The Online Therapy Bubble Is Bursting

Hebah Arroyo, an Illinois nurse practitioner, began working for the startup Done in the spring of 2020. She was drawn to the San Francisco-based company’s promise: to provide stigma-free online ADHD care, including prescription refills and virtual sessions with clinicians, for as little as $79 a month.

“It was my first telehealth role,” she says, “so that was exciting for me.”

Three months later, she resigned. “I quickly became unhappy because there was not any support for the clinicians” and the quality of care was lacking, Arroyo says. She regularly saw four patients an hour, a grueling pace that she says didn’t allow time for holistic treatment.

In a statement provided to TIME, a Done representative said clinicians can make their own treatment determinations, including length of sessions. “Done was founded with a member-first mentality, meeting members where their needs are, and providing access to high quality care in an accessible and affordable approach,” the statement reads.

But in Arroyo’s opinion, the business model wasn’t set up to serve either patients or clinicians. Everything, she felt, “was based on growing the company.”

Prioritizing growth above all else—even if it means cutting corners along the way—is a common mentality among tech startups. Now, that alleged business practice is bringing scrutiny to many of the startups that popped up or thrived during the pandemic to target mental-health treatment: an area of medicine in desperate need of innovation, since it prices out many people seeking care, historically excludes people of color, and is so inaccessible that about a third of people in the U.S. who have severe anxiety or depression don’t get treatment.

Startups like Done and its competitors, which promise to remotely treat everything from anxiety and insomnia to ADHD and substance-use disorder, say they can help fix some of those issues by offering convenient mental-health care at affordable monthly prices. Recently, though, some of the shine has worn off this industry. TIME interviewed six mental-health professionals who formerly worked for telepsych or substance-treatment startups, some of whom asked to remain anonymous because they still work in mental-health care. Regardless of their employer, they had similar complaints: appointments were too short to properly treat and assess patients; clinicians were overworked; and policies around prescribing drugs and treating complex cases often weren’t rigorous enough.

Clinicians aren’t the only ones with concerns. Federal investigators are probing prescription practices at Done and Cerebral, a popular startup that offers virtual therapy and medication management for depression, anxiety, insomnia, ADHD, bipolar disorder, and substance-use disorders for as little as $99 per month—and that some former employees have said overprescribes stimulants for ADHD. In May, pharmacy giants including CVS and Walmart stopped filling controlled-substance prescriptions from Cerebral and Done clinicians, a move Done said it was “disappointed” by in its statement to TIME and that a Cerebral executive declined to comment on. Cerebral has since stopped offering controlled-substance medications.

There are other signs the telemental-health bubble is popping. Digital health investments fell by $4 billion in the first half of 2022, compared to the first half of 2021, according to a report from digital health firm Rock Health. And virtual-care startups including addiction-counseling service Halcyon Health and ADHD-treatment and therapy provider Ahead shut down this year.

The industry must do better if it is to live up to its promise, says Dr. John Torous, director of the digital psychiatry division at Boston’s Beth Israel Deaconess Medical Center.

“Digital health still has to be health,” he says. “A lot of telemental health tried to push the boundaries at the expense of patients.”

For a long time, telehealth was pitched as the future of medicine, even though adoption of the technology lagged behind hype about its ability to streamline and improve access to care. Then, the COVID-19 pandemic pushed life online and telehealth usage increased exponentially. When the American Psychiatric Association (APA) surveyed its members in May 2020, almost 85% said they used telepsych platforms for all or most sessions, compared to just 2% before the pandemic.

“COVID really pushed both patients and providers to try something that previously was this mysterious unknown,” says Samantha Connolly, a clinical psychologist with the VA Boston Healthcare System who researches telehealth. States and federal agencies waived restrictions on providing care across state lines, and the Drug Enforcement Administration began allowing clinicians to remotely prescribe controlled substances without an in-person evaluation.

In March 2022, influential health groups including the American Telemedicine Association (ATA) and the APA urged the government to make remote-prescription privileges permanent. “We’re asking for something that’s very reasonable, which is to continue, as much as we can, the access to care that now has been maintained for two and a half years,” says Kyle Zebley, senior vice president of public policy at the ATA.

Research has shown that remote prescribing can improve access to treatment for conditions including substance-use disorder, and that telepsych care is effective for treating many mental illnesses. “The key ingredient of the care we provide is talking, and that is something that can be done effectively from a distance,” Connolly says.

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But in practice, some virtual-care startups seem to be falling short, according to people on the inside. Multiple clinicians who spoke to TIME said the fast pace and high volume of appointments made it difficult to establish the strong bond with patients that’s necessary to make progress in mental-health care.

Christopher Solomon, a recovery coach who worked for Halcyon Health before it shuttered in April, says he used to meet patients in person because he was frustrated by how difficult it was to form a rapport online. Even though traveling to meet patients face to face defeated the point of the app, “you didn’t build that connection” otherwise, he says. “It’s very hard to feel someone’s emotion through a screen.” (Halcyon Health co-founder Andrew Bryk says that’s just one person’s opinion, and company data showed high patient engagement and satisfaction.)

Sharaya Collins, a New Jersey-based psychotherapist who worked with Cerebral for about a year, also says she found it difficult to establish strong connections online, and she didn’t feel the platform was prepared to address the limitations of virtual care. Collins says she can remember at least two instances when patients were exhibiting suicidal behavior and she had to wait an “unacceptable” length of time to receive guidance from a manager on the messaging platform Slack. “To do all of this through telehealth was unnerving for me,” she says.

A psychiatric nurse practitioner who left Cerebral after six weeks also says she grew uncomfortable with how the company handled complex cases. The platform allotted 30 minutes for psychiatric evaluations, in-depth screenings that she says typically take at least an hour. The nurse practitioner eventually demanded more time for these appointments—a decision that resulted in a pay cut, since she could see fewer patients per day, but was the only way she felt she could do her job responsibly. (A Cerebral representative said it is standard to pay clinicians based on the number and type of appointments they complete.)

On one occasion, the nurse practitioner alleges one of Cerebral’s doctors forced her to see and prescribe medication for a patient with symptoms she felt were too complex to treat virtually. After that incident, she quit. “The model sounded good to start,” she says. “But the patient wasn’t getting enough.”

Cerebral CEO David Mou declined to comment on specific patient cases, but says the company closely follows clinical guidelines and has implemented a robust suicide-prevention system, through which crisis counselors reach out to patients displaying suicidal intent in their messages within an average of nine minutes. “We have very clear policies around what we treat and what we don’t treat and when you should ask for help,” Mou says.

Still, Cerebral often felt like a “therapy machine” that prioritized profits over people, says one psychotherapist who left the platform after about a year. “They started taking on so many clients. They were just hiring people that may not have really been qualified,” she says. “To me, it seems like they got greedy.” After a fundraising round in late 2021, the San Francisco startup was valued at nearly $5 billion.

Mou, however, says the company’s mission is “very clear: to democratize access to high-quality mental health care for all.” Two-thirds of Cerebral patients have never sought mental-health care before, the company says.

Others in the industry have also grown disillusioned by the intersection of business and mental health. Jason Meisel, a New York City-based nurse practitioner, formerly worked at Ahead, a virtual mental-health provider that shut down in June. He says patients often got “lost in the shuffle,” and multiple days sometimes passed before they heard back from a provider. He also felt that the platform wasn’t careful enough with its hiring decisions, bringing on clinicians who were fresh out of school and unprepared for the workload.

The feeling was “let’s just hire more and more people, jump to more and more cities, let’s get more patients and more money,” Meisel says. “As opposed to, let’s slow the f-ck down and get the foundation [right].” (Ahead co-founder Dr. Andy Rink, who left Ahead before it shut down, declined to comment on employee perceptions of the company.)

Much of the scrutiny on telepsych startups focuses on their prescription practices. Two former Cerebral employees told Bloomberg that they recalled Mou, in his prior role as chief medical officer, saying 95% of patients who see a Cerebral nurse should leave with a prescription. According to the former employees, Mou also said the rate could not be 100%, or the company would be a “pill mill.” (In an interview with TIME, Mou stressed that Cerebral clinicians are not under prescription quotas and the company “would never, ever prescribe medications to patients who don’t need it.”)

At Ahead, Meisel also says there was pressure to prescribe drugs or refill patients’ existing prescriptions using the online pharmacy Truepill, which he feels was financially motivated since Truepill invested in Ahead. “There was a push,” he says. “I just ignored it.” (Truepill and Rink did not respond to that allegation when asked by TIME. In a statement provided to TIME, Truepill CEO Sid Viswanathan said the company has “always been aligned with the mission to provide accessible, quality mental healthcare,” but no longer invests in Ahead.)

After leaving Done, Arroyo, the Illinois nurse practitioner, also took a job at Ahead. Appointments at Ahead were longer and she felt supported. But despite her more positive experience at Ahead, Arroyo thinks stimulants are being prescribed too liberally across the industry—in part because most online evaluations are too short to make a solid assessment, and in part because some companies advertise aggressively on social media and draw in patients who expect to leave with medications. “It’s very easy to rope people into believing they have ADHD,” Arroyo says.

Rink wrote in an email to TIME that, while remote prescription is a nuanced issue, “to give a blanket ‘no’ answer to remote management of ADHD is to say that most ADHD patients should not have been treated during the pandemic.”

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A business model intertwined with social media also attracts a specific type of customer. Federal data show telehealth use is highest among people who are college-educated and wealthy; white U.S. adults are also more likely to use telehealth than people of any other racial or ethnic background, except those who identify as American Indian or Alaska Native. “It sort of makes you wonder, what is the agenda with the companies?” Arroyo says.

Joel Nigg, director of Oregon Health and Science University’s psychology division and a leading ADHD expert, shares some of Arroyo’s concerns. “Pretty much everybody in the country, if not the world, experiences quite a bit of distraction these days,” he says, but that doesn’t necessarily mean they have ADHD, or that they should be prescribed drugs. Stimulants can be harmful to patients with heart conditions, for example, and they can also exacerbate anxiety disorders—so if clinicians don’t have time to do thorough assessments, they could end up overtreating or mistreating people, Nigg says.

Despite the controversy surrounding some mental-health startups, Zebley, from the ATA, believes telemental health has lived up to its promise. “There’s no turning back,” he says. “Telehealth is here to stay.”

If anything, Zebley says, scrutiny from the government, pharmacies, and the media suggest the regulatory system is working, and companies are being held appropriately accountable. “Just because there are those that have allegedly violated the standard of care, and in some cases the law, doesn’t mean you erect these massive barriers that will inhibit access to clinically appropriate services,” he says.

Some of the controversy “may, in the long run, be beneficial for the field, because it’ll help people spot the things that are not ethical or evidence-based or useful,” Torous says. “There was so much excitement about telehealth, which is justified, but people are kind of saying it’s a panacea”—and the reality has proved different.

For Torous, skepticism about certain telepsych companies is separate from his belief in the promise of telehealth as a whole. Studies have repeatedly shown that virtual mental-health care can work, and that both patients and providers like the experience. The problem isn’t with telehealth as a concept, he argues, but with the way it’s being implemented by startups trying to maximize profits. Squeezing in as many appointments as possible might deliver on that goal, but it won’t fulfill promises made to patients, Torous says.

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“Providers can’t be quick,” Nigg agrees. “They have to take their time and really do the full evaluation and get the right information.” That’s especially true if drugs are involved, he says. Deciding which patients need medications is always a challenge, and it’s “multiplied and magnified in a telehealth setting where there’s even more danger of missing stuff.”

Policymakers have a role to play in fixing some of these issues. Regulations around telehealth, interstate care, and remote prescribing changed essentially overnight when COVID-19 began spreading in 2020, and “those policies need to be cleaned up,” says Bhavneet Walia, an assistant professor of public health at Syracuse University who researches telehealth. She says there should be stronger policies specifying which drugs can and can’t be prescribed solely through telehealth and which virtual services can be reimbursed through insurance. That transparency is vital if telehealth is going to stick around, she says—and the data suggest it will.

“As we are facing out of the pandemic, the highest rate of telehealth use is actually still in mental-health therapy,” Walia says. “Even when patients can technically drive to their therapist, they prefer a visit via telehealth.”

The clinicians who spoke to TIME are split on the role telehealth should play in the mental-health field, however. Some still use virtual appointments in their own practices, where they can control factors like appointment length and prescription policies. Others feel in-person care is still the best way to form a good relationship with patients. Some say hybrid care, with occasional in-person visits to supplement virtual ones, makes the most sense.

But none of them said they’d be eager to work for another mental-health startup.

“With a startup, there’s going to be a lot of risk, there’s going to be a lot of failures, there’s going to be a lot of changes,” says Collins, the therapist in New Jersey and former Cerebral employee. “It’s just too much.”