The death of psychotherapy as we know it

A manifesto for augmented mental health

When Haris and I started our startup journey a few years ago, we had both recently struggled with our Mental Health. I was recovering from a depressive burnout after overworking myself, and he was having panic attacks out of the blue. Both of us, decided to start psychotherapy, and quickly realized that psychotherapy -although extremely helpful, and probably the best investment we’ve done in our lives- was happening in an outdated way and needed to be modernized.

We also realized that we were not alone in this. Mental health disorders are on the rise. The numbers speak for themselves. According to the World Health Organization, close to half a billion people globally suffer for some sort of mental health illness. One in five people in the US today are dealing with an illness that impacts their mental state. To put it in context, this statistic outnumbers the entire population of California. Today depression is affecting 300 million people worldwide. What’s worse is that the National Institute of Mental Health estimates that by 2030, depression is expected to be the leading cause of disease burden globally.
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While mental health disorders are on the rise, so is the demand for mental health care services. But, the current healthcare system can not keep up. Mental health disorders cost $467 billion annually to the US economy.

On top of that, behavioral health issues are a key predictor of high costs. Among the population suffering from chronic disease, those with a mental illness cost between to 2 and 3 times more than those without. Care providers have not yet adequately responded to the burden of mental health disorders while poor quality of care continues to be a problem for many patients who receive treatment. What are the culprits you might ask? Several reasons.

The current model for mental health care has seven major flaws:

1. ​Lack of objective data and tools to measure mental health. Psychologists, psychiatrists, and patients rely on outmoded forms of analysis to diagnose, evaluate, monitor, and intervene in the treatment process. From my point of view, this is the mother of all problems for mental health and the key for solving this crisis.
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2. Missed diagnosis: 50% of mental health issues are untreated or undiagnosed. What is the reason for that you wonder? The current diagnosis framework is constantly evolving and is dependent on physician’s initiative and subjectivity. Therapists, in addition, rely heavily on a patient’s ability to reveal private information which can contribute to a misdiagnosis.
3. Fragmented care. The current method for provisioning care is flawed. It is prone to delays. Care is also provided during periodic check-ins based on a snapshot view of a patient’s mental health. The inability to continuously monitor the mental health of patients when they are outside of a therapist’s office leads to subjective conclusions both from the care provider as well as from the patient. This affects not only the treatment but also the evaluation and diagnosis of mental health issues.
4. Lack of access to treatment. The current paradigm requires a patient to visit a physical location and can do so only when an appointment is available. It lacks the ability for remote patient monitoring when access to care is needed the most. In many developed countries, like Germany for example, from the time that a person requests to visit a therapist, there is a waiting time between 4 and 6 months to receive treatment. This is because of demand being so much higher than supply and it’s definitely related to the high cost of psychotherapy.
5. Lack of preventative measures. There is nothing that is being done today prior to symptom onset. Even worse, the average time from onset of symptoms to receiving intervention, is -shockingly- 7 years!!!! Obviously, within that time, disorders which could have otherwise been caught and prevented go untreated. At the same time there is nothing to prevent relapse or alert us about one.
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6. No real-time intervention. The ability to provide real-time intervention and immediate care to patients suffering a crisis is lacking from the existing model. For example, wouldn’t it be great if we could detect that someone is going into a depressive phase right when it is about to happen? Unfortunately, this is not possible today because a patient has to wait for his next appointment with the therapist. Patients receive interventions only at the time of a weekly or biweekly psychotherapy session or during sessions with a psychiatrist which take place once every 3 or 6 months. Also, the caregivers and family of people suffering from a mental health illness have no way to be alerted if something bad happens, and they have no way to intervene on-time to prevent life-threatening situations.
7. Stigma. Last but not least, mental health is stigmatized. Even in developed countries like in the US, even in progressive ecosystems like the one in Silicon Valley. I had prospective investors suggesting that I shouldn’t talk about my personal experience because it would hurt my chances of getting an investment or asking me if I am still doing psychotherapy to understand if I am “sane” or capable enough. I don’t judge these people, because they probably can’t realize that in the same way that they have physical or dental health, they also have mental health. It’s something that we all have, and something we should all care for more. The lack of objective metrics exacerbates this stigma, since mental health remains as something ineffable, something that cannot be quantified.

AI, IoT and digital therapeutics enable a new era in Mental Health
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Innovation in mental health is long overdue. While modern medicine relies almost solely on objective measurement, mental health has remained in the domain of subjective reporting. Its clinical environment hasn’t evolved with the intelligence, care, and diagnostics shown to the rest of medicine. To diagnose and track mental health issues we still rely on patient questionnaires.

In other medical and life sciences fields, practitioners and patients utilize a variety of tools and technologies. For example, cardiologists use blood pressure monitors to objectively evaluate and monitor situation of the patient. Diabetics regulate their intake of insulin and diet based on measurements taken from mobile glucose monitors. Telemedicine technologies have boomed in the healthcare sector, while mental health technology lagged behind.

BUT IT DOESN’T HAVE TO BE THAT WAY, because nowadays with the evolution of IoT, AI, mobile and digital health technologies we can have:
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• Objective data and continuous monitoring of Mental Health through sensors, wearables and mobile devices
• AI, Affective computing, and Emotion Recognition Technologies
• Digitized Evidence Based Interventions coming from Cognitive Behavioral Therapy (CBT), mindfulness and positive psychology

Enter the era of Augmented Mental Health
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In the Augmented Mental Health era, patients receive personalized care and support around the clock, families are automatically notified when their loved ones are at risk and therapists base their diagnosis on objective data.

Similar to how diabetics use a glucose monitor or how people suffering from cardiovascular disease measure their blood pressure, Augmented Mental Health technologies will become the status quo for caring for mental health.

Principles of Augmented Mental Health:

1. Diagnostics: On-time diagnosis and evaluation through longitudinal data and continuous monitoring. Patient evaluation will be based on objective mental health indicators coming out of sensors that measure a variety of characteristics associated with Mental Health such as Skin Conductance, Heart Rate Variability, Electroencephalogram to name a few or contextual data from mobile devices like hours of sleep, activity, etc. Just like a Holter monitor that can detect irregularities in a person’s heart rhythm, mental health monitoring technologies will enhance the means used for the diagnosis of a person’s mental condition. Those data will eliminate misdiagnosis and will reduce the time gap between onset of symptoms and actual diagnosis of a mental health issue.
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2. Patient Management: Continuous remote patient monitoring. Therapists will ask patients to use monitoring devices, such as wearables, to monitor the progress of their conditions 24/7. We are finally evolving away from traditional models of care that rely on isolated snapshots from a series of time- and subjectivity- limited therapy sessions, to progressive mental health care models centered around continuous mental health data. Augmented Mental Health inspires the transition from episodic care based on discrete, in-office, pencil and paper health data to continuous care based on objective data.
3. Intervention: Real-time coaching and personalized advice based on digital therapeutics. Technology will enable around the clock monitoring of a person’s mental state, and as a result, the provision of real-time patient support too. Patients will receive personalized care through digital means without necessarily having a therapist involved. Illnesses like depression will be better managed before they can lead to life threatening incidents such as suicide. If a person is about to experience a panic attack, a mobile app will alert and advise her to start taking deep breaths to help her get a handle of the situation. Imagine notifying the family of a person suffering from bipolar disorder when he is having a mood swing, or alerting the caregiver when a patient becomes suicidal.
4. Prevention. Timely identification of an outset of a mental health illness will help to act quickly and take preventative measures. And this will be done through an unobtrusive process to help patients maintain a healthy mental state.

Here is a visual look into of what care will look like in the Augmented Mental Health era:

How Augmented Mental Health Will Transform Health Care

Will patients and caregivers be the only ones who’ll reap the benefits of Augmented Mental Health? Certainly, not.

Insurance providers, employers,and pharmaceutical companies will also benefit from the use of Augmented Mental Health technologies. Insurance providers will be able to offer better plans and increased access to mental health services resulting in better quality of service and increase in customer satisfaction. They will assume less risk as the insurance claims for mental health will decrease, and as disability caused by mental health issues will be reduced.

For Employers, mental health becomes a critical matter, as 1 in 3 “sick notes” from employees are for mental health-related causes. The Augmented Mental Health ecosystem, not only will help employers lower absenteeism and health care costs, but also to reduce staff turnover as employees take a more proactive role in managing their mental wellbeing leading to higher productivity and employee satisfaction.

As far as pharmaceutical companies, for the first time, objective data will be used in psychiatric drug assessments and clinical trials to measure efficacy and pave the way for the discovery of novel drug treatments for mental illness.

Finally, through such technologies, healthcare providers will be able to ensure compliance of patients to treatment and personalize this treatment to the individual based on the objective data that they will be monitoring. Also, they will be able to better manage the mental health of patients after hospitalization and in cases where mental health comes as comorbidity disorder.

This new era of Augmented Mental Health will also bring many challenges. Adoption and clinical validation of new technologies, the protection of personal data and privacy, and shaping the regulatory framework, are just some that come to mind.

All these technologies still need to get the clinical validity in order to be used for treatment purposes, and of course we have a long way to go. Although we are still a few years away from realizing Augmented Mental Health, I am confident for 3 things: