More Americans are seeking mental health care than ever before, but many people receiving treatment have never met their psychiatrist in person—or even at all.
Telemedicine has been growing in popularity for years, but the COVID-19 pandemic sent tele-health care utilization rates through the roof. Now, after sharp increases brought by COVID-19 lockdowns, American telehealth utilization has stabilized at levels a staggering 38 times higher than before the pandemic. And Silicon Valley has taken note of these numbers.
Technology investors saw the increasing popularity of telehealth as a business opportunity. In 2020, billions in venture capital funding raced into the market, and the investments have not slowed down. In the first half of 2021 alone, venture capital investment in the digital health space totaled $14.7 billion, more than all of the investment in 2020 combined and nearly double 2019 totals.
With this new venture capital money came new expectations for growth. Many telemental health care companies began rapidly scaling, using a hypergrowth approach and a rapid tech expansion strategy.
Yet, despite billion-dollar valuations, serious quality of care concerns have emerged at several telemental health care companies. In March 2022, the Wall Street Journal reported that employees at a telemental health care startup felt pressured to prescribe—and even overprescribe—ADHD medications like Adderall. In April 2022, another startup, which specialized in ADHD management, shut down after employees claimed that they felt similar pressures to prescribe Adderall or other stimulants to patients who did not meet the diagnostic criteria for ADHD.
Prescribing controlled substances like Adderall can be good for business. After all, patients have to keep coming back for prescription refills. But what’s best for profits is not always what’s best for patients. When growth equity firms prioritize gross margins over patients’ health outcomes, the results can be deadly.
America has seen this story play out before with the opioid epidemic. Purdue Pharma, the manufacturer of OxyContin, knew that their product was being widely abused but continued to promote the deadly opioid as a safe pain management option. Perdue Pharma placed profits over patients, and the results have been devastating. Since the1990s, overdose deaths have nearly quadrupled, and the demand for opioids created by the over prescription of OxyCotin has triggered a secondary crisis of accelerating rates of heroin use, trafficking, and deaths.
As with pain management treatment, many prescription medications used to treat common mental illnesses have a high potential for misuse or abuse. Unless significant changes are made to the telemental health care model, the U.S. risks creating a new opioid epidemic—this time of Adderall, Klonopin, and other dangerous but commonly prescribed drugs that treat mental illnesses.
The stimulants, benzodiazepines, and sedative-hypnotics used to treat many common mental illnesses are controlled substances for a reason. When used judiciously, they can provide powerful relief. But the risks of addiction, misuse, and overdose are high.
Benzodiazepines like Xanax, Klonopin, and Ativan are some of the most commonly prescribed medications in America, but they are incredibly habit-forming, and long-term use can create serious side effects. Many of the 4 million daily benzodiazepine users in the United States meet DSM criteria for substance use disorder, and cessation can be immensely difficult. Patients often experience uncomfortable withdrawal symptoms that can last for months. Benzodiazepine withdrawal can even lead to lethal seizures.
As mental health care professionals, we work with patients who are severely depressed, psychotic, or even suicidal, and we have the ability to prescribe incredibly powerful medications as part of our treatment protocols. But business interests have no place in the decision making behind diagnosing patients or prescribing medications.
Telehealth can, of course, be an excellent model for providing mental health care. In fact, for many patients, it is preferable. It can often be cheaper, more convenient, and more accessible than traditional in-person treatment. Still, the model comes with real risks, including the unnecessary overprescription of medication. Telemental health care startups who model themselves after high-growth tech companies are exacerbating these risks and fueling a potential over-prescription crisis.
To avoid creating a new opioid epidemic, we must work to ensure the interests of growth-minded funders never trump the interests of patients. Telemental health care companies must reduce their prescription rates, especially for controlled substances. These medications should be prescribed as a temporary intervention to help bring severe symptoms under control or as a last resort when other interventions have failed. Non-prescription interventions should always be attempted before dangerous, habit-forming medications are prescribed, and neuropsychological testing, when appropriate, should also be conducted to confirm the need for medication.
I know that telemental health care can improve lives. My industry must work hard to ensure that we are part of the solution to America’s Mental health crisis, not part of the problem.
Tamir Aldad is a physician executive.
