How Effective Is Virtual Psychiatry vs. In-Person Psychiatry?

Summary: After a dramatic surge in the use of telehealth during and after COVID, the data on virtual psychiatry vs. in-person psychiatry are here: with some exceptions, virtual psychiatry is as effective as in-person psychiatry.

Key Points:

• Virtual psychiatry increased during the pandemic, and remains both common and popular among patients and providers
• Research indicates virtual psychiatry is noninferior to in-person psychiatry for most patients and most disorders
• Demographic variables can impact the effectiveness of virtual psychiatry vs. in-person psychiatry
• Clinical variables can impact the effectiveness of virtual psychiatry vs. in-person psychiatry

Virtual Psychiatry vs. In-Person Psychiatry: Patients Accept Help Over the Phone and Online

When we talk about mental health, one thing we need to remember is that we’re talking about people who need help with something they can’t resolve on their own. That’s true for all health issues for which people seek professional support: they ask experts, and in most cases, follow their advice. But with mental health, the situation is slightly different. Although issues of physical health are private and personal, issues related to mental health – thoughts, emotions, behaviors – may be even more private and even more personal, depending on the person and the issue.

That begs the question(s):

Is mental health support over the phone – or via video conference, text, or app – something people want and are willing to participate in? Or, stated another way, is virtual psychiatry a viable option to in-person psychiatry, from the patient perspective?

We have two sets of data which, taken together, offer a clear answer to this question. The first set is from the National Suicide Crisis Line (988), which shows the following call data for 2022-2024:

• 2022: 3.7 million calls/texts for support
• 2023: 5.2 million calls/texts for support
• 2024: 5.8 million calls/texts for support

That indicates that in extreme circumstances, people with mental health issues are more than willing to seek and accept support over the phone, via chat, or via text: 14.7 million reached out virtually for mental health support since the crisis line began full, national integration in 2022.

Next, we’ll share data from the American Psychological Association (APA) shows the surge, correction, and levelling off at a new normal for virtual psychiatry vs. in-person psychiatry.

Virtual Psychiatry vs. In-Person Psychiatry vs. Hybrid: 2020-2023

2020:

• Virtual: 64%
• Hybrid: 33%
• In-person: 3%

2021:

• Virtual: 48%
• Hybrid: 41%
• In-person: 11%

2022:

• Virtual: 31%
• Hybrid: 58%
• In-person: 11%

2023:

• Virtual: 21%
• Hybrid: 67%
• In-person: 13%

That answers our question: patients are willing and able to engage in virtual psychiatry vs. in-person psychiatry. Those figures scan with common sense: during the pandemic, patients chose virtual care out of necessity. Three years later, roughly 1/5^th of patients chose virtual care, 2/3^rds chose hybrid, and just over 1/10^th chose in-person only.

In the words of the experts at the APA, from this publication: “Telehealth is here to stay.” With that said, let’s move on to the next critical question:

Does it actually work?

Virtual Psychiatry vs. In-Person Psychiatry: Research Outcomes

Yes, it does, with some exceptions. We’ll share data from two studies and one editorial, all of which address the question of virtual psychiatry vs. in-person psychiatry. The first study, a large-scale meta-analysis called “ Telemental Health for Clinical Assessment and Treatment” examined several components of telehealth, including its viability for assessment of mental health disorders, general mental health treatment, the therapeutic alliance, treatment for specific disorders, and specific elements of psychotherapy.

Here’s what they found for each component of virtual care vs. in-person care:

Assessment:

• Virtual psychiatry is equally effective, with assessments achieving concordance with in-person assessments

General treatment:

• Virtual psychiatry is effective, with some variation by disorder type

Therapeutic alliance:

• Strong for both virtual and in-person
• In-person alliance superior
• Superior alliance did not affect outcome

Specific disorders:

• Anger: equally effective
• Anxiety: equally effective
• Depression: equally effective
  • When telehealth is added to standard care, outcomes improve
  • Telehealth + standard care superior to telehealth alone and standard care alone
• Postpartum depression: superior to in-person care, for all modalities of telehealth:
  • Phone
  • Email
  • Text
  • App
• Hopelessness: equally effective
• Pain: equally effective
• Psychological function: equally effective
• Quality of life: equally effective
• Trauma: in-person treatment moderately more effective than virtual treatmen

We’ll summarize the findings from this meta-analysis. Compared to in-person treatment, assessment and clinical outcomes for virtual care are similar, with some variation based on:

• Demographic characteristics:
  • Children: children were excluded from these studies
  • Adolescents: virtual treatment for adolescents requires significant modification/adaptation to sustain engagement
  • Females showed better outcomes than males
• Specific patient populations:
  • Psychotic disorders were excluded from these studies. Virtual care may not be suitable for disorders with psychotic features, or for psychosis
  • Patients with a history of trauma may benefit more from in-person care
• Treatment modalities:
  • Research still needed on group telehealth for mental health
  • Research needed on modalities aside from cognitive behavioral therapy (CBT), which is proven effective via telehealth

In addition to these results, researchers found that hybrid treatment, i.e. treatment that mixes in-person with virtual care, may be the most effective approach, with some studies showing superiority to virtual only support and in-person only support.

In this Debate, Both Sides Win

When we talk about how effective virtual psychiatry is, compared to in-person psychiatry, we forget that it’s not really an either/or question. And the data shows that either/or is not a helpful way to frame the question, at least not in-terms of whether one is better than the other.

Why? Because they both work – but not for everyone, and not for every disorder.

The question about whether to choose virtual psychiatry vs. in-person psychiatry depends – according to the research – on the type of disorder, the age of the patient, and the type of treatment. However, in the big picture, research shows telehealth/virtual care/telemental health is an effective approach for treating mental health disorders: that’s important news for all patients and providers.

We’ll close this article with a quote from an invited commentary by Dr. Jean Yoon, in the editorial letter

“Building the Evidence on Mental Telehealth Care and Health Outcomes,” published by the Journal of the American Medical Association (JAMA):

“While some evidence suggests comparable, or, more rarely, better outcomes with mental telehealth care, the mechanisms behind this association need to be better understood. Telehealth may potentially improve access to mental health care by enabling more frequent visits with practitioners, reducing wait times for appointments, eliminating long travel times to clinics, or addressing other barriers to in-person care. Telehealth may also help remove some of the stigma associated with receiving mental health care or provide an additional level of privacy when treatment occurs online”

In other words, virtual psychiatry – i.e. telemental health – is a major development in mental health care that can have a significant, positive impact on mental health in the U.S. For the most common mental health disorders, such as anxiety and depression, the evidence is clear: virtual psychiatry is effective, here to stay, and when combined with in-person psychiatry, evidence suggests the whole is greater than the sum of its parts.