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 **Source:** JMIR 2024 e59939
 
 FQHCs adopting telemental health showed 5-7 percent increase in visit rates among Medicaid and low-income groups, demonstrating that institutional deployment context matters. However, standalone apps (BetterHelp, Headspace, Calm) cost $260-400/month with no Medicaid coverage and predominantly serve insured/higher-income/younger/White users. Text therapy (Talkspace, BetterHelp messaging) costs $65-100/week with virtually no Medicaid coverage in any state. The disparity is structural: commercial apps optimize for paying customers, while safety-net institutions lack resources to deploy digital tools at scale.
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+## Extending Evidence
+
+**Source:** npj Digital Medicine 2025; Lancet Digital Health 2025
+
+Mental health app attrition mechanisms are structurally inequitable: limited digital literacy (structural barrier for underserved), privacy concerns (higher in marginalized populations), lack of cultural/linguistic adaptation for non-English speakers, and poor usability that assumes technical sophistication. Even in best-case RCT conditions with motivated participants, 64% attrition suggests real-world underserved populations would face substantially higher dropout rates, creating a selection effect where apps work only for the already-advantaged completer minority.