The number of Americans receiving psychotherapy has increased by 30 percent during the pandemic, as virtual sessions have replaced in-person appointments — but new research is dampening hopes that technology will make mental health care more accessible to the neediest population.
In fact, the researchers found, switching to teletherapy exacerbated existing differences.
The rise in psychotherapy has come among groups that already had more access: people with higher incomes, people living in cities, with full-time jobs and higher education, researchers found in a series of studies, the latest of which was published Wednesday in the American Journal of Psychiatry. .
Among those who did not benefit from the boom, the team found, were children from low-income families, black children and adolescents, and adults with “serious psychological problems.”
“I think the whole system of care — and perhaps online delivery is part of that — is being diverted from those who are most in need,” said Dr. Mark Olfson, professor of psychiatry at Columbia University Irving Medical Center and lead author of the Access to Care study.
“We’re seeing that those with the most stress are losing ground in terms of their likelihood of being treated, and that’s a very important and worrying trend for me,” he added.
It wasn’t supposed to be this way. In the 1990s, teletherapy was advocated as a way to reach disadvantaged patients living in remote areas where there were few psychiatrists. A decade later, it was presented as a more accessible alternative to face-to-face sessions, one that could radically reduce barriers to care.
“Telehealth has not lived up to the hype,” said C. Vaile Wright, senior director of the American Psychological Association’s office of health innovation. The reasons, she added, aren’t surprising: Many Americans don’t have access to reliable broadband, and insurers don’t adequately reimburse providers, who in turn choose to treat private pay customers.
“If you can’t afford it, regardless of the modality, you just can’t afford it,” said Dr. Wright. It’s possible, she added, that weekly therapy sessions are simply not adaptable to the general population, and the field should explore light-touch alternatives, such as single-session interventions and digital therapy.
As telehealth platforms grow, they can attract clinicians from community settings by promising flexible hours and better conditions, said Dr. Jane M. Zhu, an associate professor of medicine at Oregon Health and Science University who studies the availability of mental health services.
By selecting from a large number of patients, they can decide to treat patients with milder conditions and higher paying power. “It’s certainly something we should know,” said Dr. Zhu. “There should be light on this. Who do these companies serve? And what does that mean for the patients who need it the most?”
The percentage of Americans receiving psychotherapy remained relatively stable, at 3 to 4 percent, for decades before gradually increasing, 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 to 8.5 percent in 2021 from 6.5 percent in 2018. (By comparison, the annual percentage of adults receiving psychotropic drugs remained stable, at around 17.5 percent.)
dr. Olfson said he was surprised by the size of the increase. “We haven’t had anything like Covid before and we haven’t had this technology before,” said Dr. Olfson. “There was a lot of social isolation, a lot of loneliness. And those are the things that psychotherapy is designed to address, in a way that drugs can’t.”
The findings are based on the federal government’s Medical Expenditure Survey, which measures how American civilians use and pay for health care. The survey does not include those in the military, prisoners or in nursing homes, hospitals or homeless shelters.
Previous studies, based on insurance data, have shown that Americans’ mental health spending rose 54 percent from 2020 to 2022, amid a tenfold increase in the use of teletherapy.
New studies reveal which Americans are receiving care. An analysis of 89,619 adults published in JAMA Psychiatry last month found that the use of psychotherapy increased most among the youngest respondents, among the most educated and among those in the two highest income brackets.
Analysis of the use of telehealth by children and adolescents from 2445 households reached similar conclusions. The study, published today, showed that children from wealthier families, who use private insurance, use teletherapy far more often. Children in urban areas were almost three times more likely to use it than their rural counterparts.
During the pandemic years, the use of mental health services by black children and adolescents decreased, falling to 4 percent in 2021 from 9.2 percent in 2019. During the same period, the use of mental health services among white children increased to 18.4 percent . percent from 15.1 percent, the team found in another study.
“What we found is that it seems to only exacerbate existing differences,” said Dr. Olfson. “I think there’s a real need to try to address that.”
