Teen Therapy and Psychiatry Online: Hit or Miss?

I recently assessed a teenager hospitalized for an acetaminophen (Tylenol) overdose. Prior to the incident, she had sought online mental health therapy but discontinued it due to a lack of rapport and privacy concerns with telehealth. Her condition escalated to the overdose, which came to light only after she confided in a friend, who then alerted the school counselor. Her parents struggled to secure in-person therapy post-COVID, as she rejected online treatment.

In the wake of a pandemic that has amplified the mental health crisis among teens, the shift toward online therapy, exemplified by New York City’s recent $26 million investment in Talkspace, raises concerns. While telehealth has expanded access, it sometimes falls short in addressing the complex emotional and psychological needs of our youth, particularly in severe cases, like that of my patient. This patient’s incident also underscores the critical role of friends and school-based support systems: in-person care, especially within schools, is essential for effectively addressing the youth mental health crisis.

The Worsening Youth Mental Health Crisis

I penned an op-ed on the pediatric mental health crisis 2 years ago, which coincided with a Surgeon General’s advisory and emergency declarations from leading medical organizations. Teen mental health issues had been on the rise for a decade preceding COVID and reached crisis levels during the pandemic. The CDC disclosed alarming statistics: a third of high school students reported mental health issues, over 25% of LGBTQ+ students attempted suicide, and suicide attempts among female students surged by 50%. By fall 2022, mental health-related emergency department (ED) visits for suicidal-related behaviors among adolescent females were still at or higher than pre-pandemic levels. Yet, even now, far too many severely depressed youths are not connected with consistent treatment. The answer isn’t merely increasing ED or inpatient capacity, as children often face long waits and have high readmission rates after short stays. In fact, the leading pediatric organization advocates for keeping kids out of hospitals by enhancing community-based mental health services.

The CDC recently released a report which, unsurprisingly, found that 5- to 17-year-olds were evaluated more in psychiatric EDs in the spring and fall. School is clearly a significant trigger: transitions into school, academic pressure, bullying, and victimization are likely all at play.

The mental health crisis encompasses numerous issues, with the alarming increase in suicidal tendencies among teenagers being particularly critical. This crisis disproportionately affects certain high-risk groups and minorities, including girls and Hispanic, African American, and LGBTQ+ youth. Jewish, Asian, and Muslim children are among those who also experience the challenges associated with minority status.

However, recent data show that only 56% of public schools are prepared to meet their students’ mental health needs, with 69% observing a rise in demand for such services post-pandemic. Despite this, 88% of schools doubt their ability to adequately serve all students requiring help, hindered by professional shortages, limited external resources, and insufficient funding. Also, only 65% of schools employ full-time nurses; there is just one school psychologist for every 1,127 students, on average, nationally; and in New York City, there is one guidance counselor for every 272 students.

Integrating Mental Health Services Into Schools

One possible solution is to enhance and expand in-person, school-based mental health services to directly address the challenges of online therapy. This strategy utilizes the existing school infrastructure and relationships to offer accessible, timely, and effective support, promoting community and belonging essential for student well-being.

Schools naturally provide a supportive infrastructure for children and families, with an increasing number incorporating mental health services directly on-site. For example, our medical center at Columbia has been offering mental health services in 14 local schools since the 1980s, using familiar settings to navigate common barriers such as stigma, missed appointments, and cost. The close relationships school staff have with students and families enable a deep understanding of individual needs, while peer support within this network further strengthens the care provided.

Utilizing local resources in this manner makes schools an ideal starting point for effective mental health interventions. Critically, this approach does not negate the value of telehealth but rather positions it as a complementary or “hybrid” tool within a broader, more diversified strategy.

The Shortcomings of Telehealth-Only Care

Opponents of prioritizing investment in school-based therapy may argue for the efficiency and accessibility of telehealth, especially in reaching remote or underserved populations. In areas where there are few child psychiatrists, online treatment may be better than no treatment. However, this further supports the argument for investing in local school-based care, for both rural and urban areas.

While telehealth has its merits, particularly in temporarily bridging geographical gaps, it may fall short in delivering the depth of care required for severe cases. The impersonal nature of online interactions can hinder the formation of a therapeutic alliance, which is foundational in effective mental health treatment. An interesting new study found that talking face-to-face lights up our brains more than chatting on Zoom, suggesting real-life conversations are better for our social brains.

The lack of immediate, on-the-ground support systems in online therapy can leave high-risk adolescents without essential safety nets. Mental health providers using apps might not be integrated into the local infrastructure critical to a teen’s life. Collaboration between therapists and physicians treating these high-risk patients — known as “split treatment” — is vital, yet challenging, even when both professionals are acquainted. This collaboration becomes even more unlikely with a therapist accessed via an app. Furthermore, a 30-minute once-a-month visit, as offered in New York’s agreement with Talkspace, complemented by the option to text between visits, may not suffice for the needs of high-risk teens frequently seen in EDs.

It’s Time for a Change

The Mohonasen Central School District in Rotterdam, New York, acclaimed for its mental health program aiding over 400 students in 6 years, recently caught the attention of New York Gov. Kathy Hochul (D). In response, Hochul and the New York State Office of Mental Health just announced they are launching a statewide initiative, dedicating $20 million to establish school-based mental health clinics. This is exactly what we need.

The mental health crisis among adolescents necessitates a strategic shift toward an investment in enhanced in-person, school-based mental health services. This approach not only addresses the limitations of telehealth, but also capitalizes on the unique advantages of integrating mental health support within the educational system. By fostering direct, meaningful connections and building robust support networks, we can offer a more compassionate, effective response to the mental health needs of our youth. Ultimately, investing in such an approach is not just a matter of policy but a commitment to the well-being and future of our younger generation.

Jonathan Slater, MD, is a clinical professor of psychiatry at Columbia University Irving Medical Center in New York City, and a senior attending in Child and Adolescent Psychiatry Consultation at NewYork-Presbyterian Morgan Stanley Children’s Hospital.