Comparative Outcomes of Video, Phone, and In-Person Mental Health Care

Importance: The use of tele-mental health (MH) care is widespread, with approximately half of all MH visits occurring remotely within the US Department of Veterans Affairs health system. However, little is known regarding the relative quality of video, phone, and in-person MH care. Objective: To study the comparative effectiveness of MH care delivered via video, phone, and in-person. Design, Setting, and Participants: This retrospective comparative effectiveness study used administrative data for all patients who completed at least 3 outpatient MH appointments during the assignment period from July 2021 to October 2022. Each participant was assigned to a MH modality cohort based on how they received most of their outpatient care in the assignment period: by video, phone, or in-person. Outcomes were assessed over a 1-year follow-up period from 2022 to 2023. Data were analyzed from July 2024 to July 2026. Exposures: Receiving most outpatient MH care via video, phone, or in-person. Main Outcomes and Measures: Outcomes of interest were MH hospitalizations, MH emergency department (ED) visits, suicide behaviors, and percentage of completed appointments. Inverse probability-weighted regression adjustment was used to obtain an average treatment effect (ATE). Results: The cohort included 813 699 participants (672 833 [82.7%] male; 354 686 participants [43.6%] aged ≥60 years), including 305 189 participants (37.5%) who received most of their MH care in person, 343 543 participants (42.2%) who received most of their care via video appointments, and 164 967 participants (20.3%) who received most of their care via phone appointments. Overall, 3027 video group participants (0.9%), 6547 in-person group participants (2.1%), and 2584 phone group participants (1.6%) experienced an MH hospitalization; 5237 video group participants (1.5%), 8009 in-person group participants (2.6%), and 3713 phone group participants (2.3%) had an MH ED visit; and 3539 video group participants (1.0%), 3780 in-person group participants (1.2%), and 2086 phone group participants (1.3%) exhibited suicidal behaviors. Video group participants completed a mean (SD) of 71.1% (21.7%) of appointments, compared with 68.0% (22.2%) of appointments in the in-person group and 68.4% (23.2%) of appointments in the phone group. The expected probability of MH hospitalization was 0.005 (SE, 0.001) points lower if all patients had received mostly video care instead of phone and 0.005 (SE, <0.001) lower vs in-person care . The same pattern emerged for MH ED visits and suicide behaviors, with expected probabilities being lower for the video group compared to phone (MH ED visit: ATE, -0.006; SE, 0.001; suicidal behavior: ATE, -0.003; SE, <0.001) or in-person (MH ED visit: ATE, -0.005; SE, <0.001; P < .001; suicidal behavior: ATE, -0.001; SE, <0.001) groups. By contrast, the expected percentage of appointments completed was 4.1 (SE, 0.1) percentage points higher in the video group vs phone group and 3.6 (SE, 0.1) percentage points higher in the video group vs in-person group. Conclusions and Relevance: In this comparative effectiveness study, receiving MH care via video was associated with improved clinical outcomes compared with receiving care via phone or in-person. Findings of possible advantages of video- over phone-based care could impact care modality decision-making if video is a feasible option. Video-based care also was associated with improved outcomes compared with in-person care. However, despite controlling for imbalanced groups, there is still potential confounding, and the magnitudes of the ATEs were small; therefore, results must be interpreted with caution.