The number of Americans receiving psychotherapy rose 30 percent during the pandemic as virtual sessions replaced in-person appointments — but new research tempers hopes that technology will make mental health care more available to the neediest populations.
In fact, the researchers found that the shift to teletherapy has exacerbated existing disparities.
The increase in psychotherapy has occurred among groups that already enjoyed greater access: people with higher incomes, who live in cities, with steady jobs and more education, researchers found in a series of studies, the most recent Wednesday in The American Journal for psychiatry.
Among those who have not benefited from the boom, the team found, are children from low-income families, black children and adolescents, and adults with “severe psychological problems.”
“I think the entire health care system — and maybe the Internet is part of that — seems to be turning away from those who need it most,” said Dr. Mark Olfson, a professor of psychiatry at Columbia University Irving Medical Center and the lead author of the studies on access to care.
“We are seeing that those with the greatest need are losing ground in their likelihood of getting treatment, and that to me is a very important and worrying trend,” he added.
It wasn't meant to be. In the 1990s, teletherapy was championed as a way to reach disadvantaged patients living in remote locations where there were few psychiatrists. Ten years later, it was presented as a more accessible alternative to face-to-face sessions, one that could radically lower barriers to care.
“Telehealth didn't live up to the hype,” said C. Vaile Wright, senior director of the office of healthcare innovation at the American Psychological Association. The reasons, she added, are not a surprise: Many Americans do not have access to reliable broadband, and insurers are not adequately reimbursing providers, who in turn choose to handle private-paying customers.
“If you can't afford it, regardless of the modality, you just can't afford it,” said Dr. Wright. It may be, she added, that weekly therapy sessions simply aren't scalable to a broad population, and the field should explore light-touch alternatives such as single-session interventions and digital therapies.
As telehealth platforms grow, they can attract doctors from community settings with the promise of flexible hours and better conditions, says Dr. Jane M. Zhu, associate professor of medicine at Oregon Health and Science University, who studies mental health accessibility. .
By choosing from a large patient pool, they can choose to treat patients with milder conditions and better ability to pay. “It's definitely something we need to know,” said Dr. Zhu. “There should be light around here. Who do these companies serve? And what does this mean for the patients who are most in need?”
The percentage of Americans receiving psychotherapy remained relatively stable at 3 to 4 percent for decades before gradually starting to increase, said Dr. Olfson.
Then, two factors — the pandemic and the explosion of teletherapy — contributed to a sharp increase, with the number of adults receiving psychotherapy rising from 6.5 percent in 2018 to 8.5 percent in 2021. (For comparison, the annual rate adults taking psychotropic medications remained stable, around 17.5 percent.)
Dr. Olfson said he was surprised by the size of the increase. “We've never had anything like Covid, and we haven't had this technology before,” said Dr. Olfson. “There was a lot of social isolation, a lot of loneliness. And these are things that psychotherapy is intended for, in a way that is not possible with medication.”
The findings are based on the Medical Expenditure Panel Survey, which is conducted by the federal government and measures how U.S. citizens use and pay for health care. The survey does not include those in the military, incarcerated or in nursing homes, hospitals or homeless shelters.
Previous studies, based on insurance data, showed that U.S. mental health spending increased 54 percent from 2020 to 2022, while the use of teletherapy increased tenfold.
The new surveys indicate which Americans are receiving care. An analysis of 89,619 adults published in JAMA Psychiatry last month found that psychotherapy use grew most among the youngest respondents, among the most educated and among those in the highest two income groups.
An analysis of the use of telehealth by children and adolescents from 2,445 households came to similar conclusions. The research published today shows that children from wealthier families who use private insurance are much more likely to use teletherapy. Children in urban areas were almost three times as likely to use it as their rural counterparts.
During the years of the pandemic, Black children and adolescents' use of mental health services has declined, from 9.2 percent in 2019 to 4 percent in 2021. During the same period, mental health care use among white children rose to 18.4 percent. percent of 15.1 percent, the team found in another study.
“What we're finding is that it just seems to be exacerbating existing disparities,” said Dr. Olfson. “I think there is a real need to address this.”
