The outcomes and cost-effectiveness of telepsychiatry are overall comparable to in-person care across multiple treatment modalities, disorders, and patient groups [1-11]. However, widespread implementation of telepsychiatry has been challenging [12-14], partially due to mental health care professionals’ concerns about patients’ ability to use conferencing devices, lack of sense of closeness/connection, technical problems, and reimbursement and privacy concerns [15,16]. However, barriers related to patient preference are also possible, and the patient perspective is crucial to further characterize implementation challenges. Previous studies showed positive patient satisfaction [17-19] but potential limitations including relatively small sample sizes and/or selection biases in the context of pilot programs or specific services may have limited their generalizability.

Due to the COVID-19 crisis, our health care system and others around the world rapidly transitioned all or almost all in-person visits to remote assessments [20], in an unprecedented context of mental health care professional stress and increased need for mental health services [21,22]. This revolution in telepsychiatry provided a unique opportunity to assess how patients that may not have initially opted for telepsychiatry feel about it. Hence, the aim of this study was to qualitatively assess opinions and attitudes about telepsychiatry of a large sample of patients.

In collaboration with the Vanguard Research Group (VRG), a research consortium specializing in behavioral health, an anonymous survey was distributed to patients using telepsychiatry in 18 hospitals and community centers located in rural, suburban, small urban, and large urban areas in 11 different states across the United States (Connecticut, Florida, Maine, Michigan, New Hampshire, New York, Oregon, Rhode Island, South Carolina, Texas, and Utah). Surveys were distributed through email and/or embedded into the video platform scheduling invitations between the months of April and June 2020, and could be completed electronically, with computers, tablets, or smartphones. Study procedures were deemed exempt by the local Institutional Review Board (IRB#20-0397). Further details can be found on the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [23] listed in Multimedia Appendix 1.

The survey included 11 questions about telepsychiatry use and satisfaction using a 5-point Likert scale, as well as inquiries about both potential challenges and positive experiences (see survey in Multimedia Appendix 2). Descriptive statistics were used to report qualitative survey results. Chi-square tests were used to compare categorical variables. First, omnibus comparisons were conducted by age range and length of care at the same institution. If statistically significant differences were detected, we then tested the individual interactions of interest post hoc. All analyses were conducted using JMP (Version 13, SAS Institute Inc).

The survey was distributed to approximately 14,000 patients, of which 3070 (22%) completed it. In total, 18 surveys were excluded due to the subject disclosing not having used telemedicine. Hence, 3052 surveys were included in the analysis. Patient characteristics are listed in Table 1.

Briefly, 55% of the sample (n=1666) were aged >45 years and the majority of participants (n=2128, 71.1%) had been under care at the institution where the survey took place for ≤5 years (Table 1). Respondents were mostly using telephone (n=1924, 63.7%), followed by video (n=708, 23.4%), and a combination of telephone and video (n=390, 12.9%). When asked about their preferred method of receiving care, respondents preferred the telephone over video (n=1908, 64.1% versus n=1066, 35.9%).

The overall experience was either good or excellent for 2312 (81.5%) of respondents when asked about telephone only and for 1189 (82.2%) when asked about video (Figure 1). Only 127 (4.5%) and 74 (5.1%) respondents rated their experience as “poor” or “very poor” for telephone and video, respectively (Figure 1).

We detected differences in the overall experience by age range in the case of telephone, χ²₂₄ (n=2831)=46.3, P=.004; a lower proportion of patients aged 55-64 years declared their experience as excellent compared to other age groups (n=257, 38.2% versus n=960, 44.3%), χ²₄ (n=2840)=12.8, P=.01. In addition, a higher proportion of patients aged 45-54 years rated their experience as poor compared to other age groups (n=27, 4.2% versus n=55, 2.5%), χ²₄ (n=2840)=10.5, P=.03.

Further, 1922 (63.6%) patients either agreed or strongly agreed with the statement that remote treatment sessions (telephone or video) have been just as helpful as in-person treatment, whereas 1937 (64.2%) of respondents either agreed or strongly agreed with the statement that they would consider using remote treatment sessions in the future (Figure 2). Patients using video were more likely to strongly agree with that statement than those using telephone (n= 570, 38.9% versus n= 273, 29.9%), χ²₄ (n=2605)=29.6, P<.001.

Patients endorsed the lack of commute (n=1406, 46.1%), flexible scheduling/rescheduling (n=1389, 45.5%), reduced likelihood of missing appointments (n=1064, 39.9%), and feeling more confidence/comfort than in person (n=601, 19.7%) as positive elements/advantages of telepsychiatry (Table 2), which did not vary by age (χ²₁₈ [n=4447]=15.4, P=.64) or length of time under care (χ²₉ [n=4413]=10.7, P=.30). Some of the challenges that patients endorsed were related to missing the clinic/hospital (n=936, 30.7%) and not feeling as connected to their doctor/nurse/therapist (n=752, 24.6%), among others (Table 2). Patients under care for less than one year endorsed missing the clinic and feeling connected to it less frequently than other groups (n=195, 21.6% versus n=741, 28%), χ²₆ (n=3550)=21.5, P=.002.

In the free-text comment section, patients generally found telepsychiatry to be safe and convenient, and expressed their gratitude to mental health care professionals for providing uninterrupted care during a very challenging time. Many suggested remote assessments should be maintained, mentioning that they feel more comfortable at home, can express themselves more freely, save transportation time and costs, and/or request less time off work. Others expressed feeling disengaged, feeling frustrated with technical difficulties and having a lack of resources to address them (eg, not owning a laptop or smartphone), difficulty finding a quiet setting (eg, children interrupting, shared housing), getting tests done or filling out forms.