Patients turn to apps for therapy. But are digital startups really helping mental health?

When Pat Paulson’s son told her he was feeling anxious and depressed in college, Paulson looked through the Blue Cross Blue Shield provider directory and started calling mental health therapists. There are no available providers in the Wisconsin town where her son’s university is. So she bought a monthly subscription to BetterHelp, a Mountain View, Calif., company that connects people with therapists online.

Her son was uncomfortable with his first BetterHelp therapist. After waiting a few weeks, he saw a second therapist he liked. But she was not available the following week.

Despite the shift and the wait, Paulson is grateful she was able to find help for her son. “He was getting to the point where he was ready to give up trying to find someone,” she said.

Many adults in the US are unable to find help due to a shortage of therapists. Nearly 40 percent struggle with mental health or substance abuse issues, according to the Centers for Disease Control and Prevention.

That’s why millions of people are turning to online companies like BetterHelp that have sprung up in the past few years, advertising quick access to therapy. Often backed by venture capital firms, these for-profit businesses offer a wide mix of services, including individual and group video therapy visits with licensed professionals, text messages of support, educational videos, and prescription medications.

In their ads, some of the companies feature endorsements from celebrities, including Olympic athletes Simone Biles and Michael Phelps. But veteran therapists and officials from leading mental health professional associations say there is limited evidence of the effectiveness of the new online providers.

“There are fundamental questions about what these companies are doing and whether they’re reaching people who really need help,” said Dr. John Torus, director of digital psychiatry at Beth Israel Deaconess Medical Center in Boston and chairman of the American Psychiatric Committee on Health Information Technology Assn. “They may be doing a great job, but it’s hard to tell when we don’t have that data.”

Dr. Varun Choudhary, chief medical officer at Talkspace, a provider of online and mobile therapy, said online companies can help patients who face financial, cultural and access barriers to traditional therapy. He said clients may want the convenience of receiving care online at home.

“By bringing patients together on a teletherapy platform, Talkspace expands the capacity to deliver treatment,” he said.

The New York company says it has served more than 1 million people with 3,000 providers in all 50 states and charges $400 or more a month for four weekly live sessions.

Research shows that therapy delivered online can be effective, and spurred by the COVID-19 pandemic, many individual therapists are offering sessions with their patients online. But the rapid spread of the online commercial therapy industry has worried some traditional mental health professionals, who have raised concerns about aggressive advertising of online services and whether patient care is being compromised by inadequate training and pay for therapists working at some digital companies. In addition, the news detailed questionable prescribing protocols, after which federal law enforcement began investigations into one company.

“Online companies are flooding the Internet with enticing ads that make promises to treat depression and anxiety,” said Marlene Maheu, a clinical psychologist and founder of the Telebehavioral Health Institute, which trains practitioners in online best practices and evaluates services for employers that can to want to offer them as employee benefits. “But can you entrust them with your child who is in trouble?”

Studies have found that face-to-face video psychotherapy visits and other mental health sessions are just as effective as in-person meetings. But veteran mental health professionals are skeptical of some online providers’ texting practices and services that don’t include real-time video therapy. Research support for the efficacy of text messaging and similar services is scarce. On its own sites and publications, the American Psychological Assn. banned an online mental health company from advertising on the grounds that its services did not meet the APA’s criteria for evidence-based therapy.

“Our concern is that the patient will leave a message and it could be hours before the therapist responds,” said Vale Wright, senior director of innovation at the American Psychological Assn. “We have no peer-reviewed research to support that this is effective.”

Psychologist Bradley Boivin, who worked for three months last year as an independent contract therapist with BetterHelp — which is not the company whose ads were banned by the APA — said he has such strong concerns about the widespread use of text messages for therapy that he told his customers, he wouldn’t.

Boivin, who now works in private practice in Scottsdale, Arizona, said other BetterHelp therapists have told him they feel pressured to respond to clients’ messages at all hours of the day. A BetterHelp compensation sheet obtained by KHN shows that therapists are paid according to the number of text words they read and write.

Alon Matas, founder and president of BetterHelp, which spent more than $7 million in December promoting 556 podcasts, defended the use of text messages, saying his company’s therapists are not expected to respond to clients’ messages immediately. Each therapist uses professional judgment to decide when is the right time to use messaging and “how it works best for each individual member,” he said.

Many therapists working for online companies are independent contractors, without liability insurance or health insurance from the company, according to officials at mental health professional associations.

Online companies often attract therapists who are less experienced because pay tends to be lower than what therapists typically earn in private practice, said Laura Groshong, director of policy and practice for the Clinical Social Work Assn. “It’s a way for new clinicians to get their foot in the door, and it’s something people need to know,” she said.

BetterHelp’s compensation sheet shows that the company pays therapists on a sliding scale based on how many hours a week they work — $30 an hour for the first five hours, $35 for the next five, and so on, topping out at $70 an hour for each hour over 35. That’s less than the typical $100 to $200 per session that private practice therapists across the country charge clients.

Matas said the sheet doesn’t reflect that his company’s therapists’ base hourly compensation can be topped up with monthly stipends, payments for group sessions, bonuses and incentives for caseloads. BetterHelp has more than 25,000 therapists in its network, and Matas said it actually pays up to 60 percent more than the average fee for licensed therapists in every metropolitan area where there are therapists.

There are also concerns about online companies whose clinicians prescribe psychiatric drugs — either controlled substances that are potentially addictive like Adderall, or antidepressants like Zoloft that are not addictive but have potentially dangerous side effects.

Federal law requires doctors to examine the patient in person before prescribing controlled drugs, which are heavily regulated by the government because they can be abused. The federal government waived that provision under public health emergency rules issued at the start of the pandemic. Officials are considering whether to extend that exemption when the public health emergency period ends.

That review was upset by recent law enforcement actions following news reports in March. The Department of Justice and the Drug Enforcement Administration are investigating Cerebral, a San Francisco-based online prescription company, for possible violations of the Controlled Substances Act in prescribing Adderall. The company told news organizations that it has not been accused of violating the law and will stop prescribing Adderall and other controlled drugs for attention-deficit/hyperactivity disorder.

In a statement to KHN last month, it said, “Cerebral is cooperating fully with the Department of Justice’s investigation.”

The DEA declined to comment on the inquiry, and the Justice Department did not respond to KHN.

In a letter to the editor responding to a Bloomberg News article describing practices at Cerebral that included brief patient encounters, aggressive advertising and pressure on providers to prescribe drugs, Cerebral founder and CEO Kyle Robertson said his company did not give quotas or targets for clinicians to prescribe drugs. Cerebral “follows clinical prescribing guidelines based on the most recent research,” he wrote.

The company’s directors removed him as CEO in May.

The Cerebral allegations are “a wake-up call for everyone in the industry,” said Thomas Ferrante, an attorney at Foley & Lardner who represents some online companies. “It’s a reminder that healthcare is a highly regulated space.”

“Companies like Cerebral are disrupting telemedicine for everyone,” said Piper Buersmeyer, a psychiatric nurse practitioner who is the majority owner of Med Rx Partners, an online and in-person service that evaluates patients and prescribes medications in Vancouver, Washington. “They are a breach of trust.”

She said she is concerned that some companies do not adequately assess patients’ mental health issues before prescribing drugs.

Other companies also advertise directly to consumers for help getting medications. For example, Hims & Hers, another telehealth company in San Francisco, has run ads offering to provide “anxiety and depression medication in less than 24 hours” after customers fill out a short form and connect online with a Hims & Hers provider. Hers. A company spokesman, Sam Moore, said providers only prescribe drugs after following “evidence-based clinical protocols.”

Dr. Bob Kocher, president of Lyra Clinical Associates in Burlingame, Calif., said optimal treatment combines therapy with drugs when needed. That usually works better than treatment alone, he said. But he is concerned that some online therapy providers may not perform adequate clinical assessment of patients before and after prescribing, may rely too much on patient self-diagnosis and may not provide enough talk therapy.

“It’s not always clear that it’s depression,” said Kocher, an internist. Prescribing drugs without adequate diagnostic work-up or continued talk therapy, he said, would be “worrying because antidepressants are not without serious risks, including suicide.”

Based on her experience reviewing some online companies for employers and training therapists in online settings, Maheu is concerned that companies may not be training their therapists how to provide safe, effective and ethical therapy online. As an online provider trainer, she teaches therapists how to de-escalate suicidal or other crisis situations through the video screen. Meanwhile, there is little government or professional regulation to protect consumers, she said.

“What’s happening is a corporate takeover of behavioral health by digital entrepreneurs,” Maheu said. “This industry is a disaster waiting to happen.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with Policy Analysis and Polling, KHN is one of the three main operational programs of the KFF (Family Kaiser Foundation). KFF is a charitable, non-profit organization providing information on health issues to the nation.

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