Provision of Telepsychological Care Via Email during COVID–19 Confinement: An Exploratory Study

Abstract Within teletherapy, email interventions have been studied scarcely. For this reason, this exploratory study aims to characterize the assistance provided by email in a university telepsychology service and to compare the data with the assistance provided by telephone in the same service and period. For this purpose, the records of 81 users assisted via email during the COVID–19 pandemic lockdown in Spain were analyzed. The data were compared with those of the 338 users assisted by telephone in the same period. Despite its many limitations, results indicate high satisfaction with the email modality. Users express that they prefer a preference for using email when they do not feel safe in other ways. We found a lot of variation between the number of emails exchanged and the days that each case was active. Additionally, differences were found with telephone users in aspects such as age (email users being younger) and in a depression screening (email users scoring more positively). This study concludes on the high potential of this channel for the application of certain techniques (e.g., psychoeducation) or for people with certain characteristics.

In recent years, the use of the Internet and the evolution and development of Information and Communication Technologies (ICT) have led to the creation of a 'cyberculture', which includes different forms of relationships and interactions between people, as well as a new conception of distances and a new way of perceiving the world around us.The world of psychology has not been unaffected, and in recent years the use of telepsychology has been widely implemented (Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013).Telepsychology is defined as the provision of psychological services using h telecommunication technologies (Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013).
Within telepsychology, different classifications can be established depending on where the emphasis is placed, such as the time frame through which communication is carried out, the degree of involvement or contact with the therapist, or the technological applications or systems used, among others (Barak et al., 2009).Currently, telepsychology is experiencing a particularly important moment due to the particular conditions imposed by the recent COVID-19 pandemic (Simpson et al., 2020).During the global lockdown, telepsychology was developed intensively and extensively, and many countries adopted it as the basic way to intervene in the mental health of their citizens, and it was maintained afterwards (Batastini et al., 2021;Gordillo et al., 2022;Maher et al., 2023).
Teletherapy is the part of psychology performed by clinicians with the aim of providing psychological treatment at a distance.Within it, the most studied therapeutic alternatives have been videoconference and telephone, with generally satisfactory results in terms of efficacy and effectiveness (Baños et al., 2022;Batastini et al., 2021, Estupiñá, 2022).For example, very satisfactory results have been obtained when applying cognitive behavioural therapies in this way to tackle anxiety and depression problems (Shigekawa et al., 2018) and it has been shown to be a very useful element in preventing and addressing suicide attempts (Rojas et al., 2020).Furthermore, in terms of establishing a good therapeutic alliance, there are reviews that state that the level of alliance established can be similar to that achieved at in-person therapy (Simpson et al., 2020).Finally, it should be noted that there is meta-analytical evidence that supports that assessments conducted via videoconferencing do not lead to differential decisions with respect to those conducted in-person (Batastini et al., 2021).
However, certain teletherapy care pathways have so far been little studied.These include the use of email for therapeutic purposes, which, according to the classification of Barak et al. (2009), would be a means of providing delayed online therapy.Despite the lack of research, it appears that clinicians do use email for therapeutic purposes.For example, in a survey of Spanish psychologists, 30% of respondents stated that they had used email at some time to carry out teletherapy (González-Peña et al., 2017).Existing research on the use of email in teletherapy has mainly focused on email as a support or a supplement in the application of more conventional treatments.For example, Delsignore et al., in 2016, evaluated the outcome of email use as an adjunct in cognitive behavioral therapy groups for social anxiety disorder.Patients in the experimental group received an email from their therapist two days before each session (10 in total).The content of the emails was standardized and written in an empathic and non-judgmental tone, containing aspects such as positive feedback on the performance in previous sessions, a summary of all the work done so far, psychoeducational elements about social phobia, examples of real-life experiments and a brief description of what would be addressed in the next session.The group who received email communications had lower drop-out rates and reported less severe symptomatology after treatment.
Other studies have analyzed the content of these emails.In a study by Svartvatten et al. (2015), the content of the emails that 29 participants with depression had to send to the therapists at the end of each module of an internet-based cognitive behavioral therapy was analysed.Authors concluded that certain categories of content could be an indicator of how therapy was going to progress.Specifically, they proposed that the content of the clients' emails could be divided into 10 categories.Of these, the ones that correlated most with positive results contained references to the therapeutic alliance and the observation of positive consequences of the treatment.Lindner et al. (2014) compared the differences in an internet-based cognitive behavioral therapy for patients with depression who were supported either via telephone or email.The results showed no difference between the two methods, with a significant decrease in depressive symptomatology in both.
On the other hand, there are clinical cases described in the scientific literature in which the therapy was carried out by email.Roy and Gillet (2008) described a round of therapy with an adolescent girl.Due to the difficulties she had in understanding and communicating with the professionals, therapy via email was offered.The therapy process involved the exchange of a weekly email for 3 months, by which time the patient had decided to attend an adultoriented service.The authors emphasise that, thanks to the email therapy, optimal levels of alliance were developed, which allowed the patient to agree to in-person treatment.Boico et al. (2022), or Moscovitz et al. (2023) also used email as a channel for teletherapy, with good results.In this last study, email was used to circumvent discrimination against Muslim women in the provision of psychological services.Bocci (2020) also recommends the use of email, instead of phone, when interacting with millennials.She recognizes the limitations of email and gives several tips to improve its use.
Certainly, there are more innovative teletherapy systems than email (Baños et al., 2022) and it is clear that psychotherapy through email has major limitations (e.g., loss of non-verbal information, asynchrony, lack of immediate response, etc.).However (and above all, under specific circumstances, such as the lockdown of 2020), it can be a very useful tool for certain groups of people (for example, those who lack privacy; or those who do not want to be recognized; or those who need to ponder what they want to disclose; or those who find it very difficult to open up and need time to respond adequately to the therapist's requirements; or to avoid stigmatization or discrimination).In these circumstances, email can be useful, considering that it has been shown to be a successful intervention route in other studies.
Taking all of the above into account, there is a perceived need to increase our knowledge about psychological interventions carried out via email.For this reason, the aim of this article is to explore the characteristics of the psychological care provided via email during the lockdown in Spain between March and June 2020 and to assess whether there are differential elements compared to telepsychological care via telephone.Email consultation was provided to university students at a major Spanish university by its telepsychological service.This service, which opened in 2017, is a telematic, immediate and free psychological assistance service for students, although during the lockdown period the entire university community and their families were assisted by the COVID-19 program.Students could access consultation by telephone and email during this period, at their choice.Specifically, the aim is to explore the sociodemographic characteristics of the persons who consulted by email, the reasons for their email consultation, the aspects that led them to contact by email, the results of the interventions carried out via email, and their satisfaction with the assistance received.In addition, the aim is to study the differences with users who consulted by telephone in the same period to explore whether there are differential features in the aspects mentioned above.

Participants
The records of all the 81 users who requested assistance via email during the special COVID-19 program between 26 March and 22 June 2020 were analyzed (average age = 22.62; SD = 5.8; age range = 17-49; 77% women).Similarly, in order to be able to make the appropriate comparisons, the records of the 338 users who requested assistance via telephone in the same period were considered (average age = 29.82;SD = 13.8;age range = 13-80; 76% women).One telephone user did not provide consent and was not included.No cases were dropped due to missing values or other reasons.

Procedure
During the special COVID-19 program, users demanding assistance through email received counseling and clinical care through the email in an individualized manner.After providing consent, users were followed by a single psychologist to whom the patient was assigned upon receipt of the first mail.The interaction occurred throughout the psychologist's shifts without any limitation in time or email amount, and according to the service guidelines (Larroy García et al., 2020).Additionally, information on the interventions was recorded.The records were filled in by the 5 MSc psychologists who were responsible for attending to users via email.Specifically, information was coded on socio-demographic aspects (nationality, city of residence, who they lived with during the lockdown and academic/work situation), active psychological and/or psychopharmacological treatments, reasons for consultation as assessed by the psychologist, therapeutic actions implemented, active days of care, number of emails exchanged and reasons that led these users to contact via email instead of via telephone.This last variable was coded into five categories by consensus of the five psychologists once all responses had been analyzed.Finally, it should be noted that all users were given a screening measure of anxious (GAD-2) and depressive (PHQ-2) symptomatology.
Finally, in order to be able to make comparisons with the characteristics of the users who consulted via telephone, data were obtained on gender, age, and who lived with during lockdown, and the results of the screening tests of the 338 users who consulted via telephone on the same dates.It should be noted that these data were obtained and recorded after each intervention by the team of 15 graduate-level psychologists who were responsible for taking calls and, once the relevant information had been collected, referring the call to the MSc psychologists carrying out the clinical work.
It is important to note that users who contacted via email answered the questionnaires and reflected the information in an online questionnaire sent to them, while those who contacted via telephone provided the information verbally through the psychologists' questions.
All the psychologists who answered calls or messages previously belonged to the service and had received extensive training certified by the University.It should be noted that users were explicitly asked for permission to use their data for research purposes through a form that was sent to them at the first contact.

Measures
The 2-item Generalized Anxiety Disorder scale (GAD-2; Spitzer et al., 2006) is an easy to use 2-item instrument, scoring each answer from 0 ("not at all") to 3 ("nearly every day"), based on the Diagnostic and Statistical Manual on Mental Disorders, Fourth Edition (DSM-IV) criteria, for identifying probable general anxiety disorder cases.It has good psychometric properties and stands out for being easy to administer and therefore ideal for application in a telepsychological environment.Specifically, the Spanish version used, validated by García-Campayo et al. (2012), obtained a value of .88 on Cronbach's alpha, a high concurrent validity with, for instance, the Hospital Anxiety and Depression Scale (HADS) questionnaire.Finally, a cutoff of 3 showed adequate sensitivity (91.5%) and specificity (85.8%).In this study Cronbach's alpha was .64 for email users and .66 for telephone users The Patient Health Questionnaire-2 (PHQ-2; (Kroenke et al., 2003) is a widely used questionnaire for depression screening which has two items about the frequency of depressed mood and anhedonia over the past 2 weeks, scoring each answer from 0 ("not at all") to 3 ("nearly every day").In its original study, a score of 3 was established as the optimal cut-off point for screening purposes (Kroenke et al., 2003).In its Spanish validation (Diez-Quevedo et al., 2001), PHQ-2 showed good psychometric properties, including a high sensitivity (83%) and specificity (92%).In this study Cronbach's alpha was.76 for email users and.80 for telephone users.
Both PHQ-2 and GAD-2 were applied to users upon first contact with the service, either telephonically or through an online form for email users.
Satisfaction and Follow-up questionnaire: A week after the end of the assistance, email users were contacted via email to evaluate the assistance received and to carry out a follow-up, if requested.The assessment of the assistance was completed by 36 users (44.4% of email users) who answered the question "In general, how satisfactory was the way in which the team dealt with the problem for which you consulted?"(Response options: Completely unsatisfactory, Very unsatisfactory, Somewhat unsatisfactory, Fairly satisfactory, Very satisfactory and Completely satisfactory) and to the question "To what extent have the proposals offered during contact with the service helped you in relation to the specific problem that led you to consult?" (Response options: Could not say, Made things a lot worse, Made things a little worse, No change, Made things a little better and Made things a lot better).These questions were adapted from the Spanish version of the CRES-4 questionnaire (Feixas et al., 2012;Nielsen et al., 2004).Regarding the follow-up, it was requested by 11 users (13.6% of email users), who were contacted for assistance and given the GAD-2 and PHQ-2 questionnaires again.

Data Analysis
Descriptive and frequency analyses were performed to categorize the samples.In addition, bivariate analyses (t-tests and χ 2 ) were performed to compare differences between telephone and email users in gender, age, place of residence during lockdown and differences in scores on questionnaires administered and to compare scores on screening measures before care and at follow-up.To calculate the difference between the scores at baseline and follow-up the biascorrected and accelerated bootstrap method (BCa), with 1,000 resamples and an 95% CI, was used due to normality issues with the samples.Achieved power was estimated using G*Power software (Faul et al., 2009).In addition, the homogeneity of variances was tested using Levene's test.Finally, simple correlation analyses were also carried out to find out whether the characteristics of email care (number of emails exchanged and days of duration of the intervention) were associated with other variables such as scores on screening measures.IBM SPSS software version 27.0 was used for all analyses.

Sample Characteristics during the COVID-19 Program
Table 1 shows the characteristics of the users who consulted the service via email during the lockdown period in Spain.The data show that, in general, the users were of Spanish origin (87.7%), whose main occupation was their university studies (75.3%), mostly spent the lockdown with their parents (80.2%) and were not receiving psychotherapeutic or psychopharmacological treatment at the time of their consultation (90.1%).It should be noted that the treatment received by the remaining 9.9% was in all cases both psychopharmacological and psychotherapeutic.

Clinical and Care Characteristics of Email Users during the COVID-19 Program
Regarding the screening questionnaires provided, 79.9% (M = 4.02; SD = 1.53) of the users obtained a positive result in the anxiety test The Spanish Journal of Psychology (GAD-2) and 65.4% (M = 3.49; SD = 1.55) of the users in the depression test (PHQ-2).
The reasons for consultation are shown in Table 2.The most prevalent reasons were anxiety and uncertainty (51.9%), academic problems (34.6%), and problems of coping with the lockdown (30.9%).On the other hand, the therapeutic actions implemented by the therapists can be seen in Table 3.
About the characteristics of the email intervention, the number of days each case was active, and the number of emails exchanged were calculated.Firstly, the mean number of days each intervention was active was 16.54 (SD = 20.1).Given the high variability, the median was calculated as 8 days.On the other hand, the mean number of emails exchanged with each user was 15.19 (SD = 13.03).Similarly, the median was calculated to be 11 emails exchanged.
The number of days that the attention was active did not correlate significantly with the age of the patients (r = -.183;p = .103),nor with the measures of anxiety (r = -.114;p = .310)and depression (r = -.138;p = .220).Similarly, there were no significant correlations between the number of emails exchanged and age (r = -.165;p = .141)or the levels of anxiety (r = -.010;p = .928)and depression (r = -.026;p = .816).
Regarding the reason why users consulted by email rather than by other means (e.g., telephone) 47% (n = 38) reported that it was due to lack of privacy at home, 44.4% (n = 36) because they felt more comfortable consulting by email and it was easier for them, 6.2% (n = 5) reported not having a telephone line, 1.2% (n = 1) reported having language problems and finally 1.2% (n = 1) reported physiological problems with speech.

Satisfaction with Assistance and Follow-up Results
Regarding user satisfaction with the assistance received, 58.3% (n = 21) reported that it was Completely Satisfactory, 25% (n = 9) Very Satisfactory, 11.1% (n = 4) Fairly Satisfactory and 5.6% (n = 2) Somewhat Unsatisfactory.On the other hand, regarding the perception of how much consulting the service had helped the user, 63.9% (n = 23) responded that it made things somewhat better and 36.1% (n = 13) responded that it made things much better.
In addition, a follow-up was completed by 11 users (13.6% of email users) of whom 72.7% were women with a mean age of 25.45 (SD = 7.7).Table 4 shows how the scores in the two tests provided decreased between the measurement at the beginning of assistance and the measurement at one-week follow-up.However, these differences were only significant in the case of the PHQ-2, t(10) = 2.29; p = .045;d = .69,95% CI [0.02, 1.34].Finally, the power of this analysis was 1-β = .69.

Differences with Telephone Assistance in the Same Period
We analyzed whether there were differences in gender, age, scores on the screening instruments and place of residence during lockdown between users who had contacted the service via email (n = 81) and those who had contacted via telephone (n = 338).
In terms of gender, 76.1% of users who consulted by telephone were female compared to 77.8% by email.The difference in frequency according to gender was not statistically significant, χ 2 (1, N = 390) = 0.101; p = .75).As for the age of the patients, the mean age of those who consulted via telephone was 29.82 years (SD = 13.8) while the mean age of those who consulted via email was 22.62 years (SD = 5.8).Differences in age between the two groups were statistically significant, t(314.5)= -7.002;p < .001;d = .58,95% CI [0.33, 0.82].
Regarding the scores on the screening instruments, as shown in Table 4, no significant differences were observed between the raw scores of the two intervention modalities.However, when analyzing these differences according to the percentage of positive results in the screening (cut-off point 3 for both questionnaires), it can be observed that in the case of the PHQ-2, 65.4% of email users (n = 81) obtained a positive result compared to 23% of telephone users (n = 338).The analyses carried out indicate that this percentage is statistically higher in the email group than in the telephone users, χ 2 (1, N = 390) = 53.341;p < .001.On the other hand, it should be noted that no significant differences were found in the level of positivity in GAD-2.
Finally, statistically significant results were obtained, χ 2 (1, N = 390) = 46.687;p < .001,regarding the differences in who the users lived with during lockdown.After analysis of the residues, the percentage of users who live with their parents or with their partner and consult via mail is statistically higher than those who are in the same situation and consult via telephone.Note.Each user received multiple therapeutic actions.

Discussion
The aim of this study was to explore the characteristics of the psychological assistance provided via email in an University service providing free, telematic psychological care during the period of Spanish lockdown (between 26 March and 22 June 2020) and to establish comparisons with the assistance provided via telephone in the same service and period.All this has been done with the aim of increasing the existing knowledge about psychological assistance via email, trying to find out its differential features and specific potential within teletherapy.First, if we look at the reasons for consultation by email, we observe a clear predominance of anxiety problems, followed by academic problems and low mood.At first glance, these categories seem similar to those reported most often in studies carried out in university psychological services where people consult predominantly for anxiety or depressive problems (Labrador Encinas et al., 2016;Miguel-Álvaro et al., 2019).This could be an indicator that the reasons for consultation do not differ according to the route ofconsultation, although more formal studies would be needed to make robust inferences.Moreover, these data are congruent with the majority of the epidemiological literature, which points out that anxious-depressive problems are the most prevalent (e.g., de Pedro et al., 2016) and the most frequently demanded (Labrador Encinas et al., 2016).On the contrary, claims for specific problems (e.g., eating disorders) are infrequent if they are conceived as the main claim.This fact could be explained by the type of center and population from which the sample was obtained (a university service).
On the other hand, regarding the therapeutic actions or techniques implemented, the psychologists reported having implemented emotional ventilation and psychoeducation techniques with 100% of the users via email.As far as psychoeducation is concerned, there is ample evidence that digital media can be useful to provide psychoeducation in certain aspects (i.e., Hidalgo-Mazzei et al., 2018).We could even speak of the higher potential of email in this aspect as opposed to traditional in-person modalities since email would allow materials or videos to be attached, to which the patient can refer when needed.On the other hand, the percentage of instances when other types of techniques such as cognitive or problem-solving techniques were implemented is not negligible, even though it is assumed that due to their complexity they are more difficult to apply via email.It should be taken into account that within the limitations of the application of these techniques we can find aspects as relevant as the difficulty in capturing the nuances of verbalizations in therapy (Pardo-Cebrián et al., 2022).The fact that therapists, when using email, do not have access to the information that can be provided by the nonverbal expressions of patients that allow them to explore their emotional state makes the correct application of certain techniques very complicated.It would be of interest in the future to develop protocols or specific contents to be able to implement these types of techniques via email, taking into account the above-mentioned constraints, as is being done through certain apps (Barak et al., 2009) The data on the number of emails exchanged and the days on which each intervention was active are particularly interesting because no previous studies have been found in which this data was provided.The first thing to note is the high inter-subject variability in both data.This could be an indicator that there may be different typologies of consultants, although in this study, there were no correlations with other variables such as age or score on the questionnaires provided.The variability in the number of days that the intervention was active may also be due to the characteristics of email assistance.As previous authors have pointed out (Roy & Gillett, 2008), the main characteristic of this type of intervention is that it is deferred, so that both parties do not have a stipulated time to interact.Perhaps it would be useful to explore the effect of establishing a set of rules in this sense and their impact on attendance in order to find out whether establishing days, times and quotas for replies could be useful in the process.
One piece of information that is considered to be of great interest is the reason why users contacted the service via email rather than via telephone.Most users reported using email because they lacked sufficient privacy.This is interesting, because providing an alternative means of assistance such as email can be very useful for certain groups that may not have sufficient privacy or that may even be endangered when asking for help (e.g., victims of gender-based violence) or at times when people are forced to stay at home, as was the case during the COVID-19 pandemic lockdown when this study was conducted (Luiggi-Hernández & Rivera-Amador, 2020).The second largest category is users who were more comfortable consulting by email.This is consistent with the widely documented difficulty that some people may have in seeing a psychologist and establishing an appropriate alliance (Tortella-Feliu et al., 2016).For this reason, email can be a very useful tool for establishing a first therapeutic contact with which to begin to forge a therapeutic alliance that will allow work to be done in the future by other means (Turpin & Coleman, 2010).Even more so when it was noted that user satisfaction with the service provided was very high and users generally felt that it had helped them with their problem.Finally, 7 subjects out of 81 reported that they had consulted by email because they did not have a telephone line, were not fluent in the language or had physiological problems with speech.Although they are a minority, these responses highlight the importance of providing alternative channels for those who have more difficulties, thus establishing a diversity-sensitive .555-Note.PHQ-2 = Patient Health Questionnaire-2; GAD-2 = Generalized Anxiety Disorder-2. a The bias-corrected and accelerated bootstrap method (BCa) was used, with 1,000 resamples and 95% CI.
The Spanish Journal of Psychology approach that is so necessary in psychology (Turpin & Coleman, 2010).However, at this point we must emphasize that these conclusions, derived from small sample sizes, should be considered at an exploratory level, forming hypotheses that should be tested in more rigorous designs in the future.
Regarding the effectiveness of email intervention, the present study found that patients improved significantly in the depression score, but no such effect was found in the anxiety measure.However, the small sample size (n = 11) and the low statistical power of the analysis mean that these data should be treated with caution.In the future, more robust designs are needed to examine the effectiveness of these interventions.It should also be noted here that in the satisfaction survey, most users stated that the intervention had helped them to cope with their problem.However, in this case we must take into account that not all users who consulted by email completed the satisfaction survey, so there could be a bias.It is well established that satisfaction with a psychotherapeutic treatment is highly correlated with the success of the treatment or patient preferences (Lindhiem et al., 2014) which may mean that those who did not answer the satisfaction survey could not show the same profile of scores.
One of the most interesting parts of the results is the comparison between users who accessed the service via email and users who accessed the service via telephone.Firstly, no differences were found in terms of the gender of the users, where women accounted for a much higher percentage than men in both categories-a trend observed in other similar studies (Labrador Encinas et al., 2016;Miguel-Álvaro et al., 2019).However, significant differences were observed in terms of age, with email users being statistically younger than telephone users.This could indicate several things, all of which are of interest.Firstly, it would be congruent to think that younger people do better with written communication applications as they have grown up in an expansion of the use of these to the detriment of telephone calls (Cho, 2020).On the other hand, it would be logical to assume that younger and less mature users are likely to feel more comfortable initiating or requesting assistance in a more impersonal and less invasive way (Roy & Gillett, 2008).Furthermore younger users, are more likely to live with their parents potentially leading to privacy concerns.All of this could indicate the potential for such a channel to make it easier for a younger audience to seek counseling.
Another difference of interest was found in the percentage of users who scored positive in the depressive symptomatology screening between email and telephone users.It is likely that the characteristics of email facilitate requests for help in processes characterized by inactivity, feelings of abandonment, worthlessness or self-hatred (Lindner et al., 2014).Perhaps, because it is a more impersonal medium, this type of patient may find it easier to overcome the probable fear of judgement by the therapist.However, before drawing more solid conclusions, other studies should be conducted using more robust (non-exploratory) methods that minimize possible selection biases and allow us to know whether this pattern is maintained.
Finally, there were differences between users of both media according to where they lived during lockdown.Those who resided with their parents or with their partners accessed the service via email significantly more than via telephone.This reinforces the idea, mentioned earlier, that when individuals lack sufficient privacy or security in their environment, they prefer to consult by means such as email, as their cohabitants are less likely to be aware of it (Luiggi-Hernández & Rivera-Amador, 2020).
Some limitations of the present study have already been mentioned, such as the greater convenience of other measures to explore the effect of interventions and the small sample size in this specific analysis.In addition, Cronbach's alpha scores were somewhat low in the case of GAD-2.Other limitations of the study include the size of the sample of email users.Although not excessively low, it would be interesting to increase the sample size in future studies in order to make the study more rigorous.Furthermore, this is an observational, exploratory and non-manipulative study which, although useful for stimulating the start of research in this area, is not the most valid design in terms of the conclusions that can be drawn.Therefore, in the future, experimental studies should be generated with the aim of further investigating the knowledge of this exciting field of teletherapy.Specifically, and based on the results of the present work, it should be confirmed with more rigorous studies whether there is a specific profile of email consultations, how interventions could be adapted and what is the efficacy of the different techniques that can be applied via email, if indeed the profile of the email consultant presents differential features (such as more depressive symptomatology, for example) than patients who consult by other means such as telephone and confirm that there are situations (such as lack of privacy) that may lead people to opt for the use of email in a psychotherapeutic context.
On the other hand, some clinical implications could be derived from this study, such as the potential for email to serve as an alternative for establishing a first clinical contact with individuals who do not feel safe to attend an in-person consultation or lack enough privacy to establish a video call.Additionally, it can be a very useful means to carry out psychoeducation with patients.However, as has been repeatedly emphasized, it is important to remember that this is an exploratory study and that these clinical implications should be tested in more rigorous studies.
In summary, the present work offers interesting data on a rarely studied aspect in the scientific literature: Psychotherapeutic assistance through email.It has been observed that some techniques are used more via email than others, that user satisfaction with this modality is high and that users express that they prefer to consult by email when they do not have privacy or when they do not feel safe in other ways.In addition, differences have been found with telephone users in aspects such as age (email users being younger) and positivity in a depression screening (email users scoring more positively) for example.Many of these data suggest that email can be a valuable resource for certain users, although much more research is needed in the future.

Table 1 .
Sample Characteristics during the COVID-19 program (n = 81) Note. a All 8 subjects were undergoing psychotherapeutic and psychopharmacological treatment simultaneously.

Table 2 .
Distribution of Reasons for Consultation in the COVID-19 Program (n = 81) Note.Users could provide more than one reason for consultation.

Table 4 .
Differences in Screening Scores