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
The cited source says what the claim attributes to it.
In the citing paper
“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
The cited source says what the claim attributes to it.
In the citing paper
“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]
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]
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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Flagged first, then by citations
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BackgroundSelf-efficacy as a mediator between psychologists’ technology affinity and telehealth satisfaction
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InfluentialRapid Expansion of Direct-To-Consumer Telemental Health during the Covid-19 Pandemic: A Case Series
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“Clinicians have expressed concerns about the constraints of telepsychiatry and the experience needed to provide nuanced care (Cowan et al., 2019).”
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“Since mental health providers are often referred to as the “ gatekeepers of telehealth ” (Cowan et al., 2019, p. 1), exploring their engagement with telehealth is vital to its continuing use and development.”
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BackgroundResultInfluentialA commentary on telebehavioral health services adoption.
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Mental Health Day Hospitals and Lockdown Due to COVID-19 in Spain
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Transformation of Outpatient Psychiatry
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“Indeed, assessing and managing risk have been identi fi ed as the elements of teletherapy that providers are least comfortable with, largely due to the reduced visibility of nonverbal cues (Cowan et al., 2019; Gilmore & Ward-Ciesielski, 2019; Luxton et al., 2014).”
Torales, J. C., Alviso, A. I., Ríos-González, C. M., O’Higgins, M. G., Navarro, R. E., Ayala-Servín, N., Almirón‐Santacruz, J., Aquino-Arrúa, A., Balbuena-Monges, H., Guerra-Aquino, F., et al. (2021) · Revista del Nacional (Itaguá) · doi:10.18004/rdn2021.dic.02.018.028 · Cited by 2
Investigación en salud mental durante la pandemia de COVID-19
Valencia, J. G. (2020) · Revista Colombiana de Psiquiatría · doi:10.1016/j.rcp.2020.11.001 · Cited by 2
“video and audio quality), legal regulations, and difficulties in prescribing drugs.(7) Previous research had J ur n l P re -p ro of”
Editorial: To zoom or not to zoom – that is the question
Gnanapragasam, S., Hariman, K. W., & Ventriglio, A. (2021) · International Journal of Social Psychiatry · doi:10.1177/00207640211004991 · Cited by 2
“Greene et al. (2010) demonstrated in a study on a small group of patients receiving angermanagement group therapy that the therapeutic alliance and attrition rates were not significantly different except a lower alliance with the tele-group leader.”
BackgroundMental health services implementation in Colombia – a systematic reviewPreprint
Garavito, G. A. A., Burgess, R. A., Sanguineti, M. C. D., Peters, L. E. R., & Juan, N. V. S. (2023) · medRxiv · doi:10.1101/2023.01.17.23284625 · Cited by 2
Introducing Telepsychiatry to Medical Students with Simulated Patients: An Innovation by Necessity
Miller, M., Schatte, D. J., & Szauter, K. M. (2020) · MedEdPublish · doi:10.15694/mep.2020.000187.1 · Cited by 1
Araújo, D. D. F., & Costa, E. L. (2021) · Revista Brasileira de Terapias Cognitivas · doi:10.5935/1808-5687.20210015 · Cited by 2
“A modalidade de intervenção on-line oferece maior flexibilidade de horários, economia dos deslocamentos e menor risco de infecção (Cowan et al., 2019), além de alguns pacientes relatarem que se sentem mais abertos e dispostos em abordar assuntos difíceis (Simpson & Reid, 2014).”
BackgroundSamad, L., Teague, B., Elzubeir, K., Moreira, K., Agarwal, N., Bagge, S., Marriott, E., & Wilson, J. (2023) · Mental Health Review Journal · doi:10.1108/mhrj-06-2022-0036 · Cited by 1
Schjøtt-Pedersen, O., Seierstad, A., Evensen, S., Evensen, J. H., Færden, A., Gjerstad, C. L., Martinsen, F. F., Sørgård, K. M., & Lystad, J. U. (2023) · Nordic Journal of Psychiatry · doi:10.1080/08039488.2023.2240301 · Cited by 1
Thaler, N., & Shankar, R. (2021) · JAACAP Connect · doi:10.62414/001c.92355 · Cited by 1
Rosas, F., Gayoso, A., Tomateo-Torvisco, D., & Orellano, C. (2024) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2023.0428 · Cited by 1
“19,27 Due to the characteristics of our population sample and the acceptance found, we consider that the virtual modality for medical care can be implemented permanently alongside the in-person medical visit to increase the offer of medical care to psychiatric patients.”
Digital interventions for mental health care
Naslund, J. A., & Babalola, D. (2025) · Elsevier eBooks · doi:10.1016/b978-0-443-15728-8.00023-9 · Cited by 1
Telepsychiatry: From “Telepathy” to the Mainstream
Mucić, D., Hilty, D. M., & Shore, J. H. (2024) · Springer eBooks · doi:10.1007/978-3-031-59936-1_9 · Cited by 1
Self-citationMansoor, M. A., & Ibrahim, A. (2025) · Biomedical engineering · doi:10.5772/intechopen.1010583 · Cited by 1
Pruscino, I., Pope, K., Willoughby, K. K., & Miles, A. M. V. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1624213 · Cited by 2
“Previous research has highlighted dif fi culties in the establishment of a therapeutic alliance during the early stages of rapport-building in an online environment (60, 61).”
McGraw, M., Couturier, Y., Gaboury, I., Poirier, M.-D., & Poitras, M.-È. (2026) · Journal of Interprofessional Education & Practice · doi:10.1016/j.xjep.2026.100813 · Cited by 2
Tsulukidze, M., Cicco, G. D., Cox, T. L., Rafferty, K. A., Grande, S. W., Skop, I., & Collison, D. (2026) · PLoS ONE · doi:10.1371/journal.pone.0349065 · Cited by 1
Training nonspecialists in clinical evaluation for telepsychiatry using videoconferencing
Malhotra, S., Chakrabarti, S., Gupta, A., Sharma, K., & Sharma, M. (2021) · Indian Journal of Psychiatry · doi:10.4103/indianjpsychiatry.indianjpsychiatry_336_21 · Cited by 1
“6-8] Nevertheless, such training appears to be no different from conventional in-person training.”
Informatics Technologies in the Diagnosis and Treatment of Mental Health Conditions
Ingram, W. M., Khanna, R., & Weston, C. L. (2021) · Health informatics · doi:10.1007/978-3-030-70558-9_17 · Cited by 1
“One of the barriers to the adoption of telemedicine is the resistance of clinicians themselves due to concern over developing trust and rapport with their patients as well as concerns over safety, security, and legal issues [105].”
BackgroundA Thematic Analysis of Provider Comparisons of Telemedicine Satisfaction Measures
Garcia, R., Kallio, P., & Adelakun, O. (2022) · Hawaii International Conference on System Sciences (HICSS) · doi:10.24251/hicss.2022.476 · Cited by 1
Nursing and Telemental Health during the COVID-19 Pandemic
Sánchez-Guarnido, A. J., Gonzalez-Vilchez, M., de Haro, R., Fernández-Guillen, M., Graell, M., & Lucena, V. (2022) · Healthcare · doi:10.3390/healthcare10020273 · Cited by 1
“Before the pandemic, professionals had expressed numerous concerns regarding the implementation of TH, citing the loss of therapeutic relationships, teamwork, confidentiality and privacy, the insecurity and the legal regulation of personal data transmission, the need for professional recycling and training [14,15,17,1…”
BackgroundClinical and Information Services Needed by Telemental Health Providers
Paige, S. R., Ong, T., Wilczewski, H., Barrera, J. F., Welch, B. M., & Bunnell, B. E. (2022) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2021.0457 · Cited by 1
A look forward to digital therapeutics in 2040 and how clinicians and institutions get there
Hilty, D. M., Armstrong, C. M., Edwards‐Stewart, A., & Luxton, D. D. (2022) · Elsevier eBooks · doi:10.1016/b978-0-323-90045-4.00014-9 · Cited by 2
Self-citationBibliometric review of credentialing and quality in healthcare field
Ikhwan, A. S., & Permana, I. (2023) · World Journal of Advanced Research and Reviews · doi:10.30574/wjarr.2023.17.1.0032 · Cited by 1
“…use disorder patients K. Humphreys [15] 52 Hybrid minimally invasive esophagectomy for esophageal cancer 2019 C. Mariette [16] 235 Barriers to Use of Telepsychiatry: Clinicians as Gatekeepers K. Cowan [17] 80 Figure 3 shows the subject areas studied in the 639 publications used in this study.”
Implementing Video Consultations in a Rural Psychiatric Outpatient Clinic: A Feasibility Study
Shaker, A. A., Austin, S. F., Sørensen, J. A., Tarp, K., Bechmann, H., & Simonsen, E. H. (2023) · Perspectives In Psychiatric Care · doi:10.1155/2023/4282468 · Cited by 1
“In addition, clinicians may have some concerns regarding maintaining patient confdentiality using video conferencing, which could contribute to clinicians’ reluctance to use VC as a modality for therapy [15, 19, 23].”
BackgroundResultInfluentialDigitally enabled asynchronous remote medical management of anxiety and depression: A cohort study
Perlman, A., Pickman, Y., Dreyfuss, M., Manes, I., Bak, P., Souroujon, D., Paz, E., Ebbert, J. O., & Zeltzer, D. (2024) · Journal of Telemedicine and Telecare · doi:10.1177/1357633x241233788 · Cited by 1
“3,4,37 Indeed, a recent review on telepsychiatry in rural areas found bene fi ts including high patient satisfaction, reduced costs, and enhanced healthcare access.”
García, F., Klagges, M., Leyton, F., Nogales, I., Letelier, C. M., Martìnez, C., & Tomicic, A. (2024) · Medwave · doi:10.5867/medwave.2024.02.2777 · Cited by 1
Alshaikhi, O. A., Aldarsi, L. A., Basfar, I. A. A., Alshehri, A., Shuqdar, R. M., Ghazy, R. M., & Elrggal, M. E. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1426998 · Cited by 11
“This is similar to fi ndings of previous research, which showed that professional healthcare providers used to prefer in-person visits, and that patient management typically improves with time and frequent use of telepsychiatry (39).”
COVID-19 and Depression of College Student: A Literature Review
Ding, Y., Hong, J., & Zhang, Y. (2021) · Advances in Social Science, Education and Humanities Research/Advances in social science, education and humanities research · doi:10.2991/assehr.k.211220.305 · Cited by 1
Meller, S., Tauscher, J. S., & Ben‐Zeev, D. (2022) · Journal of Technology in Counselor Education and Supervision · doi:10.22371/tces/0015 · Cited by 1
Mental health research during the COVID-19 pandemic
Valencia, J. G. (2020) · Revista Colombiana de Psiquiatría (English ed ) · doi:10.1016/j.rcpeng.2020.11.001 · Cited by 1
Kisicki, A., Becker, S. J., Chaple, M., Gustafson, D. H., Hartzler, B. J., Jacobson, N. A., Murphy, A., Tapscott, S. L., & Molfenter, T. D. (2021) · Research Square · doi:10.21203/rs.3.rs-965869/v1 · Cited by 1
Telehealth Use Among Older Adults During COVID 19
Mondal, R. (2025) · Wiley eBooks · doi:10.1002/9781394275397.ch2 · Cited by 1
Kapoor, A. (2021) · Springer eBooks · doi:10.1007/978-3-030-58663-8_43
Rangachari, P., Mushiana, S. S., & Herbert, K. L. (2021) · Research Square · doi:10.21203/rs.3.rs-149558/v1
Teleneuropsychological Assessment During the COVID-19 Pandemic
Sharma, M., Weerawardhena, H., Wall, A. K., VanderZwaag, B., Andruchow, D., Al-Khaz’Aly, H., Cunningham, D. R., & Callahan, B. L. (2021) · Journal of Student Research · doi:10.47611/jsr.v10i1.1178
Horta, P., Costa, A. V., Mendes, S. D. S., Pires, S., Melo, S., Jorge, J. C., Borges, S., ARAUJO, M. D. V., & Mendes, G. (2021) · International Journal of Developmental and Educational Psychology Revista INFAD de psicología · doi:10.17060/ijodaep.2021.n2.v1.2174
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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