From the Editor
Recently, one of patients raved about an app that she started to use. Talkspace offers her access to psychotherapy, unbound by geography, with a variety of therapist options.
The catch: she’s paying for it. In her opinion, it’s a good investment in her mental health. In Wall Street’s opinion, it’s a good investment in their financial health: that app has raised more than $110 million (USD) in venture capital. Other popular apps have also caught the eye and the backing of Wall Street – think Calm ($144 million USD) and Headspace ($167 million USD).
Is venture capital changing mental health care? And what are the potential problems? In the first selection, we consider a new Viewpoint paper by Drs. Ravi N. Shah (of Columbia University) and Obianuju O. Berry (of New York University). They write: “Although the value of this trend is yet to be fully realized, the rise in venture capital investment in mental health care offers an opportunity to scale treatments that work and address mental illness at the population level. However, quality control, privacy concerns, and severe mental illness are major issues that need to be addressed.”
In our second selection, we look at a new paper by Robert J. Williams (of the University of Lethbridge) and his co-authors on gambling and problem gambling in Canada. Drawing on survey data, they find a surprising result: “Gambling and problem gambling have both decreased in Canada from 2002 to 2018 although the provincial patterns are quite similar between the 2 time periods.”
Finally, in our third selection, Dr. Sarah M. Bagley (of Boston University) discusses the problems of a newborn baby and its impact on his mother. The pediatrician isn’t writing about anyone – she is writing about her own experiences, and the resulting anxiety she experienced. “My story continues, but I hope that by sharing the issue of postpartum health can be better addressed among my colleagues and patients.”
DG
Selection 1: “The Rise of Venture Capital Investing in Mental Health”
Ravi N. Shah and Obianuju O. Berry
JAMA Psychiatry, April 2021
Mental health care is ripe for innovation. Less than a third of people with mental health disorders receive treatment, and even a smaller proportion receive adequate care. The private sector has taken notice of this economic mismatch (high demand with inadequate supply) and is aggressively pursuing mental health and wellness as an investment opportunity. In 2019 alone, venture capital (VC) companies invested a record-breaking $637 million in more than 60 different mental health-oriented companies, which is more than 22.8 times the investment in 2013. Calm, a smartphone application focused on audio-guided meditation, reached a milestone valuation of more than $1 billion, making it the first ‘unicorn’ mental health-oriented start-up. This rapid rise in investment in the mental health and wellness space brings new challenges related to defining, quantifying, and assessing products and services that had previously resided within traditional health care.
So begins a commentary by Drs. Shah and Berry.
They focus on the concerns and advantages of the “rise of for-profit start-ups.”
Concerns Related to Private Investment in Mental Health
Physicians, caregivers, payers, and patients should have real concerns about this trend. Silicon Valley’s motto for success, ‘move fast and break things,’ has led companies such as Uber and Theranos to break laws and cut corners. This ethos is not compatible with the Hippocratic doctrine of primum non nocere. Venture capital companies evaluate success in terms of growth of consumers and revenue, with little rigor applied to quality assessment. In fact, Pear Therapeutics is unique in achieving US Food and Drug Administration approval for a prescription digital therapeutic.
They also note concerns about privacy:
Other specific challenges that VC-backed start-ups must confront include privacy concerns, ability to adapt to personalized needs, applicability for individuals with serious mental illness, and payer adoption. A recent study of 36 mental health applications showed that 92% transmitted data to third parties, but only 69% had a privacy policy.
Possible Advantages to VC-Led Innovation in Mental Health Care
VC-backed start-ups may accelerate mental health care innovation. Companies supported by VC rely on the idea of scale – the ability to grow quickly to serve a large population to maximize return on investment. In the traditional mental health care setting, dissemination of evidence-based treatments is a major challenge because treatments take place as one-on-one encounters over several months. Venture capital companies subsidize start-ups to constantly produce new iterations of their models to generate proof of concept and to refine their product or service as it evolves. This market-based, ‘survival of the fittest’ approach means that companies only succeed if patients use and perceive benefit from these products and services. Given their consumerist mindset, VC-backed mental health companies’ strength is their transparency with diagnosis, treatment process, and costs. These are all steps forward for mental health…
A few thoughts:
- This is a thoughtful commentary paper.
- I suspect that many will have mixed emotions: excitement at the infusion of capital but also some apprehension. Is actor Matthew McConaughey reading bedtime stories (as he does for Calm) really mental health care?
- The authors make a good point here: “Many of the VC-backed applications are focused on do-it-yourself therapeutic tools that mix evidence-based approaches (eg, mindfulness) along with consumer-oriented modules (eg, bedtime stories read by a celebrity with a soothing voice). Although some argue that these applications do not provide traditional mental health treatment per se, evidence continues to emerge that these applications enhance mental health treatment…”
- Talkspace, incidentally, has been considered in a previous Reading that looked at a New York Times article:
The JAMA Psychiatry paper can be found here:
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2770792
Selection 2: “Gambling and Problem Gambling in Canada in 2018: Prevalence and Changes Since 2002”
Robert J. Williams, Carrie A. Leonard, Yale D. Belanger, et al.
The Canadian Journal of Psychiatry, April 2021
Population prevalence studies of gambling serve several purposes. They establish the current prevalence of gambling, the prevalence of each type of gambling, and the prevalence of problem gambling. This information, in turn, is very useful in understanding the overall recreational value of gambling to society, the negative social impacts of providing legalized gambling, the number of problem gamblers that would benefit from treatment, and the types of gambling most strongly associated with problem gambling.
Changes in the prevalence of problem gambling from one time period to the next, and/or differences between the prevalence rates in one jurisdiction relative to another provide important information about the incidence of problem gambling and the potential effectiveness of different policies intended to mitigate gambling’s harm.
There have only ever been 2 published national prevalence studies of gambling and problem gambling in Canada, the first in 2000 and the second in 2002 by Statistics Canada as part of the annual Canadian Community Health Survey (CCHS 1.2). There has been significant expansion of legal gambling availability in Canada since 2002 as well as the emergence of new forms of gambling (e.g., Esports betting, fantasy sport betting), new forms of payment (e.g., skins, cryptocurrency), and a new modality of access (online)…
So opens a paper by Williams et al.
Here’s what they did:
- They drew the data from “the 2018 Canadian Community Health Survey and administered to 24,982 individuals aged 15 and older. The present analyses selected for adults (18+).”
- “CCHS interviews were subsequently conducted between January and December 2018 by computer-assisted telephone interviewing (75%) and computer-assisted face-to-face interviews (25%). The interview was available in both English and French with interpretative services available for several other languages.”
- “The first part of the Gambling Module was an assessment of past year frequency of engagement in 8 different types of gambling using an abbreviated and modified version of the Gambling Participation Instrument.” People who gambled once a month or more were then asked 9 questions from the Problem Gambling Severity Index (PGSI).
- Statistical analysis was done.
Here’s what they found:
- “66.2% of the Canadian adult population reported engaging in 1 or more types of gambling in 2018.”
- “Lottery and raffle tickets are the only type of gambling in which the majority of the Canada population participate.”
- “The relative popularity of the different types of gambling in 2018 in Canada is very similar to 2002…”
- “Participation rates have decreased. This is particularly true for EGMs and bingo but is true for almost all types of gambling. Casino table games (which includes poker), is the one exception to this trend.”
A few thoughts:
- This is a good study.
- The big finding: a 45% decrease in the overall prevalence of problem gambling. (!!)
- This is interesting and good news.
- In fact, the decline of problem gambling seems to be part of a global trend.
- That said, the availability of gambling has increased in Canada in recent years. Online gambling was legalized in provinces like Alberta; the total number of casinos doubled across the country.
- The authors offer some explanations: “There are several factors thought to be at work: (a) decreased overall population participation in gambling; (b) increased population awareness of the potential harms of gambling (creating less susceptibility); (c) people being removed from the population pool of problem gamblers due to severe adverse consequences deriving from their gambling; (d) increased industry and/or government efforts to provide gambling more safely, to enact programs to prevent problem gambling, and to provide treatment resources; and (e) increasing age of the population (as older people have lower rates of problem gambling).”
The full paper can be found here:
https://journals.sagepub.com/doi/full/10.1177/0706743720980080
Selection 3: “I Am Not Burned Out”
Sarah M. Bagley
JAMA, March 23/30, 2021
In the 7 minutes prior to his birth, the fetal monitor began to show multiple decelerations. I knew what this meant. Someone yelled, ‘Push! You have to get this baby out!’ so I pushed, once. And then, his cry. I started to sob as they placed him in my arms.
A few weeks later, still home on maternity leave, I noticed that Henry’s body was warm. It was a hot day, but still. I checked a rectal temperature and it was normal. A few hours later, he still felt warm and was increasingly fussy. I check it again, 104.2°F. Crap. I pick him up and look for my phone. As I am searching, his color changes and he seems limp. I can’t find my phone. Where is it? I run outside yelling for help. The landscapers and my neighbor come running. We use the landscaper’s phone to call 911. By the time the ambulance arrives, Henry’s color had improved, but I know that a newborn with a fever buys a visit to the emergency department and inpatient admission. One of the paramedics dismisses me, ‘Why don’t you uncover him? Call your pediatrician?’
In my head, I am screaming at this guy, ‘I AM a pediatrician.’
So begins a paper by Dr. Bagley.
The Boston physician writes about her experiences with her newborn.
“About a week later, I am shaking and crying in the elevator to his pediatrician’s office for Henry’s follow-up visit after his hospitalization. I cannot control myself. I am totally overwhelmed. I cannot think. Once I am in the car, I take a breath and realize that maybe I had a panic attack. If a patient reported this experience to me, I would screen for anxiety and depression and consider a referral for therapy. But, in my head, I tell myself, ‘This is normal. I’m having a normal reaction to something that was traumatic. And really, do I have time for therapy?’”
Complicating matters: her other child has a significant allergic reaction. The stress takes a toll on her.
“As I walk to work later that day, I continue to cry. I cry because I am tired. I am overwhelmed. I just want a break. I wonder if it is time to address the worry and the sadness. I try running and meditation, yet my feelings continue to control me. I call the insurance company to get a list of therapists who focus on postpartum health. The referral list does not indicate specialization in women’s health or postpartum health. I call some numbers anyway and never receive any calls back. I ask friends and colleagues for suggestions. Someone recommends a psychologist who is wonderful but does not take insurance. She uses cognitive behavioral therapy. After 8 weeks, I feel better, not perfect but better.”
She notes the healing of time – and care:
“Now, he is almost 2½ years old. It is hard to explain completely, but at some point over the last couple of months, I felt a fog lift. I know that I need to be humble and mindful, but I am feeling more confident, less anxious. Things seem a little brighter.
But she also notes her struggles:
“As I have started talking more to friends and colleagues about my experience, I have been surprised that I am not alone (of course I am not alone, anxiety and depression especially in the postpartum period is common, why would my colleagues be immune?). I wonder what could have made my transition back to work less rough.”
A few thoughts:
- This is a moving essay.
- Dr. Bagley makes a sharp comment about burnout. “There is substantial and appropriate attention on addressing physician burnout. Each year, we are asked to fill out surveys about physician well-being, and I receive dozens of emails about different programs designed to mitigate the stresses associated with our profession. Before Henry’s birth, whenever I responded to the surveys, I never really felt as though it applied to me. I have a great job. My research is funded for the next 2 years, and I’m running a successful clinical program that I thought would take years to build. I work with compassionate colleagues and have patients who make all of it worthwhile. I have tremendous flexibility and am able to pursue projects that I am excited about and hope will make a difference. I have a supportive partner who equally shares the work of taking care of our family. I am tired, and my work is fulfilling. Framing my worry and stress in the context of physician burnout did not capture how I felt about my job or stress. In fact, I was always pretty clear that I didn’t feel burned out.”
- It’s nice to see JAMA publishing this essay.
The JAMA paper can be found here:
https://jamanetwork.com/journals/jama/fullarticle/2777720
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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