Ryan S. Sultan, MD

Integrating Telehealth into the Mental Health Ecosystem

Article Type: Viewpoint / Commentary
Journal: JAMA Psychiatry
Date: November 14, 2022
Status: Peer-Reviewed Publication

Abstract

The COVID-19 pandemic accelerated the adoption of telepsychiatry and digital mental health services. While these technologies offer potential benefits for access and convenience, their rapid proliferation without adequate oversight raises critical concerns about patient safety, diagnostic accuracy, and quality of care. This viewpoint examines the consequences of integrating telepsych companies into the mental health ecosystem without proper regulatory frameworks and proposes recommendations for ensuring safety and efficacy.

Introduction: The Mental Health Care Crisis

Mental health care delivery is in crisis in America. The pandemic exacerbated our longstanding neglect of the resources needed to provide timely high-quality evidence-based care that is equitably and accessible. CDC data shows that suicide rates across all ages and ethnic groups are increasing, particularly among youth.¹ Three-quarters of Americans report their mental health is meaningfully affected by life stressors.² Access to care is more difficult than ever due to a mismatch between supply and increasing demand: pandemic driven societal shifts and post-pandemic re-entry are leaving many in need of support and treatment yet, as was true before the pandemic, mental health clinicians are in short supply.

The Rise of Telepsych Companies

Early in the COVID-19 crisis, the United States was forced to adopt digital health tools, backed by support from digital health experts.³ The US government waived numerous preexisting telehealth regulations to ensure this prompt transition.⁴ During this period, telepsych companies proliferated. Most telepsych companies are venture capital-funded tele-mental health services, offered via a remote synchronous modality (e.g. virtual appointments with a therapist or a psychiatrist).

⚠ The Dangers of Digital Health: Critical Concerns

1. The Diagnostic Accuracy Problem

Telepsych companies have adopted technological solutions to improve efficiency. To decrease staffing costs and shorten face-to-face assessment time, these startups heavily rely on patient survey responses to measure efficacy. These surveys ask patients to self-diagnose based on a checklist rather than on clinical assessment. While this method might be efficient, it may be incomplete, unreliable or inaccurate, compromising diagnostic evaluation and subsequent treatment decisions.⁹

Example: A patient checking boxes on a screen for ADHD symptoms receives a diagnosis and stimulant prescription without a comprehensive clinical interview, collateral information, or evaluation for alternative diagnoses (anxiety, sleep disorders, trauma, etc.).

2. The Stimulant Prescribing Crisis

Regulation of ADHD diagnoses and stimulant prescribing is routine in medicine to prevent improper use of scheduled medications. ADHD evaluation and treatment is a common chief complaint to telepsych companies. Applying new technology to healthcare is higher risk than other commercial spaces. For example, if a telepsych company misdiagnoses or inappropriately treats a patient, the quality of health care delivery may be poor, or worse: the patient is exposed to potential harm, such as untoward side effects, including psychosis or addiction.

Systemic effects are already noticeable: excessive stimulant prescribing is affecting those with long-term ADHD. At present, pharmacies face stimulant medication shortages as they struggle to keep up with rising consumer demand. Do we have the needed data to understand when telepsych might be contraindicated?

3. The Regulatory Gray Area

Currently, telepsych companies exist in a gray regulatory area. Unlike hospital systems and clinics that are under the jurisdiction of regulatory agencies, such as Center for Medicaid and Medicare (CMS) and The Joint Commission, for all in-person and telehealth services, digital startups have no clear regulatory oversight to ensure the safety and quality of mental health care delivery.

Ambiguities associated with jurisdiction and oversight of these digital care delivery systems places the risk burden on the clinicians providing care in the digital environment. For example, it is unclear whether malpractice insurers will cover yet-to-be realized liabilities that will come with tele-mental health.

4. The Digital Divide and Inequality

Telepsych companies cater almost entirely to an educated population, typically with healthcare coverage and inherently with access to wifi and smart devices. This excludes vast swaths of rural and inner-city populations. It also excludes persons such as older adults who may lack digital literacy. Digital health holds the potential to create new disparities in care.

Patients who are uncomfortable with using technology or are unable to access it are marginalized with the proliferation of telepsych companies. Further, some may struggle to know what information online is trustworthy and how to responsibly release their sensitive data.

5. Fragmented, Discontinuous Care

To address the supply/demand imbalance in access to care, telepsych companies adopted strategies that favored flexible (e.g. telehealth > traditional in-person, shorter visits > longer visits) but discontinuous and piecemeal mental health treatment.

High-quality in-person mental health care may be time-intensive, nuanced, and relationship-based that require resources that are unreasonable to meet the volume demands for care currently at play. However, with limited information about how digital and in-person care compare on patient-centered and clinically meaningful outcomes, it is difficult to gauge their relative indications and quality.

6. Profit Over Patient Safety

In recent years, US telepsych companies raised nearly $40 billion in funding.⁷ While many digital health companies have addressed unmet needs for efficient and accessible care, their concern for profit and growth over patient safety compromises the overall quality of the care delivered.

Companies like Cerebral, Talkspace, and Betterhelp developed systems where therapists, psychiatrists, and other clinicians generally work as contractors in a centralized clearinghouse for new patients—prioritizing volume and efficiency over comprehensive, individualized care.

7. The Industrialization of Mental Health: Access as Excuse for Corporatization

The Fundamental Conflict:

Large telehealth corporations use "access" as a justification for industrializing mental health care, but their fiduciary duty to shareholders fundamentally conflicts with patient welfare:

• For-Profit Corporations: Legally obligated to maximize shareholder value and profits. Success measured by revenue growth, user acquisition, and stock price.
• Non-Profit Healthcare & Private Practices: Duty is to patients. Success measured by clinical outcomes, patient satisfaction, and quality of care.

These are incompatible priorities.

How "Access" Becomes an Excuse

While telepsych companies claim to solve the access crisis, they often:

• Prioritize volume over quality - More patients = more revenue, regardless of outcomes
• Minimize costly clinical time - 15-minute "med checks" replace comprehensive care
• Automate diagnosis - Self-report surveys replace clinical judgment to reduce labor costs
• Treat clinicians as contractors - Gig economy model reduces provider autonomy and continuity
• Optimize for profitable conditions - ADHD stimulants are quick, recurring revenue; complex trauma is expensive and time-intensive

Result: Mental health care becomes a commodity—optimized for profit margins, not patient healing.

The Fiduciary Duty Problem

When a telepsych company is venture-backed or publicly traded, executives have a legal fiduciary duty to shareholders. This means:

• If spending more time with patients reduces profit, the company is legally obligated to spend less time
• If rigorous diagnostic processes slow patient throughput, the company is incentivized to simplify them
• If referring patients to specialists loses revenue, the company is discouraged from making those referrals
• If safety protocols increase costs, there is pressure to minimize them

In contrast, a private psychiatric practice or non-profit clinic has no shareholders demanding quarterly earnings growth. Their duty is exclusively to patients.

Real-World Consequences

The industrialization of mental health care through corporate telepsych companies has led to:

The Stimulant Shortage: A Case Study in Industrialization

The current national stimulant shortage is a direct consequence of corporate telepsych companies industrializing ADHD treatment:

1. Corporations optimize for ADHD prescriptions - Quick, recurring revenue from monthly refills
2. Marketing targets adults self-diagnosing - "Think you have ADHD? Take our quiz!" drives customer acquisition
3. Minimal diagnostic rigor - Online surveys replace comprehensive evaluation to maximize throughput
4. Mass prescribing of stimulants - Thousands of new stimulant prescriptions per company per month
5. Pharmacies cannot keep up - Sudden demand spike creates shortages
6. Patients with legitimate, longstanding ADHD suffer - Cannot fill their prescriptions due to shortages

This is what happens when access becomes an excuse for industrialization.

Why This Matters: Betraying Medicine's Core Values

Medicine has historically been guided by the Hippocratic principle: "First, do no harm." The patient's welfare comes first.

Corporate telepsych companies, by design, cannot follow this principle when it conflicts with shareholder value. This represents a fundamental corruption of medical ethics—a betrayal of the therapeutic relationship in favor of profit extraction.

The industrialization of mental health care through venture capital-backed corporations is not "innovation"—it is the commodification of human suffering for profit.

Consequences of Not Integrating Telepsych Companies

The rapid shift of mental health towards a digital ecosystem provided an opportunity for telepsych companies to proliferate. These new telepsych companies introduced innovations such as convenience, efficiency, accessibility, electronic screening and triage, AI-driven care, and affordabilty.⁸ However, it may be that the business ecosystem may have missed the mark while trying to adapt psychiatric care into a digital health ecosystem.

While studies on telehealth delivery of mental health services are encouraging, they have yet to be scientifically validated as a non-inferior alternative to more traditional comprehensive evidence-based treatment models. The movement of mental health toward telepsych services without proven comparative effectiveness or adequate oversight may have adverse consequences.

As portions of mental healthcare shift from de-centralized brick-and-mortar healthcare organizations to digital health care, how can quality and patient safety also be ensured? Safety, access, and quality of care are not mutually exclusive. Telepsych companies could strive to simultaneously achieve goals of maintaining safety and quality of care while improving access.

Recommendations for the Telepsych Space

We propose viable future directions to better guide integration of digital ecosystems into existing systems of mental healthcare:

1. Measuring Efficacy

Applying well-established research methods for defining efficacy and effectiveness are concrete and implementable changes for telepsych organizations. Systematic head-to-head comparisons of clinical and patient-centric outcomes for digital vs. traditional care are necessary to provide needed insights for indications and applications of telepsych. Specifically, this information will facilitate a better understanding of what patient populations might benefit from each intervention.

2. Ensuring Diagnostic Accuracy

Diagnostic accuracy is a question. We can address questions of accuracy through validating digital administration of traditionally in-person psychiatric diagnostic assessments. The reputation of telepsych companies relies on clinical validation.¹⁰

3. Testing Innovative Tools

Innovative digital tools for mental health triage, including self-diagnoses, for patients may merit more experience and testing before becoming standard practice.

4. Establishing Patient Safety Standards

Applying standard healthcare ethical and professional expectations to telepsych companies would significantly improve their quality and safety. Traditional healthcare institutions have ethical and professional oversight committees that define standards for healthcare delivery.

5. Providing Digital Literacy & Hybrid Models

Telepsych companies should collaborate with established healthcare systems to construct a hybrid model, which offers possibilities for both in-person and remote treatment and is more inclusive to digital literacy.

The Path Forward: Integration, Not Replacement

Telepsych companies have the potential to significantly transform the delivery of mental health services. Integration of telepsych companies into existing operating systems of care could enable a range of expanded functions for the field such as:

• Diagnostic clarification
• Measurement-based care
• Efficient collateral data gathering (e.g. when a diagnosis requires impairment in at least 2 settings)
• Continuity of care for existing patients
• Adverse event monitoring
• Managing adherence, diversion, co-occurring conditions
• Interdisciplinary referrals
• Building trust, quality, and engagement in treatment (to reduce risks and protect patients from potential harm)

We encourage systematic and empirical comparison of digital and traditional mental health services, collaboration with established healthcare delivery systems, and oversight to guide Telepsych companies. Implementing these recommendations may better address the national mental health crisis while improving rather than compromising delivery quality and safety.

References

1. Baldessarini RJ. Epidemiology of suicide: recent developments. Epidemiol Psychiatr Sci. 2019;29:e71. doi:10.1017/S2045796019000672
2. Anderson NB, Belar CD, Breckler SJ, et al. Stress in America: Paying With Our Health. American Psychological Association. 2014.
3. Torous J, Jän Myrick K, Rauseo-Ricupero N, Firth J. Digital Mental Health and COVID-19: Using Technology Today to Accelerate the Curve on Access and Quality Tomorrow. JMIR Ment Health. 2020;7(3):e18848. doi:10.2196/18848
4. CMS.gov. Medicare telemedicine health care provider fact sheet. Published 2020 Mar 17.
5. Simon AB, Alonzo AA. The demography, career pattern, and motivation of locum tenens physicians in the United States. J Healthc Manag. 2004;49(6):363-376.
6. Thiele JS, Doarn CR, Shore JH. Locum tenens and telepsychiatry: trends in psychiatric care. Telemed J E Health. 2015;21(6):510-513. doi:10.1089/tmj.2014.0159
7. Landi H. Global digital health funding skyrockets to $57.2B with record cash for mental health, telehealth. Fierce Healthcare. 2022.
8. Fear K. Busting Three Myths About the Impact of Telemedicine Parity. NEJM Catalyst Innovations in Care Delivery. 2022 Sep 21.
9. Chmielewski M, Clark LA, Bagby RM, Watson D. Method matters: Understanding diagnostic reliability in DSM-IV and DSM-5. J Abnorm Psychol. 2015;124(3):764-769. doi:10.1037/abn0000069
10. Norden J. Clinical validation will save digital health's reputation. STAT. 2022 Aug 16.

Related Resources

Digital Health & Telehealth:

• ADHD Diagnosis - Importance of comprehensive clinical assessment vs. self-report
• ADHD Medications Guide - Proper evaluation standards before prescribing
• Neuroscience-Based Nomenclature - Evidence-based medication classification

Clinical Services:

• Schedule Consultation - Professional consultations with Dr. Sultan
• ADHD Psychiatrist NYC - Manhattan practice information
• Integrative Psychiatry NYC - Comprehensive mental health care

Research & Publications:

• Publications - Peer-reviewed research (411+ citations)
• Current Research - Ongoing studies on digital health
• Research Grants - NIH-funded studies
• Professional Profile - Academic background and expertise
• Teaching - Clinical presentations and medical education