The future of mental health: Changes, challenges and success strategies

Mental healthcare is going through a metamorphosis.  On one hand, cases of mental illness are on the rise.  On the other hand, we are seeing surging investments into digital platforms that are challenging the age-old established practices and shaping the future of mental healthcare through digital mental health solutions.

In this article, I outline the key changes redefining mental healthcare, their implications, and tactics that healthcare providers and digital mental health solution providers should adopt to navigate through the uncertainty.

Mental Illness is the real pandemic of the 21^st Century

According to WHO close to 1 billion people suffer from a mental health disorder, driving enormous personal suffering and socioeconomic costs.¹ Mental health problems in the US are growing at an alarming rate and unfortunately, the COVID-19 pandemic has only exacerbated the crisis. 

According to the Centers for Disease Control (CDC), episodes of anxiety and depression have increased up to four-fold during the pandemic.² The underserved and marginalized segments of the population are the ones that are impacted the most by the crisis.

Influencers are raising mental health awareness

Recently many high-profile athletes such as Naomi Osaka (tennis), Simone Biles (gymnastics), Ben Stokes (cricket) have openly discussed their mental health struggles. More importantly, they have taken actions to prioritize their mental health.  We revere these athletes.  They are the epitome of fitness, willpower, and self-discipline.  They work hard all their lives to prepare for top tournaments. When they decide not to participate to take care of their mental health it sends a powerful message to the masses.  This brave act has helped bring much-needed attention to mental wellness. 

Primary drivers Uberizing mental health 

With rising cases of mental health and increasing awareness, we are also witnessing a substantial increase in digital health investments. According to investment firm Rock Health,³ investors have poured $USD 14.7 billion into digital health companies in the first half of 2021, surpassing the total investments made in 2020.  Mental health was the top-funded category raking in $USD 1.5 billion in investments.  

There are four primary drivers attracting record investments in mental health.

1. A current shortage and inaccessibility of mental health resources and services. According to the National Institute of Mental Health (NAMI) in 2019, only 44.8% of adults with any mental illness (AMI) received mental health services.⁴ With the escalation in cases due to the pandemic, the need for new methods and approaches for mental health services has only widened. 
2. Increased awareness and decreased stigma resulting in increased demand for mental health services.  Social isolation during the COVID-19 pandemic has motivated employees to ask for better mental health options. In addition, employers have realized the loss in productivity due to mental illness. According to the National Alliance  on Mental Health, loss in productivity from untreated mental health in the US costs about $300 billion per annum.⁵ This has led to employers including mental health as a benefit in addition to medical, dental, and vision.  There is a surge in companies offering new corporate wellness programs that include mental health. 
3. Improved potential to understand and assess mental health due to advanced technologies. Mental health has traditionally been a very subjective field. Unlike physical health where you can conduct a blood test or swab test to determine the underlying cause of illness, mental health depends on self-reported screening questionnaires and the judgment of the provider to determine the diagnosis. There is a push for data-driven and evidence-based outcomes. With advancements in artificial intelligence and other technologies, there is an opportunity to offer evidence-based innovative solutions for screening and treating mental illnesses. 
4. Increased adoption of digital health solutions. The social constraints imposed by the Covid-19 pandemic, changes in regulations by policymakers around reimbursement rates for telehealth services, and loosening of rules by the Drug Enforcement Administration (DEA) allowing providers to prescribe medication without first conducting an in-person examination have leapfrogged the adoption of telemental and digital health solutions.

There is a rush to offer platforms that connect patients with mental health providers… like Uber connects passengers with drivers. This intense competition has expanded access to mental health services and reduced costs. However, it is also altering age-old established practices. 

Mental health is getting Twitterized

Traditional therapy is based on forging strong relationships with the patients.  The therapist invests time to listen, understand and support the patients.  However, traditional therapy models are expensive, difficult to schedule, and not scalable. 

Emerging digital mental health solutions are offering on-demand, anytime therapy. Text is a predominant mode of interaction.  There are incentives to keep interactions short – similar to how Twitter restricts the allowable words in a tweet.  Some companies use software to automate responses and others promote self-help tools.  

This disruption is causing strife for mental health providers. Firstly, they were dealing with the stresses inflicted by COVID-19.  On top of that their service delivery model has turned upside down.  Whatever they learned at med school and practiced for years is now being challenged.  Change in pay structures, 24 x7 availability, high patient volumes, and new user interfaces are leading to stress and burnout. 

For healthcare providers, determining which digital mental health solutions are effective and will be of value for their patients, is another challenge.   

All that glitters is not gold

According to the American Psychological Association, there are an estimated 20,000⁶ mental health apps available to download today.  Of these, only a handful are clinically validated.  

Clinical validation to demonstrate efficacy is a well-established and well-understood process and it is considered vitally important in the healthcare domain. Clinical studies take time, are expensive and the proposed solution goes through a rigorous validation process overseen by an independent institutional review board (IRB). 

The objective of clinical validation is to ensure that the proposed solution is safe, works for all demographic segments, and the outcomes are compared to established care standards. The findings are generally published and are available for review by experts. Clinically validated digital mental health solutions are grounded in the principle of “first, do no harm.” On the other hand, the plethora of digital applications and solutions available today follow the tech principle of “fail fast, fail often.” 

A recent analysis published in JMIR Mental Health indicated that only 3.4% of the apps offering therapeutic treatment for anxiety and depression published any evidence of efficacy.⁷  A study published in the National Library of Medicine found little correlation between app store metrics and treatment quality.⁸ Another study indicated that apps displaying incorrect or non-existent suicide hotline numbers were downloaded more than 2 million times.⁹ The ability to identify the apps and services that truly offer help is the key challenge facing patients today. 

Selecting valuable digital mental health solutions for your patients

Decision-makers need to adopt a multi-pronged strategy to parse through the myriad of solutions available today and recommend solutions that provide the best outcome to their patients, employees, and stakeholders. Outlined below are some strategies that decision-makers can adopt.

1. Practice what you preach. Providers should test the solution before they recommend it. They need to understand the workflow from not only their perspective but also from the patient’s perspective.  Patients are most likely to reach out to them with any questions and hence their support staff will also need to be educated to respond to basic questions. The providers should evaluate the solution from a patient privacy perspective too. What data is being collected? How is the data secured? Is the solution compliant? Does it have other industry certifications? Is the patient consent process clear? Are all the risks and benefits clearly articulated? These are important parameters to evaluate
2. Leverage the provider network. Rather than just relying on app store metrics and reviews, providers should reach out to their fellow providers and discuss what they are prescribing. Ask them questions about why they like a particular solution, what outcomes and impact have they observed, what are their areas of concern, and other usability-related questions.
3. Investigate 3^rd party evaluated solutions. This is an emerging area, but there is an attempt to create a marketplace of vetted solutions known as “digital health formularies”. One such example is Express Scripts that unveiled a formulary of clinically validated digital health programs addressing various health issues such as the management of diabetes, prediabetes, hypertension, asthma, chronic obstructive pulmonary disease (COPD), depression, anxiety, and insomnia.¹⁰ As these initiatives expand they will become another important source of information for decision-makers.
4. Ensure a value-based approach. Rather than focus on the initial cost of the solution, the decision-makers should focus on the value it provides over the lifecycle of the treatment. Many solutions are offered for free or for a low cost. However, these solutions may have other monetization approaches such as advertising and data mining and compromise patient privacy. Instead, decision-makers should focus on value-generating metrics such as time saved, earlier detection, treatment effectiveness, and longitudinal care when evaluating the overall benefit of the solution.

5 key tactics for digital mental health solution providers

Disruptive innovation goes through a four-stage metamorphosis process: Crisis – change – chaos – calm.  The COVID-19 crisis fueled the change in mental healthcare which is now driving chaos. Digital mental health solution providers should adopt the following tactics to help navigate through this phase of turmoil.

1	Differentiate your solution.  Rather than offering a little bit of everything for everyone, focus on offering everything for someone. Target a specific pain point that exists in mental healthcare, customize your solution for your selected target segment and focus on creating an excellent solution.
2	Provide evidence-based outcomes for your solution. Clinical studies take a long time to set up and complete. Start early on validating your solution and provide tangible metrics that indicate the overall efficacy of the outcomes. This will help drive legitimacy, build confidence, and differentiate your solution from the rest.
3	Make it easy to adopt. Make your mental health solution more readily available and easy to deploy by integrating it into existing provider workflows and electronic medical records (EMR) systems.
4	Create an ecosystem. Partner with complementary solution providers to offer a holistic solution. In a recent survey by McKinsey 90% of the participants believed patients are looking for an integrated journey from start to end with the primary focus being on convenience, followed by trust and health outcomes.11
5	Engage early with stakeholders. The creation of a digital ecosystem takes time so it’s critical to start early conversations with relevant stakeholders. 41% of the participants in the McKinsey survey believed it takes  1 – 3 years to set up an ecosystem.11 Hence, prudent planning and a clear vision are the mantras to success.

Without change, there would be no butterflies

Three key trends will happen before the chaos leads to calm.  

First, there will be consolidation and only a few platforms will remain that will offer services across the stack. This trend has already begun.  According to Rock Health Investments, there were 131 digital health mergers and acquisitions (M&A) deals within the first half of 2021.³ Overall, 2021 is on pace to set a 1.8x year-over-year increase in M&A deals relative to 2020. 

Digital health companies are the largest acquirers of other digital health firms. Some recent examples of such consolidation include the merger between Ginger.io and Headspace, and the acquisition of SilverCloud Health and Conversa Health by Amwell. 

Second, regulation will catch up. The US Food and Drug Administration (FDA) will update guidelines, payer models will evolve, and legislatures will draft laws to protect the health of providers and users. Finally, outcome-based metrics and clinically proven frameworks will become the mainstay. The winners will be ones that marry great customer experience with evidence-based solutions that improve patient lives.