Introduction

With the COVID-19 pandemic, there has been an important growth in the use and implementation of remote (telephone and online video) consultations in mental health [1]. This growth is reflected in the almost four-fold increase in literature around remote mental health care between 2018 (n = 201) and 2021 (n = 749). Many studies indicated the negative effects of the pandemic on mental well-being [2,3,4,5]. In this regard, digital technologies may play a key role in the care of psychological difficulties and for providing necessary support, most specifically in a period of quarantine and social distancing. The initiation and promotion of remote (mental) health was considered one way of optimally residing patient contacts during the pandemic, but more studies on the use of remote (mental) health are deemed necessary.

For many mental health care practitioners, the COVID-19 pandemic has been an opportunity towards remote care, being able to implement and evaluate remote mental health in practice. In general, implementation of online video consultations was particularly slow to start but intensified with the increasing length of the pandemic [6]. In a recent study amongst patients and practitioners, online video consultations were deemed overall well-accepted, especially for clinicians working from home [7]. Others indicated rather mixed experiences with the changes of service activity towards remote care, with patients addressing the lack of a therapeutic ‘safe space’ and concerns regarding those with limited technical options and socio-demographic inequalities [3, 8]. Other barriers mentioned by health practitioners included changing workflow routines and schedules, a lack of training, privacy considerations, increased provider and staff acceptance, and reimbursement possibilities for health care providers (6, 9–10). From a health care provider point of view, remote care was deemed satisfactory for quite some respondents (59%), of which the majority indicated being open to the further use of remote care after the pandemic [11]. While remote mental health has been deemed cost-effective (or at least as effective as face-to-face care), studies are generally of poor quality and several barriers of implementation have been noted towards generalizability of findings [12]. In addition, few patient-centered studies were available such that identifying the acceptance and difficulties associated with remote mental health from a patient perspective proves to be challenging.

This study aims to describe and understand the experiences associated with several forms of remote consultations (both telephone and online video) for mental health care during the COVID-19 coronavirus pandemic with psychiatrist and psychologists, focusing in depth on the experiences of patients.

Methods

This study was a web-based survey, presented in Dutch and circulated online from 11 March to 12 October 2021. The study was approved by the Ethical Committee of the University Hospital Brussels (UZ Brussel), number B1432020000152.

The custom-designed survey included demographic questions regarding age, gender, housing and education. It was followed by questions regarding their ongoing mental health consultations: regarding the profession of their therapist (i.e., psychologist or psychiatrist), the nature of the consultations (telephone, online video, face-to-face or combinations) and by who any remote consultations were initiated and whether this was by choice. This section was followed by 13 exploratory multiple-choice questions asking participants to compare previous offline experiences with their experiences with telephone consultations and /or online video consultations, depending on the channel(s) they had reported using. These questions were based on results of a previous study exploring patients’ attitudes using focus groups (Blancke et al., in preparation). Questions were answered on a 5-point Likert-scale, ranging from ‘highly disagree’ to ‘highly agree’. Afterwards, these 13 questions were clustered into four categories. The first and second category focused on advantages for respectively telephone and online video consultations (6 items, αtele = 0.72; αvideo = 0.77) and included statements such as ‘Video consultations made it easier for me to discuss difficult topics’. The third and fourth category focused on disadvantages for respectively telephone and video consultations (7 items, αtele = 0.85; αvideo = 0.86) and included statements such as ‘I found my therapist to be less involved’. A final multiple-choice question (with the possibility to provide multiple answers) probed for patient’s opinions regarding the potential use of online video and/or telephone consultations in a number of situations, e.g., when the patient faces transportation problems or when the patient might feel sad, angry or anxious.

Statistics

Descriptive statistics were reported in terms of absolute and relative frequencies for categorical outcomes, and in terms of mean (M), standard deviation (SD) and range for continuous outcomes. To compare the nature of initiation of the consultations between psychiatrists and psychologists, the chi squared test of independence was used, corrected for multiple testing using the Benjamini-Hochberg (False Discovery Rate (FDR)) correction. To interpret the general stance of the participants for both telephone consultation and online video consultation separately, two-sided one-sample t-tests were conducted, comparing category means with the value ‘3’, which corresponded with a neutral position towards that statement. To compare participants’ feelings towards possible advantages and disadvantages towards telephone and online video consultations, two-sided independent sample t-tests were conducted. To compare telephone and online video consultations for a subsample of participants who reported experiences with both, two-sided paired sample t-tests were conducted. For both analyses, the obtained p values were again corrected for multiple testing using the Benjamini-Hochberg FDR correction. Patient preferences about whether or not they approved the use of telephone or online video consultations in certain situations were described in terms of absolute and relative frequencies. For testing differences between telephone and online video consultations, the chi square test of independence was used again complemented with a correction for multiple testing (Benjamini-Hochberg). All data were analyzed using SPPS (version 26.0).

Results

Participants

A total of 521 patients participated in the survey. Participants who did not report any experience with telephone or online video consultation (N = 142) or were not residing in Belgium (N = 4) were excluded, resulting in 375 participants to be included for data analysis (see Fig. 1). Participants were mainly female (80.0%). The mean age was 40.4 (SD 11.6, range 11–80). Of the 375 respondents, 164 (43.9%) lived with a partner, 78 (20.7%) lived with others than a partner, and 133 (35.4%) lived alone. Of respondents, 2.9% had completed primary education, 26.4% completed secondary education and 70.7% had completed higher education or university.

Fig. 1
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Flowchart with overview of included study participants

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Nature of Consultations

Respectively, 202 participants (53.9%) and 308 participants (82.1%) indicated having visited the psychiatrist or the psychologist during the last year. Furthermore, 145 participants (38.7%) indicated to have visited both a psychiatrist and a psychologist during the last year. In total, 88 participants reported only having had remote consultations with a psychiatrist, 220 participants only with a psychologist, and 67 participants had remote consultations with both.

Regarding psychiatric consultations that were kept by video and/or telephone (N = 155), 105 participants (67.7%) reported on their experiences regarding video-consultations, 36 participants (23.2%) reported on only telephone consultations and 14 participants (9.0%) reported on a combination of online video and telephone consultations. Regarding psychological consultations that were kept by video and/or telephone (N = 287), 241 (84.0%) consulted by means of online video, 30 (10.5%) by telephone and 16 (5.6%) had a combination of online video- and telephone consultations (see Fig. 1). The nature of consultations between psychiatrists and psychologists was statistically different (p < .001) with more use of online video consultations and less face-to-face or telephone consultations by the psychologist.

Psychiatric remote consultations were initiated on request of the treating psychiatrist and psychologist without possibility of choice for 47.0% and 29.1% of respondents, respectively N = 95 and N = 89. Psychological consultations were initiated more often together with the participants’ agreement compared to psychiatrist consultations (54.9% compared to 38.6%, p = .008). Remote consultations initiated solely on the behalf of participants were present in 14.4% (consultation with a psychiatrist) and 16.0% (consultation with a psychologist) of cases. Also here, the person and manner of initiating the consultation was statistically different between psychiatrist and psychologist (\({\chi }_{2}^{2}=17.701\), p<.001).

Patient Experience

To explore the patient experience, results were analyzed for the sample as a whole, irrespective of the professional (i.e., psychiatrist or psychologist) providing the services. Of all the participants, 28.8% of participants saw advantages (average score > 3) regarding telephone consultations, compared to 39.3% for remote online video consultations. Moreover, 49.3% saw clear disadvantages (average score < 3) for telephone consultations and 32.7% for online video consultations. More specifically, for telephone consultations, participants tended to disagree with potential advantages over face-to-face (M = 2.57, SD = 0.76), t(71) = -4.80, p < .001) and took a neutral stance towards potential disadvantages (M = 2.96, SD = 0.95), t(71) = − 0.32, p = .74. For online video consultations, participants again tended to disagree with potential advantages (M = 2.85, SD = 0.79), t(301) = -3.26, p < .002, but also disagreed with potential disadvantages (M = 2.58, SD = 0.91), t(301) = -8.05, p < .001.

When comparing the experiences of the subsample of participants who reported experience with both telephone and video consultations (N = 30), the advantages of video consultations (M = 2.76, SD = 0.72) were considered slightly stronger compared to telephone consultations (M = 2.58, SD = 0.70), t(29) = -2.59, p = .023. No difference in disadvantages was found between online video consultations (M = 2.71, SD = 0.81) compared to telephone consultations (M = 2.93, SD = 0.87), t(29) = 2.12, p = .051.

Patient Preference

When participants were asked regarding the appropriate use of remote consultations, less than 10% of respondents argued that these would never be appropriate. Transportation problems were most mentioned, followed by consultations primarily focusing on medication (for telephone consultations) and for consultations primarily focusing on practical aspects (for online video consultations). Conversations where participants were angry or sad were deemed feasible to be held remotely using telephone for close to a quarter of participants, whereas over one third considered these to be feasibly using online video consultations. Introspective consultations via video were considered feasible by twice as much participants compared to consultations over the phone. A detailed overview about the observed appropriateness according to participants can be found in Table 1. Patients’ perceptions about the possible advantages and disadvantages of telephone and online video consultations are listed in Table 2. Online video consultations were more accepted in comparison to telephone consultations, as the patient did not have to move around to go to the therapist and as it gave a better insight into the home situation. Furthermore, telephone conversations made the interaction shallower, made the participant feel more isolated, made the participant feel more as if the therapist did not understand and sense the participant well, and left the participant with a less involved feeling about the therapist in comparison to online video consultations (p < .05).

Table 1 Appropriate use of remote consultations, according to the personal experience of patients having used telephone consultations (N = 72) and online video consultations (N = 302)
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Table 2 Patients’ perceptions of possible advantages and disadvantages of telephone and online video consultations
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Discussion

This study described specific patients’ experiences associated with remote mental health care consultations (both telephone and online video). In comparison to earlier studies addressing the health practitioners’ perspective regarding remote care as being satisfactory for approximately 59% of health practitioners [11], our study showed a more tempered acceptance towards remote consultations from a patient perspective. However, several situations were deemed positive, for which remote consultations should remain present, including when being faced with transportation issues of when discussing more practical aspects of care or medication. This was in line with earlier reports from practitioners providing them with the opportunity to work from home [7], but also addressing difficulties related to privacy considerations which made remote consultations less ‘attractive’ [6].

The results of this study must be approached with care. There may be a certain response bias as to receiving primarily the more ‘positive’ and ‘negative’ responses, leaving out the more ‘neutral’ ones. In addition, remote consultations may have been appreciated more during the COVID-19 pandemic as they would have been outside of a pandemic, primarily out of fear for contamination and a way of retaining contact for patients residing in loneliness. Also, remote consultations may have been more imposed upon the patients, leaving fewer room for choice by the patient him/herself in terms of the ongoing pandemic. Finally, patients may have been reluctant about sharing personal issues over modalities that provided little or no guarantees of privacy. Our study, however, did not focus on privacy-related disadvantages, which is an item that should be further investigated. Overall, whether the here presented results reflect an overall satisfaction surrounding remote consultation that remains present upon the ending of the pandemic, will need further evaluation in the near future.

One of the challenges for remote mental health care will remain to reach the more vulnerable patient populations, including patients with limited remote access [13]. If these barriers can be countered, remote consultations become a true possibility for integration within standard care [6, 14], going rather towards a hybrid model of patient-centered care integrating both face-to-face and remote care depending on the patient’s needs.

Conclusion

Compared to face-to-face consultations, video consultations were better received by health-care patients compared to telephone consultations, especially when the patient was restricted to home or when the consultation aim included sharing rather straightforward information such as medication. Remote consultations were less well received and offered more barriers when there was a need for a more therapeutic consultation and when discussing emotions. In conclusion, online video consultations compared to telephone consultations performed significantly better, especially in terms of sharing emotions of anger and sadness, although it must be mentioned that the majority of patients tended to disagree with potential advantage over face-to-face contacts and approximately 10% of respondents argued that neither form of remote consultations would ever be appropriate.