Wealth disparities impact telehealth access for mental health care
A new study led by researchers at the Johns Hopkins Bloomberg School of Public Health found that mental health visits for patients with depression from high-wealth neighborhoods in Maryland were significantly more likely to happen via telehealth compared to patients with depression from low-wealth neighborhoods in Maryland from mid-2021 through mid-2024.
Telehealth visits by phone or web-based teleconferencing became popular during the COVID-19 pandemic after in-person health care options were scaled back and telehealth restrictions relaxed. The researchers investigated how mental health care visits changed from before and over the course of the COVID-19 pandemic.
For their study, the researchers analyzed deidentified Johns Hopkins Health System electronic health records from mid-2016 to mid-2024 for patients diagnosed with depression. The researchers then categorized patients by the average neighborhood wealth using a measure called the Area Deprivation Index. The tool captures overall socioeconomic deprivation at the Census-block-group level based on factors including income, education, employment, and housing quality. For their study, the researchers compared patients from the highest and lowest quartiles of deprivation ratings.
From mid-2016 to mid-2019, the study found only a few dozen patients in the study cohort had telehealth visits. During the pandemic, the percentage of visits conducted via telehealth peaked in mid-2020 and continued to account for a substantial portion of mental health care through the end of the study period in mid-2024: From mid-2021 to mid-2024, 65% of mental health care visits in psychiatry and 24% of mental health visits in primary care were conducted via telehealth.
The study was published online February 14 in PNAS Nexus.
Telehealth for mental health may reduce barriers to accessing care for some, but our findings suggest that telehealth may not be improving access to care for all patients, especially those living in low-wealth/high-deprivation areas.”
Catherine Ettman, PhD, study lead author, assistant professor in the Bloomberg School’s Department of Health Policy and Management
The authors note that telehealth visits, particularly video telehealth, typically require a personal computer, high bandwidth internet access, significant privacy, and a modest amount of technical knowledge.
For their telehealth analysis, the researchers used electronic health records from 132,275 visits for 29,608 patients with depression getting mental health treatment in primary care and 172,080 visits for 7,577 patients with depression getting mental health treatment in psychiatry from July 2020 through June 2024. About two-thirds of the patients were female.
The study found that from mid-2021-when Maryland lifted many COVID restrictions-to mid-2024, the odds of telehealth use relative to in-person visits were significantly higher for patients from high-wealth/low-deprivation neighborhoods compared to those from low-wealth/high-deprivation neighborhoods-about 1.62 times higher for primary care visits and 1.67 times higher for psychiatry department visits.
The researchers also examined overall visits-both telehealth and in-person-by patients with depression from mid-2016 to mid-2024. The cohort included 42,640 patients over 270,754 visits in primary care and 12,846 patients over 336,918 visits in psychiatry.
During the pre-pandemic period from mid-2016 to mid-2019, the rate of mental health care visits in psychiatry increased in both groups but rose more quickly among patients from high-wealth/low-deprivation areas compared to low-wealth/high-deprivation areas. After Maryland lifted its COVID emergency restrictions in July 2021, the rates of telehealth visits fell for both groups, with the low-wealth/high-deprivation patients returning to pre-pandemic levels and the high-wealth/low-deprivation patients remaining at levels above pre-pandemic levels.
The authors note that the findings may not be generalizable to all health systems or places.
“It is important to consider how telehealth may improve access to care and what we can learn from the groups it has helped most so that we can adjust and support patients who may need more mental health care services,” says Ettman.
“Trends in Mental Health Care and Telehealth Use Across Area Deprivation: An Analysis of Electronic Health Records from 2016-2024” was co-authored by Catherine Ettman, Grace Ringlein, Priya Dohlman, Jason Straub, Carly Lupton Brantner, Elizabeth Chin, Sazal Sthapit, Elena Badillo Goicoechea, Ramin Mojtabai, Michael Albert, Stanislav Spivak, Theodore Iwashyna, Fernando Goes, Elizabeth Stuart, and Peter Zandi.
Funding was provided by the National Institute of Mental Health (R01-MH126856), Johns Hopkins School of Medicine inHealth, Meta Platforms, Inc., the Johns Hopkins Business of Health Initiative, and the Louisiana Board of Regents Endowed Chairs for Eminent Scholars program.
Ettman, C. K., et al. (2025). Trends in mental health care and telehealth use across area deprivation: An analysis of electronic health records from 2016-2024. PNAS Nexus. doi.org/10.1093/pnasnexus/pgaf016.
