Beyond Convenience: Continuing a Cautious Appraisal of Virtual Mental Health Care

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The rapid expansion of virtual psychiatric care, particularly during and following the COVID-19 pandemic, has transformed mental health service delivery. While virtual modalities have demonstrably increased accessibility and logistical flexibility, especially for mood and anxiety disorders, their adoption has outpaced critical evaluation in more complex psychiatric contexts. This article appraises the limitations of virtual psychiatric care, especially in treating diagnostically subtle and clinically nuanced conditions such as eating disorders (EDs), substance use disorders (SUDs), borderline personality disorder (BPD), posttraumatic stress disorders (PTSDs), and other trauma-related illnesses.

Platforms like Zoom and Doxy have transformed the delivery of mental health care. During COVID-19, telemedicine accounted for over half of psychiatric visits for depression (52.6%), bipolar disorder (55.0%), and anxiety (53.9%), with weekly visits dropping by nearly 11% from prepandemic levels.¹ Many reviews now deem virtual care not inferior to in-person care for many common disorders.^2,3 Despite studies suggesting noninferiority of telepsychiatry and virtual therapy for common psychiatric conditions, this equivalence does not generalize to all diagnoses or settings, and may be premature.

Six underexplored domains are considered, including the neurobiological trade-offs of digital interaction, research bias in virtual care literature, unique challenges of complex cases, patient and clinician distractibility, variability in therapist competence in digital care, and structural limitations in supervision, training, and ethical oversight.

Neurobiological and Relational Trade-Offs

In-person psychotherapy enables a multi-sensory relational experience foundational to emotional attunement, diagnostic accuracy, and rapport. Nonverbal cues such as facial microexpressions, posture, grooming, fidgeting, and eye contact are essential tools, particularly when treating conditions marked by minimization or concealment, such as anorexia nervosa or SUDs. Even high-definition video can constrain access to these cues, often further degraded by limited camera angles, inadequate lighting, or patient disengagement.^4,5

Neuroimaging studies have demonstrated attenuated activation in brain regions essential to empathy and social cognition, including the superior temporal sulcus, fusiform gyrus, insula, medial prefrontal cortex, and amygdala, during virtual interactions compared to in-person encounters.⁶ These neural circuits are frequently implicated in psychiatric conditions marked by interpersonal dysfunction, including BPD and major depressive disorder. Disrupted interpersonal synchrony and decreased mirror neuron engagement may weaken the therapeutic mechanisms of empathy and coregulation during remote care.⁷

Diagnostic Subtlety in Complex Conditions

While virtual care may be comparably effective for depression and anxiety, its application to more complex psychiatric presentations raises concerns. EDs and SUDs often rely on direct observation, physical cues, and nuanced interpersonal dynamics for assessment and treatment efficacy due to lower rates of patient truthfulness in reporting. Camera manipulation, oversized clothing, and digital disengagement can obscure physical deterioration or behavioral rituals. Even hybrid models that offer virtual therapy alongside in-person medical visits may still fall short in providing cohesive, integrated care. A modification of virtual therapy may become a standard of care, where camera positioning includes the full body of both the patient and the therapist; however, it would be intriguing to see the reactions from patients and clinicians should this approach be implemented.

SUD patients also often require structured, in-person environments for medication administration, urine toxicology, and behavioral accountability, which are difficult to replicate remotely.⁸ Additionally, ambivalence, shame, and denial, hallmarks of diagnoses such as EDs, SUDs, and BPD, necessitate skilled real-time interpretation of incongruent verbal and nonverbal cues, which are often lost in virtual formats.⁹

Research Bias and the Illusion of Equivalence

Supportive studies of virtual care often focus on short-term symptom reduction and patient satisfaction, excluding high-acuity or comorbid cases. Many are conducted by authors with a biased interest, affiliated with digital health platforms, or funded by industry stakeholders.^10,11 These studies often rely on self-reported data¾measuring tools not yet validated for virtual conditions¾and rarely examine long-term outcomes, dropout rates, or nuanced treatment variables. All of these may limit the studies’ relevance for complex diagnoses, not to mention the ethical dilemma for some to release and publish data that may not support their platform or investment.

Furthermore, publication bias also favors positive findings and tends to omit studies that fail to support an expected outcome.¹² Meta-analyses, while influential, inherit the limitations of their source studies and may obscure population-specific concerns if not stratified by diagnosis, severity, or sociodemographic factors.¹³ The inherent challenges of conducting double-blinded or placebo-controlled trials in psychotherapy exacerbate this issue, necessitating caution in interpreting claims of modality equivalence. Conversely, studies favoring in-person care may underreport barriers such as cost, transportation, and geographic access.

Variability in Therapist Competence and Training Gaps

Many clinicians entered virtual care spaces with little to no formal preparation. Skills specific to teletherapy, such as screen presence, latency management, and compensating for missing nonverbal input, require targeted instruction that is rarely offered in graduate programs or medical residencies.^14,15 Clinicians' natural aptitude to adapt varies widely, and few systems are in place to ensure proficiency.

Supervision models have also not adapted to virtual formats. Observing subtle relational dynamics or offering in-the-moment feedback is difficult remotely, and asynchronous therapy platforms remove real-time attunement entirely. These structural gaps have left many therapists learning on the job in an unvalidated system not designed to support their adaptation.

Clinician Distractibility and Attention Drift

Virtual care further introduces new vulnerabilities to clinician distraction. Managing multiple screens, session video, access to records, and lab results during a session imposes cognitive load that can impair presence and responsiveness. A 2023 survey found that a minimum of 18% of providers admitted to checking personal messages during sessions, likely an underreport due to social desirability bias.¹⁶ Such lapses are not trivial¾even momentary disengagement during emotionally significant conversations reduces empathic accuracy and damages alliance.¹⁷

Virtual formats also remove transitional rituals that traditionally recenter clinicians, such as walking a patient out or resetting the room. This lack of environmental reset may contribute to burnout, empathic fatigue, and a decline in emotional engagement over time.

Training, Equity, and Systemic Limitations

Telepsychiatry and virtual therapy rely on digital fluency, privacy, and adequate technology, assumptions that do not hold true for all populations. Patients in rural areas, those from low-income backgrounds, or those living in multigenerational homes may lack secure internet access, private space, or suitable devices.¹⁸ These disparities can unintentionally impact care quality, HIPAA regulations, session duration, and therapeutic effectiveness. Despite virtual health's promise of increased access, unequal digital infrastructure perpetuates inequity.

Ethical and legal ambiguity further complicates care. Cross-state licensure, unclear emergency protocols, and variations in malpractice coverage create gray areas in high-risk situations such as suicidality or medical instability. Additionally, virtual sessions conducted in patients’ bedrooms or informal spaces may disrupt therapeutic framing and containment, especially in trauma-focused or personality disorder work.

Accepting the Inevitable and What to Do

Regardless of clinician’s varied opinions, a generational evolution is underway in the field of mental health care, one in which convenience has increasingly taken precedence over well-studied implications related to substance, depth, and the pursuit of best-quality treatment. This shift is not merely technological; it reflects broader cultural values that prioritize flexibility, speed, and accessibility, even in the face of clinical complexity.

While virtual psychiatry and therapeutic interventions offer undeniable benefits for individuals who might otherwise lack access or resist in-person care due to geography, stigma, mobility issues, or personal preference, these gains come with trade-offs in certain cases that the field can no longer afford to overlook. Virtual modalities serve many patients well, particularly those with lower-acuity conditions; however, they remain cautiously suited for certain diagnostic categories and clinical situations. The assumption of treatment equivalency is not yet fully supported by the current breadth of evidence, especially in the treatment of complex cases of those with eating disorders, substance use disorders, trauma, and severe personality and mood disorders.

Moving forward, the field must establish virtual care as a distinct clinical modality with its own training requirements, validated tools, and ethical frameworks. Clearly independent research would better support findings come to studies with self-reported outcomes, and loner-term follow-up studies can measure effectiveness and sustainability. Graduate programs should include mandated instruction in digital communication nuances, while platforms must evolve to support richer therapeutic environments. Hybrid care models may offer a solution that balances flexibility with clinical integrity, especially when strong rapport, physical assessment, or therapeutic containment is required.

In the meantime, while efforts to validate and improve virtual therapy and telepsychiatry must remain a priority, what is no longer on the horizon but already here is the integration of artificial intelligence (AI) into mental health care. This technological leap introduces a new layer of uncertainty, a lack of understanding, and a fear of where the profession may be headed. All this change, coming at an exponentially rapid pace, raises similar concerns about therapeutic efficacy, safety, and human connection. If not carefully regulated and researched, AI-driven interventions are already and further risk diminishing the irreplaceable benefits of human-to-human interaction in psychiatry, psychotherapy, and medicine as a whole.

Ultimately, innovation in psychiatric care must prioritize clinical excellence, not just convenience. The future of mental health treatment will undoubtedly include virtual elements, but to serve patients effectively, we must ensure that digital care models are grounded in evidence, tailored to complexity, and delivered by clinicians equipped with the specialized training skills this modality demands.

Dr DeSarbo is the medical director and neuropsychiatrist at ED-180 Treatment Programs. He is also the author of the book The Neuroscience of a Bucket List.

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