This is a Physician in the Loop special topic.

Three months, or a chatbot now

More Americans said they would use a therapist three months away than a chatbot available immediately. The wait is the thing to fix, and the handoff to a person is the thing to require.

Ask someone who needs help to make a choice. A licensed therapist, three months from now. Or a chatbot, right now, with no clinician watching. A survey published on Oct. 14 asked 1,185 American adults about similar offers, one at a time. About two-thirds said they would likely use the therapist three months away, half a chatbot monitored by a therapist within a month, and fewer than half a chatbot on its own, available at once.

Take the finding carefully. It was fielded on an online panel in the summer of 2024, so it is not a probability sample. And because each option moved the wait and the supervision together, it cannot separate a wish for a human reviewer from a reaction to the delay. What it does describe is a demand, and the supply behind the wait is thin. About 157 million people lived, as of the end of June this year, in areas the federal government has designated as short of mental health professionals. By that measure, about a quarter of the need was met. Neither figure counts the wait itself.

So the comparison that matters is a chatbot against a wait, not a chatbot against a therapist. That reframing changes what to build, which is the monitored middle option, and what to require, which is the handoff to a person.

What the unsupervised option is being asked to carry is now in court. On Oct. 14 eight states sued OpenAI in their own courts under their consumer protection laws, and Texas followed on Oct. 23. The eight allege that ChatGPT gave dangerous medical advice, encouraged paranoia, pushed users toward harming themselves or others, and misled the public about how thoroughly the company tests for safety. None of that has been tested in court. OpenAI says it has built child safety protections into ChatGPT and will keep improving them, and that its model for teenagers is designed to reduce exposure to self-harm and other harmful material.

Testing paid for by the National Institute of Mental Health suggests these systems sort the clearest cases well and the middle ones badly. In an evaluation published in Psychiatric Services in August 2025, thirteen clinical experts graded 30 hypothetical questions by self-harm risk, and ChatGPT, Claude and Gemini, in the versions available in late 2024, were tested against that grading. All three declined every question in the highest risk category, and where they declined they mostly pointed the user to a crisis hotline. Two of the three matched the experts at both ends of the range. None of them reliably told the levels in between apart. What was counted was whether a chatbot answered directly, not whether its answer was any good.

The monitored option has a trial behind it, of a purpose-built therapy chatbot, run by the team that built it. 210 adults were assigned either to the tool or to a waiting list, and those who got it reported larger falls in symptoms than the controls at four weeks and at eight, averaging about half for depression and a third for anxiety among those who used it. Note the conditions. The trial's senior author watched the messages coming in from participants, at least early on, for responses the software should not have given.

Illinois, Nevada, Maine and Rhode Island answered the other way and now prohibit offering therapy through a chatbot, on the view that therapy is a licensed act. The case for that is strong. Software cannot be held responsible for a patient, and a product sold as supervised risks being supervised thinly and then used as a reason not to hire clinicians. The trial that worked shows what real supervision takes. Its staff read the traffic and stepped in fifteen times over safety, an arrangement that does not survive a million users. But a ban does not shorten a queue. It does not stop the patient in that queue from opening a general chatbot, where no clinician is reading along. Maine's ban leaves room for a chatbot inside approved research or a federal Medicare or Medicaid program, and that is where a monitored tool should have to prove itself.

California came at it from the other end. Its companion chatbot law, in effect since Jan. 1 this year, requires operators to keep and publish a protocol routing users at risk of suicide or self-harm to crisis services, and from July 2027 to report a yearly count of crisis referrals. Another Rhode Island law, effective Jan. 1, 2027, will require a referral to crisis services as soon as a user expresses suicidal thoughts or a risk of self-harm. Much of what the American Medical Association asked Congress for in April, including disclosure and an immediate crisis referral, is already law in New York and California and will be in Rhode Island in January, for one class of chatbot. California's and Rhode Island's laws omit the adverse event reporting the association also asked for, though a California amendment signed in September will let the public report child safety incidents.

So apply the same duty to any chatbot that discusses mental health, not to companion products alone. The companies should not wait for California's first count of crisis referrals in 2027 to publish how often a flagged conversation reached a person. And the harder work sits with health systems and their medical staffs. Measure the time to a first behavioral health appointment. Publish it. Put something better than a voicemail in front of the people waiting. Anyone in crisis can reach the 988 Suicide and Crisis Lifeline by call or text.

Across the survey's three options, willingness fell as the wait shortened and the oversight thinned. The work is to make that middle option real and the first one sooner. The third option needs nobody's permission and no clinician is watching it, so the one thing to require of it is the handoff. A person in crisis passed to a person. And a count of whether it happened.

This special topic was read by an AI voice. Its sources are linked at physicianintheloop.org.