Editor’s Note: Dr. Thomas R. lnsel, Co-Founder & President of Mindstrong Health, and former Director of the National Institute of Mental Health, is a keynote speaker at this year’s Oliver Wyman Health Innovation Summit. Tom is a psychiatrist, neuroscientist, former Professor of Psychiatry at Emory University, and previously a leader of Verily’s Mental Health Team. We recently sat down with Tom to learn more about how Mindstrong Health is using patients’ smartphone keyboard data to advance mental health treatment.
Q: Where does “mental health” sit in the greater healthcare spectrum?
Dr. Thomas Insel: The mental healthcare system is so badly broken, it doesn’t even qualify as a system. Ten million people in the United States have a serious mental illness like schizophrenia but very few receive consistent, coordinated care. Even more prevalent are disorders like depression or anxiety. Most people with depression or an anxiety disorder get a prescription from their primary care physician and are told to come back in four weeks. That’s not quality healthcare for someone with a brain disorder.
It’s important to understand that we spend a huge amount of money on mental healthcare – now over $200 billion each year – because we don’t do it well. We have effective, relatively inexpensive treatments including psychosocial treatments on which we spend too little while we spend way too much on hospitalization, emergency room visits, and late-stage care of co-morbid medical conditions. Most of our psychiatric treatments, whether medical or psychosocial, are given late in the course of a chronic disorder, usually precipitated by a crisis, which is the most costly way to manage these very treatable conditions.
Q: Where does mental healthcare sit in the spectrum of medical care?
Dr. Thomas Insel: Much of medicine has moved toward more precise, specialized care. Think about diabetes with real-time blood glucose measurement and management, or oncology where understanding of oncogenomics has resulted in targeted therapies. We are just beginning to realize this possibility in mental healthcare. With the ability to passively, objectively measure brain function, we will be positioned to detect deterioration in cognition and intervene early, before a potential relapse escalates, and we will be able to assess the efficacy of interventions, such as drug response.
"Digital phenotyping is about making sense of the information found on these powerful computers we carry around in our pockets."
Q: What is Mindstrong Health’s overarching mission for advancing mental health with technology?
Dr. Thomas Insel: Mental healthcare doesn’t have biomarkers or objective measures that guide treatment decisions. At Mindstrong, our foundation is objective measurement that can guide care. Building on this foundation, our overall goal is to transform mental healthcare with the aid of technology to see better clinical outcomes at lower cost with higher quality. I know that sounds like every other health tech company, but our approach starts with rigorous, objective measurement. We believe measurement-based care is the key and it has been conspicuously absent in mental healthcare. We use digital tools for measuring outcomes and for deploying interventions. Our approach is to provide better data, rapid response, and guidance for care managers, all driven by continual feedback to reduce relapse and prevent a crisis.
Q: How is Mindstrong working with digital phenotyping to better understand patients’ mental states through their phone habits?
Dr. Thomas Insel: Digital phenotyping is about making sense of the information found on these powerful computers we carry around in our pockets. Since much of our lives are played out on smartphones, the data from a smartphone can yield insights into how we are thinking, feeling, and behaving. Mindstrong has a major focus on ethics and privacy, so our approach to digital phenotyping is focused on keyboarding behavior as a surrogate for traditional cognitive tests, like the neuropsychological tests done in a clinic or laboratory. We analyze how you type (such as taps, scrolls, and clicks) not what you type – we never capture content – to identify features through machine learning that predict a range of cognitive traits and mood states. In current partnerships, we are demonstrating how these measures, which are passive and continuous, can be useful for clinical care.
"Maybe we have an opportunity here to turn the tables, to take the same technology which often seems to be part of the problem, and try to make it part of the solution."
Q: What is the potential for digital phenotyping to help diagnose patients earlier?
Dr. Thomas Insel: We believe digital phenotyping will have wide ranging applications in understanding and treating brain health conditions. I’ll just give you a couple of examples. In one of our biggest studies, the Mindstrong app will be used by 5,000 people admitted to a Level 1 trauma center. We know that about 20 percent will develop posttraumatic stress disorder over the subsequent year but current tools have not been able to predict individual risk. So we’re using the Mindstrong technology to come up with predictors that will allow us to know which individual will benefit from a preemptive intervention.
In other projects, we are defining a digital smoke alarm to get an early indicator of relapse to preempt a crisis. This kind of passive data collection is a powerful concept. Patients don’t have to fill out forms or answer questions online. And most importantly, it’s collecting data ecologically – in a patient’s home environment, day and night. As long as they’re using their phone, we get deep, continuous information about how they’re functioning.
Q: What do you envision the future of mental healthcare to look like? What does the industry need to do moving forward?
Dr. Thomas Insel: We envision that it will be possible to detect mental health deterioration early, and to provide smarter, preemptive care that improves outcomes and reduces resource utilization.
Ultimately, there will be less reliance on medication alone. Some of our most powerful treatments are nonmedical interventions. But they’re not being used because they’re not being paid for and we don’t have people to deliver them. Going forward, we need to create a healthcare system for mental illnesses that includes medication, psychosocial treatments, and a range of interventions that might include family support and peer support. We’ve known for 30 or 40 years that for people with serious mental illness there’s a whole suite of psychosocial interventions that are very effective for recovery. Yet, in a large recent government survey, fewer than 3 percent of people have access to those treatments. Of course, technology will be a part of this future but only a part. Mental healthcare 2028 will be high tech and high touch together.
"I believe mental health will be the part of medicine most transformed by the digital revolution."
Q: Where is Mindstrong’s greatest opportunity to make an impact? Where do you see your opening?
Dr. Thomas Insel: There are very few people who do not respond to treatment. So, the real challenge is not developing treatments but getting people the treatments that work. Can technology connect people to treatment? Ironically, most of the conversation today is about technology such as social media isolating people further or making them feel like they don’t measure up. Maybe we have an opportunity here to turn the tables, to take the same technology which often seems to be part of the problem, and try to make it part of the solution.
In other industries like retail, transportation, and entertainment, technology has created a new set of expectations. People expect to get services, goods, and information quickly at their own convenience without brick and mortar. Healthcare hasn’t yet figured out how to provide the goods and services and information for hypertension, diabetes, or depression but it’s only a matter of time before the public begins to expect the same kind of convenience for healthcare they enjoy for retail, transportation, and entertainment. Remember that mental disorders are the chronic disorders of young people – about 75 percent have onset before age 25. This generation of digital natives has grown up expecting to have information and services literally at their fingertips 24/7. We have to think carefully about how we create a culture for healthcare that matches what most people expect in the digital age. The excitement in digital mental health is that so much of our assessments and our interventions can now be delivered via a smartphone. We can solve the problems of access, delay, quality, and stigma that have kept people from getting care and we can do this at a global scale. There are now 3 billion smartphones, so the opportunity is unprecedented. I believe mental health will be the part of medicine most transformed by the digital revolution.