How much should you trust BetterHelp, Talkspace, Cerebral and other mental health start-ups touted by celebrities?

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When Pat Paulson’s son told her he was feel­ing anx­ious and depressed at col­lege, Paul­son went through her Blue Cross Blue Shield provider direc­to­ry and start­ed call­ing men­tal health ther­a­pists. No providers in the Wis­con­sin city where her son’s uni­ver­si­ty is locat­ed had open­ings. So she bought a month­ly sub­scrip­tion to Bet­ter­Help, a Moun­tain View, Cal­i­for­nia, com­pa­ny that links peo­ple to ther­a­pists online.

Her son felt uncom­fort­able with his first Bet­ter­Help ther­a­pist. After wait­ing sev­er­al weeks, he saw a sec­ond ther­a­pist, whom he liked. But she wasn’t avail­able the fol­low­ing week.

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

Many U.S. adults aren’t able to find help because of a short­age of ther­a­pists. Near­ly 40% are strug­gling with men­tal health or sub­stance abuse issues, accord­ing to the Cen­ters for Dis­ease Con­trol and Prevention.

So mil­lions of peo­ple are turn­ing to online com­pa­nies like Bet­ter­Help that have sprung up in the past sev­er­al years, adver­tis­ing quick access to ther­a­py. Often backed by ven­ture cap­i­tal firms, these for-prof­it busi­ness­es offer a wide mix of ser­vices, includ­ing one-on-one and group video ther­a­py vis­its with licensed pro­fes­sion­als, sup­port­ive tex­ting, coach­ing videos, and pre­scrip­tions for medications.

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

“There are fun­da­men­tal ques­tions about what these com­pa­nies are doing and whether they are reach­ing peo­ple who real­ly need help,” said Dr. John Torous, direc­tor of the dig­i­tal psy­chi­a­try divi­sion at Beth Israel Dea­coness Med­ical Cen­ter in Boston and chair of the Amer­i­can Psy­chi­atric Association’s Health Infor­ma­tion Tech­nol­o­gy Com­mit­tee. “They may be doing won­der­ful work, but it’s hard to know when we don’t have that data.”

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

“By bring­ing togeth­er patients on a telether­a­py plat­form, Talk­space expands capac­i­ty to deliv­er treat­ment,” he said. The com­pa­ny, head­quar­tered in New York, says it has served more than a mil­lion peo­ple with 3,000 providers across all 50 states, and it charges $400 or more per month for four week­ly live sessions.

Research sug­gests 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 pro­lif­er­a­tion of the online com­mer­cial ther­a­py indus­try wor­ries some tra­di­tion­al men­tal health pro­fes­sion­als who have raised con­cerns about aggres­sive adver­tis­ing for online ser­vices and whether patient care is com­pro­mised by inad­e­quate train­ing and pay for ther­a­pists work­ing at some dig­i­tal com­pa­nies. In addi­tion, news reports have detailed ques­tion­able pre­scrip­tion pro­to­cols, after which fed­er­al law enforce­ment launched probes of one company.

“Online com­pa­nies inun­date the inter­net with appeal­ing ads that make promis­es about treat­ing depres­sion and anx­i­ety,” said Mar­lene Maheu, a clin­i­cal psy­chol­o­gist and founder of the Tele­be­hav­ioral Health Insti­tute, who trains prac­ti­tion­ers in best online prac­tices and eval­u­ates ser­vices for employ­ers who may want to offer them as ben­e­fits to work­ers. “But can you trust them with your kid who’s in trouble?”

Therapy via Text

Stud­ies have found face-to-face video psy­chother­a­py vis­its and oth­er men­tal health ses­sions to be just as effec­tive as in-per­son encoun­ters. But vet­er­an men­tal health pro­fes­sion­als are skep­ti­cal of some online providers’ tex­ting prac­tices and ser­vices that do not involve real-time video ther­a­py. Research sup­port for the effi­ca­cy of tex­ting and sim­i­lar ser­vices is scarce. On its own sites and pub­li­ca­tions, the Amer­i­can Psy­cho­log­i­cal Asso­ci­a­tion has barred adver­tis­ing from one online men­tal health com­pa­ny on the grounds that its ser­vices do not meet the APA’s cri­te­ria for evi­dence-based therapy.

“Our con­cern there is that a patient will leave a text and it might be hours before the ther­a­pist responds,” said Vaile Wright, senior direc­tor for inno­va­tion at the Amer­i­can Psy­cho­log­i­cal Asso­ci­a­tion. “We don’t have peer-reviewed research to sup­port that this is effective.”

Psy­chol­o­gist Bradley Boivin, who worked as an inde­pen­dent con­tract­ing ther­a­pist with Bet­ter­Help for three months last year, said he had such strong con­cerns about the exten­sive use of tex­ting for ther­a­py that he told his clients he wouldn’t do it.

Boivin, who now works for a pri­vate prac­tice in Scotts­dale, Ari­zona, said oth­er Bet­ter­Help ther­a­pists told him they felt pres­sured to reply to client texts at all hours of the day. A Bet­ter­Help com­pen­sa­tion sheet obtained by KHN shows ther­a­pists get paid by the num­ber of text words they read and write.

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

Many ther­a­pists work­ing at online com­pa­nies are inde­pen­dent con­trac­tors, with no lia­bil­i­ty insur­ance or health insur­ance from the com­pa­ny, accord­ing to offi­cials at asso­ci­a­tions for men­tal health professionals.

The online com­pa­nies often attract ther­a­pists who are less expe­ri­enced because the pay is typ­i­cal­ly low­er than what ther­a­pists in pri­vate prac­tices gen­er­al­ly earn, accord­ing to Lau­ra Groshong, direc­tor of pol­i­cy and prac­tice for the Clin­i­cal Social Work Asso­ci­a­tion. “This is a way for new clin­i­cians to get a foot in the door, and that’s some­thing peo­ple should know,” she said.

The Bet­ter­Help com­pen­sa­tion sheet shows that the com­pa­ny pays ther­a­pists on a slid­ing scale based on how many hours per week they work — $30 per hour for the first five hours, $35 for the next five, etc., top­ping out at $70 per hour for any hours in excess of 35. That’s less than the typ­i­cal $100 to $200 per ses­sion that pri­vate-prac­tice ther­a­pists around the coun­try charge clients.

Matas said the sheet does not reflect that ther­a­pists’ base hourly com­pen­sa­tion by his com­pa­ny may be sup­ple­ment­ed with month­ly stipends, pay­ments for group ses­sions, bonus­es, and case­load incen­tives. Bet­ter­Help has more than 25,000 ther­a­pists in its net­work, and Matas said it effec­tive­ly pays up to 60% more than the medi­an com­pen­sa­tion for licensed ther­a­pists in every met­ro­pol­i­tan area where it has therapists.

A Virtual Pharmacy

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

Fed­er­al law requires doc­tors to see a patient in per­son before pre­scrib­ing con­trolled drugs, which are those tight­ly reg­u­lat­ed by the gov­ern­ment because they can be abused. The fed­er­al gov­ern­ment waived that pro­vi­sion under pub­lic health emer­gency rules issued ear­ly in the covid pan­dem­ic. Offi­cials are con­sid­er­ing whether to extend that waiv­er when­ev­er the pub­lic health emer­gency peri­od is over.

That review has been roiled by recent law enforce­ment actions fol­low­ing news reports in March. The Jus­tice Depart­ment and the Drug Enforce­ment Admin­is­tra­tion are inves­ti­gat­ing Cere­bral, a San Fran­cis­co online-pre­scrib­ing com­pa­ny, for pos­si­ble vio­la­tions of the Con­trolled Sub­stances Act for its pre­scrib­ing of Adder­all. The com­pa­ny told news orga­ni­za­tions it has not been accused of vio­lat­ing the law and it would pause pre­scrib­ing Adder­all and oth­er con­trolled drugs for atten­tion-deficit/hy­per­ac­tiv­i­ty dis­or­der. In a state­ment to KHN last month, it said, “Cere­bral is ful­ly coop­er­at­ing with the Jus­tice Depart­ment investigation.”

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

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

The company’s direc­tors removed him from his posi­tion in May.

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

“Com­pa­nies like Cere­bral are wreck­ing 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 destroy­ing trust.” She said she was con­cerned that some com­pa­nies do not ade­quate­ly eval­u­ate patients’ men­tal health issues before pre­scrib­ing medicines.

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

Dr. Bob Kocher, pres­i­dent of Lyra Clin­i­cal Asso­ciates in Burlingame, Cal­i­for­nia, said the opti­mal treat­ment pairs talk ther­a­py with med­ica­tion when need­ed. That gen­er­al­ly works bet­ter than med­ica­tion alone, he said. But he is con­cerned that some online ther­a­py providers may not per­form an ade­quate clin­i­cal eval­u­a­tion of patients before and after they pre­scribe, may rely too much on patients’ self-diag­no­sis, and may not pro­vide enough talk therapy.

“It’s not always clear it’s depres­sion,” said Kocher, a prac­tic­ing internist. Pre­scrib­ing med­ica­tions with­out ade­quate diag­nos­tic work or con­tin­u­ing talk ther­a­py, he added, would be “wor­ri­some, because anti­de­pres­sants are not with­out their own 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 give their ther­a­pists train­ing in how to deliv­er safe, effec­tive, and eth­i­cal ther­a­py online. As a train­er of online providers her­self, she teach­es ther­a­pists how to de-esca­late sui­ci­dal or oth­er cri­sis sit­u­a­tions over the video screen. Mean­while, there’s lit­tle gov­ern­ment or pro­fes­sion­al reg­u­la­tion to pro­tect con­sumers, she added. “What’s hap­pen­ing is a cor­po­rate takeover of behav­ioral health care by dig­i­tal entre­pre­neurs,” Maheu warned. “This indus­try is a cat­a­stro­phe wait­ing to happen.”

– Har­ris Mey­er is a jour­nal­ist cov­er­ing health care, busi­ness, law, cul­ture, & wine. KHN (Kaiser Health News), run by the Kaiser Fam­i­ly Foun­da­tion, is a nation­al news­room that pro­duces in-depth jour­nal­ism about health issues.

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