The virtual mental health floodgates have opened
Sep 01, 2020
12 min read
How COVID-19 brought the mental health epidemic to an inflection point and drove a booming virtual market
The mental health crisis in the US has been brewing for years while rarely receiving the emphasis deserved, but the COVID-19 pandemic centered the matter squarely in the minds of adults and youth alike. Prior to the pandemic, the state of mental health in America was already worrisome:
- 1 in 5 adults in the US experiences mental illness each year.
- 1 in 5 adults with a mental illness in the US report not being able to receive the treatment they need.
- 122 million people live in areas considered to have mental healthcare professional shortages.
Throughout 2020, however, the country dealt with a new level of grief and fear connected to the COVID-19 pandemic as well as broad-scale reckoning with structures of inequality that plague the US. A report generated by Mental Health America, using screening results from 1.5 million people, found that there was a 93% and a 62% increase, from 2019 to 2020, in the number of people who took an anxiety and depression screen, respectively. A CDC report that surveyed adults in June 2020 found that the prevalence of anxiety disorder symptoms increased by over three times compared to the second quarter of 2019 and that the prevalence of depressive disorder symptoms increased by approximately four times.
Evidently, the COVID-19 pandemic has spotlighted the shortcomings of a system and a culture that downplay the importance of mental health as a pillar of overall health. It has simultaneously catalyzed immense growth in funding for mental healthcare startups. This article addresses:
- The recent acceleration of investment and the evolution of mental health policies and sentiment
- The landscape of virtual mental health care and its advantages
- The challenges of a digital ecosystem that improves care for some but leaves others behind
- What lies ahead for this rapidly developing field
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An era of change for mental health
Looking more specifically into the rising demand for mental health care, Teladoc Health released a report toward the end of 2020 showing that virtual mental health care use has expanded not just within populations that have historically utilized mental health services, but also across communities that, in the past, have not sought out mental health care as much. Notably, patients over 65 have had a 16% increase in visits since June 2020, and Gen Z has had the largest year-over-year growth rate. The Medicaid population, a historically underserved population in mental health care and one of the populations most affected by the COVID-19 pandemic, has also seen increases in access and utilization to mental health care—the number of Medicaid members with access to Teladoc services have more than doubled year-over-year. One important caveat is that while virtual mental health services have risen overall, this trend is not uniform across all segments of the population.
There have been improvements on other fronts as well—increasingly, mental health is becoming less of a stigmatized topic of discussion. Many high-profile figures are opening up about their mental health, shifting this historically taboo topic into the public sphere. Even the Tokyo Olympics became a platform for discussing the mental health challenges of elite athletes. Some psychiatrists suggest that when celebrities talk about their mental health, it normalizes the topic and brings individuals and society closer to finding solutions. Campaigns, such as Deconstructing Stigma, are also working to spark candid conversations about mental health by spotlighting photographs and interviews of people with mental illnesses.
Although these strides bode well for the future of mental health care in the US, healthcare policies also need to be revisited for lasting change. Of the 60 million people living with a mental health illness in the United States, nearly half do not receive any treatment, and despite a federal parity law, people with mental illnesses still do not receive adequate mental health care. First passed in 1996, the Mental Health Parity and Addictions Act has been revised several times, and it is meant to prevent insurance plans that offer mental health care benefits from providing lesser benefits compared to the medical/surgical benefits. However, accessibility, cost, and stigma remain as significant barriers to receiving adequate care. Other factors include the following:
- The shortage of mental health professionals and the lack of in-network providers are persisting barriers that limit a patient’s options.
- Two-thirds of primary care providers report difficulties in finding mental health professionals to refer their patients to.
- Demand is projected to outstrip supply by 15,600 psychiatrists by 2025. Insufficient recruitment into psychiatry programs in the past several decades, likely because of low reimbursement rates by commercial and government payers, is one culprit.
- This demand is not uniformly distributed across the US; rural areas are characterized by an accessibility disadvantage and are more likely to experience a severe provider shortage.
With mental health professional shortages in every US state, virtual services can help improve access, convenience, and integration with primary care. Public demand is propelling a movement for better care—news mentions of mental health was at an all-time high in March 2021. If the state of mental health in America has declined in the past year and a half, the state of mental health care solutions is at a unique position—the rising interest in mental health has driven large companies and entrepreneurs alike to shift their attention to mental health care. And investor dollars have followed:
- Mental health startups received $576 million in the first quarter of 2020, an increase of over 400% compared to Q4’19.
- The $1.37 billion venture capital funding raised through Q3’20 surpassed the $1.06 billion raised in 2019.
- By the end of 2020, mental health-related startups received a historic $1.5 billion from venture capitalists.
- Q1’21 saw a record $852 million in global mental health funding.
These developments foreshadowed the versatility of virtual mental health, which is explored in the next section.
Types of virtual mental health services
Just as mental health exists not as a binary state of being “well” or “unwell,” there are different levels and types of care that are appropriate for each situation. The expansion of virtual mental health care involves more than translating in-person care to a digital format. While virtual visits with a clinician can be seen as a close substitute for in-person therapy, other types of services, such as chat-based therapy, digital therapeutics, and guided meditation are starting to permeate the space as well. Here is a breakdown of the mental health tech landscape.
Meditation, mindfulness, and stress management apps fall under this category, and they often address concerns such as stress, anxiety, or insomnia. As these programs tend to be more self-guided and self-initiated, they are appropriate for people who are not quite seeking the level of care that therapists or psychiatrists offer, but are still looking for some level of support. Its low commitment level also makes it suitable for complementing other virtual or in-person services. Some of the top companies in this category are Calm, Headspace, and Insight Timer.
Accelerated because of the pandemic-prompted shift to virtual care and resulting policy and reimbursement changes, many therapists and psychiatrists are now making virtual services a permanent offering. Within this category, the two main modes of communication are video/phone calls and messaging. AI-powered chatbots are also becoming an increasingly popular option because of their low cost and 24/7 availability. Leading the way is Wysa, an AI-powered chatbot that leverages cognitive behavioral techniques to help users build mental resilience.
While virtual therapy can be seen as a close substitute for in-person therapy, many of these companies also have options that expand beyond this to meet patients where they are. For users seeking a lower level of support, common features include guided meditations and other wellness initiatives, similar to the suite of mental wellness companies mentioned above. For users seeking other forms of treatment, psychiatrists are also available for appointments and to prescribe medication. This teletherapy category encompasses many of the services available on the market. Leading companies in this market include Talkspace, BetterHelp, and Ginger.
Similar to how a medication can be prescribed to treat a disease, digital therapeutics are interventions driven by evidence-based, clinically-proven software to treat, manage, or prevent disease. A trailblazer in this category is Pear Therapeutics, which developed reSET, a prescription digital therapeutic for treating substance use disorder and the first digital therapeutic to receive FDA authorization to improve disease outcomes. Another breakthrough product in this field is EndeavorRx, the first prescription video game to help improve attention function in children with ADHD.
Some companies also straddle the line between different categorizations of virtual mental health, offering products at different levels to cater to multiple cohorts. TRIPP is a digital health company that specializes in using virtual reality to help the general population maintain and improve mental wellness. At the same time, TRIPP’s CEO and co-founder Nanea Reeves explains that creating a product for a broad user base has provided data and feedback on different engagement models and usage patterns that can inform more specialized offerings. The company is currently conducting studies on addiction, recovery, and substance use disorder to understand how their VR and AR products may translate to particular mental health diagnoses. And TRIPP’s recent acquisition of PsyAssist is a move into the realm of psychedelic-assisted therapy. This speaks to the versatility of the digital health ecosystem, that it is always evolving and progressing to meet consumers where they are.
Advantages of virtual mental health
Access is a top priority for mental health services: Recall the magnitude of the mental health professional shortage and that nearly half of the 60 million adults living with a mental illness do not receive treatment. Digital mental health care is bridging this gap by offering a range of services that are immediately accessible and suitable for different needs.
Accessibility also spans social media platforms. Gen Z is pioneering a seismic shift in online etiquette: the traditionally taboo topics of mental health and mental illness are becoming more common points of conversation on social media. In tandem with stimulating conversations about mental health, these changes are also repositioning these internet communities as platforms that reduce stigma.
One platform where this can be observed is TikTok, a popular short-form audio-video social media property. Some mental health professionals have taken to this app as a platform to raise awareness and educate others on mental health and mental illness. One New York Times article looks at how personal experiences shared on TikTok helped women and people of color self-identify potential symptoms of ADHD, a disorder most commonly diagnosed in white boys. And with Gen Zers more likely to report mental health concerns, social media sites, especially those like TikTok where Gen Z makes up 60% of its users, are poised to play a role in the collision of social media and mental health.
Virtual care eliminates the geographical barrier and thus travel time needed for an appointment. With virtual care, providers are also able to catch a glimpse into their patients’ home lives, a more personal perspective that can’t be seen with office visits. Some programs also allow users to remain anonymous, a feature that many may find more comfortable.
When one of the main barriers to receiving mental health care is the time it takes between referral and appointment, virtual mental healthcare has proven useful in streamlining this bottleneck.
Virtual mental health care enables a suite of services for different purposes. Meditation and mindfulness apps can be considered the first tier of care, followed by apps that provide some level of clinician-guided therapy. Digital therapeutics are still another grade of care that users can seek based on their level of need.
Adjacent to these layers of care is facilitated peer support, which combines the expertise of a trained moderator with the support and mentorship of people who are going or have gone through similar experiences, creating an environment that nurtures growth. This is a feature that can be integrated within any company to supplement its other services. One such example is Modern Health, an app-based mental health suite for employee benefits, including digital programs and 1:1 coaching and therapy. In addition to these care services, it also boasts therapist- and coach-led community sessions called Circles to facilitate growth and healing for participants. Beyond its usage in dedicated mental health companies, this kind of facilitated peer support extends to other care companies as well. For instance, Monument is an online alcohol treatment program with therapist-moderated support groups, and Health in Her HUE connects Black women to healthcare providers, resources, and support. The key point in facilitated peer support is the power of peer accountability as well as the personal empowerment found in drawing upon lived experiences to help others.
In line with this sentiment of expanding accessible and suitable care, many companies are targeting specific populations and catering to their needs. To name a few:
- Mantra Health provides mental health care to students.
- Brightline serves pediatric populations.
- Hurdle Health focuses on culturally-sensitive care for the BIPOC community.
- Tia incorporates mental health into women’s health care.
This spectrum of care helps to meet patients where they are.
Care is often thought of as an active service, occurring when a person engages with a provider or, more recently, with an app. But this concept of care doesn’t account for the time between appointments or sessions. Enter text-based therapy. These allow people to contact a mental health professional at any time. Many of these platforms are offered alongside other interface methods within a care program, thus establishing a communication suite of in-person, video, phone, and/or messaging options. Some companies, such as Magellan Health, are moving beyond providing care at a single point of contact and are leveraging technologies like machine learning, robotics, automation, and geolocation to facilitate care continuously.
Along similar lines, mental health wearables have helped patients stay more continuously connected to their mental health. Similar to how continuous glucose monitors track blood sugar levels throughout the day and alert the user of abnormal fluctuations, or how other wearable technology monitors a person’s vitals, mental health wearables detect things like stress, anxiety, and/or depression symptoms. This is a nascent field—research on the feasibility of wearables to accurately detect mental health states is still developing, and customers have privacy and security of their personal information to worry about as well. While the FDA regulates medical devices, wearables do not always fall under that category, making some of them exempt from federal oversight.
The more this type of care gains traction, the more comprehensive mental health care will become. But it is imperative that this development is guided by concerns for patient consent, data privacy, and data security.
In response to the pandemic, Congress passed the CARES Act, which, among other policies, lifted many restrictions on telemedicine use. Of relevance here is the change that telehealth services are now reimbursed at the same rate as in-person visits. Post-pandemic, there is hope that many of the regulatory flexibilities enacted will become permanent changes.
As virtual mental health services evolve, there are opportunities for technologies, such as artificial intelligence and virtual reality, to supplement the tech landscape. Developing tools like these is important because it pushes the tech landscape to keep advancing and creates solutions to solve growing problems. Importantly though, while these features can complement, facilitate, or enhance care, they are not replacements for the connection and compassion that in-person care provides.
Here are two ways artificial intelligence can augment digital mental health care:
Chatbots to increase access: AI-powered chatbots providing 24/7 support to users are populating mental health companies such as Wysa and Woebot Health. Chatbots have the capacity to provide emotional support appropriate for the user’s mental state and situation, direct the user through guided meditation and mindfulness exercises, and connect the user to a licensed therapist if needed.
A report published in 2020 found that 82% of respondents would prefer to talk to a robot than a human for mental health support, citing reasons that robots are nonjudgmental, unbiased, and efficient. What’s even better for consumers is the affordability of subscriptions to chatbot-powered services—compare $60-200 an hour for in-person therapy with free or freemium chatbot services. Woebot, being currently venture-funded, is downloadable from the App Store for free, and Wysa operates on a freemium model. Of course, licensed therapists and other providers go through years of rigorous training and provide what computers cannot, underscoring the importance of collaboration, and not a replacement, with chatbots.
Passive data collection to improve quality of diagnosis and early detection: Artificial intelligence is also leveraged in continuous monitoring and tracking devices, such as cellphones, fitness trackers or wearables, and software built into apps. This kind of passive data collection holds enormous potential for analysis by artificial intelligence.
The nature of AI is that it can identify trends or patterns in large datasets that humans cannot effectively analyze. One result is the improvement of early detection. For instance, researchers at Sonde Health have developed an AI model that can detect mental health issues through analyzing a suite of vocal biomarkers. In a similar cadence, researchers at Stevens Institute of Technology developed an AI system to detect depression in written content.
With clinician misdiagnosis for mental health disorders surprisingly common, tools like AI can help to augment care and improve the quality and accuracy of diagnosis. At the same time, patient consent to their data use needs to be a top priority, especially when it is valuable for innovation. This article discusses the privacy-first rule in data-based innovation. Keep in mind, though, that there are no clear ethical guidelines in regards to patient privacy, informed consent, and information security.
Virtual reality (VR) has the power to immerse the user into a controlled, simulated environment to enhance therapeutic effects. Reeves weighs in about learnings from TRIPP: “It’s a very interesting mental health hack when you understand that you are in your current reality, but you can experience an environment that’s architected to support you through immersion in an alternate reality.” VR can help users process information in alternate settings or even “practice” behaviors in certain environments. It has been shown to help manage depression, phobias, PTSD, and anxiety.
Virtual reality also offers opportunities for extreme personalization. Reeves says of TRIPP’s virtual reality development process: “Some cohorts respond differently to certain environments than others. We found that we needed more variety and data about what worked for each unique group of users. Ultimately we discovered that giving users choice in their experience is key.” These are options like choosing a male or female voice, an environment that is more organic or more cosmic, and the topic the user wants to explore that day. Giving users agency in their own experience allows TRIPP to simulate a safe environment that supports each unique user’s emotional and mental wellbeing.
With research substantiating the use of virtual reality in mental health treatment building, companies are also branching out to incorporate virtual reality into meditation and mindfulness apps. VR is also able to be personalized, opening opportunities for tailoring interventions specific to the patient. The scalability of VR also lends itself to remote treatment options.
Two Sides of the Accessibility Coin
One of the greatest benefits of virtual mental health services is its accessibility—as previously discussed, social media sites can be a platform for creators to disseminate mental health content to reach millions. But while there are licensed mental health professionals on these sites, there are also creators without licenses or training. Combined with the fallibility of material being posted on non-fact-checked websites, the currently inevitable downside to this widely accessible content is the question of accuracy and legitimacy. Content on these platforms may be misleading or misinterpreted, so users should verify the information they find online and not jump to conclusions. For instance, people should not self-diagnose themselves based on what they consume online. Informal tools like social media should be secondary to professional or formal sources.
Furthermore, this accessibility perk doesn’t necessarily benefit everyone equally. Different demographics of people experience telehealth in different ways. In the process of connecting to care, people may face challenges that hinder them from using telehealth:
- Socioeconomic barriers: Though virtual services have allowed people to reach a medical professional online, it hasn’t necessarily reduced the cost to be widely more affordable. For instance, at BetterHelp, costs range from $60–$80 per week (compared with $60–$200 per week). And virtual services are only useful for those with access to a computer and reliable internet.
- Language and cultural differences: According to the American Psychological Association, 86% of psychologists in 2015 were white, 5% were Asian, 5% were Hispanic, 4% were Black, and 1% were multiracial or from other racial groups. This becomes a problem for people of color who are searching for a therapist with the same racial or cultural background as themselves.
- Generational mismatches: Digital literacy and mental health awareness across generations vary, with older generations lagging on both fronts. This raises questions of how to improve the interface and education about mental health for older Americans.
These challenges are not always isolated; people may face a combination of these barriers, making it even more difficult to connect to care. Innovation in virtual mental health is helping with these hurdles. For instance, AI chatbots can be a temporary reprieve for those struggling to afford care. Set against the backdrop of more companies making strides for culturally competent care, this highlights the question of bias in artificial intelligence. AI bots are only as good as the data they are trained with, and unrepresentative datasets can have devastating effects in practice. Not only does algorithmic bias reveal social inequities in the healthcare system, it also exacerbates it.
On the flip side of things, widespread recognition that bias in AI can also stem from existing, unconscious prejudices is fueling more research into how to combat bias in healthcare, a long overdue venture.
Virtual Mental Health: A Paradox?
That social media and digital technology can negatively impact mental health presents a looming question: Is it paradoxical for the same platforms that are exacerbating mental health to also be the ones with the capacity to improve it? With numbers like an average of 1300 hours spent on social media last year, colloquial terms like “nomophobia” (NO MObile PHone PhoBIA: the fear of being away from your phone), and phrases like “smartphone addiction” popping up in the news, is it wise to invest resources and effort into developing technologies that would increase screen time? Can platforms that exist on the smartphone really solve the mental health crisis?
There isn’t necessarily a right or wrong answer to these questions. It may very well be that it depends on the person and that these solutions work for some but not others, or that an optimal combination of in-person and virtual care exists for each person. In the case of TRIPP, Reeves says the product team has carefully considered how to create a virtual experience that allows users to separate from the often negative, judgmental, and competitive nature of many social platforms. “We don’t want to be part of the echo chamber of content designed to manipulate. Instead we’re trying to use technology in more beneficial ways and use machine learning and algorithms in ways that are designed to support users better.”
Perhaps personalization of virtual care will improve the experience, or perhaps a monumental shift in how society values and recognizes mental health and mental health care is needed before long-term change can happen. In the meantime, the burgeoning research and tech development endeavors promise innovation and disruption to the current digital mental health landscape.
Despite, and to some extent, because of the pandemic turmoil that has exacerbated the state of mental health in the US, it is a revolutionary period of time for virtual mental health companies to amend the fragmented healthcare system. They are doing this by:
- Providing more tiers of care and options for people at varying stages of need
- Accelerating the time it takes to connect patients with a mental health care professional
- Capitalizing on technology trends like artificial intelligence to boost access to and quality of care
In the past decade, there has been a trend for integrating mental health care into primary care settings, and now, for offering virtual services as part of that integrated model. (Behavioral health integration is another term that is broader in meaning but follows the same principles. Behavioral health includes mental health and also covers conditions for which behavior and health are connected, such as substance use and eating disorders.) Integration means that mental health services, including assessment and treatment, are expanded to be accessible to patients in the primary care setting. Rather than having to go to different places for different types of care, patients would be able to get help from under the same roof, cutting down inconveniences like transportation time. It also improves communication and coordination, thus boosting the likelihood that patients actually get connected to a provider.
One specific approach to integration is known as Collaborative Care. A 2012 Cochrane Review evaluated the effectiveness of this model and found that it produced improved outcomes for patients with depression and anxiety. Under this strategy, behavioral health specialists work collaboratively with primary care physicians to provide care to the patient.
All of these elements point toward more conversations around mental health—about expanding access to care for marginalized populations, utilizing new trends and technology to augment care, and reorienting health as a holistic measure—all of which help to chip away at the stigma surrounding mental health. As Reeves emphasizes, “We shouldn’t separate out mental health as some other category outside of health. Health is health.” This discourse is also promising for long-term, permanent growth in mental health investment.
Indeed, the flurry of mental health startups that has emerged in recent years is largely seen as an advantageous trend to the future of mental health care. But even this trend has an uncharted dark side to it. The boom in investment for these companies garners much interest from consumers, leading them to register for these services. Inevitably, though, some of these startups will fail, and what becomes of their customers then? Ideally, mental health care is consistent, in order for patients to reap the full benefits of a steady, long-term service or relationship with the provider. With mental health care already suffering from a fragmented care pipeline, how will patients deal with this additional hurdle? Is this a necessary “one step backward” in the bigger picture of an ecosystem evolving to meet newfound demand?
Also given that there are no formal regulations or review boards that govern the development or implementation of mental health apps, this is an area for expansion, whether it is instituting a set of standards (unlikely) or educating consumers about choosing an appropriate app for their needs.
With patients highly satisfied with their telemental health experiences and many planning to continue utilizing virtual mental health services post-pandemic, this digital ecosystem is positioned to develop more powerful tools and techniques to meet consumer demand, provide accessible care to overlooked populations, improve care quality, and overall expand the current repertoire of mental health services. Finally, looking at the bigger picture, the rise in mental health care, regardless of remote setting or not, is a step forward toward treating health holistically.
Elena is a Research Fellow at HTD interested in both healthcare and public health perspectives of virtual care. She holds a bachelor's degree in biology from Brown University.