videoconferencing psychotherapy a systematic review

Videoconferencing Psychotherapy: A Systematic Review

Autumn BackhausVA San Diego Healthcare System, San Diego,

California

Zia AghaVA San Diego Healthcare System, San Diego,

California and University of California, San Diego

Melissa L. Maglione, Andrea Repp,Bridgett Ross, and Danielle Zuest

VA San Diego Healthcare System,San Diego, California

Natalie M. Rice-ThorpUniversity of California, San Diego

James Lohr and Steven R. ThorpVA San Diego Healthcare System, Center of Excellence for Stress and Mental Health, San Diego, California

and University of California, San Diego

Individuals with mental health problems may face barriers to accessing effectivepsychotherapies. Videoconferencing technology, which allows audio and video infor-mation to be shared concurrently across geographical distances, offers an alternativethat may improve access. We conducted a systematic literature review of the use ofvideoconferencing psychotherapy (VCP), designed to address 10 specific questions,including therapeutic types/formats that have been implemented, the populations withwhich VCP is being used, the number and types of publications related to VCP, andavailable satisfaction, feasibility, and outcome data related to VCP. After electronicsearches and reviews of reference lists, 821 potential articles were identified, and 65were selected for inclusion. The results indicate that VCP is feasible, has been used ina variety of therapeutic formats and with diverse populations, is generally associatedwith good user satisfaction, and is found to have similar clinical outcomes to traditionalface-to-face psychotherapy. Although the number of articles being published on VCPhas increased in recent years, there remains a need for additional large-scale clinicaltrials to further assess the efficacy and effectiveness of VCP.

Keywords: telehealth, telemental health, telemedicine, videoconference, psychotherapy

One out of every four adults in the UnitedStates meets criteria for a mental disorder(WHO World Mental Health Survey Consor-

tium, 2004), but only 13.4% of adults in theU.S. receive mental health treatment (NationalInstitute of Mental Health, 2011). Many types

Autumn Backhaus, Psychology Service, VA San DiegoHealthcare System; Zia Agha, Department of Family Med-icine, VA San Diego Healthcare System and the Universityof California, San Diego; Melissa L. Maglione, AndreaRepp, Bridgett Ross, and Danielle Zuest, Research Service,VA San Diego Healthcare System; Natalie M. Rice-Thorp,Counseling and Psychological Services, University of Cal-ifornia, San Diego; James Lohr, Psychiatry Service, VASan Diego Healthcare System Center of Excellence forStress and Mental Health and Department of Psychiatry,the University of California, San Diego; Steven R. Thorp,Research Service and Psychology Service, VA San DiegoHealthcare System Center of Excellence for Stress andMental Health and Department of Psychiatry, the Univer-sity of California, San Diego.

This material is based on work supported by the Depart-ment of Veterans Affairs, Veterans Health Administration,Office of Research and Development (Career DevelopmentAward to Dr. Thorp from Clinical Science Research andDevelopment and Merit Review Award DH107-054-2 toDrs. Agha and Thorp from Health Services Research andDevelopment) and the Department of Defense (W81XWH-08-2-0076) to Dr. Thorp. All views and opinions expressedherein are those of the authors and do not necessarilyreflect those of our respective institutions, the Departmentof Veterans Affairs, or the Department of Defense.

Correspondence concerning this article should be ad-dressed to Steven R. Thorp, VA San Diego HealthcareSystem, 8810 Rio San Diego Drive, Mail Code 116A4Z,San Diego, CA 92108. E-mail: [email protected]

Psychological Services In the public domain2012, Vol. 9, No. 2, 111131 DOI: 10.1037/a0027924

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of psychotherapies have been demonstrated tobe effective in treating mental disorders, yetpractical and psychological factors often pre-vent patients from receiving mental health care(Olden, Cukor, Rizzo, Rothbaum, & Difede,2010). One such factor is the location in whichmental health services are available. In theUnited States, 77% of the counties have a se-vere shortage of mental health professionals(Thomas, Konrad, Holzen, & Morrissey, 2009).Another factor is that relatively few providersare trained in the therapies with the greatestempirical support (Shapiro, Cavanagh, & Lo-mas, 2003; Van den Berg, Shapiro, Bicker-staffe, & Cavanagh, 2004), and most of thosetrained specialists reside in metropolitan areas(Wallace, Weeks, Wang, Lee, & Kazis, 2006).This can greatly limit access to care for indi-viduals living in rural areas.

Many individuals do not have the means totravel great distances to seek specialized mentalhealth services, and this problem is com-pounded during times of economic crisis or highfuel prices. In addition, the nature of manymental disorders leads patients to avoid anxiety-provoking situations such as large groups ofpeople (e.g., urban centers, hospitals) and trav-eling on roads (e.g., driving phobias after acci-dents or roadside bomb attacks). Individualsmay be more inclined to seek treatment in fa-miliar and convenient community clinics orfrom the comfort of their homes if those optionsare available to them.

Telehealth refers to the use of technology toprovide health care when providers are geo-graphically distant from patients (Field, 1996;Schopp, Demiris, & Glueckauf, 2006). Manymental health professionals use informationtechnology such as telephones, e-mail, and webforums to communicate with patients. Ad-vanced technology (e.g., computers, smartphones, virtual reality), including videoconfer-ence (VC) technology, may further enhance ac-cess to mental health treatment. The VA HealthCare System has responded to the need for ruralservices for Veterans in part by developing out-patient clinics and Vet Centers in more sparselypopulated areas, but the VA has also emerged asone of the largest providers of telehealth. Infiscal year 2007, there were over 45,000 visitsfor mental health services by telehealth (tele-mental health) in the VA system (Godleski,Nieves, Darkins, & Lehmann, 2008). Reflecting

the high volume of clinical visits via telementalhealth in recent years, the number of publica-tions on telemental health from 2000 to 2008was more than triple the number of publicationsfrom the previous 30 years (Richardson et al.,2009). However, there appears to be a need formore empirical, rather than descriptive, articles.

Videoconferencing psychotherapy (VCP) isone type of telehealth that can offer patientsimproved access to mental health professionalswith specialized expertise (Mair & Whitten,2000). We conducted the current review be-cause, despite the surge in publications, no re-views (to our knowledge) have focused solelyon psychotherapy via videoconferencing. Manydifferent terms have been used when describingpsychotherapy in this format, and we aimed todescribe those terms while synthesizing the lit-erature. Furthermore, it has not been clearwhether articles have been primarily descriptiveor empirical. Because of the expanding litera-ture on this topic and the recent publication ofseveral excellent clinical trials, we saw a needfor a specific and updated review. We chose toperform a systematic review because our aimwas to conduct a thorough review of the avail-able literature, according to a predeterminedprotocol, in order to address very specific re-search questions (Centre for Reviews and Dis-semination, 2009; Kitchenham, 2004). Consis-tent with the goals in conducting a systematicreview, we focused on identifying, appraisingand synthesizing research-based evidence andpresenting [it] in an accessible format . . . fromwhich conclusions can be drawn and decisionsmade (Higgins & Green, 2011, para. 1.2.11.2.2). The review protocol includes specificsearch strategies, including the use of strict in-clusion and exclusion criteria for each study.We followed a systematic review protocol toidentify strengths and gaps in the literature, toprovide empirically derived conclusions, andto offer suggestions for future studies.

We posed 10 specific questions related to theresearch available on VCP. Among all of thearticles that met our inclusion criteria, wesought to answer:

1. What are the types of articles publishedand what is the relative frequency of eachtype of article?

2. What are the publication rates over timefor empirical and nonempirical articles?

112 BACKHAUS ET AL.

3. To guide future reviews, what are thecommon terms used in the literature todescribe live remote psychotherapy viavideoconferencing and traditional, in-person psychotherapy?

From the included empirical articles, wesought to answer:

4. What formats and types of psychother-apy have been conducted via videocon-ferencing?

5. Which populations have been studied?6. What are the primary assessment instru-

ments that have been used?7. Is VCP feasible? That is, can it be im-

plemented successfully in different for-mats, with different populations, and us-ing different types of therapy? Moreover,can emotions be conveyed through VC,and are costs manageable?

8. Are there differences in the therapeuticrelationship when psychotherapy is de-livered via teleconferencing rather thanin person?

9. Are providers and consumers satisfiedwith VCP?

10. Are the clinical outcome data for VCPcomparable to in-person psychotherapy?

Method

Search Strategy

To identify eligible articles, we searched thePubMed, PsycINFO, and PILOTS electronicsearch engines. Ten different search combina-tions were used. We began by combining theterms psychotherapy and telemedicine.Next, we combined each of the terms mentalhealth, therapy, and psychotherapy withthe terms video and telehealth, video andtelemedicine, and teleconferencing (nine ad-ditional searches). We conducted the searcheson January 27, 2011. We screened all titles andabstracts, and we obtained complete reports forthe articles that appeared eligible for inclusion.We examined the reference lists of obtainedarticles for potentially appropriate articles thatmay have been missed in the electronicsearches.

Selection Criteria

We established three inclusion criteria: (a)published in English language, (b) published inpeer-reviewed journals, and (c) focused on liveVCP (i.e., through specialized video telehealthequipment, video phones, or computer moni-tors). We excluded: (a) search engine resultslacking an abstract (including letters to the ed-itor); (b) articles that were focused on psychi-atric services other than psychotherapy (e.g.,assessment; consultation, medication manage-ment in combination with psychotherapeuticsupport); (c) dissertations; (d) nonvideo tele-phone interventions (e.g., telephone conferencecall group therapy); (e) nonvideo computer in-terventions (e.g., online psychoeducation); (f)self-administered interventions; (g) e-mail in-terventions; or (h) video therapy that was notlive (e.g., review of recordings). For the non-empirical articles, we allowed literature reviewsthat were not solely focused on VCP (since wewere aware of none which did so) but had asignificant discussion of VCP issues. For em-pirical articles, we required that at least one ofthe following outcomes was reported: therapeu-tic relationship, satisfaction, clinical outcomedata, or feasibility. Eligibility of articles basedon these criteria was determined by a consensusof all authors.

Classification

Analysis of all articles. In answering re-search Questions 13, all 65 articles were ana-lyzed. For Question 1, we classified the types ofarticles as either nonempirical or empirical. Wedivided the nonempirical articles into two sub-categories: (a) reviews of the literature, or (b)descriptions of particular programs. We dividedthe empirical articles into three subcategories:(a) uncontrolled studies (encompassing casestudies, case series, and cross-sectional sur-veys); (b) controlled, nonrandomized studies; or(c) randomized controlled trials (RCTs). To ad-dress Question 2, we created bar graphs of thenonempirical and empirical articles and visuallyinspected them for patterns. For Question 3, weexamined each included article by hand to iden-tify the most frequently used terms in eacharticle to describe the two modes of treatment(remote video technology and traditional in-person therapy).

113VIDEOCONFERENCING PSYCHOTHERAPY

Analysis of empirical articles. Analysisfor research Questions 410 included empiricalstudies only. The 47 empirical studies and theirsample sizes can be seen in Table 1. Prior toanswering questions four through 10 we at-tempted to determine whether different empiri-cal articles were reporting on the same data set,through examining the articles or contacting theauthors. We discovered that 10 of the empiricalarticles represented five pairs of studies whichhad overlapping samples (Bouchard et al., 2004and Bouchard et al., 2000; Frueh et al., 2007and Frueh et al., 2007; Germain, Marchand,Bouchard, Drouin, & Guay, 2009 and Germain,Marchand, Bouchard, Guay, & Drouin, 2010;Marrone, Mitchell, Crosby, Wonderlich, &Jollie-Trottier, 2009 and Mitchell et al., 2008;Morland et al., 2010 and Greene et al., 2010).For the articles with overlapping samples, wechose only to include the data from the articlewith the largest sample size (if one was larger),

and thus, included five of these articles. The fiveexcluded articles are noted in Table 1 with anasterisk (*).

For Questions 46, we determined percent-ages based on the total number of samples(rather than articles) to avoid double-counting,and thus analyzed only the 42 unique samplesfor those topics (i.e., populations studied, for-mat and types of psychotherapy, assessmentsused). For Question 4, we classified the psycho-therapy format (individual, group, family, cou-ples, mixed, undefined) and type (cognitivebehavioral therapy [CBT], family therapy,substance abuse therapy, eclectic or undefined,or other defined therapy). For Question 5, weclassified the empirical samples by psychiatricdiagnoses, military status (active duty, Veteran,or civilian), and developmental status (child/adolescent, general adult, or older adult). ForQuestion 6, we hand-searched each empiricalarticle for individual instruments and classified

Table 1Empirical Studies

Uncontrolledstudies

N

Nonrandomized controlledstudies

N

Randomized controlledstudies

NAuthor(s) Author(s) Author(s)Bakke et al., 2001 2 Bouchard et al., 2004 21 Day & Schneider, 2002 80Bischoff et al., 2004 3 Cluver et al., 2005 10 Frueh, Monnier, Yim et al., 2007 38Bose et al., 2001 13 Germain et al., 2009 48 Frueh, Monnier, Grubaugh et al., 2007 38Bouchard et al., 2000 8 Germain et al., 2010 46 Glueckauf et al., 2002 27Cowain, 2001 1 Grady & Melcer, 2005 112 Greene et al., 2010 112Deitsch, et al., 2000 4 Harvey-Berino, 1998 166 King et al., 2009 37Earles et al., 2001 3 Morgan et al., 2008 86 Marrone et al., 2009 116Frueh et al., 2005 18 Simpson et al., 2006 6 Mitchell et al., 2008 128Ghosh et al., 1997 1 Tuerk et al., 2010 47 Morland et al., 2004 20Goldfield & Boachie, 2003 1 Morland et al., 2010 125Griffiths et al., 2006 15 Nelson, et al., 2003 28Hill et al., 2001 2 Ruskin et al., 2004 119Himle et al., 2006 3Kaplan, 1997 2Manchanda & McLaren, 1998 1Nelson & Bui, 2010 1Oakes et al., 2008 1Oliver & Demiris, 2010 2Passik et al., 2004 8Shepard et al., 2006 25Shore & Manson, 2004 1Simpson, 2001 10Simpson et al., 2002 11Simpson et al., 2003 12Todder et al., 2007 2Todder & Kaplan, 2007 1 Study is excluded from analysis of research Questions 46 due to having overlapping samples with another study.

114 BACKHAUS ET AL.

those as reporting no measures, only nonstan-dardized measures, or at least one standardizedmeasure. For Questions 710, we determinedthe number of articles that addressed each out-come (feasibility, therapeutic relationship, sat-isfaction, and clinical outcome data) andreviewed the articles in each category to syn-thesize the conclusions.

Results

We identified 728 unique articles from the ini-tial electronic searches, and the search of referencelists yielded an additional 93 unique articles. Thus,the total denominator for articles to consider was821. A total of 756 articles were excluded. Of theexcluded articles, 17 (2%) were non-English, 52(7%) did not have an abstract, 191 (25%) were notfocused on psychotherapy, 64 (8%) were non-video telemedicine, 13 (2%) were nonpeer re-viewed, 368 (49%) were focused on a disciplineother than mental health (e.g., radiography, phys-ical therapy, neurology), and 51 (7%) were ex-cluded for other reasons (e.g., nontelemedicine,self-directed therapy). (Note that due to roundingerrors, percentages in Results may not always total100%). Sixty-five articles were identified as meet-ing our criteria for inclusion. These articles arelisted with an asterisk (*) in the Reference section.Types of Articles (Question 1)

Eighteen (28%) of the 65 articles reviewedwere nonempirical studies. Of these, eight(44%) were literature reviews and 10 (56%)offered program descriptions (see Table 2). Aswe anticipated, we did not find any literature

reviews that were solely focused on VCP(which was the impetus for the current review);therefore, we included the eight reviews thatincluded substantial discussions of VCP. Therehave been a number of excellent reviews thathave discussed psychotherapy via VC, but theseeither presented overviews of some combina-tion of many psychological service domainsprovided via VC provided via teleconferencing(such as assessment, pharmacotherapy, psycho-therapy, education, consultation, or supervision;e.g., Antonacci, Bloch, Saeed, Yildirim, & Tal-ley, 2008; Capner, 2000; Hilty, Marks, Urness,Yellowlees, & Nesbitt, 2004; Monnier, Knapp,& Frueh, 2003; Norman, 2006; Richardson etal., 2009), focused on psychotherapy only butnot only VC (e.g., Bee et al., 2008), or focusedon neither psychotherapy or VC yet had somediscussion about VCP (i.e., Hailey, Roine, &Ohinmaa, 2008).

Among the program descriptions are pioneer-ing overviews of VC (called two-way TV) forgroup therapy (Wittson, Affleck, & Johnson,1961; Wittson & Benschoter, 1972), a descrip-tion of a biofeedback telehealth program (Folen,James, Earles, & Andrasik, 2001), an overviewof telehealth psychiatry services provided inparticular countries (Freir et al., 1999; Gam-mon, Bergvik, Bergmo, & Pedersen, 1996; Mie-lonen, Ohinmaa, Moring, & Isohanni, 2002), adescription of a university VC program with afocus on family therapy (Kuulasmaa, Wahlberg,& Kuusimaki, 2004), and a description of VCPfor caregivers of older adults with dementia(Wright, Bennet, & Gramling, 1998). Addition-ally, there are discussions about the design ofrandomized noninferiority trials (Egede et al.,2009; Morland, Green, Rosen, Mauldin, &Frueh, 2009). The noninferiority trials utilize amethodology that will allow for rigorous com-parison of VTC [video teleconferencing] andin-person modalities and a sophisticated analy-sis of equivalency (noninferiority) . . . used todetermine if a novel intervention is no worsethan a standard intervention (Morland et al.,2009, p. 514).

The remaining 47 (72%) articles were empir-ical studies. There were 21 controlled studies(45% of the empirical studies). Nine nonran-domized trials (19%) and 12 randomized trials(26%) were identified. Twenty-six of the empir-ical studies (55%) had no control condition forcomparison. The majority of the uncontrolled

Table 2Nonempirical Studies

Literature reviewsProgram/Project

descriptions

Antonacci et al., 2008 Cartreine et al., 2010Bee et al., 2008 Egede et al., 2009Capner, 2000 Folen et al., 2001Hailey et al., 2008 Freir et al., 1999Hilty et al., 2004 Gammon et al., 1996Monnier et al., 2003 Kuulasmaa et al., 2004Norman, 2006 Mielonen et al., 2002Richardson et al., 2009 Morland et al., 2009

Olden et al., 2010Wright et al., 1998


studies were case study designs (54%; n 14)(e.g., Cowain, 2001), followed by cross-sectional survey designs (35%, n 9; e.g.,Simpson, 2001) and case series designs (11%,n 3). Deitsch, Frueh, and Santos (2000) andSimpson, Morrow, Jones, Ferguson, and Breb-ner (2002) reported on only a single psychother-apy session for each subject. The mean samplesize for all of the uncontrolled studies was sixparticipants.

Patterns of Publication Rates (Question 2)There were only two articles meeting our

search and selection criteria that were publishedbefore 1996 (i.e., Wittson et al., 1961 andWittson & Benschoter, 1972), but there was atleast one peer-reviewed publication per yearduring the 15 year period of 19962010. Figure1 excludes the two pre-1996 outliers to illustratethe pattern of publication rates for nonempiricalarticles, empirical articles, and their combina-tion during three year periods since 1996.

Terms Used (Question 3)The most frequently used terms within each

article to describe the two modes of treatment(remote and in-person) were tabulated and thesummary of the terms is listed in Table 3. Themost commonly used term to describe the re-mote mode of treatment was videoconferenc-ing (and variations of that term), representing40% of the articles, followed by telepsychia-try (17%) and telemedicine (11%). Manyarticles were focused on descriptions of psycho-

therapy only provided via videoconferencing(without discussion of in-person psychother-apy), and many of the empirical studies did notoffer an in-person control condition. Accord-ingly, only 28 of the articles used any term forin-person psychotherapy. The most commonterms used were face-to-face (often abbrevi-ated FTF or F2F; 57%), in-person (14%), andsame room (11%).

Formats and Types of Psychotherapy(Question 4)

Regarding psychotherapy formats studied, ofthe 42 unique empirical samples, 71% (n 30)reported an individual therapy format (e.g.,Bakke, Mitchell, Wonderlich, & Erickson,2001), 17% (n 7) described group therapy(e.g., Frueh, Henderson, & Myrick, 2005), and10% (n 4) discussed family therapy (e.g.,Hill, Allman, & Ditzler, 2001). The remainingsample (2%; Shore & Manson, 2004) combinedindividual and group psychotherapy. None ofthe studies reported using a couples therapyformat.

Regarding types of psychotherapy, the largestproportion of samples (45%; n 19) identifiedcognitivebehavioral therapy (including behav-ior therapy and exposure therapy) as the pri-mary treatment type (e.g., Bouchard et al.,2000). Treatment types categorized as eithereclectic, various, or undefined (e.g., Ruskin etal., 2004) comprised 11 (26%) of the empiricalsamples utilized. Three samples (7%) utilizedVC for various types of family therapy (e.g.,

Figure 1. Number of nonempirical, empirical, and total articles published during three yearperiods since 1996.

116 BACKHAUS ET AL.

Hill et al., 2001), and two (5%) focused onsubstance abuse treatment programs (e.g., Kinget al., 2009). For the remaining seven articles(17%), there was one study for each of thefollowing specific treatment types: biofeedback(Earles, Folen, & James, 2001), Dignity Ther-apy (Passik et al., 2004), hypnosis (Simpson etal., 2002), psychoanalysis (Kaplan, 1997), EyeMovement Desensitization and Reprocessing(Todder & Kaplan, 2007), Problem SolvingTherapy (Oliver & Demiris, 2010), and Cop-ing Skills for PTSD (Morland, Pierce, &Wong, 2004).Populations Studied (Question 5)

As noted, there were 42 unique empiricalsamples. Among these, 36 (86%) studied adults,and one of these was identified as an older adultpopulation (60 years and older). Four of thesamples (10%) were composed of childrenand/or adolescents and two (5%) were mixed orunclear ages. Regarding military status, 31 em-pirical samples (74%) were civilian (nonmili-tary) populations, nine samples (21%) werecomposed of Veterans, and the remaining twosamples (5%) combined civilian and military

participants. There were no studies of activeduty service members meeting our inclusioncriteria.

Across the 42 samples, the majority (n 39)reported data on sex of participants. Among thesamples that reported the sex of participants,nearly 60% of participants were male (approx-imately 800 participants) while female partici-pants (approximately 550 participants) ac-counted for just over 40%. Only 23 of the 42unique samples included in our review reportedrace or ethnicity of study participants, and 14 ofthe 23 (61%) had samples where at least half ofthe sample was Caucasian. Notable exceptionsincluded three studies in which a majority of thesample was African American (55%, Frueh etal., 2007), Hispanic (100%, Nelson & Bui,2010), or American Indian (100%, Shore &Manson, 2004). These studies supported thefeasibility and effectiveness of VC in these sam-ples.

Regarding the clinical problems addressed,nine of the samples (21%) were composed ofindividuals diagnosed with trauma disorders(post traumatic stress disorder and acute stressdisorder). Nineteen percent of the sample pop-

Table 3Terms for Modes of Treatment Most Frequently Used in Reviewed Articles

Traditional therapy Remote video technology

Face-to-face treatment or face-to-face therapy (16) Behavioral telehealth (1) In-person treatment, in-person therapy (4) Computer-based treatment (1) Office-based (1) Interactive video, interactive television (2) On-site counseling (1) Internet-based videoconferencing (1) Same-room treatment, same-room therapy (3) Remote counseling, remote consultation, remote

treatment, remote communication technologies, orremote methods (1)

Standard therapy, standard behavior therapyinterventions (2) Telecommunications or telecommunications media (1)

Traditional therapy (1) Telehealth, telehealth technology, or telehealth-mediateddelivery (5)

Telemedicine or telemedicine methods (7) Telemental health, telemental health services, or

telemental healthcare (4) Telepsychiatry (11) Telepsychology or rural telepsychology (3) Telepsychotherapy (1) Videoconference, videoconference access, videoconference

treatment, videoconferencing, videoconferencing utility,video-conferencing, video conference, videoteleconferencing, or video-conferencing technology (26)

Videophones (1)Note. Numbers in parentheses indicate how frequently a term was the primary term used in an article.


ulations (n 8) had general or mixed present-ing problems. Twelve percent (n 5) of thesample were comprised of individuals with eat-ing disorders (such as anorexia nervosa andbulimia nervosa). The remaining clinical targetswere: mood disorders (n 3; 7%); anxietydisorders other than posttraumatic stress disor-der and acute stress disorder (n 3; 7%; twopanic disorder with agoraphobia and one obses-sive compulsive disorder); addiction issues(n 3; 7%); pain/psychophysiological issues(n 3; 7%); adjustment to cancer (n 3; 7%);other (n 3; 7%; family issues, gender reas-signment, and caregiver stress); and mixed de-pression and/or anxiety (n 2; 5%).

Assessments Used (Question 6)Of the 42 unique samples from the empirical

studies, seven (17%) did not list any measuresused, and all of those articles described uncon-trolled studies. Nonstandardized measures,including qualitative questionnaires and inter-views (e.g., Bakke et al., 2001; Bischoff, Hol-list, Smith, & Flack, 2004; Simpson et al.,2002), and author-created measures (e.g., Clu-ver, Schuyler, Frueh, Brescia, & Arana, 2005;Deitsch et al., 2000; Harvey-Berino, 1998; Kinget al., 2009) were used by 11 (48%) of thearticles. At least one standardized measure withwell-accepted psychometrics was reportedby 29 (69%) of the empirical studies. The mostcommon measures were versions of the BeckDepression Inventory (BDI; e.g., BDI-II; Beck,Steer, & Brown, 1996), which was cited in 10different articles; the Working Alliance Inven-tory (WAI; Horvath & Greenberg, 1989), whichwas cited in nine different articles; and theStructured Clinical Interview for the DSMIV(SCID-IV; SCID-I; First, Spitzer, Gibbon, &Williams, 1996), which was cited in six differ-ent articles.

Feasibility (Question 7)The authors in each of the articles reviewed

indicated that VC was a feasible means to de-liver psychotherapy. As noted above, VCP hasbeen successfully used in several formats usingvarious types of psychotherapy. Researchers re-ported the successful expression and interpreta-tion of emotions via VC (Bischoff et al., 2004;Cluver et al., 2005; Deitsch et al., 2000; Frueh

et al., 2005; Griffiths, Blignault, & Yellowlees,2006; Hill et al., 2001; Manchanda & McLau-ren, 1998; Oliver & Demiris, 2010; Simpson,2001; Simpson et al., 2002). Moreover, pro-grams offering telehealth services may realizedecreased costs for patients in terms of time andtravel expenses (Davalos, French, Burdick, &Simmons, 2009; Grady, 2002). Eighteen ofthe 47 empirical studies (38%) explicitly ad-dressed how this mode of treatment can contrib-ute to reductions in travel burdens and costs,reduced intervention costs, and/or increased ac-cess to care for rural, underserved, or geograph-ically isolated populations.

Therapeutic Relationship (Question 8)Of the 47 empirical articles, 16 (34%) exam-

ined the patient-provider relationship in ther-apy. Fourteen of these studies concluded thatpatients and providers perceive a strong thera-peutic alliance over VC (e.g., Bouchard et al.,2000; Ghosh, McLaren, & Watson, 1997; Mor-gan, Patrick, & Magaletta, 2008; Simpson,2001), comparable to in-person sessions (Ger-main et al., 2010). Some patients discussedenhancement of the therapeutic relationshipduring VC (Simpson, 2001). However, in onefamily therapy group (Glueckauf et al., 2002)and in another group therapy setting (Green etal., 2010), the patients reported lower therapeu-tic alliance with the provider when using VCcompared to those who received treatment inperson. In the Glueckauf et al. study, teens withepilepsy and their parents rated the quality ofthe therapeutic relationship across three modal-ities (face-to-face in office, by speakerphone,and by VC). The parents rated the therapeuticrelationship as good across the three modalities(and there were no differences among the mo-dalities). The teens, however, reported that inthe VC condition the therapeutic alliance wasweaker. The authors speculated that the neuro-psychological deficits that can co-occur withepilepsy may have made it difficult to encodeand interpret social interactions in that format.In the Green et al. study of group anger man-agement therapy provided face-to-face in officeor by VC, the participants (male Veterans) inboth conditions rated therapeutic alliance ashigh (over 4 on a 5-point scale, suggestingagreement with positive statements about therelationship), but there was more variance in the

118 BACKHAUS ET AL.

VC condition and the ratings in the VC condi-tion were significantly lower than the face-to-face condition. While ratings of alliance didpredict clinical outcomes for individuals, themean ratings within conditions did not medi-ate outcomes between the conditions (inwhich VC was not inferior to face-to-facetreatment). The authors posited that alliancemay have been impacted by the nature of thetreatment (a long, intense, group-based inter-vention) or patient-specific factors (such ascomfort with technology or treatment his-tory). As with the Glueckauf et al. study, it ispossible that group interventions via VC maybe challenging for some individuals due to thepotential for increased distractions and com-peting stimuli (e.g., the presence of otherpeople in the room and video equipment inthe room).

Satisfaction (Question 9)Twenty-six of the 47 articles (55%) exam-

ined patient and/or provider satisfaction. Instudies without a comparison group, researchersoften concluded that users were generally satis-fied when engaging in psychotherapy over tele-medicine (Deitsch et al., 2000; Frueh et al.,2005; Myers, Valentine, & Melzer, 2008; Simp-son, Bell, & Britton, 2006; Simpson et al., 2003;Simpson et al., 2002), and studies that com-pared VC to in-person psychotherapy reportedsimilar satisfaction levels between the condi-tions (Cluver et al., 2005; King et al., 2009;Morgan et al., 2008; Nelson, Barnard, & Cain,2003; Ruskin et al., 2004). When sources ofdissatisfaction arose, they primarily involvedtechnical challenges, but such issues appearedto have little impact on overall satisfaction lev-els (e.g., Cowain, 2001; Folen et al., 2001).Both the patient-provider relationship in ther-apy and patient and/or provider satisfaction wasreported in seven (15%) of the studies.

Clinical Outcome Data (Question 10)For our final research question, we sought to

determine if the clinical outcome data for VCPis comparable to in-person psychotherapy. Sixtypercent (n 28) of the 47 articles examinedclinical outcomes. We have organized the re-sults into five general categories of clinicalproblems studied in those 28 articles: depres-

sion and/or anxiety (including posttraumaticstress disorder and acute stress disorder), eatingdisorders, physical problems, miscellaneous,and addictions. We draw particular attention tothe outcomes from randomized empirical stud-ies.

Ten of the 47 empirical articles (21%) pre-sented clinical outcome data on anxiety and/ordepression (see Table 4). Two randomized em-pirical studies (Nelson et al., 2003; Ruskin etal., 2004) reported no significant differencesbetween in-person conditions and VCP condi-tions for symptoms of anxiety and depression,with both conditions showing symptom im-provement. Interestingly, Nelson and col-leagues (2003) found the VCP group to have afaster decline in depressive symptoms as com-pared to the in-person group. These outcomesare supported by less rigorous studies that re-ported improved clinical outcomes for VCP pa-tients with anxiety and/or depression. Posttrau-matic stress disorder was specifically examinedby Frueh et al. (2007) in a RCT and by Tuerk,Yoder, Ruggiero, Gros, & Acierno (2010), andGermain et al. (2009) in nonrandomized com-parisons studies. While the two nonrandomizedstudies found no major differences between thein-person groups and the VCP groups (bothgroups demonstrated clinical improvements), inthe randomized study neither group had signif-icant changes in their posttraumatic stress dis-order (PTSD) symptoms.

Six of the 47 empirical articles (13%) pre-sented clinical outcomes for patients with eatingdisorders (see Table 5). Mitchell et al. (2008)was the only study with a randomized compar-ison between in-person treatment and VCP.Their results indicated that both the in-personand VCP groups had similar treatment retentionand both showed clinical improvements, includ-ing reduced binging and purging frequenciesand abstinence from binging and purging be-haviors. However, the in-person group had astatistically greater reduction in eating-relateddistorted cognitions than the VCP group. Thein-person group experienced a greater reductionin self-reported disordered eating-related cogni-tions and depressive symptoms, although theauthors noted that, the differences overall werefew in number and of marginal clinical signifi-cance (Mitchell et al., 2008, p. 581). Theseresults are supported by the additional studiesexamining clinical outcomes for eating disor-


ders, which generally reported improvements insymptom presentation.

Four of the empirical studies (9%) addressedoutcomes related to a variety of physical healthconcerns (see Table 6). The only RCT focusedon patients with epilepsy (Glueckauf et al.,2002). Results indicated no significant differ-ences between the in-person and VCP groups,and both showed clinical improvement. The re-maining studies found VCP to have positiveoutcomes for patients with chronic pain andirritable bowel problems (Earles et al., 2001),cancer (Shepherd et al., 2006), and obesity(Harvey-Berino, 1998).

Five of the empirical studies found positiveoutcomes for miscellaneous clinical areas suchas parentchild problems, gender reassignment,mood disorders, adjustment, and anger (see Ta-ble 7). In the only RCT, Morland and others(2010) found VCP to be just as effective as inperson for treating individuals with anger diffi-culties.

Three of the empirical studies (6%) providedclinical outcome data for addiction related prob-

lems, including alcohol, substance abuse, andgambling (see Table 8). All three studies indi-cated that VCP was an effective method fordelivering addiction focused interventions.

Discussion

The aims of this systematic review were toidentify, synthesize, and interpret the literatureon VCP by using a predefined search and selec-tion protocol to answer 10 specific questions.We will discuss the issues relevant to each ofthe 10 questions we posed.

Types of Articles (Question 1)Among the 65 articles selected for review

were 18 nonempirical studies, split almostevenly between literature reviews and programdescriptions. None of the reviews focusedsolely on VCP, but they provided rich discus-sions and analyses of issues that are relevant toVCP. The program descriptions can be usefulguides to individuals who are interested in the

Table 4Clinical Data: Depression and Anxiety Disorders

Study Problem OutcomesType ofstudy

Bouchard et al., 2000 Panic w/agoraphobia () Panic attacks (severity and frequency),panic apprehension, severity of disorder

EU

() Global functioning, perceived self-efficacyCowain, 2001 Anxiety & depression () Functioning EU

() Depression/anxietyManchanda & McLaren, 1998 Anxiety & depression () Anxiety/depression EUHimle et al., 2006 OCD () OCD symptoms EU

() Global functioningBouchard et al., 2004 Panic w/agoraphobia Majority of both groups free of panic

symptomsEN

Germain et al., 2009 PTSD Both conditions: EN() PTSD, anxiety and depression() Overall functioning and perceptions of

physical and mental healthTuerk et al., 2010 PTSD Both conditions: EN

() PTSD symptoms() Depression

Frueh, Monnier, Grubaugh,et al., 2007

PTSD-combat Neither modality had significant changes insymptoms

ER

Nelson et al., 2003 Depression All modalities were effective at () depression;VCP group had faster decline of symptoms

ER

Ruskin et al., 2004 Depression/anxiety No significant differences between conditions,both had:

ER

() Depression/anxiety() Health and GAF

Note. EU Empirical Uncontrolled; EN Empirical Nonrandomized Control; ER Empirical Randomized Control.

120 BACKHAUS ET AL.

logistics of beginning clinical work or researchin the field. There were 47 empirical studiessince 1996, representing nearly three quarters ofthe articles reviewed. However, the methodol-ogy in many of the extant studies was weak, andthese limitations make it difficult for providersand researchers to replicate and compare re-sults. Over half of the studies presented uncon-trolled data (e.g., case studies, case series,cross-sectional surveys) with small samples,which could allow a number of untested con-

founding variables to influence the results. Inour experience, it is easier to enlist participantsfor traditional in person psychotherapy than forVCP, so it is likely that control subjects couldbe recruited for most studies of VCP.

Several of the studies had reported on sharedsamples. It was not always clear from the writ-ten reports when samples were overlapping,which would result in an apparent inflation inthe quantity of studies. In fact, only 42 uniquesamples were studied and only 21% of those

Table 5Clinical Data: Eating Disorders


Bakke et al., 2001 Bulimia nervosa Absence of binge/purge at follow-up EUGoldfield & Boachie, 2003 Anorexia nervosa () Weight EU

Improved medical conditionSimpson et al., 2003 Eating disorders () Symptoms EU

() Nutritional knowledge() Nutritional content of diet

Simpson et al., 2006 Bulimia nervosa () Binging (for half (6) of participants) EN() Purging (for 1 participant)() Depression (for 5 participants)() Borderline symptoms (for 4 participants)

Marrone et al., 2009 Bulimia nervosa Operating characteristics analysis: Reduction inbinge eating at 6th week is associated with bestoutcomes for VCP; 8th week for in person

ER

Mitchell et al., 2008 Bulimia nervosa Both conditions had similar retention rates ERBoth groups showed clinical improvements, but in

person group had slightly greater () indistorted cognitions and depression.


Table 6Clinical Data: Physical Problems


Earles et al., 2001 Chronic pain & irritable bowel () Pain EU() Pain medication() Bowel irritability() Ability to relax() Outlook() Mood

Shepard et al., 2006 Cancer () General distress EU() Anxiety() Wellbeing (emotional, functional, physical)

Harvey-Berino, 1998 Obesity Both groups: EN() Weight() Eating behaviors, exercise

Glueckauf et al., 2002 Epilepsy () In problem severity, frequency ER() Prosocial behaviors



had subjects randomized to condition. More-over, some studies reported nonmanualized orblended interventions (e.g., psychotherapy andpharmacotherapy; individual and group ther-apy) and mixed diagnostic groups. Many of thecontrolled studies described differences be-tween VC and in-person conditions but ne-glected to discuss the statistical or clinical sig-nificance of within-group changes. The majorityof the controlled studies presented superioritydesigns, and these were generally underpow-ered due to small sample sizes, potentially miss-ing true differences between conditions. Thelack of statistical differences in these studiesdoes not mean that outcomes from VC andin-person are identical, and noninferiority andequivalence designs offer an alternative to thestandard approach (Greene, Morland, Durkal-

ski, & Frueh, 2008). As Richardson et al. (2009)stated with regard to VC for interventions morebroadly, the evidence base for VCP remainsunderdeveloped.

Patterns of Publication Rates (Question 2)Within the parameters of our search criteria,

we found only two publications focused onVCP prior to 1996, reflecting that this area ofstudy is in early stages. Consistent with theobservation that general telemental health pub-lications have increased rapidly in recent years(Richardson et al., 2009), we found a similar(though less pronounced) pattern of increasedpublications on VCP. The number of nonem-pirical articles published from 2008 to 2010equaled the sum of all such publications from

Table 7Clinical Data: Miscellaneous


Ghosh et al., 1997 Gender reassignment () Social and clinical adjustment EUNelson & Bui, 2010 Parent-child problem () Anger management skills EU

() Parenting skills() Parent-Child Communication

Grady & Melcer, 2005 Variety (mood, anxiety,personality)

Both groups showed improvement in: ENGAF and medication compliance but VCP was

significantly better than in person for bothNo differences between groups in # of labs ordered,

self-help recommendations made, # of patientsprescribed 2 or more medications

Day & Schneider, 2002 Variety (e.g. family problems,body/image)

No significant differences between modalities(speaker phone, in person, VCP) in therapeuticprocess or outcomes

ER

Morland et al., 2010 Anger No significant differences between modalities: ER() Anger symptoms


Table 8Clinical Data: Addiction


Frueh et al., 2005 Alcohol () Participant alcohol abstinence EUOakes et al., 2008 Gambling () Indicators of problem gambling EU

() Work adjustment() Social adjustment() Depression/anxiety

King et al., 2009 Substance abuse No significant differences between groups: ER() Abstinence and attendance


122 BACKHAUS ET AL.

1996 to 2007. Similarly, the number of empir-ical publications from 2002 to 2010 was nearlytriple such publications from 1996 to 2001.During each of the 3-year periods starting in1996, the number of empirical publications hasoutpaced the nonempirical publications, sug-gesting that future years may continue that trendand bring additional original data to guide workin this field. The total number of publicationsdemonstrates a near-linear trend of more fre-quent publications in recent years, and the mostrecent three years together represent a third ofall publications in the past 15 years.

Terms Used (Question 3)Several of the review articles included in this

review appeared to equate telehealth, telementalhealth, e-health, or telepsychiatry with VC (An-tonacci et al., 2008, noted that these terms areoften used interchangeably). Multiple termswere used within many articles to denote psy-chotherapy via remote video technology, andoften the term used in the title of an article wasnot the term used most frequently in the body ofthe text. As the field has developed, it has be-come more important to be precise in technicalterminology for mental health services providedremotely to convey specifically what formatwas used and to ensure inclusion of relevantstudies in literature reviews.

Many of the empirical studies we revieweddid not offer an in-person control condition, butwhen it was discussed, traditional in-personpsychotherapy was most often referred to asface-to-face. The terms in person andsame room were less frequently used, but weargue that these terms are more descriptive(since in VC, participants are also face-to-face onscreen), and thus, we have used theterm in person in this article. Videoconfer-encing was the most commonly used term todescribe remote treatment, so a search for thatterm should yield the most appropriate articleson the topic. We encourage other researcherswho focus on this mode to use that term ratherthan more generic terms. Videoconferencinghas the advantage of being more precisely de-fined (it is more specific than the terms tele-health or telemedicine), and it includes im-ages and sounds conveyed through differenttypes of equipment such as video phones andcomputers. We chose the term Videoconfer-

encing Psychotherapy for this review becauseit conveys the type and remote mode of treat-ment most efficiently and accurately. After wehad conducted our review, we realized that be-fore the terms telemedicine and telehealthwere in wide use, the technology was some-times described as two-way TV or interac-tive TV (e.g., Wittson, Affleck, & Johnson,1961; Wittson & Benschoter, 1972), so thoseterms should be included in future searches forVCP.

Formats and Types of Psychotherapy(Question 4)

The literature covered a range of treatmenttypes and therapy formats, with the largest pro-portion of studies utilizing individual CBT toinvestigate VCP. Nearly one half of the psycho-therapies studied were described as CBT. Al-though CBT is a broad term that can encompassa wide range of techniques, there is clear evi-dence that manualized treatments like CBTs canbe conducted via VC. Group, couples, and fam-ily therapy present some particular technicalchallenges and possibilities for providers choos-ing to use VC technology, and more studies ofpsychotherapies in these formats are necessaryto inform providers about these issues. Over aquarter of the empirical studies did not definethe intervention or described eclectic psycho-therapies. Clear descriptions of establishedtreatment protocols will advance the knowledgebase by helping clinicians and researchers rep-licate and extend the work that has been done.

Populations Studied (Question 5)VCP has been applied to individuals with

many clinical conditions. The largest categoryof problems addressed was trauma disorders(including PTSD and acute stress disorder). Thenext largest category of clinical conditions stud-ied was general or mixed presenting problems.While such heterogeneous samples may be eas-ier to recruit, it is challenging to interpret find-ings of mixed diagnostic groups. VCP may beparticularly well suited to trauma disorders. Oneof the hallmarks of PTSD is avoidance of un-comfortable situations that may remind the per-son of the traumatic event, and, in our ownwork, some individuals with PTSD have told usthat psychotherapy by VC offers a more com-


fortable therapeutic distance between them andthe provider as the therapeutic relationship isbeing established (Thorp, Fidler, Moreno,Floto, & Agha, 2012, pp. 198199). Patientsmay be initially reluctant to disclose personalinformation, even to mental health professionals(Olden et al., 2010). Telehealth can encouragepatients to exchange more information with theprovider since they feel less intimidated thanduring in-person interactions (Kavanagh & Yel-lowlees, 1995; Tachakra & Rajani, 2002; Woot-ton, Yellowlees, & McLaren, 2003). In fact,some patients rated telehealth higher than in-person encounters in terms of ease of self-expression (Chae, Park, Cho, Hung, & Cheon,2000). There is a need for more data describingVCP with generalized anxiety disorder, pho-bias, and personality disorders, as these disor-ders may pose particular challenges or benefitsin this modality (e.g., maintaining clinical fo-cus; maintaining therapeutic alliance; conduct-ing specific exposure therapies at a distance).

There were four VCP studies of childrenand/or adolescents, but only one description of alarge RCT (in progress) of VCP for older adults(Egede et al., 2009). Richardson et al. (2009)notes that, given potential limitations in trans-portation and mobility, older adults in particularmay benefit from mental health services byVCP. However, older adults may also have dis-comfort with using VCP equipment, and mayhave sensory impairments (e.g., difficulty hear-ing) that could interfere with that mode of treat-ment (Jones & Ruskin, 2001). In our own work,we have found that older adults can becomemore comfortable with the VCP format withtime, and with hearing difficulties communica-tion may be improved with headphones or azoomed lens on a therapists lips (Thorp, et al.,this issue).

While there appears to be an adequate bal-ance of men and women included in studies ofVCP, there is a need for greater attention topotential differences in process variables andoutcomes related to sex of participants. Few ofthe studies reported results separately by sex orhad hypotheses or analyses focused on sex dif-ferences. Thus, the lack of focus on this issuecould reflect that there truly are no differencesin feasibility, satisfaction, alliance, and clinicaloutcomes or it could reflect a lack of attention tothis topic. It is certainly possible that sex couldinfluence feelings of alliance in the video format

or comfort with technology generally, so it ap-pears that the issue is deserving of more empir-ical analysis.

There have been few studies of telementalhealth that address ethnic and racial differencesamong participants and how it impacts services,and these have focused primarily on assessmentservices (Richardson et al., 2009). More studieswith a focus on potential racial and ethnic dif-ferences would be worthwhile. Minorities mayface greater obstacles to accessing empiricallybased psychotherapies, and thus VCP has thepotential to increase access for these groups.Cross-cultural studies could inform how com-fort with the technology may differ across cul-tures.

Assessments Used (Question 6)Many of the studies we examined used mul-

tiple standardized instruments to assess broaddomains of clinical and process variables. How-ever, over one third of the empirical studies wereviewed reported either nonstandardized mea-sures or no measures at all. While customizedmeasurement (unstructured interviews and au-thor-created instruments) may augment stan-dardized instruments, the field is sufficientlyadvanced to demand psychometrically soundinstruments be used in all empirical studies ofVCP. We surveyed the most common instru-ments used across studies (full list available onrequest) to guide future providers and research-ers, and found that the BDI was the most pop-ular choice (reflecting the studies of mood dis-orders and comorbid mood symptoms). TheWAI was used often to contrast therapeuticalliance between modes of treatment, and theSCID was conducted to confirm psychiatric di-agnoses. The broad use of these measures withestablished reliability and validity suggests thatthey are good choices for many VCP studies.

Feasibility (Question 7)The extant literature shows that many psy-

chotherapy types have been delivered throughVC, and these psychotherapies have addressed awide range of clinical problems. Importantly,studies generally agreed that participants areable to express and interpret emotions throughthe live video format. Many of the researchersnoted that only minimal changes were required

124 BACKHAUS ET AL.

to conduct psychotherapy via VC. Indeed, pri-marily what is absent in VCP is the ability touse senses of touch and smell, which are usedsparingly in most psychotherapies. There aresome differences in the quality of the visual andauditory stimuli that are available through VC(see Thorp, et al., this issue; e.g., more limitedvisual range, potential for visual or auditoryartifacts such as grainy images and delayedsounds), and these possibilities should be dis-cussed with patients at the outset of treatment inthis modality. Moreover, crisis procedures mustbe modified because the therapist will not be inthe same room. This includes the therapistknowing the phone number and address of thepatient location and having a clear plan in placewith the patient and clinical personnel at theremote location (Thorp et al., in press).

The term feasibility can encompass manydomains, and more than a third of the studiesaddressed specific facets of feasibility (e.g.,costs, access). The field has advanced to a pointwhere procedures and measurement could beestablished to monitor these particular aspectsof feasibility. It will be important for futurestudies to more precisely define what type offeasibility is being measured, so that researchersand clinicians can evaluate the feasibility ofVCP by settings, psychotherapy formats, psy-chotherapy types, populations, cost, logistics,and access.

Therapeutic Relationship (Question 8)One third of the studies we reviewed ex-

amined the quality of the therapeutic relation-ship in VCP. Most found that therapeuticalliance was strong in VCP, and in most of thecontrolled studies the ratings of therapeuticalliance was found to be equivalent betweenVCP and in-person psychotherapy. However,a few articles reported an enhanced (Simpson,2001) or diminished (Glueckauf et al., 2002;Green et al., 2010) alliance via VCP. Futurestudies could investigate how alliance is in-fluenced by population type (e.g., rapport maybe more difficult to establish with some diag-noses), therapy format (e.g., individual vs.group), or technology used (e.g., standardvideoconferencing equipment, video phones,online teleconferencing).

Satisfaction (Question 9)Slightly more than half of the studies we

included in our review assessed satisfaction,and these generally found that patients and pro-viders were satisfied with the format despiteoccasional frustrations with technical issues.Satisfaction with videoconferencing will likelyimprove as audio and video technology ad-vances. The use of satisfaction as an outcomehas been criticized due to limitations in studymethodologies (Mair & Whitten, 2000; Nor-man, 2006; Richardson et al., 2009). For exam-ple, many of the studies have not included acontrol condition, making it difficult to differ-entiate satisfaction with the format from satis-faction with the treatment. Additionally, au-thors have created many customized measuresof satisfaction with unclear psychometric prop-erties, and the lack of standardization of themeasures makes it difficult to compare resultsacross studies. In addition to general satisfac-tion, it is important to measure sources of sat-isfaction (e.g., convenience, therapeutic dis-tance) and dissatisfaction (e.g., audiovisualproblems; feeling disconnected). It is recom-mended that, when satisfaction is included as anoutcome variable in VCP studies, reliable andvalid measures of satisfaction should be used,the measures should allow for some detail aboutsources of satisfaction and dissatisfaction andshould serve as an adjunct to other clinicaloutcome measures, and control conditionsshould be included when possible.

Clinical Outcome Data (Question 10)Two-thirds of the studies examined clinical

outcome data. Across the broad range of clinicalproblems that were addressed, the researchersreported that care provided via VCP workedwell, and the Nelson et al. (2003) study con-cluded that it worked a little faster than inperson treatment. As we have suggested, it ispossible that individuals with different psychi-atric diagnoses may differentially respond totreatment via VC, but the numbers of studies fordifferent diagnoses remain too small for mean-ingful meta-analyses of those differences to beperformed. In addition, as we have noted, manyof the studies have suffered from weak meth-odological design and small sample sizes.Moreover, for some studies it was unclear if the


interventions produced statistically or clinicallysignificant changes (in either condition, if acontrol group was utilized).

Conclusions and Recommendations

Telehealth can encompass many technolo-gies, and there are many mental health servicesthat have been delivered by telehealth, includ-ing assessment, psychoeducation, training, con-sultation, and supervision. Current advances intechnology, including telehealth in general andVCP in particular, offer an innovative solutionto the mental health provider shortage in ruralareas and for some specialties. Based on thegrowing literature base of VCP, we concludedthat the more focused field of psychotherapy viavideoconferencing was mature enough to merita systematic review. We sought answers to 10general questions about VCP. Overall, the liter-ature regarding the provision of VCP has beenexpanding and the general findings are support-ive of VCP as a treatment option. It appearsclear that video telehealth is feasible, at least insome contexts and in some situations. The dataalso suggest that most users of the technology(both patients and providers) are satisfied withthis mode of treatment for psychotherapy. Thus,there is some preliminary outcome evidencethat VCP is a viable alternative to in persontherapy, but further research is needed in thisarea.

Several important issues have not been ad-dressed systematically or commonly within theVCP literature and were outside the plannedscope of our review. We did not address liabil-ity, issues about consent, sense of control, legalissues, reimbursement issues, ethical issues,contraindications, or regulatory and licensureissues, but we have cited excellent reviews thatdiscuss these issues in telehealth generally. Wenoted that within VC treatment studies, the clin-ical impact of gender and ethnoracial factors onoutcomes remains unclear. More diverse sam-ples are needed to ensure adequate power to testhypotheses about these variables. We did notconduct a meta-analysis of clinical outcomesbecause there are only 21 controlled studies toanalyze and nine of these did not randomlyassign participants to condition.

As Frueh et al. (2000) and Schopp et al.(2006) have suggested, it is important to con-sider whether successful video telehealth pro-

grams can be sustained. Sustainability will beinfluenced by ongoing provider training, patienteducation, maintenance and upgrading of equip-ment, and reimbursement of health care pro-vided through videoconferencing. The adoptionof new technologies, such as smart phones withinteractive video, may encourage the use ofVCP. However, these technologies may alsogenerate new issues of crisis management, lia-bility, and confidentiality.

We agree with Frueh et al. (2004) that thefield of telepsychiatry is young, and, therefore,more efficacy studies, with strong internal va-lidity, are recommended. Most standard clinicaltrial approaches are designed to examine differ-ences rather than equivalence or noninferiorityin outcomes, but because we do not expectmeetings by VC to be superior to meetings inperson, the latter designs are more appropriate.Although small clinical trials with low statisti-cal power have been useful for demonstratingadequate and general feasibility and satisfactionwith VCP, such trials are unlikely to show truedifferences in clinical outcomes between VCPand in-person care. These trials lack the statis-tical power to provide real evidence of equiva-lence or noninferiority (Greene et al., 2008).Randomized noninferiority designs may offerstronger evidence that VCP is as good as in-person treatment. Noninferiority trials establishwhat would constitute clinically significant dif-ferences in outcomes and test whether one treat-ment produces results that are clinically nonin-ferior to another (standard) treatment, but thesetrials often require large sample sizes (Morlandet al., 2010).

In conclusion, VCP shows great promise asan alternative to traditional in-person psycho-therapy, and improvements in technology willmake this modality more accessible. However,many of the recommendations of Frueh et al.(2000) still hold today: there remains a needfor additional large scale, randomized clinicaloutcome trials which will provide importantinformation about the efficacy, and eventuallyeffectiveness of VCP (including process vari-ables, clinical outcomes, relative rates of at-trition, and cost-effectiveness). The strongerstudies will have large sample sizes, standard-ized measurement of variables of interest,well operationalized treatment protocols, andmeasures of treatment adherence, attrition,therapeutic alliance, feasibility, satisfaction,

126 BACKHAUS ET AL.

and clinical outcomes of these services for avariety of populations.

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Received February 1, 2011Revision received January 9, 2012

Accepted January 10, 2012

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