Access to psychotherapy has risen substantially among U.S. adults with mild to moderate distress since 2018, according to a new study from Columbia University’s Mailman School of Public Health and the Department of Psychiatry at Columbia Vagelos College of Physicians and Surgeons. The increase in psychotherapy use is particularly notable among younger adults, women, college-educated individuals, and those with higher family incomes. Privately insured individuals also experienced greater gains in psychotherapy use compared to those who are publicly insured or uninsured. The findings are published in JAMA Psychiatry.
In 2021, psychotherapy use via telehealth was also significantly higher among adults with higher incomes, higher education, and full-time employment.
“While psychotherapy access has expanded in the U.S., 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, Columbia Mailman School professor of Epidemiology and Psychiatry. “This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress.”
Psychotherapy remains one of the most common forms of mental health care in the U.S. In a prior study, Olfson found that the percentage of all U.S. adults receiving psychotherapy rose from 6.5% in 2018 to 8.5% in 2021.
In the current study, the researchers analyzed data from the 2018-2021 Medical Expenditure Panel Surveys, which are nationally representative of the civilian non-institutionalized U.S. population. The study included a sample of 86,658 adults — about 22,000 individuals each year.
In 2021, psychotherapy use was highest among young adults (12%), followed by middle-aged adults (8.3%), and lowest among older adults (4.6%). As expected, those with the most severe distress had the highest rates of psychotherapy use, while those with mild or moderate distress had intermediate use, and those with no distress had the lowest. Nearly 40% of adults using outpatient psychotherapy in 2021 accessed at least one session via teletherapy.
The COVID-19 pandemic, which caused widespread social isolation, stress, and economic disruption, further accelerated the adoption of telemental health services. While teletherapy provides a convenient and less stigmatizing option for care, concerns persist that certain groups — such as individuals with more severe mental health issues, older adults, lower-income individuals, and some minority groups — have not benefited equally from this expansion.
Financial barriers, such as lack of insurance coverage and high out-of-pocket costs, are key obstacles to seeking mental health care. Additionally, low reimbursement rates for Medicaid can discourage therapists from participating in insurance networks, exacerbating shortages in therapy availability. Olfson’s research shows that adults with lower incomes or without private health insurance were also less likely to use teletherapy than their wealthier, privately insured counterparts.
“Technological challenges, preferences for in-person care, and financial barriers can hinder access to teletherapy,” said Olfson. “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,” said Olfson. “Ensuring that individuals in psychological distress can access care is a national priority. Addressing technical and financial barriers to teletherapy could help bridge the gap in access and promote equity in mental health care.”
Co-authors are Chander McClellan and Samuel H Zuvekas of the Agency for Healthcare Research and Quality; Melanie Wall, Columbia Mailman School and Vagelos College of Physicians and Surgeons; and Carlos Blanco, National Institute on Drug Abuse.
