Digital mental health is in its infancy, and I’m excited to see what it can do when it grows up.

Thomas Insel MD has just written “What’s next for digital mental health companies?” in Stat News, a brilliant thought piece on the state of digital mental health. He cuts through some of the hype surrounding mental health startups fuelled by $5.1 billion in venture capital investment in 2021, while pointing to the infinitely larger potential of applying technology to improve a system that today fails most people with mental health problems.

It’s a testament of how limited mental health services are today that mental health startups are growing so fast by doing relatively simple things like moving clinicians from an office to a screen and helping them accept insurance. It is a great start, improving access to mental health professionals outside major cities and making the process of finding a clinician more efficient. Locating a therapist or psychiatrist who accepts insurance and has availability was nearly impossible before SondermindHeadwayAlmaSpring HealthLyra HealthModern Health and Cerebral came along. However, most of those startups target people who have private health insurance and/or generous employer benefits, leaving the majority of the US population just as underserved as it was by the old system. In 2020, only 6.6% of Americans had mental health outpatient services paid for by their employer, 39% by private health insurance, over 40% paid out of pocket (SAMHSA survey). Merely moving the same pool of clinicians online also doesn’t solve the fundamental problem that we have far fewer clinicians than we need: a shortage of 6,984 according to the latest HRSA numbers, which is probably an understatement.

I agree with Tom that the digital mental health industry – and digital health more broadly – is in its infancy. I worked in financial services and retail when they were being transformed by technology in the late 1990s and early 2000s. Healthcare is 20 years behind those industries. One key factor in retail and finance moving faster was that consumers have a lot more power and choice in those industries; they voted with their feet and moved towards better offerings quickly. My first startup job was at one of the ecommerce darlings of the time, eToys, which was backed by big VCs like today’s mental health startups. I didn’t understand until much later that we weren’t in the business of selling toys; we were in the business of providing a better customer experience through technology. Instead of hunting around mall toy stores for that hot out-of-stock-everywhere toy, grandparents could have it delivered straight to the kid’s home, gift-wrapped. During the holiday season the whole company worked in the warehouse to make this happen.

I also share Tom’s optimism that technology has the potential to truly transform mental health care. His point about measurement and accountability reminded me of my early ecommerce experience. I remember when web analytics companies invented page view and session metrics in the early 2000s. Before then we were measuring ‘server hits’ (a thoroughly useless metric) and had no idea what happened between a user coming to our website and placing an order – or more often leaving without placing an order. Along came sophisticated web analytics, and it was like a light switch being turned on. We could see what our users were doing on the website, which pages and features were a success and which needed improvements. As product managers started running A/B tests and using behavioural data to make product decisions, consumers were able to shape products in a way that had never happened before.

Like retail before web analytics, mental health is barely measured in clinical practice today, despite a proliferation of scales. Eiko Fried, a professor at the University of Leiden who studies mental health measurement, analysed the content of 7 leading depression scales and found 52 disparate depression symptoms (Fried 2017). The most commonly used measurement tools are questionnaires like PHQ-9 and GAD-7, which Pfizer generously made freely available to help doctors assess whether a patient needs medication 🤔. These surveys ask questions such as: “How many days in the past 2 weeks have you been feeling bad about yourself — or that you are a failure or have let yourself or your family down?” and “How many days have you had trouble falling or staying asleep, or sleeping too much?” Humans are not very good at self-assessing and tracking these data points over time; technology can help here. A new crop of mental health measurement companies like Ksana HealthHealthRhythms and Kintsugi are working on more accurate ways to measure mental health, using passive sensor data from smartphones, daily surveys called ecological momentary assessments (EMA) and voice diaries. My company Flourish Labs is developing håp, an app combining short EMA-style self-reflections that we call Check-ins with sleep data from wearables to help our members track their own mental health and wellbeing. Our app is still in beta and we’re evolving it with active input from students (our first user group), with the help of our partners Active Minds and Youth Era.

eToys went bust in 2001, as did many other ecommerce pioneers along the way. Today, ecommerce is nearly 25% of the world’s retail sales, and nearly 40% in early adopter countries like the UK. Amazon went on to a build huge business with a relentless focus on better customer experience and analytics. Some argue that the major tech companies are overdoing the analytics and user tracking these days, but there is no doubt that it has led to vastly better (and free) products and experiences for users. Mental health and wellbeing data is more sensitive than your shopping basket content and browsing habits, so as a young industry we have to be much more thoughtful on how we use data to benefit people who want to improve their mental health, with their permission.

It will be interesting to see who emerges as the Amazon of digital health. Amazon being one of the contenders of course… although I’ll place my bet on a startup that nobody has heard of yet today.

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