Client perspectives: Telehealth for mental health services

Abstract

Objective

The COVID-19 pandemic required mental health clinicians globally to transition to the delivery of care via telehealth. This study aimed to gain an understanding of clients’ satisfaction with and attitudes towards telehealth mental health services.

Method

Seventy adults who had attended a clinic for mood and anxiety disorders, and participated in at least one telehealth consultation with a psychologist or psychiatrist, completed an anonymous online survey.

Results

The majority of participants (81.5%) reported satisfaction with telehealth mental health care provided during the COVID-19 pandemic. However, satisfaction overall was significantly higher amongst participants who had received both telehealth and face-to-face mental health care, compared to participants who received care via telehealth only. Advantages of telehealth care reported included convenience and increased access to mental health clinicians. However, disadvantages of telehealth care included greater difficulty developing a rapport with a clinician and expressing oneself via telehealth.

Conclusions

Whilst client satisfaction with telehealth mental health care for mood and anxiety disorders is generally high, clinicians should consider the limitations of telehealth from clients’ perspectives. In particular, strategies to enhance therapeutic connection during telehealth sessions may be needed, and client preferences for mode of delivery should be taken into consideration when possible.

Keywords

telehealth telepsychiatry mental health clinical psychiatry depressive disorders

Globally, mental health conditions are not only highly prevalent but also severely underserviced.¹ The COVID-19 pandemic not only led to an increase in anxiety and depressive disorders but also created a severe disruption to mental health services.¹ However, one opportunity that has arisen from the COVID-19 pandemic is the recognition of the potential role of telehealth to improve access to mental health care.^2,3 In Australia, as with many other countries, mental health clinicians were required to rapidly transition to the delivery of services via telehealth.^4,5 Worldwide, there is now increasing recognition of the need to understand how to best utilise telehealth for mental health services beyond the COVID-19 pandemic.

Several studies have described the experiences and attitudes of clinicians delivering telehealth mental health services.^4,6 However, it is also important to gain an understanding of clients’ experiences and their satisfaction with and attitudes towards telehealth mental health services. For example, the limited research to date has identified that whilst client satisfaction with telehealth mental health services is high overall, those participating in video-conferencing were more likely to consider continuing remote treatment than those participating in telephone consultations.⁷

This study aimed to explore the perspectives of clients of an outpatient clinic for mood and anxiety disorders regarding telehealth mental health care. Specifically, the study aimed to examine clients’ satisfaction with the care they received overall, and with telehealth services in particular. Clients’ perspectives of the advantages and disadvantages of both telehealth and face-to-face mental health care were also investigated.

Methods

Participants

Participants were adults who had (i) attended at least one session with a psychiatrist and/or psychologist at a clinical service for mood and anxiety disorders, via telehealth or face-to-face, in 2020 or 2021; (ii) were aged 18 years or older, (ii) could read and write in English and (iv) provided informed consent online to participate. The study was approved by a Human Research Ethics Committee (HREC#:210649). Analyses were restricted to the N = 70 survey respondents who had attended at least one of their consultations via telehealth. Participant characteristics and service usage are reported in Table 1.

Table 1.

Participant characteristics and clinical service usage (N = 70).

	n	(%)
Gender
Female	48	(68.6)
Male	19	(27.1)
Non-binary	2	(2.9)
Unknown	1	(1.4)
Age
18–24 years	10	(14.3)
25–34 years	15	(21.4)
35–44 years	14	(20.0)
45–55 years	15	(21.4)
55–64 years	13	(18.4)
65 years and over	3	(4.3)
Services received from an outpatient clinic for mood and anxiety disorders
Psychiatrist only	36	(51.4)
Psychologist only	19	(27.1)
Psychiatrist and a psychologist	13	(18.6)
Attended all sessions via telehealth	53	(75.7)
Attended both telehealth and face-to-face sessions	17	(24.3)
Number of sessions attended	mean	(SD)
Telehealth sessions	6.13	(6.22)
Face-to-face sessions	6.71	(6.62)

Procedure

Data was collected in April 2022. Eight hundred and two adults who had attended the clinical service in 2020 or 2021 were emailed an invitation to participate in an anonymous online survey. The mixed-methods survey included measures of satisfaction and open-ended questions regarding telehealth and face-to-face mental health services. The sample of N = 70 participants included in analyses (who had attended at least one of their consultations via telehealth and completed measures of satisfaction) was thus 8.7% of past clients invited to complete the survey.

Measures

The survey included three measures of client satisfaction. Two were measures of overall satisfaction: (i) the Yes Survey⁸ and (ii) the Client Satisfaction Questionnaire-8 (CSQ-8).⁹ The third measure specifically assessed clients’ satisfaction with the telehealth mental health consultations they had received from the service: (iii) Telehealth Usability Questionnaire (TUQ).¹⁰ The TUQ asks respondents to rate 21 items on a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree). A response of 5 to 7 indicates an agreement with a statement.¹⁰

The survey also included questions regarding demographics, the number of consultations with a psychiatrist and with a psychologist, the number of consultations via telehealth and via face-to-face and barriers to both telehealth and face-to-face mental health care. Open-ended questions in the survey asked participants about their experiences with telehealth and face-to-face mental health consultations with the service, including the advantages and disadvantages of both telehealth and face-to-face consultations.

Statistical analyses

Quantitative data were analysed using IBM SPSS program (version 24). Descriptive analyses and independent t-tests were conducted to examine for any differences in client satisfaction scores between clients who had telehealth sessions only and those who had both telehealth and face-to-face sessions. Statistical significance was defined as p < .05. The qualitative survey data was analysed using an inductive thematic analysis (i.e. allowing the data to determine the themes) with a semantic approach (i.e. analysing the explicit content).^11,12 Two researchers independently conducted coding across the whole dataset and reviewed the data again once a structure of themes, sub-themes and codes was agreed upon. Any differences in categorisation were discussed until an agreement was reached.

Results

Satisfaction

Table 2 presents the means and standard deviations of the total scores of the three client satisfaction measures, and the subscale scores for the YES Survey⁸ and the TUQ,¹⁰ amongst (i) those who received mental health care via telehealth only and (ii) those who received care via both telehealth and face to face. Table 2 also presents the results of two-tailed independent t-tests conducted to examine for any differences in client satisfaction scores between these two groups. Participants who had both telehealth and face-to-face mental health care had significantly higher total scores on the YES Survey and the CSQ-8, and significantly higher scores on both subscales of the YES Survey (p < .001) than participants who received mental health care via telehealth only. However, there were no significant differences between the two groups in mean scores on the TUQ, which specifically assessed satisfaction with telehealth care.

Table 2.

Satisfaction scores in participants receiving mental health care via (i) telehealth only and (ii) telehealth and face-to-face.

Measure	Subscale	Telehealth		Telehealth and F2F		t	df	p
Measure	Subscale	N	Mean (SD)	n	Mean (SD)	t	df	p
YES		52	75.87 (26.38)	16	98.81 (14.90)	4.395	45.450	0.000
	Outcome	53	6.72 (4.01)	17	10.71 (2.64)	4.722	41.471	0.000
	Experience	52	69.06 (23.18)	16	88.13 (13.50)	4.091	43.917	0.000
CSQ-8		49	21.98 (8.99)	17	29.59 (2.60)	5.316	62.950	0.000
TUQ		48	114.79 (28.68)	17	117.82 (30.57)	0.368	63.000	0.714
	Usefulness	48	5.91 (1.40)	17	5.88 (1.62)	0.065	63.000	0.948
	Ease of use	48	5.77 (1.36)	17	5.79 (1.48)	0.059	63.000	0.953
	Effectiveness	48	5.30 (1.56)	17	5.62 (1.38)	0.746	63.000	0.459
	Reliability	48	4.51 (1.57)	17	4.77 (1.65)	0.561	63.000	0.577
	Satisfaction	48	5.36 (1.50)	17	5.54 (1.56)	0.417	63.000	0.678

YES = YES Survey; CSQ-8 = Client Satisfaction Questionnaire-8; TUQ = Telehealth Usability Questionnaire; F2F = face-to-face.

On the TUQ, 81.5% of participants agreed that they were satisfied overall with the telehealth services provided by the mental health service and 80.0% reported that they would use such telehealth services again.

Barriers to telehealth and face-to-face mental health care

Table 3 presents the proportion of participants who endorsed potential barriers to telehealth and face-to-face mental health services. Participants were presented with a list of possible barriers and asked to select as many that applied to them.

Table 3.

Barriers to telehealth and face-to-face mental health care.

Barrier	n (%)
Barriers to face-to-face mental health care
Distance/travel	44 (62.9%)
Time/my availability	31 (44.3%)
Work commitments	25 (35.7%)
Lack of available services in my area	23 (32.9%)
Restrictions in service availability related to COVID-19	22 (31.4%)
Cost	17 (24.3%)
My concerns related to COVID-19	11 (15.7%)
No barriers	7 (10.0%)
Other barriers	7 (10.0%)
Need for childcare	2 (2.9%)
Barriers to telehealth mental health care
I feel there is a lack of connection/rapport with my clinician	25 (35.7%)
No barriers	24 (24.3%)
Lack of stable internet connection	14 (20.0%)
Video quality issues	9 (12.9%)
Confidentiality and privacy issues	7 (10.0%)
Lack of experience with telehealth services	5 (7.1%)
Lack of suitable equipment	3 (4.3%)
Other barriers	2 (2.9%)

The most frequently reported barriers to face-to-face mental health care were distance/travel (reported by 62.9% of participants) and time (44.3%), whereas the most frequently reported barrier to telehealth mental health care was a feeling of a lack of connection or rapport with the clinician, which was reported by over a third (35.7%) of participants.

Qualitative results: Advantages of telehealth and face-to-face mental health services

Thematic analysis of the qualitative data resulted in the generation of core themes and sub-themes. Table 4 presents the main themes, sub-themes and selected examples of participant statements. As outlined in Table 4, the sub-themes regarding the advantages of telehealth delivery of mental health care included convenience, accessibility, a preference for telehealth due to the symptoms of depression and anxiety and reduced concerns about exposure to COVID-19. The sub-themes regarding the advantages of face-to-face mental health care included better communication, rapport and connection with a clinician, a perception by some participants that there was more accurate assessment and understanding by clinicians and more progress made in therapy and advantages of a clinic location. Conversely, some participants reported that they felt more relaxed and able to focus when taking part in telehealth consultations from home.

Table 4.

Advantages of telehealth and face-to-face mental health care: Themes, sub-themes and selected examples of participant statements.

Sub-theme	Selected examples
Theme 1: Advantages of telehealth

Subtheme 1.1: Convenience
• The ability to have the consultation from home • Less travel and time involved • Reduced incidental costs (eg parking) • Easier to fit into work • The ability to attend from any location or if sick	‘Easier to fit in around work, I used to have to take a half day off for an appointment. With telehealth I was able to cut that back to 1.5 hours or so off work’ (Participant 62)‘It is easy and convenient. I can be anywhere at any time, and can also attend whilst feeling sick’ (Participant 34)‘I could feel relaxed talking to my therapist from my couch and the comfort of my room’

Subtheme 1.2: Improved accessibility
• Greater access to clinicians if living a long distance away, particularly in rural or regional Australia • Continuity of clinician if the clinician or patient move • Enables access to care if have poor physical mobility • More likely to attend if the session is via telehealth • Shorter waitlists for telehealth appointments	‘Access is the main benefit. There is a major deficit of mental health services in my city’ (Participant 4)‘I live in a rural setting and could not see a suitable mental health professional by any other means’ (Participant 15)‘I prefer telehealth over face-to-face. Some days are just too hard to make the trip into the [clinic] office. Having telehealth as an option means I’m more likely to attend the sessions (and therefore, receive the help I need)’ (Participant 63)

Subtheme 1.3: Telehealth preferable due to symptoms of mental illness
• Telehealth is preferable if finding it difficult to leave the house due to symptoms of anxiety (eg social anxiety) or depression (eg fatigue) • Reduced stress associated with travel fatigue (eg finding a park and getting lost)	‘If I have a low mood and don’t want to leave the house instead of cancelling I can still get the help I need through telehealth’ (Participant 38)‘With a history of anxiety and agoraphobia - it can be very difficult for me to leave my home for F-t-F appointments. I am much more likely to attend sessions if via telehealth’ (Participant 62)‘No travel, no parking, no getting lost all means less anxiety’ (Participant 35)

Subtheme 1.4: Reduced concerns about COVID-19
• Reduced concerns about exposure to COVID-1	‘Covid-safe; no risk of infection while in the waiting room or during the appointment’ (Participant 49)

Theme 2: Advantages of face-to-face mental health care

Subtheme 2.1: Better communication, rapport and connection with a clinician
• Building a relationship and sense of connection with a clinician is easier • Feel more comfortable expressing oneself • The ability to read body language is easier • More real or genuine • It can be easier to start with face-to-face sessions to build an initial connection with a clinician and then transition to telehealth sessions	‘Just being in the same room and feeling connected and really supported. For me there is no comparison. As humans beings we need to interact with each order, more so when traumatic events are happening in our lives’ (Participant 21)‘I feel like it gives both parties a better understanding of each other, including body language and tone’ (Participant 20)‘I do agree that telehealth works well but mostly with individuals I have met face-to-face before other methods. Having had some personal connection first makes it easier to connect later as though the same’ (Participant 61)

Subtheme 2.2: More accurate assessment and understanding by clinicians
• Better assessment by clinicians • It is harder to ‘mask’ or pretend that one is well in face-to-face sessions • Physical examination possible if required	‘The ability of the psychologist to see my level of agitation expressed physically (such as rocking and stimming)’ (Participant 15)‘[Telehealth] makes it easy to “mask”’ ‘“Pretend” to be doing better than I really am’ (Participant 13)

Subtheme 2.3: More effective
• More progress can be made in face-to-face therapy sessions • Face-to-face therapy sessions can be perceived as more effective	‘I am an old school person and for me face to face meetings of any kind are more productive’ (Participant 20)

Subtheme 2.4: Advantages of a clinic location
• Greater privacy • Preference for a separate location to everyday life for mental health care • Benefits to mental health in leaving the house and interacting with people • Travel time allows to prepare and wind down from a mental health consultation	‘Being able to attend in a dedicated space, no disruptions or noises unlike telehealth’ (Participant 55)‘Travel time to and from appointments helps to prepare and wind down’ (Participant 40)‘Being in their office offers a sense of confidentiality more so than sitting in my bedroom in my sharehouse’ (Participant 6)

Theme 3: Experiences during telehealth

Subtheme 3.1: Technology issues
• Technical problems can interfere with focus during a mental health session • When technology works well it can enable a good experience with telehealth	‘…no issues with internet connectivity/lag with video’ (Participant 66)

Subtheme 3.2: Positive experiences during telehealth
• Feeling more comfortable at home can enable greater focus in telehealth consultations • Easier to discuss worksheets shared on screen	‘I’m better able to focus on my health and the purpose of the session, in a space that I find comfortable, without the stress I normally feel commuting to appointments. Further, being limited to a face on a screen makes it feel personal without causing me to be distracted by how the clinician is dressed/sitting/fidgeting/glancing etc’ (Participant 16)

Discussion

This study aimed to gain an understanding of clients’ satisfaction with and attitudes towards telehealth mental health services for mood and anxiety disorders. The findings have implications for the integration of telehealth into routine mental health care. Firstly, the majority (81.5%) of adult clients who completed the study survey reported satisfaction with telehealth delivery of mental health care during the COVID-19 pandemic. Importantly, for some participants, telehealth enabled them to access mental health care when they would not have been able to otherwise, due to geographical location, COVID-19 restrictions, or symptoms of mental illness.

However, satisfaction with clinical services received overall was significantly lower amongst participants who had received mental health care via telehealth only, compared to those who had received both face-to-face and telehealth care. Clinicians should be aware of the limitations of telehealth mental health care. In particular, many participants described greater difficulty developing a rapport with a clinician via telehealth, along with difficulties with expressing themselves and non-verbal communication. This is consistent with the observations of psychiatrists in Australia,^13,14 as well as the findings of surveys of mental health professionals in Australia and New Zealand ^4,15 and clients in the US.⁷ For a small number of participants in our survey, this extended to a sense that less progress was made during telehealth therapy sessions.

The clinical implications are clear. In circumstances where a mixed mode of delivery is possible, it may be beneficial for initial mental health appointments to be face-to-face, in order for a client to develop a relationship with a new clinician. Further, the preferences of clients should be taken into account when possible. However, when telehealth delivery of mental health care is the only option, mental health clinicians should be mindful that it may take longer to develop a rapport with clients and for clients to feel comfortable expressing themselves. Strategies that clinicians may use to enhance therapeutic alliance when delivering mental health care via telehealth may include more regular check-ins with clients and consideration of voice and body language to convey empathy and understanding.¹⁵

The limitations of this study should be noted. There was a possible bias in recall and reporting, given that participants completed the survey between 4 months and 2 years and 4 months after their sessions with the clinical service. This, along with the low survey response rate (of 8.7%), may have impacted the validity of the data. Nevertheless, these findings regarding client perspectives were consistent with previous reports of observations by mental health clinicians, as described above. It should also be noted that whilst our survey was conducted amongst adults with the most common mental health problems, depression and anxiety, it is not known if people with different mental illnesses would report different perspectives. For example, clients experiencing psychosis may report different needs.¹⁶ Further, clients with different demographic characteristics may report different preferences. For example, Indigenous clients of mental health services in remote Australian communities are more likely than non-Indigenous clients to prefer face-to-face consultations to telehealth beyond the COVID-19 pandemic.¹⁷ In addition, limited access to technology may be a barrier to telehealth for clients with socioeconomic disadvantage.¹⁴

Conclusions

The majority of adult clients with mood and anxiety disorders reported satisfaction with telehealth mental health care provided during the COVID-19 pandemic. Telehealth provides a significant opportunity to improve access to mental health services by overcoming barriers such as geographical location and symptoms of mental illness. However, clinicians should consider the limitations of telehealth from clients’ perspectives when integrating telehealth into routine mental health care. In particular, strategies to enhance communication and a sense of connection during telehealth sessions may be needed, and client preferences for mode of delivery should be taken into consideration when possible.

Footnotes

Acknowledgements

We would like to thank the clients of the Black Dog Institute (BDI) Clinical Services who participated in this survey and Dr Claire McAulay for her assistance with data collection and analysis. S.B.H is supported by an NHMRC Investigator Grant (grant no’ 1178666). The BDI Clinical Services are supported by NSW Health.

Disclosure

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical statement

Informed consent

All participants provided informed written consent online.

ORCID iD

Joanna Crawford

References

World Health Organization . World mental health report: transforming mental health for all. Geneva, 2022. World mental health report: Transforming mental health for all (who.int).

Bell

Kaufmann

Malhi

. Telehealth: a new opportunity for out-patient psychiatric services. BJPsych Int 2023; 20: 33–37.

Reay

Looi

Keightley

. Telehealth mental health services during COVID-19: summary of evidence and clinical practice. Australas Psychiatry 2020; 28: 514–516. DOI: 10.1177/1039856220943032.

Farrer

Clough

Bekker

, et al. Telehealth use by mental health professionals during COVID-19. Aust N Z J Psychiatry 2023; 57: 230–240. DOI: 10.1177/00048674221089229.

Looi

Allison

Bastiampillai

, et al. Telepsychiatry and face-to-face psychiatric consultations during the first year of the COVID-19 pandemic in Australia: patients being heard and seen. Australas Psychiatry 2022; 30: 206–211. DOI: 10.1177/10398562211046301.

Connolly

Miller

Lindsay

, et al. A systematic review of providers' attitudes toward telemental health via videoconferencing. Clin Psychol 2020; 27. DOI: 10.1111/cpsp.12311.

Guinart

Marcy

Hauser

, et al. Patient attitudes toward telepsychiatry during the COVID-19 pandemic: a nationwide, multisite survey. JMIR Ment Health 2020; 7: e24761. DOI: 10.2196/24761.

Department of Health, State Government of Victoria . National mental health consumer experiences of care project final report: development and evaluation of a consumer experiences of care survey instrument. Victoria, Australia, 2013. National Mental Health Consumer Experiences of Care Project (amhocn.org).

Larsen

Attkisson

Hargreaves

, et al. Assessment of client/patient satisfaction: development of a general scale. Eval Program Plann 1979; 2: 197–207. DOI: 10.1016/0149-7189(79)90094-6.

10.

Parmanto

Lewis

Jr. Graham

, et al. Development of the telehealth usability Questionnaire (TUQ). Int J Telerehabil 2016; 8: 3–10. DOI: 10.5195/ijt.2016.6196.

11.

Braun

Clarke

. Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern‐based qualitative analytic approaches. Couns Psychother Res 2021; 21: 37–47, DOI: 10.1002/capr.12360.

12.

Chapman

Hadfield

Chapman

. Qualitative research in healthcare: an introduction to grounded theory using thematic analysis. J R Coll Physicians Edinb 2015; 45: 201–205. DOI: 10.4997/jrcpe.2015.305.

13.

Looi

Pring

. Private metropolitan telepsychiatry in Australia during Covid-19: current practice and future developments. Australas Psychiatry 2020; 28: 508–510. DOI: 10.1177/1039856220930675.

14.

Looi

Pring

. To tele- or not to telehealth? Ongoing COVID-19 challenges for private psychiatry in Australia. Australas Psychiatry 2020; 28: 511–513. DOI: 10.1177/1039856220950081.

15.

Bailey

Knowles

Grenyer

BFS

. Efficacy and recommendations for the delivery of telehealth psychotherapy for people with personality disorder. Australas Psychiatry 2023; 32: 125–134. DOI: 10.1177/10398562231222768.

16.

Randall

Raisin

Waters

, et al. Implementing telepsychiatry in an early psychosis service during COVID-19: experiences of young people and clinicians and changes in service utilization. Early Interv Psychiatry 2023; 17: 470–477. DOI: 10.1111/eip.13342.

17.

Amos

Middleton

Gardiner

. Remote mental health clients prefer face-to-face consultations to telehealth during and after the COVID-19 pandemic. Australas Psychiatry 2022; 30: 18–22. DOI: 10.1177/10398562211043509.