An unexpected side effect of the tragedy of the Covid-19 pandemic is unprecedented opportunity for innovation in mental health care, largely due to the rapid expansion of telehealth and the increased demand for mental health services.
As an example, one insurance company reported that claims for telehealth increased from 200 in February 2020, just before the full force of the pandemic hit the U.S., to 38,000 just three months later. We don’t know how much of this shift will be sustained once Covid-19 has been tamed, nor do we know its complete impact on clinical outcomes, but the pandemic experience shows that profound change in the delivery of mental health care can be rapid and widespread once the right incentives are in place.
The question is no longer whether technology will transform mental health care, but when and how it will occur. 2020 was an unprecedented year for investment in mental health start-ups. According to Rock Health, the venture capital industry invested $1.8 billion in mental health startups in 2020, a threefold increase over 2019.
This has proven favorable to entrepreneurs and may prove profitable to investors, but will it be helpful to patients?
The majority of innovations have focused on increasing access to care but this, by itself, probably won’t improve mental health. We believe that meaningful change also depends on innovations that increase engagement, facilitate integration with primary care, and focus on quality. And if they are to make a substantial impact on public health, innovations will need to address the needs of people with serious mental illness, a population largely neglected by entrepreneurs.
We believe in these approaches so strongly that we’ve co-founded companies, Humanest Care and Valera Health, to tackle these issues.
Meeting patients where they are
More than half of the people who need mental health care do not get treatment. Most seek emotional support from social media, and some receive medications from primary care, but many are unwilling to seek medication or therapy even when these treatments are appropriate and available. Engaging people with treatment by going directly to them has been successful in other areas of medicine and should be feasible in mental health where there are no surgical procedures or invasive diagnostics that require in-person visits.
The mental health direct-to-consumer marketplace has largely been wellness apps for mindfulness or therapy apps for providing talk therapy. This is a good first step, but standalone solutions are not sufficient.
To improve population health, we need an online stepped-care system in which individuals with mental health needs begin as members instead of patients and are offered a selection of low-intensity but evidence-based interventions, such as problem-solving exercises and peer support. Should the need arise, they can easily transition to traditional individual or group therapy, with or without the use of prescribed medication, as well as higher levels of care such as intensive outpatient programs.
The steps of care need to be tailored to individual’s needs, which vary significantly based on severity of symptoms, personal preference, and cultural background. Offering everyone with mild anxiety a combination of hourlong therapy sessions and medications may work for some of them, but will intimidate, overwhelm, or alienate others.
To bend the curve for population health, we must engage people on their terms, and we must avoid imposing on them the rigid treatment structures of traditional care.
Integration with primary care
The U.S. mental health care system is woefully fragmented: Primary care physicians rarely communicate with their patients’ therapists, who rarely coordinate care with psychiatrists. At a systemic level, insurance companies often carve out behavioral health from the rest of medical care, with separate facilities, data systems, and reimbursement requirements. New technology-based solutions risk contributing to the fragmentation by introducing new software and clinical workflows.
Yet promising evidence-based approaches to integrate care are beginning to take root. Efforts based on principles of collaborative care, with a health coach as a high-touch coordinator of care between primary care physicians and mental health specialists, are beginning to show promise in streamlining workflows and improving outcomes at scale. Yet much more needs to be done.
To provide a coherent patient journey, clinical information needs to be easily shared between patients, therapists, prescribers, and social workers, among others. We need to establish compatibility standards that allow different technologies to talk to each other. In the interim, tech-enabled health coaches will play an increasingly critical role in creating a seamless patient experience that integrates between inpatient, outpatient, and pharmacy services.
Measuring and assessing quality of care
It’s not enough to create new technologies, even if they improve engagement and integration. To improve population health, innovations also need to prove the quality of care by measuring outcomes and improving care iteratively as part of a learning health care system. The shift to telehealth offers an unprecedented opportunity to collect outcomes and learn iteratively, but few telehealth providers have leveraged modern data science to its full potential.
Telehealth 2.0 for mental health could, and should, bake in real-time measurement, using facial recognition software to quantify blink rate and tics, assessing affect from facial expressions, and including linguistic analysis to capture sentiment and coherence. Initially, these novel measures need to be validated with well-accepted clinical instruments such as the PHQ-9 questionnaire for depression. Ultimately, these measurements can also be used to improve the quality of clinicians by providing tailored feedback about their performance across different diagnoses.
By using data intelligently, the best mental health systems will become closed-loop learning platforms that continually improve.
Addressing serious mental illness
Although the most expensive and most challenging patients tend to be those with serious mental illness, such as schizophrenia, bipolar disorder, and severe depression, the vast majority of investments have backed companies that focus on wellness or the needs of patients with mild or moderate levels of anxiety or depression. This approach is financially rational for entrepreneurs, since the population with mild-to-moderate mental health issues is larger and better insured. But neglecting the most seriously ill patients will limit the public health impact of mental health technology.
We need digital solutions that coordinate recovery from serious mental illness by combining clinical care, social support, help with employment and housing, and strategies to empower patients to live independently. Here again, health coaches will play a critical role, enabled by digital tools. These lower-cost workers who excel at engaging patients and coordinating care can make it possible for clinicians to spend most of their time rendering care rather than wrestling with paperwork — an important shift for enabling these delivery models to scale.
Challenges to innovation
To successfully innovate in mental health, companies need to overcome multiple barriers:
First, they need to establish a path to reimbursement. As payers increasingly move toward value-based care, providers will increasingly need tools to meaningfully measure outcomes and quality. We are optimistic that the shifting reimbursement landscape will become an incentive rather than a barrier.
Second, the field needs a framework for regulation. This does not necessarily need to come from government, but establishing rubrics for safety, clinical efficacy, and data security will be critical to ensure quality. Otherwise, companies pursuing mental health technologies may prioritize growth over quality and short-term gains over long-term clinical outcomes.
Third, companies must earn the public’s trust. Distrust of big tech companies is a challenge for startups to become the key innovators in health care. While they might avoid some of this techlash, they must also confront a culture that fundamentally encourages rapid growth to meet investor expectations. Some companies have already been accused of pushing medications in an effort to maximize revenue. Reconciling the “move fast and break things” mentality of startups with the cautious and rigorous approach of medicine will take conscious effort and discipline.
The Covid-19 pandemic has taught us that health care can be transformed rapidly and successfully. The behavioral health needs resulting from this pandemic are likely to require even more profound changes. The technology revolution can meet this emerging public health need, but only if we focus innovation on the problems that matter and create the incentives to ensure success.
David Mou is the president and chief medical officer of Valera Health and a psychiatrist at Harvard Medical School. He reports financial interests in Osmind and is an adviser to Janssen Pharmaceuticals. Thomas R. Insel is a cofounder of Humanest Care, chair of the Steinberg Institute in Sacramento, Calif., and former director of the National Institute of Mental Health. He reports financial interests in Alphabet, Alto Neuroscience, Apple, Compass Pathways, Humanest Care, Karuna Therapeutics, Microsoft, Mindstrong Health, Neurawell Pharmaceuticals, Valera Health, and Owl Analytics.