larry fisher writes about business for The New York Times and other publications.
Published September 7, 2017
When Sigmund Freud hung out his shingle in late 19th-century Vienna, the maladies of the mind he treated were called hysteria or melancholia, and the standard of care was the analyst’s couch. As those poetic descriptors gave way to the more clinical-sounding “mental illness,” treatment shifted to the psycho-pharmacologist’s pill. Lately depression and its brethren, together with addiction, are increasingly tagged as problems of “behavioral health.” And the modality of choice seems to be shifting again — this time to apps and algorithms — a change with the potential to profoundly improve the outcomes, as well as the economics, of behavioral health care.
There are already over 1,000 apps for depression, hundreds for bipolar disease, and many more to aid addicts in recovery, to train restless Western minds in meditation and to improve compliance with drug regimens, diet and other lifestyle interventions. This boom in behavioral health modalities is reflected in a steep increase in the number of behavioral health business startups in the past two years. Indeed, as of last month, there were 374 companies and 539 investors registered as mental health startups on AngelList.
In part, this is about supply and demand. In the United States, one out of five adults experience some form of mental illness. Yet, according to the National Institute of Mental Health, half of them receive no treatment at all. The U.S. population has risen by 37 percent since 1995; the number of psychiatrists rose only 12 percent in the same period. Moreover, there is no particular reason to believe that practitioners are more productive: no breakthrough drug for depression, the most common mental affliction, has been introduced in over three decades.
And what’s grim in the United States is grimmer elsewhere. The World Economic Forum predicts that the global costs of mental health will hit $6 trillion annually by 2030, greater than the economic toll of diabetes, respiratory disorders, cardiovascular disease or cancer.
So, what’s the aforementioned glimmer of hope? The influence of data science on your mental well-being may start small, with cheery apps like Happify that prompt you to think pleasant thoughts. Or it may loom large, as with the Human Connectome Project, a quest to create a comprehensive map of neural connections in the brain. In between are applications and web-based services that facilitate finding an appropriate counselor or that provide online cognitive behavioral therapy — aka CBT, the most widely used evidence-based practice for treating mental disorders. Consumers who already share every detail of their days with Google, Facebook and Amazon may not hesitate to share their inner lives as well.
Drinking From a Firehose
As cofounder and president of the New York-based incubator StartUp Health, Unity Stoakes has a front-row seat for the race to transform behavioral health with data. Though he spends his days shifting through tons of chaff for a few kernels of wheat, Stoakes is an optimist. “I believe mental illness, behavioral health, well-being, whatever you call it, is one of the areas that is most profoundly being affected” by the shift in emphasis, Stoakes explains. “There really hadn’t been a spotlight shone on mental illness. Now a wave of innovators is coming into focus.”
“For a while it was really taking concepts that had existed for decades and moving them from paper to digital,” he adds. “Now we’re starting to see a lot more in the second wave because of data integration, new analytic platforms, the proliferation of mobile technologies. The billions or trillions of new sensors that are now everywhere are creating new ways to monitor, diagnose and interact with people in their day-to-day lives.”
Behavioral health companies need a blend of clinicians and technologists, and a long-term perspective, Stoakes says. He points to Valera Health, a portfolio company whose three founders are all MDs but who also have experience in information technology and finance. “Things will move faster than people realize, with developments that will blow peoples’ minds. We expect some seismic shifts.”
Ebersman notes that, of the 50 million people in the United States who suffer from some form of mental illness, only one in seven will receive effective care.
What Data Science Can Do Now, and Later
Anyone who has sought mental health care knows the whole process is fraught. You get a list of names from your primary care provider and start calling. The first half-dozen don’t return your calls; the next three are completely booked, and half a dozen more no longer take insurance. When you do finally find a therapist who is available and still takes insurance you have to wonder if that’s because he or she isn’t very good.
David Ebersman was the chief financial officer of Facebook when it went public. He helped a family member find therapy and decided there had to be a better way, so he left Facebook to found Lyra Health, aiming to use technology to make getting mental health care less frustrating.
Ebersman notes that, of the 50 million people in the United States who suffer from some form of mental illness, only one in seven will receive effective care. “Maybe that would be more acceptable if we there weren’t any good treatments. But we actually have effective treatments for many of these conditions.”
Lyra’s first offering works a bit like eHarmony and other dating sites. Prospective patients and providers fill out online questionnaires; clever algorithms match compatible types. The service is sold to employers to include in their benefit offerings. “One of the things that’s so magical about Facebook is how the experience is completely personalized,” Ebersman says. “We’re trying to build health care that provides you with the right match for your unique needs.”
Lyra is all about what technology can do now; Mindstrong Health, another high-profile startup, is more about the future. Mindstrong has patented a biomarker panel that measures brain function from interaction patterns captured passively and continuously from human-computer interfaces found in ubiquitous mobile technology. The high concept is to combine genetics, artificial intelligence and smartphones to diagnose and eventually treat mental disorders. Mindstrong is conducting a study of how 600 people use their mobile phones, attempting to correlate keyboard use patterns with specific maladies.
For common afflictions such as depression, obsessive-compulsive disorder and PTSD, “we have been able to already identify some of the connectional differences,” Thomas Insel (one of Mindstrong's founders) says in his popular TED talk. “As you begin to look at people who have these disorders, you find that there is a lot of variation in how the brain is wired. But there are some predictable patterns, and those are risk factors for these disorders. New tools can show us the presence of brain changes years before symptoms emerge.”
“The reason why you see all these apps is that’s the only thing venture capitalists can see a way to monetize,” explains Cynthia Robbins-Roth, a longtime biotech consultant.
Where Capitalists Fear to Venture
The abundance of apps and the paucity of pills reflect the relative cost difficulty of developing them. The brain is poorly understood — current drugs are largely the result of serendipitous discovery — and all drug development is expensive. A new brain drug could cost billions to develop and to clear multiple regulatory hurdles. By contrast, anyone who knows how to write code can develop an app for a cost in the thousands (if not hundreds), and there are no pricey clinical trials, no FDA review.
“The reason why you see all these apps is that’s the only thing venture capitalists can see a way to monetize,” explains Cynthia Robbins-Roth, a longtime biotech consultant. “It’s so hard to do clinical studies in therapy world. Venture funds weren’t willing to try to figure out a way to manage the risk of these studies.”
With the United States in the midst of an opioid addiction crisis, one might imagine that investors would flock to the search for a solution. But try telling that to Steven Hurst, founder and president of Savant HWP. Savant has a novel anti-addiction drug that has shown promise in animal tests and passed safety trials in healthy human volunteers. Yet he’s stymied for lack of capital.
“Everybody knows addiction is arguably the largest of unmet medical needs,” says Hurst. “In the U.S., somebody dies from a drug overdose every 10 minutes. I’ve got a drug I’m confident will help. And it’s just sitting, because we don’t have the capital.”
Savant’s drug works by normalizing dopamine regulation in the brain’s reward center, which is affected in all forms of substance abuse. So the potential market is immense. But investors are spooked by new chemical entities, drugs that target different receptors, and drugs that must cross the blood-brain barrier. Savant’s drug is a trifecta.
The same factors that trouble investors raise red flags at the FDA, so clinical trials of new brain drugs are a challenge. Nevertheless, Hurst says Savant’s time will come. “Our sector, neuroscience, will become the hot thing in ten years,” he says. “We’re working very hard to be a pioneer in what we call neuro-transformational medicine.”
A Trial of One
With the rapid proliferation of behavioral health software, quality is by no means consistent. And there has been considerable pushback from psychologists — at least those not busy writing code. “The user’s ability to find a reliable and credible app may become increasingly difficult,” concluded a study of over 1,000 apps for depression by the peer-reviewed journal, JMIR mHealth and uHealth. Of course, many critics have said that depression meds are no more effective than placebo and psychotherapy no more helpful than talking to a friend.
In the interest of science, I decided to try an app. Many people have said that meditation improves their overall sense of well-being, and there have even been studies using MRIs showing that regular meditation not only improves mood but creates lasting structural change in the brain. I asked around and friends recommended Headspace, created by Andy Puddicombe, a British Buddhist monk turned entrepreneur, and 10% Happier, created by Dan Harris, an ABC anchor (in)famous for an on-camera panic attack, with Joseph Goldstein, co-founder of the Insight Meditation Society and a prominent Buddhist scholar.
Choosing by rigorous scientific criteria — Puddicombe’s plummy Bristol accent was more soothing than Goldstein’s nasal New Yawkese — I settled on Headspace and started the free 10-day trial. I had tried meditating before and found it really hard to do; my mind refuses to settle down. But Forbes says that more than 11 million people have downloaded Headspace, and over 400,000 are paying subscribers. Headspace also ranked as the highest quality “mindfulness-based” iPhone app in a study in the peer-reviewed Journal of Medical Internet Research. Maybe it would work for me, too.
Headspace tells you to pay attention to your breath, and if your mind wanders, that’s okay, just take note of that and come back to the in-and-out of your breathing. The early segments are just three minutes long, so this is not too difficult, and there really is something pleasing about Puddicombe’s voice. After a week my mind is still uncooperative. But I think I’ll stick with it for a while.
What was a radical idea in the 1970s is almost conventional wisdom now, but solid research has been lacking. Daniel Goleman, best known for his book, Emotional Intelligence, and Richard J. Davidson, a professor of psychiatry and psychology at the University of Wisconsin, have just completed Altered Traits, which aims to get above the hype.
“The data we reviewed is very supportive of the idea that meditation-based interventions are very helpful for mental well-being,” Goleman says, confessing that he actually hasn’t looked at any of the meditation apps. “I think it’s great that more people are getting exposed to the practice, but the more you do the better it gets.”
It’s All About Access
Cynthia Robbins-Roth moved from biotechnology to behavioral health services after she and her family survived a small airplane crash, but afterward suffered severe post-traumatic stress disorder. She’s found, in her own case and in those of her clients, that most people need more human intervention, not less. Nevertheless she does see a place for the apps and algorithms.
“Behavioral health apps have a market in large part because many folks can’t access effective mental health care,” she says. “There are not enough great professionals available, and some of the significantly effective therapeutic approaches can’t be accessed easily. So apps give clinics a way to leverage access to treatment. But I’m still waiting to see how much added value they bring.”
Amid the imponderables, one reality about behavioral health is indisputable: at the societal level, treatment is both inadequate and expensive. If necessity is, indeed, the mother of invention, we can expect change — and digital technology offers the path of least resistance.