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Article Type: Viewpoint / Commentary
Journal: JAMA Psychiatry
Date: November 14, 2022
Status: Peer-Reviewed Publication
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→ Authors Ryan S. Sultan, M.D.1 1Department of Psychiatry, Columbia University and New York State Psychiatric Institute Funding: NIDA/AACAP K12 research training grants |
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.
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.
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).
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→ Key Safety Concerns with Telepsych Companies The rapid, unregulated growth of digital mental health companies has created significant risks:
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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.).
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?
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.
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.
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.
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.
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⚠ Critical Concern: Capitalism vs. Patient Care The rise of venture capital-backed telepsych companies represents a dangerous shift in mental health care delivery—the industrialization of psychiatry and psychotherapy through corporate capitalism. |
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:
These are incompatible priorities.
While telepsych companies claim to solve the access crisis, they often:
Result: Mental health care becomes a commodity—optimized for profit margins, not patient healing.
When a telepsych company is venture-backed or publicly traded, executives have a legal fiduciary duty to shareholders. This means:
In contrast, a private psychiatric practice or non-profit clinic has no shareholders demanding quarterly earnings growth. Their duty is exclusively to patients.
The industrialization of mental health care through corporate telepsych companies has led to:
| Traditional Model (Doctor's Office / Non-Profit) |
Corporate Telepsych Model (Venture-Backed Company) |
| 60-minute initial psychiatric evaluation | 15-minute video chat after online survey |
| Comprehensive diagnostic interview | Self-report checklist (patient diagnoses themselves) |
| Collateral information (school, family, previous providers) | Patient-reported information only |
| Ongoing relationship with same psychiatrist | Different contractor each visit (discontinuity of care) |
| Coordination with therapist, PCP, school | Siloed medication management only |
| Conservative medication approach with monitoring | Quick stimulant prescription to retain customer |
| Success = patient improves clinically | Success = patient remains subscribed (recurring revenue) |
The current national stimulant shortage is a direct consequence of corporate telepsych companies industrializing ADHD treatment:
This is what happens when access becomes an excuse for industrialization.
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.
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.
We propose viable future directions to better guide integration of digital ecosystems into existing systems of mental healthcare:
| Issue / Concern | Recommendation |
|---|---|
| Efficacy Telepsych companies' treatment interventions may have limited efficacy. |
Systematic head-to-head comparisons of clinically meaningful and patient-centric outcomes for digital vs. traditional in-person care. |
| Diagnostic Accuracy The diagnostic accuracy of telepsych companies' assessments is questionable. |
Study and validate online use of traditionally in-person psychiatric diagnostic assessments. |
| Experimental Tools New innovative digital tools designed to triage patient needs may be highly prone to error. |
Innovative digital tools merit more experience and testing before becoming standard practice. |
| Patient Safety Telepsych companies are currently not held to the same standard for patient safety and delivery as large healthcare institutions are. |
For telepsych companies to succeed, ethical and professional standards need to be defined or applied to the telepsych space. |
| Digital Literacy Patients who are uncomfortable with using technology or are unable to access it are marginalized with the proliferation of telepsych companies. |
Telepsych companies can collaborate with established healthcare systems to construct a hybrid (in-person and remote) model. |
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.
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
Innovative digital tools for mental health triage, including self-diagnoses, for patients may merit more experience and testing before becoming standard practice.
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.
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.
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:
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.
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