many beliefs, attitudes, and feelings about telehealth that may be inconducive for the adoption of these technologies.”
From Overcoming Clinician Technophobia: What We Learned from Our Mass Exposure to Telehealth During the COVID-19 Pandemic (2022) · cites this paper as Cowan et al., 2019
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“Many barriers to telehealth implementation are rooted in policies and systems such as constraints in reimbursement and credentialing (Cowan et al., 2019) and added administrative and training burdens (Perry et al., 2020).”
From Overcoming Clinician Technophobia: What We Learned from Our Mass Exposure to Telehealth During the COVID-19 Pandemic (2022) · cites this paper as Cowan et al., 2019
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“Recent reviews of barriers to telehealth indicate a central theme of clinician reluctancy (Cowan et al., 2019; Langarizadeh et al., 2017).”
From Overcoming Clinician Technophobia: What We Learned from Our Mass Exposure to Telehealth During the COVID-19 Pandemic (2022) · cites this paper as Cowan et al., 2019
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“Poor sound quality may limit understanding and mutual contact [41-44].”
From Physicians’ Perspectives of Telemedicine During the COVID-19 Pandemic in China: Qualitative Survey Study (2021) · cites this paper as [41]
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“In telemedicine, the inability to examine the patient in person not only affects the physicians’ habits, but also sound and light present during telemedicine examinations can affect physicians’ diagnoses and treatment recommendations [41].”
From Physicians’ Perspectives of Telemedicine During the COVID-19 Pandemic in China: Qualitative Survey Study (2021) · cites this paper as [41]
In the citing paper
“In telemedicine, the inability to examine the patient in person not only affects the physicians’ habits, but also sound and light present during telemedicine examinations can affect physicians’ diagnoses and treatment recommendations [41].”
From Physicians’ Perspectives of Telemedicine During the COVID-19 Pandemic in China: Qualitative Survey Study (2021) · cites this paper as [41]
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Gabellone, A., Marzulli, L., Matera, E., Petruzzelli, M. G., Margari, A., Giannico, O. V., & Margari, L. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11123294 · Cited by 37
“The identification and correction of any critical issues, based on the users and providers’ opinions, are critical for improving telemedicine services [68].”
BackgroundSherrill, A. M., Wiese, C. W., Abdullah, S., & Arriaga, R. I. (2022) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-022-00273-3 · Cited by 31
Landes, S. J., Pitcock, J. A., Harned, M. S., Connolly, S. L., Meyers, L. L., & Oliver, C. M. (2021) · Psychological Services · doi:10.1037/ser0000571 · Cited by 37
Ruiz-Cosignani, D., Chen, Y., Cheung, G., Lawrence, M., Lyndon, M. P., Ma’u, E., & Ramalho, R. (2022) · Journal of Telemedicine and Telecare · doi:10.1177/1357633x211069664 · Cited by 35
“25,26,34,43,45,64,68 Also, provider service user cultural gaps and values differences, 69 and cultural and religious practices and beliefs, 36,41,57,63 such as gender issues, or the view that speci fi c topics should not be discussed unless discussed with a religious leader, were also reported as…”
BackgroundVillarreal‐Zegarra, D., Alarcon-Ruiz, C. A., Meléndez‐Torres, G. J., Torres-Puente, R., Navarro‐Flores, A., Cavero, V., Ambrosio-Melgarejo, J. I., Rojas-Vargas, J., Almeida-Huanca, G., Albitres‐Flores, L., et al. (2022) · JMIR Mental Health · doi:10.2196/34760 · Cited by 33
“Lack of access to technology (especially in low-resource countries), limited training in teleconsultation or reluctance of health personnel to use the technology, problems related to patient safety or privacy, and limited legislation on teleconsultation at the country level are necessary elements to evaluate during th…”
BackgroundOccupational Therapy in Mental Health via Telehealth during the COVID-19 Pandemic
Sánchez-Guarnido, A. J., Domínguez-Macías, E., Cervera, J. A. G., González-Casares, R., Marí-Boned, S., Represa-Martínez, Á., & Herruzo, C. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18137138 · Cited by 32
“Previous experience with these types of mental health interventions has generally been favorable in terms of patient acceptance and satisfaction, feasibility, and efficacy, without negatively affecting the therapeutic relationship [11].”
BackgroundAccess to Virtual Mental Healthcare and Support for Refugee and Immigrant Groups: A Scoping Review
Hynie, M., Oda, A., Calaresu, M., Kuo, B. C. H., Ives, N. G., Jaimes, A., Bokore, N., Beukeboom, C., Ahmad, F., Arya, N., et al. (2023) · Journal of Immigrant and Minority Health · doi:10.1007/s10903-023-01521-1 · Cited by 31
Psychiatric Emergencies During the Covid-19 Pandemic: A 6-Month Observational Study
Lorenzo, R. D., Frattini, N., Dragone, D., Farina, R., Luisi, F., Ferrari, S., Bandiera, G., Rovesti, S., & Ferri, P. (2021) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s307128 · Cited by 32
“Patients with auditory, visual or cognitive impairments as well as individuals with psychotic symptoms, acute crisis or at risk of self-harm appear not to be eligible for tele-psychiatry.(52) The inability of patients to receive the psychological and relational support, which previously all professionals of MHC regula…”
ResultGullslett, M. K., Kristiansen, E., & Nilsen, E. R. (2021) · JMIR Human Factors · doi:10.2196/23150 · Cited by 35
“A recent review of the field of telepsychiatry highlights the use of digital solutions as an effective way to improve access, enhance quality, and provide efficient care [4,20].”
BackgroundMethodInfluentialQuantifying the Impact of COVID-19 on Telemedicine Utilization: Retrospective Observational Study
Vogt, E. L., Welch, B. M., Bunnell, B. E., Barrera, J. F., Paige, S. R., Owens, M., Coffey, P. S., Diazgranados, N., & Goldman, D. A. (2021) · Interactive Journal of Medical Research · doi:10.2196/29880 · Cited by 34
“However, there has historically been a gap between the increasing research interest in telemedicine and its broad-scale implementation and acceptance by health systems due to reimbursement limitations, technical barriers, physician attitudes, and lack of physician education [15,16].”
Yellowlees, P., Parish, M. B., González, Á. D. S., Chan, S. R., Hilty, D. M., Yoo, B., Leigh, J. P., McCarron, R. M., Scher, L. M., Sciolla, A., et al. (2021) · Journal of Medical Internet Research · doi:10.2196/24047 · Cited by 34
“Despite this success, with STP being the current standard telepsychiatry practice [8,9], administrative and technical challenges exist, especially around scheduling of telepsychiatrists and patients [10,11], and STP itself is simply a virtual extension of in-person care that cannot be scaled to enable a physician to s…”
Self-citationTerry, D. L., & Buntoro, S. P. (2021) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-021-00215-5 · Cited by 29
Solà, J., Cortés, M., Perruchoud, D., Marco, B. D., Lobo, M. D., Pellaton, C., Wuerzner, G., Fisher, N. D. L., & Shah, J. (2022) · Frontiers in Medical Technology · doi:10.3389/fmedt.2022.899143 · Cited by 29
“It is clear to most practicing physicians, and reinforced by studies, that digital solutions must go beyond the technology itself to drive widespread clinical adoption (68–71).”
Mental health services implementation in Colombia–A systematic review
Garavito, G. A. A., Burgess, R. A., Sanguineti, M. C. D., Peters, L. E. R., & Juan, N. V. S. (2023) · PLOS Global Public Health · doi:10.1371/journal.pgph.0001565 · Cited by 31
“They could also be unsuccessfully implemented due to clinicians’ and managers’ lack of trust in efficacy, integration into mental health systems and missed in-person experience [93].”
BackgroundHamlin, M., Ymerson, T., Carlsen, H. K., Dellepiane, M., Falk, Ö., Ioannou, M., & Steingrímsson, S. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.829374 · Cited by 30
Telepsychiatry: learning from the pandemic
Greenhalgh, T., & Wherton, J. P. (2022) · The British Journal of Psychiatry · doi:10.1192/bjp.2021.224 · Cited by 29
Benudis, A., Re’em, Y., Kanellopoulos, D., Moreno, A., & Zonana, J. (2022) · Psychiatry Research · doi:10.1016/j.psychres.2022.114496 · Cited by 29
Cultivating the Therapeutic Alliance in a Telemental Health Setting
Glass, V. Q., & Bickler, A. (2021) · Contemporary Family Therapy · doi:10.1007/s10591-021-09570-0 · Cited by 28
Schoebel, V., Wayment, C., Gaiser, M., Page, C., Buche, J., & Beck, A. J. (2021) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2021.0121 · Cited by 28
Telepsychiatry in an Era of Digital Mental Health Startups
Achtyes, E. D., Glenn, T., Monteith, S., Geddes, J. R., Whybrow, P. C., Martini, J., & Bauer, M. (2023) · Current Psychiatry Reports · doi:10.1007/s11920-023-01425-9 · Cited by 32
Torales, J., Vilallba-Arias, J., Bogado, J. A., O’Higgins, M., Almirón-Santacruz, J., Ruiz Díaz, N., García, O., Amarilla-Salvioni, D., Castaldelli-Maia, J. M., Ventriglio, A., et al. (2023) · International Journal of Social Psychiatry · doi:10.1177/00207640211070762 · Cited by 31
“The effectiveness of Telepsychiatry is well documented in the medical literature (Chakrabarti, 2015; Cowan et al., 2019; O’Brien & McNicholas, 2020).”
BackgroundHyland, K. A., McDonald, J. B., Verzijl, C. L., Faraci, D. C., Calixte-Civil, P. F., Gorey, C. M., & Verona, E. (2021) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2021.02.006 · Cited by 27
Cristiano, A., Musteata, S., Silvestri, S. D., Bellandi, V., Ceravolo, P., Cesari, M., Azzolino, D., Sanna, A., & Trojaniello, D. (2021) · JMIR Aging · doi:10.2196/29623 · Cited by 28
“Moreover, the focus of most studies has been on exploring a single device (eg, tablet) [21] or function (eg, telemonitoring of daily activities) [20,26,27] and not a platform or a system including different devices and services.”
BackgroundThe Symbiosis of Virtual Reality Exposure Therapy and Telemental Health: A Review
Ong, T., Wilczewski, H., Soni, H., Nisbet, Q., Paige, S. R., Barrera, J. F., Welch, B. M., & Bunnell, B. E. (2022) · Frontiers in Virtual Reality · doi:10.3389/frvir.2022.848066 · Cited by 28
Therapist perspectives on telehealth-based virtual reality exposure therapy
Ong, T., Ivanova, J., Soni, H., Wilczewski, H., Barrera, J. F., Cummins, M. R., Welch, B. M., & Bunnell, B. E. (2024) · Virtual Reality · doi:10.1007/s10055-024-00956-7 · Cited by 26
“…care) has been embraced broadly, some therapists and clients also report feeling less capable of expressing themselves over phone or video calls (Aviram and Nadan 2023; Connolly et al. 2022; Cowan et al. 2019), which may negatively impact therapeutic relationships (Aafjes-Van Doorn et al. 2023).”
Shih, Y.-H., Wang, J.-Y., Chou, P.-H., & Lin, K.-H. (2023) · Annals of Medicine · doi:10.1080/07853890.2023.2187078 · Cited by 24
Telehealth use by mental health professionals during COVID-19
Farrer, L. M., Clough, B. A., Bekker, M. J., Calear, A. L., Werner‐Seidler, A., Newby, J. M., Knott, V. E., Gooding, P., Reynolds, J., Brennan, L., et al. (2022) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/00048674221089229 · Cited by 27
Trends in telehealth and its implications for health disparities
Edmiston, K. D., & Alzubi, J. (2022) · doi:10.52227/25241.2022 · Cited by 25
“Research suggests privacy is a pervasive concern, which could limit the acceptance of telemedicine alternatives to in-person care, especially in sensitive interactions like psychiatry and in the wearing of digital devices that store large amounts of information accessible to third parties “without user consent” (Cowan…”
BackgroundLynch, D. A., Stefančić, A., Cabassa, L. J., & Medalia, A. A. (2021) · Psychiatry Research · doi:10.1016/j.psychres.2021.113871 · Cited by 23
Purtle, J., Nelson, K. L., Horwitz, S. M., Palinkas, L. A., McKay, M. M., & Hoagwood, K. E. (2022) · Psychiatric Services · doi:10.1176/appi.ps.202100176 · Cited by 23
Zulfic, Z., Liu, D., Lloyd, C., Rowan, J., & Schubert, K. O. (2020) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/0004867420937788 · Cited by 23
Evers, E. C., Fritz, S. A., Colditz, G. A., & Burnham, J. P. (2022) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofab661 · Cited by 24
“Similar to other specialties [32, 33], in our study, internet access was an important concern.”
ResultGarcini, L. M., Vázquez, A. L., Abraham, C., Abraham, C., Sarabu, V., & Cruz, P. L. (2023) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2022.2158837 · Cited by 22
“Yet, despite apparent advantages and rapid scaling of telepsychology services, Latinx families have experienced significant disparities in access to teleservices (Cowan et al., 2019; Vázquez et al., 2021).”
BackgroundAsmundson, G. J. G., Blackstock, C., Bourque, M. C., Brimacombe, G., Crawford, A. S., Deacon, S. H., McMullen, K., McGrath, P. J., Mushquash, C. J., Stewart, S. H., et al. (2020) · FACETS · doi:10.1139/facets-2020-0082 · Cited by 23
“Some of the reasons suggested for this lack of adoption and penetration of virtual care are: poor implementation; health governance and funding that does not contribute to care across regional or provincial boundaries; lack of funding and remuneration for virtual care; and inadequate training for health care providers…”
BackgroundHein, H. J., Glombiewski, J. A., Rief, W., & Riecke, J. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-060020 · Cited by 21
Perez, D. L., Biffi, A., Camprodon, J. A., Caplan, D. N., Chemali, Z. N., Kritzer, M. D., Moo, L. R., Newhouse, A. L., Ramirez-Gomez, L. A., Razafsha, M., et al. (2020) · Cognitive and Behavioral Neurology · doi:10.1097/wnn.0000000000000239 · Cited by 21
Rolfes, J. J., & Paulsen, M. E. (2021) · Journal of Perinatology · doi:10.1038/s41372-021-01256-7 · Cited by 25
Henson, S. J. S., Chamberlain, C. E. W., Smith, B. J., Li, E. J., Castro, C. M., & Altman, M. (2022) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-022-00263-5 · Cited by 25
“Some clinicians report difficulty judging non-verbal behavior (Thomas et al., 2021) and hold a belief that technological disruptions may be a barrier to developing rapport (Cowan et al., 2019; Morland et al., 2010).”
BackgroundCascini, F., Gentili, A., Causio, F. A., Altamura, G., Melnyk, A., Beccia, F., Pappalardo, C., Lontano, A., & Ricciardi, W. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1147210 · Cited by 21
“As reported by various sources, digital health implementation is a process whose development is rooted in bureaucracy, such as constraints in reimbursement and credentialing and administrative and training burdens (35, 36).”
BackgroundDigital Technology in Psychiatry: Survey Study of Clinicians
Sterling, W. A., Sobolev, M., Meter, A. V., Guinart, D., Birnbaum, M. L., Rubio, J. M., & Kane, J. M. (2022) · JMIR Formative Research · doi:10.2196/33676 · Cited by 21
“Studies of telepsychiatry suggest that successful implementation of digital technology into clinical settings depends on clinician enthusiasm and confidence in the safety and efficacy of the new platform, as well as access to proper training [13-15].”
BackgroundOng, T., Barrera, J. F., Sunkara, C., Soni, H., Ivanova, J., Cummins, M. R., Schuler, K. R., Wilczewski, H., Welch, B. M., & Bunnell, B. E. (2024) · Frontiers in Virtual Reality · doi:10.3389/frvir.2024.1332874 · Cited by 19
Dursun, O. B., Turan, B., Pakyürek, M., & Tekin, A. (2020) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2020.0237 · Cited by 21
Schroeder, R. A. (2020) · Journal of the American Psychiatric Nurses Association · doi:10.1177/1078390320970638 · Cited by 20
“Workforce issues are further compounded by geography where states report shortages of outpatient mental health services and rural providers (Cowan et al., 2019).”
Background
Metadata
- Authors
- Cowan, K. E., McKean, A. J., Gentry, M. T., & Hilty, D. M.
- Affiliations
- Mayo Clinic (US)
- University of California, Davis (US)
- Corresponding author
- McKean, Alastair J.
- Venue
- Mayo Clinic Proceedings
- Publisher
- Elsevier BV
- Published
- 2019-12
- Volume
- 94
- Issue
- 12
- Pages
- 2510-2523
- ISSN
- 0025-6196 (ISSN-L)
- OpenAlex
- W2990993692
- Cited by
- 380
- References
- 140
- Citations by year
- 2026: 22 · 2025: 40 · 2024: 49 · 2023: 65 · 2022: 75 · 2021: 84 · 2020: 45
- FWCI
- 8.34
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Mayo Clinic Proceedings (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare Systems and Technology
- Keywords
- telepsychiatry, telehealth adoption barriers, clinician attitudes, telemedicine, telemental health, clinical workflow, organizational culture, patient satisfaction
- MeSH terms
- Humans, Mental Health Services, Telemedicine, Videoconferencing
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