The Rise of Psychotherapy Largely Benefits Socioeconomically Advantaged Adults

A cross-sectional study demonstrated significant psychotherapy increases from 2018 to 2021 among adults with mild or moderate distress, college education, greater family income, and private insurance, as well as young adults and females.1 In 2021, people were significantly more likely to use teletherapy if they had a greater income, were employed, and were college-educated.

Last February, the same team reported that the proportion of US adults receiving psychotherapy increased from 6.5% in 2018 to 8.5% in 2021.2 This previous report found the rate of outpatient mental health care decreased for individuals with serious psychological distress, particularly among older adults, the unemployed, lower-income, less educated, and rural residents.

"While psychotherapy access has expanded in the US, there's concern that recent gains may not be equally distributed, despite or maybe because of the growth of teletherapy," said Mark Olfson, MD, MPH, from Columbia Mailman School professor of Epidemiology and Psychiatry.3 "This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress."

Due to this concern, investigators sought to characterize trends and patterns in outpatient psychotherapy using the 2018 to 2021 Medical Expenditure Panel Surveys.1

The repeated cross-sectional study included 89,619 adults (51.5% female) with 29% aged 18 – 34 years, 48.8% aged 35 – 64 years, and 22.2% aged ≥ 65 years. The team measured age-, sex-, and distress-adjusted differences in psychotherapy between 2018 – 2021. They also measured for differences in age, sex, and distress in teletherapy.

Investigators examined trends across levels of sociodemographic characteristics and distress. Psychological distress was measured using the Kessler-6 scale; a score ≥ 13 indicated serious psychological distress, 1 – 12 indicated mild to moderate distress, and 0 indicated no distress.

The study revealed psychotherapy use increased significantly quicker between 2018 and 2021 for females (7.7% to 10.5%) than males (5.2% to 6.3%), younger individuals aged 18 – 34 years (8% to 11.9%) than older individuals aged ≥ 65 years (3.6% to 4.6%), college graduates (7.6% to 11.4%) than those without a high school diploma (5.5% to 7%), privately insured (6.1% to 8.9%) than publicly insured (8.8% to 8.8%), adults at 2 to 4 times the poverty level (5.7% to 8.2%) than below the poverty level (9.7%. to 10%), employed (5.7% to 8.9%) than unemployed aged 18 – 34 and ≥ 65 years (10.8% to 10.5%, and urban adults (6.5% to 8.7%) than rural (6.4 to 5.9%).

Controlling for distress levels showed teletherapy use was significantly greater among younger adults than middle-aged (35 – 64 years) (difference, -3.7 percentage points; 95% confidence interval [CI], -5.1 to -2.3) and older adults (aged ≥ 65 years) (difference, -6.5 percentage points; 95% CI, -8.0 to -5.0). Teletherapy was also significantly greater among participants who were not married (difference, 2.9 percentage points; 95% CI, 1.6 to 4.2), college-educated adults (difference, 4.9 percentage points; 95% CI, 3.3 to 6.4), people who were higher on the federal poverty level (difference, 2.3 percentage points; 95% CI, 1.2 to 3.5), privately insured (difference, -2.5 percentage points; 95% CI, -3.4 to -1.5), and urban residents (difference, 2.7 percentage points; 95% CI, 1.5 to 3.8).

“Technological challenges, preferences for in-person care, and financial barriers can hinder access to teletherapy," Olfson said.2 "There is growing concern that the rise of telemental health could deepen existing disparities in access to care. The trends we are seeing underscore the need for targeted interventions and health policies that expand psychotherapy access to underserved groups.”

References

1. Olfson M, McClellan C, Zuvekas SH, Wall M, Blanco C. Trends in Outpatient Psychotherapy Among Adults in the US. JAMA Psychiatry. Published online December 04, 2024. doi:10.1001/jamapsychiatry.2024.3903
2. Derman, C. Psychologically Distressed Patients Faced Challenges During COVID-19. HCPLive. February 8, 2024. https://www.hcplive.com/view/psychologically-distressed-patients-faced-challenges-during-covid-19. Accessed December 4, 2024.
3. Study shows significant rise in psychotherapy use among adults, but gains are uneven across socioeconomic groups. EurekAlert! December 4, 2024. https://www.eurekalert.org/news-releases/1066713. Accessed December 4, 2024.