The DOI matches its Crossref record; 132 of the 140 references it cites were found in a registry or an index.
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
In the citing paper
“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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“safety, privacy, technological limitations, financial and regulatory issues, credentialing, and education) [1, 2, 12, 13], lack of investment [10], and unprepared care systems [12].”
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“These programs could raise awareness of the benefits of e-health technology, improve skills, familiarity and confidence with the technology, and ultimately reduce concerns (Cowan et al., 2019; De Witte et al., 2021; Di Carlo et al., 2020).”
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“However, they often failed to meet their stated objectives and even posed real risks to the user (28–30).”
BackgroundFreske, E., & Malczyk, B. R. (2021) · Societies · doi:10.3390/soc11040141 · Cited by 8
Clary, K. L., Nason, E. E., Selber, K., & Smith, K. S. (2022) · Smith College Studies in Social Work · doi:10.1080/00377317.2022.2041148 · Cited by 8
“Recent research has demonstrated that clinicians report satisfaction when using technology that supports practice; however, clinicians continue to report concerns related to building rapport, maintaining confidentiality, and ensuring safety (Cowan, McKean, Gentry, & Hilty, 2019).”
BackgroundArchard, P. J., Kulik, L., Fitzpatrick, S., Awhangansi, S., Moore, I., Giles, E., Morris, N., & O’Reilly, M. J. (2022) · Mental Health Practice · doi:10.7748/mhp.2022.e1596 · Cited by 8
Lohaus, T., Rogalla, S., & Thoma, P. (2022) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2022.0037 · Cited by 8
Chakravarty, R. K., Chakrabarti, S., & Shah, R. (2022) · Journal of Family Medicine and Primary Care · doi:10.4103/jfmpc.jfmpc_1644_21 · Cited by 7
“[39,40] In the absence of a control group of patients who had used in‐person services, it was difficult to determine whether satisfaction rates would still be the same if the patients from the COVID phase had access to conventional outpatient services.[40] However, the relatively large number of patients from the pand…”
BackgroundMethodPerinatal mental health and COVID-19: Navigating a way forward
Smith, K., Howard, L. M., Vigod, S. N., D’Agostino, A., & Cipriani, A. (2022) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/00048674221137819 · Cited by 9
Patients’ experiences with tele-mental health services during COVID-19 in Pakistan
Asad, N., Pirani, S., Osama, K., & Nadeem, T. (2024) · Eastern Mediterranean Health Journal · doi:10.26719/2024.30.4.283 · Cited by 7
“Our participants reported concerns consistent with previously documented evidence relating to technical issues, such as poor bandwidth, connectivity issues and audio lag ( 17,18 ).”
ResultEbrahimjee, A., Hodsoll, J. P., Valmaggia, L., Hickling, L. M., & Riches, S. (2024) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x2400028x · Cited by 10
“…before the COVID-19 pandemic, where day-to-day use of video calling was less common, and service providers were not incentivised or trained to provide video call-based interventions (Chiauzzi et al ., 2020; Cowan et al ., 2019; Glueckauf et al ., 2018; Mace et al ., 2018; Sampaio et al ., 2021).”
Chen, Y., Zhang, L., Zhang, S., Zhang, J., Hong, Y., Li, Q., & Zhou, Y. (2025) · Journal of Affective Disorders · doi:10.1016/j.jad.2025.01.129 · Cited by 9
Autistic People's Experiences With Mental Health Services: Intersectionality Matters
Adams, D., Malone, S. A., Lawson, W. B., Breasley, J., Girdler, S. J., & Carroll, A. (2025) · Neurodiversity · doi:10.1177/27546330251369785 · Cited by 9
“…( ‘ telemental health ’ ) was limited before the COVID-19 pandemic due to concerns amongst therapists and mental healthcare professionals (e.g., Cowan et al., 2019), but has since become commonplace, with both autistic people and therapists accepting the bene fi ts and challenges (L. Adams…”
Neumann, A., König, H., & Hajek, A. (2025) · JMIR Mental Health · doi:10.2196/70925 · Cited by 7
“Therefore, providing guidelines, resources, and support for providers may be beneficial in the future to enable wide-spread use of the services (eg, [50]).”
InfluentialTelehealth Professionalism Education for Advanced Practice Nursing Students
Chike-Harris, K. E., Lauerer, J., Powers, A., & Stanley, A. C. (2021) · Nursing Education Perspectives · doi:10.1097/01.nep.0000000000000910 · Cited by 7
Huang, I., Delay, R., Boulware, A., McHugh, A., Wong, Z. J., Whitaker, A. K., Stulberg, D. B., & Hasselbacher, L. A. (2022) · Contraception X · doi:10.1016/j.conx.2022.100083 · Cited by 7
“[14] Cowan KE, McKean AJ, Gentry MT, Hilty DM.”
BackgroundLui, L. M. W., & McIntyre, R. S. (2022) · Schizophrenia Bulletin Open · doi:10.1093/schizbullopen/sgac036 · Cited by 7
Delves, M., Luscombe, G. M., Juratowitch, R., Srikanth, R., Trollor, J. N., Brown, D., & Embury, A. (2022) · Journal of Policy and Practice in Intellectual Disabilities · doi:10.1111/jppi.12448 · Cited by 7
Mosheva, M., Barzilai, Y., Hertz‐Palmor, N., Mekori‐Domachevsky, E., Avinir, A., Erez, G., Vardi, N., Schoen, G., Lahav, T., Sadeh, H., et al. (2023) · Healthcare · doi:10.3390/healthcare11050765 · Cited by 7
“However, before the pandemic, outside the research setting, the use of telepsychiatry was slow and limited by clinicians’ concerns about regulation and quality of care [20,21].”
BackgroundPincus, L. E. (2020) · Pragmatic Case Studies in Psychotherapy · doi:10.14713/pcsp.v16i1.2070 · Cited by 7
“Crucially, I also only understood some of the most common barriers to the widespread adoption of telemental health—namely clinician and patient preference related to such factors as therapeutic alliance (Cowan et al., 2019)—in theoretical terms.”
BackgroundEcker, A. H., Amspoker, A. B., Hogan, J., & Lindsay, J. A. (2020) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-020-00150-x · Cited by 7
Magal, T., Negev, M., & Kaphzan, H. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182312540 · Cited by 7
“Previous studies have demonstrated clinician concerns regarding the quality of online examination as well as regarding therapeutic alliance during telepsychiatry [12,40,41].”
BackgroundResultKoppel, P. D., & Gagne, J. C. D. (2021) · JMIR Research Protocols · doi:10.2196/27940 · Cited by 5
“Even in telepsychology, where research is more robust [33], providers remain concerned about the impact of videoconferencing on therapeutic alliance and nonverbal communication channels [16,34] and are uncertain about how best to adapt techniques.”
BackgroundKisicki, A., Becker, S. J., Chaple, M., Gustafson, D. H., Hartzler, B. J., Jacobson, N. A., Murphy, A., Tapscott, S. L., & Molfenter, T. D. (2022) · BMC Health Services Research · doi:10.1186/s12913-022-08114-y · Cited by 6
“Reimbursement for telehealth has often been cited as a barrier by MH [8, 9] and SUD treatment providers [4], even before the COVID-19 pandemic and despite legislative action to address the reimbursement barrier [10].”
BackgroundAutistic young people’s experiences of remote psychological interventions during COVID-19
Adams, L., Adamo, N., Hollocks, M. J., Watson, J., Brewster, A., Valmaggia, L., Jewitt, E., Edwards, J., Krisson, M., & Simonoff, E. A. (2023) · Autism · doi:10.1177/13623613221142730 · Cited by 8
“Overlapping challenges include effective communication, rapport, and therapeutic alliance (Cooper et al., 2018; Cowan et al., 2019; Norwood et al., 2018).”
Clinicians’ perspectives and usage of rehabilitation technology: a survey
Curtis, S., Sheehan, L. M., Buchman, E., & Bhattacharjya, S. (2023) · Disability and Rehabilitation Assistive Technology · doi:10.1080/17483107.2023.2284365 · Cited by 6
Yellowlees, P., Parish, M. B., González, Á. D. S., Fisher, A., Chan, S. R., Hilty, D. M., McCarron, R. M., Scher, L. M., Sciolla, A., Shore, J. H., et al. (2023) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2023.0238 · Cited by 6
Self-citationMedical specialists’ use and opinion of video consultation in Denmark: a survey study
Møller, O. M., Vange, S. S., Børsch, A. S., Dam, T. N., Jensen, A. M. B., & Jervelund, S. S. (2024) · BMC Health Services Research · doi:10.1186/s12913-024-10868-6 · Cited by 6
Cuevas, C. D. L., Gutiérrez-Rojas, L., Álvarez-Mon, M. Á., Andreu-Bernabeu, Á., Capitán, L., Gómez, J. C., Grande, I., Hidalgo‐Mazzei, D., Mateos, R., Moreno-Gea, P., et al. (2022) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2022.0051 · Cited by 6
The Efficacy of Telepsychiatry in Addiction Patients: A Systematic Review
Kamma, H. K., Alabbas, M., Elashahab, M., Abid, N., Manaye, S., Cheran, K., Murthy, C., Bornemann, E. A., & Franchini, A. P. A. (2023) · Cureus · doi:10.7759/cureus.38133 · Cited by 7
“In several states, obstacles and problems with payment regulations persist [23].”
BackgroundInfluentialO’Connell, M., Gluskin, B. S., Parker, S., Burke, P. J., Pluhar, E., Guss, C. E., & Shrier, L. A. (2023) · Prevention Science · doi:10.1007/s11121-023-01506-4 · Cited by 7
“For delivering telehealth services to AYA with depression, additional telehealth considerations include provider rapport and safety procedures (Connolly et al., 2020; Cowan et al., 2019; Montoya et al., 2022; Reay et al., 2020).”
BackgroundYouth telemental health and COVID-19
Archard, P. J., O’Reilly, M., Fitzpatrick, S., & Fox, J. (2021) · Irish Journal of Psychological Medicine · doi:10.1017/ipm.2021.27 · Cited by 6
“…risk via video link or telephone can be anxiety provoking and can feel more like surveillance than support to young people and caregivers (Cowan et al., 2019), leaving clinicians feeling obliged to escalate any self-reported risk information and potentially increasing demand on crisis…”
BackgroundPace, C. S., Muzi, S., Moretti, M. M., & Barone, L. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1266930 · Cited by 7
Shaker, A. A., Simonsen, E. H., Tarp, K., Borisov, R., Sørensen, J. A., Bechmann, H., & Austin, S. F. (2024) · JMIR Formative Research · doi:10.2196/50580 · Cited by 5
“In addition, using VCs in clinical practice, particularly for therapeutic interventions, requires establishing a virtual therapeutic alliance, which can be experienced as new and challenging for some users [15,16].”
BackgroundMethodWetzlmair-Kephart, L.-C., O’Malley, A., & O’Carroll, V. (2025) · PLoS ONE · doi:10.1371/journal.pone.0302088 · Cited by 7
“Reportedly, the seamless integration of hybrid working arrangements that entail switching between in-person and remote consultations in clinical practice often constitutes a barrier and reduces uptake rates of teleconsultations [84].”
The Effects of COVID-19 Pandemic on Adults Living in Turkey and Ways of Coping
Usluoğlu, F., Togay, A., Atıcı, M., & Şahin, İ. (2022) · Social Work in Public Health · doi:10.1080/19371918.2022.2117754 · Cited by 5
Shaker, A. A., Austin, S. F., Sørensen, J. A., Storebø, O. J., & Simonsen, E. H. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-060690 · Cited by 4
Moeller, A. M., Hansen, J. P., & Andersen, P. T. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.984026 · Cited by 5
Ivey, G., & Denmeade, L. (2023) · Psychoanalytic Psychotherapy · doi:10.1080/02668734.2022.2158210 · Cited by 6
“Despite the documented benefits of telepsychology, psychotherapists have been hesitant to embrace this technology (Cowan et al., 2019; Isaacs Russell, 2018; Pierce et al., 2020; Sampaio et al., 2021).”
BackgroundXue, Y., Saeed, S. A., Muppavarapu, K. S., Jones, K., & Xue, L. L. (2023) · Psychiatric Quarterly · doi:10.1007/s11126-023-10033-y · Cited by 5
Adem, J. B., Melaku, M. S., Zeleke, T., Tesfaye, M., Lemessa, F., & Walle, A. D. (2023) · International Journal of Mental Health Systems · doi:10.1186/s13033-023-00596-5 · Cited by 5
“Studies show that healthcare professionals prefer in-person visits and may even prefer in-person therapy, but after using telemedicine technologies, their perceptions of it improved, suggesting that more exposure for clinicians may be needed to allay their concerns about rapport and to enhance their attitude toward th…”
BackgroundKim, K. H., Lee, S. M., Hong, M., Han, K., & Paik, J. (2023) · BMC Psychiatry · doi:10.1186/s12888-023-05258-x · Cited by 5
“Telemedicine use in mental health issues, which have surged during the pandemic, has been proven effective and safe in evaluation and management [19].”
BackgroundBlack veteran use of video telehealth for mental health care.
Day, G., Ecker, A. H., Amspoker, A. B., Dawson, D. B., Walder, A. M., Hogan, J., & Lindsay, J. A. (2023) · Psychological Services · doi:10.1037/ser0000827 · Cited by 5
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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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