The pandemic-era expansion of telehealth created what researchers did not previously have: a large, diverse, longitudinal dataset on mental health treatment delivered remotely. Millions of patients received telehealth mental health services who had never done so before. That natural experiment has now generated several years of outcome data.
The findings challenge both the enthusiasts and the skeptics.
Where telehealth works as well as in-person care
For the treatment of depression and generalized anxiety disorder using cognitive behavioral therapy protocols, the evidence for telehealth equivalence is now reasonably strong. Meta-analyses and multiple randomized controlled trials report that telehealth and in-person CBT for depression and anxiety produce comparable outcomes on standard symptom measures, with no significant differences in most studies.
The Krzyżaniak et al. 2024 systematic review is among the most comprehensive evaluations of this question to date. A Behavioral Health News summary of the meta-analytic evidence reaches the same conclusion: telehealth and in-person CBT are clinically equivalent for anxiety and depression presentations in most studies.
This is meaningful. CBT for depression and anxiety represents a large proportion of outpatient mental health caseloads. For this population, the evidence supports telehealth as a genuine alternative rather than a compromise.
Where the evidence is weaker
The equivalence findings do not generalize across all conditions or all populations. For trauma treatment — particularly somatic and body-based approaches — the evidence for telehealth equivalence is considerably weaker. The same is true for severe personality disorders, psychosis spectrum conditions, and populations with significant technology access barriers.
The practitioners who are most concerned about telehealth quality are often working with precisely these populations. Their concern is supported by the data.
The dropout problem
One finding that appears consistently across telehealth outcome studies is elevated dropout rates. Telehealth treatment shows higher early dropout rates than in-person care in multiple studies, with the largest observational studies reporting a substantial increase in early discontinuation — particularly in the first two visits.
A PMC meta-analysis on outpatient mental health dropout found that dropout rates are high across settings, with dropout mostly occurring during the first two visits. A PMC study on telehealth implementation and attendance patterns documents that while widespread telehealth implementation increased total appointments in some settings, early dropout patterns still vary considerably by setting. Research published in JAMA Network Open has also examined telehealth availability and care patterns in large cohort populations.
The mechanisms are not fully understood. Proposed explanations include reduced therapeutic alliance formation, technology-related barriers, and the lower activation energy required to cancel a remote appointment. Whatever the cause, the dropout differential is consistent enough across studies that it should factor into how practitioners think about their telehealth caseload.
What we still do not know
The long-term outcome data — beyond twelve months — remains sparse. Whether the equivalence findings hold over the course of multi-year treatment relationships is an open question. So is the question of how telehealth affects the treatment of co-occurring conditions, which represent a substantial proportion of real-world caseloads.
The evidence supports telehealth as a legitimate treatment modality for a defined population. It does not support the conclusion that modality is irrelevant to outcomes.
Do you have additional information about telehealth outcome research or dropout patterns? We update our articles and research regularly. Contact our editorial team with corrections, updates, or sources.