The must-see Netflix documentary, “The Social Dilemma,” released early this year, draws attention to the link between heavy smartphone use and mental health disorders like anxiety and depression. But there’s a paradox brewing, because the latest solutions for mental health ask people to spend more time on their phones.
Digital mental health is trending. Think texting your therapist via Talkspace or meditating with Calm. Five of the top 10 venture capital-backed mental health startups are smartphone apps. The top 20 mental wellness apps were seeing 3 million new downloads per month before Covid-19 began striking hard in March, which grew to 4 million in April.
While the expanded access to mental health resources is remarkable, these products face two contradictory goals. Technology is built to engage, to keep us logged in for as long as possible. But if excessive screen time is worsening mental health issues, good mental health care should probably help us disengage from our phones.
Is it possible to have both a successful tech product and an effective form of mental health care? We think the answer is yes — as long as digital mental health companies adopt three best practices.
Mental health well-being first, venture capital metrics second
When pitching investors, digital startup founders tend to emphasize app downloads, active users, and customer lifetime value. These metrics inform revenue and growth potential. But they indicate the business’ health, not the user’s. It is essential that digital mental health startups understand the difference, even while chasing both.
To assess quality of care, it’s important to look at patient-reported outcomes. How has the user’s quality of life changed during the course of treatment? How is their mood, sleep, and productivity? Like traditional therapists, providers on the other side of the app should use evidence-based scales to diagnose patients and monitor their improvement, such as the PHQ-9 for depression or GAD7 for anxiety.
The challenge with an engagement metric like time in app is that it says nothing about quality of care and, if anything, might be harmful to the user who, thanks to the app, may have become more glued to their phone. Paying providers based on patients’ time using the app, or even their own time in the app, is antithetical to effective mental health care. Provider compensation should be tied to quality of care, not quantity of care.
One path forward for digital mental health startups is to focus on payer partnerships. Companies that prioritize the right metrics and show improved patient outcomes are more likely to get commercial health insurers and employers to pay for their mental health solutions.
There is still a place for classic venture capital metrics like customer lifetime value, but rather than keeping individuals hooked (which is poor medical practice), value comes from serving new patients every year through partner health plans.
Replicate the boundaries of traditional therapy in a digital world
In adapting therapy for mobile, developers have added new features. A popular one is 24/7 access to a therapist via text, which certainly drives engagement. Digital tools are fundamentally changing what mental health care looks like. While innovation is important, it is essential not to forget that the methods of traditional therapy have been tried and tested, and that there is science behind them.
Meeting with a therapist at a regular time and place creates a frame, a distinct environment in which to work on mental health so that issues interfere less with daily life. In the traditional setup, patients have ways to contact their therapists in case of emergency, but are encouraged to internalize coping strategies so they become more instinctual and less dependent on external reinforcement. Patients practice and learn between appointments how to quell their anxiety independently, or how to let it subside on its own. That incentive disappears with 24/7 texting and with any app that prioritizes user engagement over patient progress.
There are serious risks to this 24/7 feature. Priming a patient who is struggling with loneliness to expect instant responses from a therapist is dangerous. A single delayed reply could increase their sense of alienation. There is no doubt that more frequent communication could help some people, especially early on in treatment. But experts have clarified that texting is not a science-backed method of therapy, and that constant communication with a therapist can diminish one’s autonomy and self-reliance.
Companies must create boundaries to replicate the frame in an otherwise flexible digital environment. One option is asynchronous communication: Patients can write to their provider around the clock but are cautioned to expect a response within one business day. Or they can use the app’s scheduling functionality to book a midweek check-in as needed. Technology can also enable providers to toggle features on or off based on their assessment of what will most benefit the individual.
Offer practical advice on healthy technology use
Digital mental health apps should educate users on how smartphones and social media contribute to stress, anxiety, and depression. One way to do this is by offering a daily tip on the homepage such as limiting screen time and replacing it with activities that promote life satisfaction, muting notifications overnight to improve sleep quality, or deleting social media accounts, temporarily or permanently.
In other words, address the elephant in the room. Only by acknowledging the irony of a tech-based solution to a tech-based problem can digital mental health startups avoid the pitfalls described in “The Social Dilemma.” As with any kind of health care, users deserve to know the risks of smartphone-based treatment, including overdependence on technology. They can weigh the risks against the benefits and become active agents in their own treatment. Suggestions on healthy technology use will complement the core product offering, whether that is teletherapy or mobile meditation, leading to better patient outcomes and greater customer satisfaction.
Developing and selling digital mental health tools is a balancing act. There will often be a mismatch between what will most impress investors and what will best serve patients, but these goals are not mutually exclusive. Companies must understand that the number one goal of health tech, unlike other tech, is not to engage and immerse patients in their phones but to support and embolden them in their real lives. These are the companies that will ultimately do well while also doing good.
Payal Marathe is an M.B.A./M.P.H. candidate at Columbia University. Ravi N. Shah is a psychiatrist, medical director of the psychiatry faculty practice and assistant professor of psychiatry at Columbia University Irving Medical Center in New York City, and a co-founder of Mantra Health, a telemental health company.
Thank you for writing this article. I agree the goal of therapy is to foster self-determination and freedom and that digital has a remarkable opportunity to help if done correctly. I have never seen any research about ongoing continuing contact in the clinical relationship fostering dependency, being dangerous, and/or that it can diminish self-determination. Can you please expand on this and provide some research. Thank you.