Digital mental health start-ups may be looking like big tech companies — consider the $5.1 billion in venture capital investment in 2021 — but is their economic value matched by their impact and clinical value?
It’s an inconvenient question with a short answer: It’s too early to tell.
There’s no question that the most successful companies are disrupting the delivery of mental health care by offering access and convenience. And why not? Unlike medical or surgical specialties built around procedures, most mental health care involves assessment by an interview and treatment with medication and psychotherapy. Every part of this can be done remotely, with quicker response times and greater convenience than available in traditional office-based practices.
It’s no surprise, then, that a start-up like Cerebral (disclosure: I am a scientific advisor for this company), which launched with remote medication and therapy less than two years ago, is already one of the largest providers of mental health care in the nation.
But digital mental health is still in its first chapter: transferring the same care from office to internet to improve access and convenience. If digital mental health is to truly transform care, its next chapter needs to focus on improving outcomes. How will that happen? Here are a few ideas that have emerged from my six years spent straddling the worlds of technology and mental health care.
I see three problems that need to be solved to improve outcomes in mental health. Each of them can be solved (in part) as technology disrupts the traditional mental health care system, but not through another app or another algorithm. The solutions ironically derive as much from the culture of the tech industry as its products.
The first problem is engagement — or lack of it. People who need mental health treatment the most tend to be the least likely to seek it. Almost two-thirds of people who die by suicide and more than half of young people who make suicide attempts have not been receiving mental health care. Any visitor to a public or private mental health facility finds little attention to the patient’s journey, and even less concern for the needs of families.
Tech companies know how to create engagement, arguably too well. As digital mental health companies disrupt brick-and-mortar mental health care, they can use tech’s demonstrated potential to reach and engage people by understanding users’ experiences and building products for (and with) them, not just for payers or providers.
The second problem is quality of care. As with every other aspect of medicine, better quality will require training providers in evidence-based care, measuring results of treatment, and improving practice based on this feedback — none of which has been standard in traditional mental health care.
Although technology can be used to scale training with a pace and depth that has never before been possible, measurement and feedback may be the most important innovations for digital mental health. Tech companies may actually be too good at collecting data and using feedback to iteratively improve performance. A part of this culture could go a long way to improve a field that lacks any biomarker and has yet to embrace objective measurements of mood, cognition, or behavior. I believe that natural language processing and digital phenotyping can transform teletherapy 1.0 into a real-time measurement-based care system to create teletherapy 2.0.
The third problem is accountability. In the world of therapy, the financial incentives for the provider are to prolong treatment, not complete it. I have yet to see any public mental health clinic or private psychiatric hospital hold its providers accountable to anything like a set of objectives and key results.
Digital mental health companies should incentivize getting results rather than keeping people in therapy. Value-based payment, which will depend upon the ability to better measure outcomes, is still aspirational in mental health. The culture of tech companies can point the way to solutions here as well. These companies are, of course, focused on accountability to their boards and shareholders. But their execution strategies are defined by objectives and key results or some similar, detailed plan for demanding internal accountability.
In the past five years, digital mental health companies have begun the transition from a dysfunctional delivery system that ignores consumers, neglects quality, and avoids accountability to a better model. Academic articles about technology and mental health usually point to small effect sizes or the lack of regulation. These articles remind us that we need to manage expectations and guard against misuse, important considerations in the first chapter of the digital mental health playbook.
The bigger issue is that the traditional mental health care delivery system has failed patients and families for too long. The next iteration of digital mental health can use innovative approaches to engagement, quality, and accountability from the tech industry to build mental health care that improves outcomes.
Thomas R. Insel is a psychiatrist and neuroscientist; cofounder of MindSite News, Mindstrong Health, and Humanest Care; a former director of the National Institute of Mental Health, and author of “Healing: Our Path from Mental Illness to Mental Health” (Penguin Press, February 2022). He is an adviser or board member for Alto Neuroscience, Cerebral, Compass Pathways PLC, Embodied, Healthcare Capital, Koa Health, NeuraWell Therapeutics, Owl Insights, Psych Hub, Uplift Health, and Valera Health, as well as several nonprofit foundations.