Self-Stigma Not the Driver of Telepsychiatry Use, Iranian Study Finds

When psychiatrists in Tehran set out to understand why some patients choose video calls and phone consultations over the traditional couch, they expected shame to be a major factor. The conventional narrative about telepsychiatry has long assumed that people avoid in-person psychiatric clinics because they fear being seen walking into a mental health facility, being recognized by neighbors, or confronting the internalized belief that seeking help makes them weak or defective. A new cross-sectional study from Iran challenges that assumption in a striking way: self-stigma, measured with a validated psychological instrument, turned out to be essentially irrelevant to whether patients chose remote or face-to-face psychiatric care.

The research, conducted by a team affiliated with Tehran University of Medical Sciences and published in BMC Psychiatry, surveyed 347 adult patients receiving psychiatric services at Roozbeh Hospital and two private clinics in Tehran between October 2022 and April 2024. Roozbeh is one of Iran’s most prominent psychiatric teaching hospitals, giving the study access to a broad clinical population rather than a narrow convenience sample. Participants completed the Self-Stigma of Seeking Help scale, a widely used instrument known as SSOSH that quantifies the degree to which people internalize negative beliefs about seeking psychological assistance, alongside detailed questions about their demographic characteristics, clinical history, and patterns of service use.

The headline finding is deceptively simple: mean SSOSH scores did not differ significantly between patients who used remote services and those who attended in person. Roughly 44.7 percent of participants reported using remote psychiatric services, a substantial proportion that reflects how deeply telepsychiatry penetrated Iranian mental health care during and after the COVID-19 pandemic. Yet the psychological profile of remote users, at least on the stigma dimension, was indistinguishable from that of clinic attendees. Only 2.6 percent of the entire sample explicitly cited stigma-related concerns as a reason for choosing remote care, a figure so small that it effectively rules out self-stigma as a meaningful driver of telepsychiatry adoption in this population.

What did predict remote service use? The researchers ran a logistic regression model that isolated several independent predictors, and the results paint a picture driven overwhelmingly by geography, logistics, and practical experience rather than psychology. Patients living outside Tehran were more than six times as likely to use remote services as residents of the capital, with an odds ratio of 6.042 and a 95 percent confidence interval spanning 3.304 to 11.049, a statistically robust association with a p-value below 0.001. This finding makes intuitive sense: Iran’s psychiatric specialist workforce is heavily concentrated in major cities, and patients in smaller towns and rural provinces often face long journeys, significant travel costs, and lost income to reach a qualified psychiatrist. For them, a video consultation is not a matter of preference but of access.

The second strongest predictor was a history of discontinuing treatment. Patients who had previously dropped out of psychiatric care were more than three times as likely to choose remote services, with an odds ratio of 3.426 and a confidence interval of 1.952 to 6.012. This is a clinically important signal. Treatment discontinuation is one of the most persistent problems in psychiatry, with substantial proportions of patients abandoning medication or therapy within months of starting. If remote services are particularly attractive to people who have already struggled to maintain engagement with traditional care, telepsychiatry may function as a retention tool, offering a lower-friction pathway back into treatment for patients who found the demands of in-person attendance unsustainable.

Education and satisfaction with care rounded out the significant predictors, though with more modest effect sizes. Each increment in educational level was associated with roughly a 49 percent increase in the odds of using remote services, with an odds ratio of 1.493 and a confidence interval of 1.084 to 2.056. Higher satisfaction with care similarly predicted remote use, with an odds ratio of 1.442 and a confidence interval of 1.063 to 1.957. The education association likely reflects digital literacy and comfort with technology-mediated communication, which remain unevenly distributed across populations. The satisfaction finding suggests that patients who have positive experiences with remote consultations tend to continue using them, reinforcing a feedback loop in which service quality drives sustained adoption.

The methodological design deserves attention for what it can and cannot establish. As a cross-sectional study, it captures a single moment in time and cannot determine whether self-stigma causally influences service choice; it can only report associations. The SSOSH scale itself is a well-validated measure, but it assesses internalized stigma about help-seeking specifically, not the full spectrum of public stigma, anticipated discrimination, or family-level stigma that may shape behavior in different ways. The sample was drawn from a major urban hospital and private clinics in Tehran, which may limit generalizability to patients with no current contact with psychiatric services at all, the group for whom stigma is often hypothesized to be the most powerful barrier to initial help-seeking.

Nevertheless, the study’s implications for mental health policy are considerable. If stigma is not the primary barrier for people already within the treatment system, then investments in telepsychiatry should focus on the factors the data actually identify: geographic accessibility, continuity of care for patients at risk of dropping out, digital usability, and the overall quality of the consultation experience. The authors conclude that enhancing the quality and usability of remote services may further improve treatment adherence and equitable access to mental health care. This reframing matters because resources are finite. Money spent on destigmatization campaigns, while valuable for other reasons, may not translate into increased telepsychiatry uptake among existing patients if the real obstacles are broadband access, device availability, scheduling flexibility, and reimbursement structures.

The Iranian context adds a distinctive dimension to the findings. Iran has a rapidly expanding telemedicine infrastructure, accelerated by pandemic-era policy changes, but also faces significant regional disparities in specialist distribution. The sixfold odds ratio associated with living outside Tehran quantifies something that health planners have long suspected qualitatively: remote psychiatric services are functioning primarily as a geographic equalizer. In countries with similar specialist maldistribution, from middle-income nations in the Middle East to rural regions of high-income countries, the same dynamic likely operates, suggesting that the study’s core insight, that convenience and access rather than stigma drive telepsychiatry use among established patients, may travel well beyond Iran’s borders.

For clinicians, the message is that remote and in-person psychiatric care are not simply two flavors of the same service differentiated by patient psychology. They serve overlapping but distinct populations with different practical constraints and treatment histories. A patient who has discontinued care twice and lives four hundred kilometers from the nearest psychiatrist is not primarily wrestling with shame about seeking help; that patient is wrestling with distance, cost, and the accumulated friction of a system that was not designed around their circumstances. Recognizing this distinction, the researchers argue, is the first step toward building remote mental health services that meet patients where they actually are, both geographically and in their treatment journeys, rather than where assumptions about stigma have long presumed them to be.

Subject of Research: The relationship between self-stigma and the use of telepsychiatry versus face-to-face psychiatric services among adult patients in Iran

Article Title: No significant association between self-stigma and telepsychiatry use: a cross-sectional study in Iran

Article References: Hedayati, F., Mohammadjafari, A., Mirsepassi, Z., Hooshyari, Z., Shakibazadeh, E., Ahmadipour, A., & Amini, H. (2026). No significant association between self-stigma and telepsychiatry use: a cross-sectional study in Iran. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08617-6

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08617-6

Keywords: telepsychiatry, self-stigma, mental health, help-seeking behavior, Iran, BMC Psychiatry, remote psychiatric services, treatment adherence, access to care, cross-sectional study, SSOSH scale, psychiatric care