Digital Mental
Health Care

After a lifetime of severe depression, a woman who asked to be called Yvette was drawn to online mental health provider Cerebral after seeing their ads on social media promising fast and affordable care. Just months later, after being prescribed multiple powerful drugs after just two 15-minute sessions, she felt her condition worsening. She told CBS News that the therapist brushed her off when she shared her struggles. Not long after, Yvette's family discovered her after a suicide attempt. Fortunately, after being hospitalized and undergoing a lengthy evaluation with a new doctor who prescribed a change of medications, she survived. But the question lingers: How did this online mental health journey take such a dark turn? “I thought I was honestly signing up for something that was gonna change my life in a good way,” she told CBS News.

The disturbing accounts of Yvette and others cast a shadow over the booming online mental health care industry.

Long before the onset of the pandemic, even before the advent of the internet, various forms of technology, such as telephones, video, computers, and satellites, had already given rise to remote psychological counseling. Counseling can be traced back to 1972 when Stanford University and UCLA established computer-assisted counseling sessions during an international computer communications conference. Since the 1950s, telemedicine and telepsychiatry have been in use. A study analyzing telepsychiatry found that video conferencing was the most widely used mechanism for delivering mental health services in remote areas.

There is some evidence that online counseling can be effective. A study conducted by Medicare concluded that there was little difference between teletherapy and offline psychotherapy. The study cautioned that more data and a longer investigation are needed, but according to the experience of some practitioners, the results are obvious. “What we’ve seen is that telehealth is essentially just as effective as face-to-face psychotherapy—and retention rates are higher,” David Mohr told the American Psychological Association. Mohr, the director of the Center for Behavioral Intervention Technologies at Northwestern University’s Feinberg School of Medicine, has spent his career studying telepsychology and digital mental health.

So, where do things go wrong? Firstly, telepsychiatry should be practiced in the same way as standard medicine. As conducted by psychiatrists, telepsychiatry acknowledges the intricacies of mental disorders, adheres to established protocols, and places a strong emphasis on ensuring patient well-being. This includes precise diagnoses, proven treatments, and personalized care.

But millions using online platforms may not be seeing licensed therapists. When things go wrong, it’s often on digital mental health startups which prioritize growth and profit generation, frequently leading to disruptions in established clinical norms. During Mental Health Awareness Month in May 2022, BetterHelp allocated a substantial advertising budget of $19.8 million, representing nearly half of their total advertising expenditures for the year up to that point. Of this figure, 49% was channeled into advertising on Facebook. Facebook was the leading advertising outlet for TalkSpace as well.

Additionally, BetterHelp has established brand partnerships with some of the most influential figures on social media. The KOLs shared their “personal videos,” detailing their mental health struggles and encouraging their followers to seek assistance. At the conclusion of these videos, these YouTubers continued to promote BetterHelp services, including affiliate links, reportedly earning money for each subscription their fans signed up for.

This profit-driven approach may lead to unsatisfactory patient experiences.

Derek, who requested not to use his last name to protect his privacy, had experienced being ghosted by online healthcare providers. “I was using one of the apps and getting psychiatric help, and it was about maybe two to three months into me starting a medication, and the doctor canceled the next visit and went off the app, and I had no way to call them or talk to them in any way.” Derek feels lucky that he wasn’t in danger, but he still considers this to be a very unpleasant experience. “Even just doing a regular check in, you know, that was still pretty pretty terrible to just be ghosted like that.”

For a lot of patients, these kinds of experiences are traumatizing. The user named “Opening_String_4669” shared his story in the Betterhelp community on Reddit. “I tried really hard to open up so I could get the most out of it because I can't afford $360 per month. But a couple hours before the second phone session she canceled and stopped commenting on my journal entries. I didn't think anything about it at first because she said she was sick. I didn't share journal entries then since she was sick. I rescheduled the phone session and for that session she never showed up.” It was an upsetting experience. “I feel stupid enough for telling my soul.”

Derek is not alone in regretting using the platform. An online community called “cerebralfraud,” has 1,200 members who share their complains about Cerebral. Many users within this community have raised complaints regarding Cerebral’s refund issues and accuse Cerebral of defrauding its customers. A user named “MathematicianSad7885” was offered only a 50% refund after their therapist had only shown up to one of three scheduled sessions.

The extensive use of these platforms may indicate a significant unmet demand. One big problem for mental health care in the U.S. — there’s not enough of it. At present, for a population of 330 million, we have about 530,000 therapists, a little more than half the amount that the World Health Organization suggests is needed for a healthy society. There’s also a striking lack of diversity among therapists, which falls far short of meeting the needs of minority groups.

Scholars and practitioners in the industry hoped that virtual therapy could level the playing field by making mental healthcare more accessible. However, the data tells another story. In 2019, nearly 20% of White Americans received mental health care, while the figures were significantly lower, at less than 10%, for individuals identifying as Black/Latino or Asian/Pacific Islander.

There is no doubt that online mental health platforms are convenient. Take Betterhelp, for example. After completing your personal information and a psychological assessment form, you can register a user account via email. The platform then uses the information to match you with a mental health counselor. This entire process takes no more than 15 minutes. For individuals residing in areas with limited access to mental health resources, this offers greater and more detailed choices for assistance. Additionally, for some, the benefit it offers is not only geographical but also a matter of time.

“I’ve done both in-person and online therapy before,” said Derek. “I definitely prefer online therapy for the convenience of it. It's much easier to work into my schedule. I don't have to take time in my day to go to some office.” For him, it also prevented “the awkward waiting room scenario.”

Derek’s previous counselor, Tammy Carson, who is a licensed Clinical Social Work/Therapist in Florida and Massachusetts and works for several different platforms, believes that online mental health providers offer more choices to patients. “It's meeting people's needs.” she said. “I don’t see it as better or worse. It's an individual decision based on the patient.”

Counseling on online platforms can take many forms, from sending text messages or making voice calls to conducting remote video sessions. Varying levels of face-to-face contact can cater to different individuals' needs for privacy and security. In fact, the stigma of being seen to seek help is considered a strong factor that contributed to the rapid growth of online mental health platforms. Some platforms, like Betterhelp, do not accept insurance, which, though more expensive, makes them more preferable to some patients. Carson suspects that these patients do not want mental health counseling expenses to appear in their insurance records, even though this means they need to pay fees ranging from $60 to $90 per week.

Yet, while patients pursue higher safety and privacy, what the digital mental health platforms are doing is often just the opposite. In 2023, BetterHelp was accused of violating its privacy promises by sharing over 7 million health information of consumers with social media platforms such as Facebook, Snapchat, Criteo, and Pinterest for commercial purposes.

Even more alarmingly, online platforms have been responsible for misdiagnosis with dangerous results as mentioned at the beginning. And some therapists on the sites are not properly licensed. As CBS News reviewed Cerebral's more than 1,500 prescribers listed on its website, it turned out that only five are board-certified psychiatrists. The majority – some three-quarters of their prescribers – are nurse practitioners from specialties outside of mental health.

As a result of lawsuits by patients, BetterHelp has altered its terms of use, stipulating that therapists registered on the platform must possess recognized professional certification based on their state and/or jurisdiction. This change reflects the outcome of users continuously advocating for their rights.

Telehealth existed before the pandemic, but according to Time’s report, it wasn’t allowed to be widespread by federal regulations. The telemedicine coverage of medical insurance is full of restrictions. In addition, it imposes restrictions on a series of health professionals who are allowed to provide remote health care services, and the reimbursement rate of virtual appointments is lower than that of face-to-face consultation. This policy has had a chain reaction to the broader medical care field, and private insurance companies and Medicaid programs often follow the medical insurance policy.

Once Congress relaxed these rules in 2020, the use of telemedicine soared.

However, in 2022, the Biden administration announced the end of the public health emergency, and the public's concerns about the quality, cost and potential fraud of telehealth were lingering. The industry is stepping up its lobbying efforts to ensure that its benefits will not disappear.

A large part of telemedicine policy is decided by state governments. At present, most state laws stipulate telehealth in terms of privacy, insurance and licensing. For example, clinicians usually have to obtain a license to practice in the state where the patient is located. In online prescription, most states require the establishment of patient-provider relationship before electronic prescription of medicines. But based on the experiences of some patients, it may be worth considering and revising the laws regarding the types of telehealth encounters that can occur on these platforms. For instance, do these encounters comply with the telehealthcare encounter requirements mandated by state laws or government and private payers? Do these encounters meet the existing standards of care, especially when prescriptions are issued as part of remote healthcare encounters?

What should a good platform be like in terms of online mental health? Carson believes a good platform should provide both patients and clinicians with opportunities for feedback. She believes that this can keep clinicians and patients in good condition. “It can keep them honest if they know that they're going to get a review after,” she says. At the same time, she thinks this mechanism would help clinicians know how to help people better. Talkspace is a platform that she thinks has done a good job in this regard. “I have improved on that site based on some feedback that I got,” she shared.

It’s worth being known that online therapy isn’t for every patient — or every health condition. “If somebody is suicidal and needs lots of meds and needs to be monitored (they are not suitable for online therapies),” says Carson.

Besides, finding the right therapist is more important than finding the right platform. “It’s all about the relationship. It's all about the rapport,” she explains. If the therapist they first connect with doesn’t feel like a good fit, patients “should keep trying and they should find somebody that they can build a rapport with.” She believes that this kind of courage is a necessary mental preparation in the process of trying to heal oneself.

Derek, who no longer needs counseling assistance now, shares the same viewpoint. “Keep trying,” he says. “It may be discouraging at first, but keep trying. It does get better. It does help.”