The number of Americans receiving psychotherapy increased by 30 percent during the pandemic, as virtual sessions replaced in-person appointments — but new research dampens the hope that technology will make mental health care more available to the neediest populations.
In fact, the researchers found, the shift to teletherapy has exacerbated existing disparities.
The increase in psychotherapy has occurred among groups that already enjoyed more access: people in higher-income brackets, living in cities, with steady employment and more education, researchers found in a series of studies, the most recent of which was, published Wednesday in The American Journal of 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 “serious psychological distress.”
“I think that the whole system of care — and maybe the internet delivery is a piece of this — appears to be pivoting away from those in greatest need,” 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’re seeing that those with the greatest distress are losing ground, in terms of their likelihood of being treated, and that to me is a very important and disconcerting trend,” he added.
It wasn’t supposed to be this way. In the 1990s, teletherapy was championed as a way to reach disadvantaged patients living in remote locations 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 lower barriers to care.
“Telehealth did not live up to the hype,” said C. Vaile Wright, senior director of the office of health care innovation at the American Psychological Association. The reasons, she added, are no surprise: Many Americans lack access to reliable broadband, and insurers do not adequately reimburse providers, who, in turn, choose to treat privately paying clients.
“If you can’t afford it, no matter the modality, you just can’t afford it,” Dr. Wright said. It may be, she added, that weekly therapy sessions are simply not scalable to a broad population, and the field should explore light-touch alternatives, like single-session interventions and digital therapeutics.
As telehealth platforms grow, they may be attracting clinicians from community settings with the promise of flexible hours and better conditions, said Dr. Jane M. Zhu, an associate professor of medicine at Oregon Health and Science University who studies the accessibility of mental health services.
Selecting from a large patient pool, they may opt to treat patients with milder conditions and more ability to pay. “It’s certainly something we should know,” Dr. Zhu said. “There should be light around this. Who are these companies serving? And what does this mean for patients who are most in need?”
The percentage of Americans receiving psychotherapy remained relatively steady, at 3 to 4 percent, for decades before beginning a gradual rise, 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 taking psychotropic medication remained stable, at around 17.5 percent.)
Dr. Olfson said he was surprised by the magnitude of the increase. “We haven’t had something like Covid before, and we haven’t had this technology before,” Dr. Olfson said. “There was a lot of social isolation, a lot of loneliness. And those are things that psychotherapy is designed to address, in a way that medication can’t.”
The findings are based on the Medical Expenditure Panel Survey, which is conducted by the federal government and measures how American civilians 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 Americans’ mental health spending increased by 54 percent from 2020 to 2022, amid a tenfold increase in the use of teletherapy.
The new studies flesh out which Americans are receiving the care. An analysis of 89,619 adults published in JAMA Psychiatry last month found psychotherapy use grew most among the youngest respondents, among the most educated and among those in the highest two income brackets.
An analysis of the use of telehealth by children and adolescents from 2,445 households reached similar conclusions. The study, published today, found that children from wealthier families, using private insurance, were far more likely to use teletherapy. Children in urban areas were nearly three times as likely to use it as their rural counterparts.
During the years of the pandemic, the use of mental health services by Black children and adolescents decreased, falling to 4 percent in 2021 from 9.2 percent in 2019. In the same period, the use of mental health care among white children rose, to 18.4 percent from 15.1 percent, the team found in another study.
“What we find is that it does appear to be just exacerbating existing disparities,” Dr. Olfson said. “I think there’s a real need to try to address that.”