Getting mental healthcare is an uphill battle. VCs in the hottest part of healthcare say that's driving a 'coming of age' for startups that want to help.
- The state of mental healthcare in the US is critical.
- Suicides and other so-called "deaths of despair" are skyrocketing, but few people can get therapy thanks to cumbersome insurance policies and a national therapist shortage.
- A fresh crop of Silicon Valley startups is trying something new.
- Before sending patients to traditional therapy, companies like One Medical and Modern Health are offering help in the form of primary care and virtual, text-based coaching.
- The basic idea is to treat mental healthcare more like physical healthcare.
- Visit Business Insider's homepage for more stories.
It was midway through his chemotherapy treatments for cancer that venture capital investor Yumin Choi had his first panic attack.
Then 31, Choi had been diagnosed with the blood cancer non-Hodgkin's lymphoma just weeks before. He'd been handling the news with a surprising amount of composure, calmly explaining the diagnosis to his wife and then coming up with a detailed treatment plan, he said. He even continued working long hours as an investor for health-tech firm HLM Venture Partners.
But suddenly, after a fever and a migraine landed him in the hospital, anxiety took over. One after another, a series of scary thoughts sacked his mind. He started pacing his hospital room. Nothing helped. Thirty minutes later, it was over.
Eventually, like his panic, Choi's cancer also ebbed away. Three weeks into what was supposed to be a 6-week course of chemotherapy and radiation, the disease had vanished.
But while his physical body healed, the anxiety stayed.
'A lot of it is mental'
Choi realized he needed to talk to someone - not about his physical symptoms, but his emotional ones.
"What most people don't realize in healthcare is that you can solve for the physical, but a lot of it is mental. You get unmotivated. You start to ask, 'What's the point?'" Choi told Business Insider.
It's not that Choi hadn't considered therapy; the barriers just seemed insurmountable - even for someone who worked in healthcare. He'd have to find a counselor who was accepting new patients, set out the time to travel to their office, and also make sure his insurance covered the cost.
Suddenly, he had a lightbulb moment: A mental health startup in his work portfolio called AbleTo was designed for people like him.
"That was the first point in my life where I was like, 'Oh, I'm the patient!'" Choi said.
There was one problem, though.
AbleTo was great for people with serious mental illnesses brought on by physical ones, but it wasn't as well-suited to someone like Choi, whose anxiety was more like a hiccup on an otherwise healthy emotional backdrop.
There was another mental health startup that did seem appropriate for him. Called Joyable, the platform lets anyone text with a trained counselor about issues ranging from mild anxiety to depression.
So Choi encouraged the founders to meet and consider combining forces. This March, AbleTo acquired Joyable - giving a wide range of people access to an equally wide range of tools to help, Choi and Trip Hofer, AbleTo's CEO, told Business Insider.
A big shift in Silicon Valley
The change to both companies is one example of a broader shift happening across Silicon Valley, as startups and investors increasingly focus on mental health. Startups like AbleTo and clinic-operator One Medical are increasingly approaching conditions like anxiety and depression more like they would a physical condition. In other words, mental illness is being addressed as something everyone experiences on a dynamic spectrum.
Funding for mental health startups has boomed in the past few years, too, skyrocketing from roughly $3 million in 2011 to $378 million in 2018, according to data from the venture-capital firm Rock Health. Investment in the field stood at just $159 million in 2017.
The new approaches and funding come at a pivotal moment, when the stigma surrounding mental illness is falling in some places, while suicide rates and other so-called "deaths of despair" are at an all-time high. The ongoing shortage of traditional therapists isn't helping. Neither is the fact that insurers are still finding ways to deny mental health coverage, even on the heels of measures that were supposed to bring equal coverage to mental health services.
Oftentimes, the new mental health tools do not take the form of traditional therapy.
Instead, they're delivered digitally, through a phone or computer, or at the offices of a primary care doctor where you might go for a check-up, helping remove some of the barriers to entry so that people can get help sooner.
Why a spectrum model could make sense for mental health
Courtesy Yumin Choi
Increasingly, physical and mental health are seen as inextricably linked, like two sides of a coin.
"I don't really distinguish between primary care and mental health," Christine Celio, a psychologist and the national clinical lead for mental health standards at clinic startup One Medical, told Business Insider. "Primary care is mental health."
Yet in many parts of the country, mental healthcare is far less accessible than physical healthcare. As of December 2018, just three US states had enough psychiatrists to meet the needs of half their populations, according to the non-profit Kaiser Family Foundation. In comparison, 20 states had enough primary care doctors to meet the needs of half their populations.
Digital tools can help increase access and connect people to support sooner, according to April Koh, the co-founder of mental health startup Spring Health. That might help prevent issues like mild anxiety or temporary depression from escalating, she said.
"If you're depressed, you have no motivation to jump through any hoops," Koh, told Business Insider in January.
"If anything, accessing mental healthcare should be the easiest thing," Koh said.
Other companies that haven't historically dealt with mental health are picking up on the trend too.
'Mental health is coming of age'
"Mental health is coming of age," Mamoon Hamid, a partner at venture firm Kleiner Perkins and the firm's lead investor in mental-health startup Modern Health, told Business Insider in May. "It's no longer something that's fringe, or just for specific people. It's for everyone."
Part of the interest is driven by the shortage of therapists. Part has to do with insurance companies failing to cover the cost of traditional therapy, as Bloomberg News recently reported.
"No one can find a therapist in their insurance network," Alyson Friedensohn, the cofounder of Modern Health, told Business Insider in May. "So what happens is only people who can afford it end up going."
Cathryn Donaldson, a spokeswoman for insurer trade group America's Health Insurance Plans, told Business Insider the denials happen for a variety of reasons, from clinicians not providing the right documentation to therapists being out-of-network. Another big problem is that there are no good standards for assessing the quality of many mental health treatments, she said.
"We need ways to support better quality assessment of behavioral health care," Donaldson said.
Researchers have drawn attention to the lack of standards too, including in a 2017 article in the Journal of Medical Internet Research Mental Health and in a 2018 study published in the journal Clinical Psychology and Psychotherapy.
There's hope that the new tools can help by tracking patients' progress over time or coming up with new "digital biomarkers" to evaluate mood, Chipper Stotz, an analyst at Rock Health, told Business Insider in April.
Separating 'bona fide treatments' from 'noise'
There's a decent amount of research bolstering the idea that counseling delivered virtually can be as helpful as counseling delivered in person. Still, experts say more research on specific treatment methods is needed.
For a study published in the Journal of Affective Disorders, researchers randomly assigned patients with depression to get either in-person therapy or text-based therapy for 8 weeks. At the end of the study, both groups fared equally well, the researchers concluded. The authors of another study published in the journal Cyberpsychology, Behavior, and Social Networking compared a set of face-to-face therapists and clients with a set of online therapists and clients. They found that the online group performed slightly better than the in-person group.
As new research-backed services blossom, however, other sketchy digital wellness tools have also bloomed.
Of the 25 most-downloaded apps claiming to fall under the auspices of mental health, most "simply offered relaxation, meditation, or mindfulness skills, rather than bona fide behavioral health treatments," according to the authors of a recent study published in the journal Nature.
Still, even some of the more casual wellness apps are beginning to branch into evidence-based healthcare.
For example, makers of the wellness app Calm recently launched Calm Science, an initiative aimed at researching and building the evidence for Calm as a health-improvement strategy. Similarly, the wellness app Headspace created science-focused division Headspace Health last summer.
Startups are tackling in-person mental healthcare too
Throughout Choi's cancer treatment in 2015, there were moments where one thought would send him into a spiral of negative thinking. Oftentimes, panic struck when he noticed small things, like swollen lymph nodes in his throat, and worried they could be a sign that the cancer had returned.
Had he been able to address some of those emotions when they first started to crop up, he believes he would have been able to identify what was causing them and tackle the feelings head-on. Instead, he either became sad or panicked, and took it out on himself or his wife, who became his primary care giver. Or, he ignored the feelings and let them build up until, weeks or months later, they'd rear their head again with a vengeance.
"Every time you have something like chest pain, your mind reverts. You have this anxiety that you carry with you on a daily basis," Choi said.
He hopes digital tools like AbleTo will make it easier for people like him to get help fast - before a problems snowball.
That's also the idea behind a recent push for primary care startups like One Medical and Carbon Health to more deeply embed mental health into their practices.
Both companies screen patients for depression and anxiety during physicals, for example, by asking two questions that are part of the standard depression screening test known as the PHQ9. Those questions ask patients how often, over the past two weeks, they've felt little interest or pleasure in doing things and how often they've felt depressed or hopeless.
"To me, a lot of mental healthcare shouldn't be at the specialty care level, but instead at the primary care level," Greg Burrell, Carbon Health's director of medicine and cofounder, told Business Insider, so you can go talk to someone right away about your emotional state just like you'd get a routine physical.
"We're removing that kind of stigma where it's like 'Ok, we're only talking about your knees today.' Instead, we're saying, 'You can talk to us about this. We're not freaked out by it, it's not weird,'" she said.
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