CALIFORNIA

Need mental health help? There are apps for that, but picking the
right one is tough
A number of increasingly popular apps aim to capture the market for people who are reaching out with questions about
mental health, including severe conditions. (Joan Alturo / For The Times)

BY JENNY GOLD | KAISER HEALTH NEWS 

JUNE 21, 2021 5 AM PT

In the eyes of the tech industry, mental health treatment is an area ripe for disruption.

In any given year, 1 in 5 adults in the U.S. experience a form of mental illness, according
to federal estimates. And research indicates only about half of them receive treatment in
a system that is understaffed and ill distributed to meet demand.

For tech startups looking to cash in on unmet need, that translates into more than 50
million potential customers.

Venture capital firms invested more than $2.4 billion in digital behavioral health apps
in 2020 — more than twice the amount invested in 2019 — touting support or treatment
for issues such as burnout, depression and attention deficit hyperactivity disorder. At
least seven mental health app companies have achieved “unicorn” status — being valued
at more than $1 billion.

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But even as industry hype mounts, researchers and companies are scrambling to prove
these apps actually work. Of the estimated 20,000 mental health apps available for
download on personal computers and smartphones, just five have been formally vetted
and approved by the Food and Drug Administration, which largely has taken a hands-
off approach to regulating the space.

“Development has really outpaced the science,” said Stephen Schueller, a clinical
psychologist at UC Irvine who specializes in the development and evaluation of digital
mental health products.

Type “depression” or “anxiety” into an app store, and you’ll be met with a dizzying list of
results. There are thousands of “wellness” apps such as Headspace that counsel people
on breathing exercises and other techniques to help them feel more mindful. Apps such
as Woebot and TalkLife profess to help manage conditions such as anxiety and
postpartum depression using games, mood journaling or text exchanges with peers or
automated bots.

Some apps are meant to be used alongside in-person therapy, and others are meant to
be used on their own. Several of the most popular, such as Talkspace, BetterHelp and
Ginger, promise access to treatment with a licensed therapist over text message, phone
or video. Others, including Brightside and Cerebral, connect users to psychiatrists who
can prescribe antidepressants.

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Most products make their money by charging consumers a monthly or annual fee, with
the option to purchase extras such as video sessions with a therapist. Others contract
directly with employers or insurers.
And, yes, a small portion of these apps have promising research to back them up.
Several studies, for example, have found that cognitive behavioral therapy, a mainstay
of treatment for depression and anxiety that seeks to help patients change negative
thought patterns, is as effective when delivered using web-based platforms as when
done in person by a licensed professional. And the pandemic has bolstered claims that
patients are willing to trade in-person visits for the ease of online connection.

“Digital mental health can be viewed as a way to extend the mental resources that we
have,” said David Mohr, who directs the Center for Behavioral Intervention
Technologies at the Northwestern University Feinberg School of Medicine. A step-care
model, for example, would allow patients with milder symptoms to be treated via
technology while reserving in-person care for patients who need something more.

The challenge for consumers is separating the apps that might help from those that offer
little more than distraction — or could actually do harm.

Some companies offering mental health treatment had recently been doing something
totally different. For example, an online seller of erectile dysfunction and hair loss
treatments has started offering psychiatric evaluations and prescribing and selling
antidepressants.

Tech companies are by nature for-profit and, in the rush to compete in a saturated
market, many are selling a product with an appealing user interface but little evidence
of effectiveness. A 2020 analysis by Australian researchers reviewing nearly 300 apps
for anxiety and depression found just 6% of the companies that boasted an evidence-
based framework in the app store description for their products had published any
evidence.

Nor do star ratings and download totals offer much context: An April study from Beth
Israel Deaconess Medical Center and Harvard Medical School found little correlation
between app store metrics and treatment quality.
“No one is competing based on privacy, safety or evidence. They’re competing on
aesthetics, in part, on page ranking, marketing on brand awareness,” said Dr. John
Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical
Center and one of the authors of the April study. “There’s an implicit assumption that
the app is better than nothing. But what if it isn’t better than nothing?”

One problem, said Dr. Ipsit Vahia, a geriatric psychiatrist and medical director of the
McLean Institute for Technology in Psychiatry, is that randomized control studies of the
kind that might prove an app’s effectiveness can take years, far slower than the rapid
innovation in tech. “In general, the healthcare industry and the technology industry
work at very different paces,” Vahia said.

Dr. David Mou, a psychiatrist at Massachusetts General Hospital who is chief medical
officer at Cerebral, said he agrees that everything new in healthcare must be done
deliberately and conservatively to avoid patient harm. But he said some people in the
mental health field are painting all companies with the same brush and failing to
differentiate those that are data-driven from those trying to grow at any cost.

“They look at us and say we’re all VC-backed bros in a basement trying to redesign
healthcare,” Mou said. “And that’s not true. It may have been true 10 years ago, but it
isn’t true today.” The long-term winners, he said, will be those that are “evidence-based
and measure quality like crazy.”

Cerebral offers online therapy and medication management and delivery for a variety of
mental illnesses. The monthly subscription fees range from $29 to $325, depending on
the level and frequency of care, as well as insurance coverage. Mou said Cerebral is
already able to demonstrate some advantages. While many top hospital systems might
have a months-long wait for care, he said, someone in crisis can reach a Cerebral
provider almost immediately. “Within minutes you are able to talk with someone with
one of our instant live visits. That in itself is a huge win.”
Even critics of the tech explosion are quick to acknowledge that the current brick-and-
mortar system of mental health is dated and inadequate. In recent years, the issues
surrounding mental illness and lack of access to treatment have infiltrated public
dialogue. Brain illnesses that many families once squirreled away from view have
become the stuff of celebrity culture and dinner-table chatter.

Yet even as advocates have made strides in acceptance, truly improving the lives of
people with mental illness has proved to be stubbornly difficult. Over the last several
decades — while the U.S. successfully lowered death rates for cancer, heart disease and
other major illnesses — deaths by suicide and drug overdose have continued to climb.

Federal law theoretically requires insurance companies to cover mental illness as they
would any other illness. But finding affordable care remains a challenge, largely because
of a shortage of licensed mental health professionals and ongoing inequities in
insurance coverage.

In a nation where huge swaths of the population lack a primary care doctor and health
insurance — but most everyone has a cellphone — connecting people to treatment via
mobile apps would seem a logical solution. And, for some, the opportunity to talk about
their mental health challenges anonymously makes online treatment an attractive
alternative.

Still, many of the experts who welcome the potential for innovation in mental health
treatment acknowledge that consumers are getting little guidance in how to choose a
reputable option. “Wellness” apps that promote a healthy lifestyle or apps that help
people manage their disease without providing specific treatment suggestions can avoid
FDA regulation. But even those that offer patient-specific diagnoses and treatment
recommendations that would seem to fall squarely under the FDA’s authority do not
seem to garner the agency’s attention, according to industry experts.
“The FDA has been really, really lax on enforcing in digital health for reasons that are
not entirely clear to me,” said Bradley Merrill Thompson, a lawyer at Epstein Becker
Green who advises companies on FDA regulations. “Anybody could spend 20 minutes
on the app store and find dozens of examples of apps that make medical device claims,
and that have been doing so for some time, without any effort by the FDA to rein them
in.”

In response to questions from KHN about the agency’s approach to regulating mental
health apps, the FDA sent a brief statement. “As circumstances change and new needs
arise, FDA is ready to meet and address these challenges, especially in the areas of
mental health,” the statement reads in part. “We would like to see more evidence-based
products in this area, which is why we remain committed to facilitating the development
of additional safe and effective therapies for patients who rely on these products.”

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Dr. Tom Insel, a psychiatrist and neuroscientist, has a unique view of the evolving
landscape. In 2015, Insel left his job as director of the National Institute of Mental
Health, a post he had held since 2002, trading the halls of government for the open
floor plans of Silicon Valley to work in digital mental health. He started at Google’s
Verily, then co-founded Mindstrong Health, a startup researching how smartphone
technology could be used to predict and diagnose mental health crises. He has since left
to advise California officials on behavioral health issues.

Insel said he believes in the promise of digital mental health but that it will take time to
find its highest and best use. He noted, for example, that most of the apps on the market
focus on the problem of access: They make care more convenient. But they’re
overlooking a more basic problem: quality. Unlike most fields of medicine, mental
health providers rarely measure whether the care they provide makes patients better.
“A lot of what we need is not just more access. It’s not just recreating the brick-and-
mortar system and letting people do it by phone or Zoom,” Insel said. Instead, he
argued, digital health should focus on measuring whether treatments improve people’s
lives.

“I have no doubt that this field will transform mental health treatment and diagnosis,”
Insel said, “but we’re in the first act of a five-act play. I don’t think we’re anywhere near
the kinds of solutions that we need in the real world.”

This story was produced by KHN (Kaiser Health News), one of the three major
operating programs at KFF (Kaiser Family Foundation), an endowed nonprofit
organization.

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