We conducted a scoping review of the biomedical literature, following the Journal of Biomedical Informatics’ updated methodological guidance [2] and procedures from similar scoping reviews, including formal content and thematic analyses [19-21]. As we were interested in identifying and understanding the nature of published TMH guidelines during the pandemic, we conducted a scoping review with qualitative analysis to identify and synthesize the emerging literature. As a preliminary step, we reviewed existing literature to ensure that our research aims and timeline had not already been addressed. We searched the PubMed/MEDLINE and ScienceDirect databases for reviews using keywords related to our aims and found none [22].

We searched the PubMed/MEDLINE and ScienceDirect databases on March 14, 2022, and again on July 16, 2024. Search strings included “(tele*[Title]) AND (guid*[Title])” and “(tele*[Title]) AND (practic*[Title])” in Pubmed/MEDLINE, “(telemedicine OR telehealth) AND (guide OR guidance OR guiding)” in ScienceDirect, and “(telemedicine OR telehealth) AND (practice OR practical OR practicing)” in ScienceDirect. We limited search results to articles published between January 1, 2020, and July 16, 2024, and restricted the search to titles only. No other restrictions were applied. Three researchers (TO, JI, and HW) conducted the searches and used database features to export the results into CSV files, which were then merged into an Excel spreadsheet (Microsoft Corporation). The search results from the 3 researchers were compared to ensure consistency.

We included articles if they were available in English and provided recommendations, best practices, or guidelines for mental health via telemedicine. We excluded articles if they were duplicates, if their primary focus was unrelated to TMH care, if the article was a brief editorial introduction to a particular journal section, or if the entire article could not be located through the University of Florida library or interlibrary loan service. We applied the Healthcare Provider Taxonomy of the National Uniform Claim Committee [23] to article titles and abstracts to identify records relevant to mental health. This was done to focus solely on work directly defined as mental health. One researcher (TO) applied the group/individual taxonomy to each article title; in cases where the title was ambiguous, the researcher also considered the abstract. The research team reviewed the results for accuracy. Two researchers (TO and JI) independently reviewed the articles for selection. Final exclusions were made during the full-text review.

We extracted the entire content of the articles, including guidelines and recommendations for TMH health care practice, for qualitative analysis. We then conducted both content analysis and thematic analysis [3-5]. The content of each article was reviewed to identify principles, proposals, suggestions, advice, or considerations to promote TMH practice, using MAXQDA (VERBI GmbH), a qualitative coding and analytic platform [6]. Two researchers (TO and JI) independently reviewed the articles to identify practice guidelines and key themes through content and thematic analyses [21, 24-28].

One researcher (JI) coded each full-text article based on the 3 questions above. The content analysis focused on (1) changes advised or guidelines recommended for TMH providers (research questions 1 and 2), (2) facilitators and benefits related to telemedicine usage (research question 3), and (3) concerns and barriers to telemedicine usage (research question 3) [26]. These 3 categories were chosen because they generally capture topics found in the guidelines and recommendations of the resulting articles. We developed a codebook based on the expected definitions of these topics and revised the codebook with each iteration of coding (see Table 1 for the codebook).

After the initial content analysis, a single reviewer (JI) completed another iteration of coding using thematic analysis to capture emergent topics within the 3 content analysis codes. The thematic analysis focused on items already identified in the content analysis, using techniques such as repetition of concepts, typology, metacoding, missing data, and cutting and sorting [26, 28]. For all coding, the unit of analysis was meaningful phrases—including bulleted lists and entire paragraphs. One author (JI) completed 3 iterations of content and thematic analyses. The codebook and coding were reviewed and refined by the research team for consistency and accuracy (see Table 1 for the codebook with exemplar quotes). Using frequency by recording and metacoding, we categorized the codes into themes, subthemes, and topics [27].

Given the generalized focus on characterizing the existing literature on TMH guidelines and recommendations, the scoping review does not include a formal quantitative synthesis or an assessment of the risk of bias. Instead, we used the results from content and thematic analyses—in the form of themes, subthemes, and topics—to answer our research questions.

Our initial search identified more than 1300 articles (see Figure 1 and Multimedia Appendix 1). We excluded 158 duplicates and 221 articles during the title and abstract screening, resulting in 969 articles for full-text review. By applying the Healthcare Provider Taxonomy of the National Uniform Claim Committee, we excluded 864 articles related to other medical specialties, focusing on 105 articles for TMH guidelines [23]. During the full-text review, we excluded an additional 29 articles: 8 due to the inability to access the full text and 21 because the article topic did not meet the inclusion criteria. We exported the final 76 articles to MAXQDA for content and thematic analyses.

The final articles were predominantly written in 2020 (28/76, 37%) and 2021 (28/76, 37%), with 11 published in 2022, 8 in 2023, and 1 in 2024. We found only a handful of journals that repeatedly published articles relevant to the scoping review: Australasian Psychiatry (n=5), Archives of Clinical Neuropsychology (n=5), Journal of the American Psychiatric Nurses Association (n=4), Indian Journal of Psychological Medicine (n=5), Behavior Analysis in Practice (n=3), Telemedicine and e-Health (n=2), Cognitive and Behavioral Practice (n=2), JMIR Mental Health (n=2), Contemporary Family Therapy (n=2), International Journal of Medical Informatics (n=2), and Indian Journal of Psychiatry (n=2). Over half of the resulting articles were original research (39/76, 51%), followed by viewpoints and reviews (15/76, 20%), guides and suggestions (13/76, 17%), and systematic or scoping reviews (9/76, 12%). A total of 27 original research articles were published between 2020 and 2021, and 12 were published between 2022 and 2024. We found 47 different organizations cited by the resulting articles, with the APA referenced 10 times [7-13, 16-18], the ATA mentioned 3 times [8, 9, 17], and the International Organization of Psychophysiology and Cognitive Sciences (IOPC) [13, 17], Centers for Medicare & Medicaid Services (CMS) [9, 12], Centers for Disease Control and Prevention (CDC) [9, 12], Institute of Medicine [14, 16], and Telemedicine and Psychiatry Operational Guidelines 2020 cited 2 times [15, 19].

Content and thematic analyses yielded 2483 codes, with the majority found in Changes Advised (1366/2483, 55.01%). For this scoping review, however, we focus on code presence within a record rather than total frequency (see Figure 2). While all resulting records had Changes Advised codes, 40 out of 76 (53%) included specific Concerns, and 36 out of 76 (47%) included Facilitators (see Figure 2 and Table 1 for the codebook). Over the 3 iterations of coding, we identified 8 subthemes in Changes Advised, 7 in Facilitators, and 6 in Concerns. Each subtheme included topics of discussion relevant to the subtheme.

This scoping review aimed to identify the types of guidelines and recommendations available to providers in peer-reviewed sources, highlight the most common recommendations presented, and examine notable benefits and challenges associated with TMH guidelines. We analyzed TMH guidelines and biomedical recommendations published between 2020 and 2024, identifying key themes based on their frequency across the literature, and categorized the types of guidance available to providers during that time. Through content and thematic analyses, this study identified 3 main themes along with their associated subthemes and topics. Our findings highlight Concerns and Facilitators of TMH that were directly addressed by published guidelines, as well as overarching patterns in TMH guidance from 2020 to 2024. Using a qualitative approach, we presented these elements not only by frequency but also by their relevance within the broader thematic structure. Notably, our review found that the most frequently cited Facilitators of TMH care was its ability to increase access for isolated and vulnerable patient populations [8-10, 14, 16, 17, 19-22, 24-34]. Concerns focused on Provider-Centered Barriers, including the lack of visual and physical cues during sessions, as well as environmental and technological limitations that made TMH care inaccessible for certain patient populations [9, 17, 18, 22, 24, 28, 29, 32-34, 41, 44-46, 48, 49, 52-54]. The Changes Advised theme responded directly to these concerns by presenting solutions and actionable recommendations aimed at addressing the identified challenges. Among the most prominent recommendations identified in the 76 articles were the call for Further Research across all aspects of TMH care and the need for comprehensive telemedicine education for providers at various levels [8-12, 14, 17-22, 24, 26-28, 31-34, 37-42, 44-47, 50-64, 67, 68, 70-81].

While all included articles offered at least some form of recommendation, only a few provided concrete, step-by-step guidelines. Among these, some offered guidance specific to certain treatments [10, 34, 35, 37, 49, 55, 58, 63, 69], 1 provided instructions for using the Zoom platform for telemedicine delivery [67], and others outlined general best practices for providers [7, 12, 16-18, 24, 25, 32, 36, 37, 42, 55, 63, 67-69]. This range of guidance highlights the extent to which TMH care can differ from traditional in-person visits.

The guidelines generally appeared to draw on information and rules of thumb from trusted organizational resources, serving as a conglomeration of established best practices. Across the reviewed literature, we identified 47 distinct organizations cited as sources for developing TMH recommendations and guidance. Several organizations were referenced multiple times, including the APA, ATA, IOPC, CMS, CDC, the Institute of Medicine, and the Telemedicine and Psychiatry Operational Guidelines 2020 [7-19, 63]. The reliance on multiple trusted organizational resources in place of direct clinical evidence highlights a significant need for more empirical research that links specific telemedicine practices to measurable outcomes. Furthermore, the higher number of original research articles published between 2020 and 2021—compared with the 3 subsequent years combined—suggests that while evidence is beginning to emerge, the momentum for generating new data may have slowed. The guidelines we assessed covered a broad range of topics, from providing patient orientation for telemedicine to outlining best practices for developing therapy plans and engaging with patients during virtual visits. These resources seem to serve as foundational tools—offering insights into essential technology requirements, availability, and general checklists to help ensure the delivery of high-quality care. However, to truly meet the complexities of telemedicine, more detailed and tailored guidelines will be needed. In the future, comprehensive TMH protocols may need to be developed not only for individual countries but also adapted at the state or territorial level, depending on specific regulatory frameworks. These future guidelines must also account for therapist compliance with local laws and professional standards.

In the review, we found 9 step-by-step guides focused on specific TMH treatments. For example, Smith et al [37] developed a guide for virtual family play therapy, focusing on “recommendations for assessment, therapy structure, therapist roles, session preparation, and how to use virtual tools to enhance treatment.” These guides are ultimately recommendations and have yet to be assessed for validity. As more step-by-step guides become available, there should be a parallel initiative to evaluate their quality and validity. Such efforts would help ensure that providers deliver evidence-based, high-quality TMH care. Developing these guidelines would also support the systematic provision of care that incorporates innovative techniques and remains ethically sound.

Finally, the guide on how to use a particular telemedicine platform successfully for TMH care addressed the “gap in support” [67]. While telemedicine platforms may offer their own guides, question-and-answer sections, and other customer support services, it is important to explore platforms specifically designed to facilitate TMH practices. Within these platform-specific guidelines, the development of specialty resources—such as a TMH guide—would help ensure high-quality care and address many of the concerns raised by providers, including technical aspects of telemedicine use and how to recognize visual and auditory cues from patients [37]. After all, platforms may have different features and technical aspects that can impact TMH care. For example, platforms have been shown to exhibit acoustic differences [82]. If providers are unaware of such variations in audio or visual quality, their ability to deliver effective care may be hindered.

It is unsurprising that 59 of the 76 (78%) peer-reviewed publications stated the need for Further Research to support the success of TMH care; however, the necessity of acting on this recommendation is critical. While a general call for robust telehealth evaluation has been cited [24, 31, 32, 34, 38, 44, 52, 55, 60, 61, 64, 68, 70, 77, 78, 80], our review highlights the many specific facets of TMH care that still require investigation. Evaluations of TMH care must consider both patient and provider perspectives [61]. Researchers and clinicians should strive to evaluate and validate the assessments, exercises, and treatments used in TMH care to ensure the highest quality of care and to identify best practices [11, 17, 18, 31, 32, 34, 44, 51, 52, 55, 62, 63, 67, 72, 75, 79, 80]. Although original research publications providing evidence-based recommendations are on the rise, the guidelines themselves have not undergone significant changes—though the ATA and APA guidelines have been consistently updated. While major revisions may not be necessary, a maintained and regularly updated resource list of evidence-based telemedicine practices should be available to providers. As Sperling et al [44] noted, “scientific studies examining the reliability and validity of tele-np-t [tele-neuropsychological testing] are outnumbered by published editorials, white papers, descriptive reports of institutional practices, and/or practice surveys related to tele-np...[it is] imperative that professionals...turn their expertise and attention to conducting well-designed experimental studies.” Naturally, evaluations must be conducted via telemedicine and across different countries to assess and account for the impact of language, culture, and socioeconomic factors in TMH care [62]. As Law et al [51] pointed out, different TMH techniques should be evaluated and compared to determine which telemedicine approaches work best for specific patients, providers, and scenarios.

The articles included in the scoping review highlight that, although telemedicine research has been conducted in the past, the existing evidence does not adequately support current practice. With the rapid uptake of telemedicine due to the COVID-19 pandemic, it now encompasses far more dimensions and considerations than the current body of evidence can fully address. As Finley et al [59] and other authors have noted, while the literature demonstrates positive, evidence-based outcomes with TMH care, further large-scale research is needed to determine whether these outcomes are generalizable beyond the original studies—and whether TMH practices are ultimately “sustainable long-term despite short-term feasibility” [32, 33, 52, 59, 78]. Further research is needed on how guidelines, protocols, and best practices are developed and implemented at professional, organizational, and national levels. Pre–COVID-19 studies explored telemedicine as an emerging technology; however, its current state reflects widespread adoption without clear guidance for direct integration into practice.

While COVID-19 served as the catalyst for significant regulatory upheaval and changes in telemedicine-related laws to ensure the protection of both providers and patients, none of the articles proposed changes to the laws and regulations. Of the 28 articles that discussed laws and regulations, all focused on complying with current legal requirements. There was an emphasis on providers’ understanding of the laws in their region [7, 11, 12, 16, 17, 25, 52, 63, 66] and the idea that any recommendations presented in the articles should never supersede laws or ethics [17, 35, 63]. However, no mention was made of the need for regulatory changes. Interestingly, several articles recommended reviewing and revising the ethics surrounding TMH care provision [14, 15, 17, 18, 29, 33, 51, 53]. We infer that, due to the unknowns and the use of emergency protocols by nations, authors chose to omit recommendations for regulatory and policy changes. However, the suggestions for revisions in ethical standards indicate a need to reconsider legal standards as well. For example, Singh and Sagar [53] noted that, although guidelines may be available, it is not necessarily the case that the practitioner has had the opportunity to adequately train or qualify to provide TMH care [53].

Although we did not observe a direct call for changes in regulatory standards, we did note recommendations for updating patient consent forms and ensuring that patients understand the limitations of TMH care [7, 10, 11, 13, 17, 18, 25, 29, 63]. Fox-Fuller et al [18] emphasized that providers must “weigh ethical considerations when determining” whether TMH care is appropriate and should include potential limitations in care within the informed consent. They also pointed out another recommendation supporting changes to APA standards and the ethical principles of TMH assessments [17, 35, 63]. Such recommendations not only suggest potential policy and regulatory shifts but also highlight the need for telemedicine education, as well as consideration of accessibility and inequities in care. Practice guidelines focus on reminding providers to be mindful of laws and regulations but generally do not offer recommendations for legal and regulatory changes, as they are intended to guide care.

Telemedicine may not be a new technology, but its widespread use became prominent in 2020. It incorporates many levels of innovation, such as the integration of new technologies with telemedicine [10, 11, 18, 19, 33, 42, 44, 54, 66, 67], the development of new exercises for patients [18, 27, 34, 45, 66, 67], and the screening of patients for successful telemedicine use [7, 18, 42]. For a provider to use these innovations effectively, some form of training is necessary. Interestingly, only 17 out of the 76 (22%) articles directly discuss the need for telemedicine-specific training. This result may reflect both the novelty of the widespread use of telemedicine and the emphasis on developing guidelines and recommendations for immediate use by providers.

Some articles addressed the need for formal educational processes, such as medical school education or continuing medical education [7, 11, 16-18, 25, 27, 34, 36, 37, 45, 46, 63, 64, 66, 67, 70], while others highlighted more immediate forms of education available during the pandemic, such as webinars or consulting with colleagues experienced in telemedicine [11, 17, 18, 36, 63]. The guides and best practices that emphasized greater integration of telemedicine into formal education echo the theme that there is a need for evidence-based outcomes and assessments of validity to develop successful education programs. Tailoring education to specialty practice concerns and needs can be achieved through diligent research [34, 46, 63]. Understanding the necessary adaptations of platforms, exercises, and treatments is essential for TMH care, but it is also important to consider the cultural and socioeconomic aspects of both providers and patients [16, 34]. While knowledge of cultural mannerisms may be critical in care—especially as providers can broaden their patient base through telemedicine—there must also be consideration of patient accessibility and health disparities in the context of telemedicine [16].

Telemedicine is often credited with increasing access to care for patients and reducing health disparities and inequities [83]. However, with the rise in telemedicine research during the pandemic, inequities and disparities in health became more apparent [84-86]. In our literature search, we found 32 articles that highlighted the need to consider accessibility in various forms—such as the need for interpreters, providers who can communicate in multiple languages, patients requiring the appropriate equipment for successful care, and the need for a distraction-free space [7, 11, 13, 17, 18, 27, 60, 61]. Of these 32 articles, 19 focused on sociocultural considerations. For example, Comer [28] noted that providers need expanded sociocultural training, as “telehealth offers new opportunities to treat individuals in underserved communities.” When providers are unable to adequately meet their patients’ needs, a barrier is created—one that is often most acutely felt by underserved populations [48]. Zhu et al [47] described a revealing need centered on increasing accessibility: “A report published by the Rural Policy Research Institute outlined a need for research to understand the acceptability for long-term TMH service use among rural adults, especially those who are older or racially/ethnically diverse. This also includes studying how to adapt evidence-based treatments to a cultural context and video-based platform.” Once again, the need for more research to determine best practices—especially when considering care inequities and health disparities in telemedicine—is critical. Looi et al [21] also highlighted this vital consideration: “Sensitivity to cultural, health and socioeconomic disparities is also needed to avoid inequities in access.” Not only is sociocultural and socioeconomic consideration necessary in telemedicine implementation, but it should also be integrated into all aspects of the telemedicine visit. This includes providers’ understanding of whether a certain treatment or assessment may be less effective due to cultural factors or obstacles [11]. As telemedicine has become more widely used, new research at larger scales will provide a better understanding of how to effectively increase access to care without exacerbating care inequities and health disparities. With only 19 out of 76 (25%) articles discussing sociocultural and socioeconomic factors in telemedicine implementation, there is a clear need for further research to address this gap in the literature.

This scoping review aimed to provide a snapshot of the guidelines and recommendations produced for providers between 2020 and 2024. Future research could determine whether these themes were addressed through a larger, comprehensive systematic literature review. We intended was to identify what providers could easily find and access within peer-reviewed biomedical databases. As a result, our review is limited to guidelines published between 2020 and 2024. Because of the large number of results from our general search strategy, we conducted a title-and-abstract screening. Outside of the exclusion and inclusion criteria, we did not validate the resulting articles. Future research, particularly systematic reviews, should consider the types of guidelines available for providers; the types of assessments, guidelines, checklists, and techniques that are validated for TMH care; changes in the guidelines over time, especially beyond our restricted 2-year review; and evidence of the sustainable and successful implementation of TMH care in practice.

This scoping review of 76 articles characterizes the TMH guidelines published between 2020 and 2024 and identifies key, shared recommendations to support the implementation and success of TMH care. We applied systematic qualitative analyses to better understand the most frequently noted themes in the resulting peer-reviewed literature and how they contribute to successful TMH care. This methodology also helped identify how key themes are interconnected and build upon each other. Research at larger scales is essential to develop effective guidelines and protocols for successful therapy plans and to ensure that telemedicine does not exacerbate health inequities. Future research should examine how TMH guidelines have adapted and changed in response to provider and patient needs, how these guidelines address accessibility and inequities, and how they account for regional and international variations.