Not Either, Or, But Both


John Peloquin, PhD, MBA, is president-CEO of Discovery Behavioral Health mental health, substance use and eating disorder treatment centers.

Over the past two years, we have witnessed a tumultuous shift in behavioral health care—which includes the treatment of mental illness and substance use—that no one could have predicted. The continued tragedy of the Covid-19 pandemic set in motion an unparalleled real-life, real-time experiment in the effectiveness of telehealth. It also offered a glimpse of what healthcare will look like over the next decade.

But first, let’s go back to the start of the pandemic in 2020. With doctors’ offices shuttered nationwide for fear of spreading the contagion, the federal government decided to rethink its policy regarding drugs, which required patients to be examined by physicians before a prescription would be issued. Obviously, that was impossible under the circumstances.

So, the rule was suspended. No longer would potentially addictive drugs, including amphetamines like Adderall, and benzodiazepines, such as Xanax, Ativan, Valium and Klonopin, require an in-person visit to be dispensed. Each of these medications is highly effective over the short term but has a huge potential for abuse without medical supervision.

Dispensing drugs without direct medical supervision…what could possibly go wrong? Needless to say, plenty, but more about that in a moment.

On the bright side, the meteoric rise of telehealth during the pandemic has provided Americans unprecedented access to mental healthcare that was previously difficult or impossible to obtain due to a lack of insurance, geography, or family and work obligations. Unfortunately, it has also opened the door to the possibility of a new addiction crisis.

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Opioid Crisis, Redux

It might seem like another century, but just three years ago, the number one health concern in America was the opioid crisis, which was ravaging wide swaths of America without regard to age, income, race, ethnicity or geography. For the first time, the average lifespan of American adults was less than their parents’, what sociologists were calling “deaths of despair,” and was fueled by addiction to legal and illegal opioid painkillers.

The opioid crisis didn’t disappear; it simply became overshadowed by the Covid-19 pandemic. To be clear, according to the Centers for Disease Control and Prevention’s latest statistics, more Americans died from drug overdoses in 2021 than ever before. There were more than 100,000 drug overdose deaths, a 28.5% increase from 2020.

Despite this grim background, too many venture capitalists viewed the pandemic as just another opportunity to cash in on telehealth apps. I observed that many of these apps overprescribed medications at the expense of the necessary but time-consuming work provided by counseling. The economy-of-scale model might work for ride-hailing, food delivery or vacation rentals, but behavioral health is an entirely different proposition. The same “fake it until you make” mantra falls short when you’re dealing with the mental well-being of individuals.

As might be expected, the rapid growth of telehealth over the past two years caught the attention of federal law enforcement for possible violations of the Controlled Substances Act.

The Department of Justice now has opened a formal investigation and is halting all further prescribing of Adderall by telehealth firms. Whistleblowers are starting to emerge with allegations of telehealth executives putting profits before patient health.

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Suddenly, this all sounds eerily familiar.

The Future Of Telehealth

So, where does telehealth fit into the future of healthcare?

Telehealth is one tool in the toolbox of patient care that has tremendous value. However, one thing is certain after the unintended experiment of the past two years: Telehealth is not the be-all and end-all answer to the problems that persist in the nation’s healthcare system. Still, there is an important role for it to play in the post-pandemic era, albeit the picture is still foggy.

In 2022, as we transition to more of a mixed model of telehealth and in-person visits, there will be a lot of questions to address. How do we know when to switch a patient’s care from telehealth to clinic-based treatment? How do we monitor control quality in a remote setting? How many patients are too many for a telehealth care provider? And who gets to decide the answers to these questions?

A recent NIH study sheds new light on the telehealth phenomenon and addresses one question about the effectiveness of telehealth. The study looked at the cancellation rate of counseling sessions as a measure of telehealth’s effectiveness. The cancellation rate fell dramatically during the pandemic when telehealth was the only available option. It seems telehealth improves “visit adherence” by removing some obstacles patients encounter in keeping face-to-face visits, such as transportation, childcare and other logistical barriers. However, it is also critical to consider that the decline in cancellations may have been related to the enhanced need for behavioral health services during the Covid-19 pandemic.

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Toward Behavioral Health Integration

Rather than view the future of behavioral health as a choice between mental telehealth and clinical care, the focus should be on integrating the two. Telehealth can play a valuable role in providing foundational access for everyone who needs care. It’s the doctor’s office that never closes, providing informed, evidence-based advice from qualified medical professionals like nurses, physician assistants and trained therapists.

Telehealth’s reliance on technology is both its advantage and disadvantage. Technology is fast, efficient and elegantly uniform. It can help reduce some of the unintended variability and even errors in patient care, the kind of unintended consequences described in the popular new book Noise: A Flaw in Human Judgment.

Telehealth cannot replace the level of care that in-person clinical visits can only provide. And while human judgment is inherently imperfect, technology has its own flaws. Algorithms could eliminate human-centric variability, but they can produce their own biases or systemic errors that create negative outcomes. Also, not everyone in our nation has access to high-speed internet or smartphone-enabled devices, limiting telehealth’s efficacy.

The future of behavioral healthcare is not telehealth versus clinical visits. An integrated model combining technology and in-person care can provide the best of both worlds.


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