[Summary] Bending the Curve for Mental Health: Technology for a Public Health Approach (Insel 2019)

TLDR; Mental health is a public health problem and current institutions are not enough. Tech can "close the unconscionable gap between what we know and what we do" and ensure the public is served.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595506/#__ffn_sectitle

TLDR; Mental health is a large public health problem and technology can close the gap between what traditional clinicians and institutions can do and the growing number of people who aren’t being served. We have evidence for what works but it is not accessible to the public: technology can take existing knowledge to create better diagnostics (digital phenotyping), make interventions more accessible, and help provide valuable data/insights to care teams.

“In this field, perhaps more than any other area of health care, we need to close the unconscionable gap between what we know and what we do… We have the evidence base and the experience to bend the curve on morbidity and mortality. Yet we have not translated this knowledge into an effect on public health. Closing the gap between what we know and what we do is the most urgent and tractable problem we face in the world of mental health care.”

Mental health issues are clearly a public health crisis and we need to change how we approach it.

• “I usually started my seminars with a quick quiz about morbidity and mortality rates for mental illness, global burden of disease statistics, and questions about access to care. Invariably, my audience, the next generation of the mental health workforce, would look at me dumbfounded. No part of their training had addressed mental health as a public health crisis. During these years, the suicide mortality rate increased 33%, mental illnesses became the group of disorders with the highest years lost to disability, and depression surpassed all other chronic illnesses as a source of global disability.1–3 Yet our training model continued to address mental health care from a classic medical model without the broader scope of public health.”

Public health approach

“We need to close the gap between population health needs and mental health care reach.” Many more people need help than seek it, and the current institutions with traditional clinicians and providers are not enough.

• “High rates of mental illness are found in our criminal justice system, school system, homeless shelters, primary care clinics, and emergency departments. Sometimes it seems that people with mental illness are everywhere except the mental health care system. Indeed, most population-based epidemiological studies find that more than half of the population with mental illness is not receiving mental health care.4 We can improve mental health care for the fraction being seen by psychiatrists, psychologists, social workers, and other mental health providers, but this will not bend the curve on population health unless we expand our scope of care to the millions who are outside the mental health tent. We need to close the gap between population health needs and mental health care reach.”

Technology: Problem or Solution

Even though there are concerns about smartphones’ negative effects on mental health, they offer a nearly ubiquitous platform to serve others instead of waiting for them to come to clinicians.

• “But how can we serve the millions of people who are not receiving care? The simple answer is to go to them rather than waiting for them to come to us. Technology provides an unprecedented tool for outreach. With three billion smartphones in circulation and people increasingly living through these powerful pocket computers, we now have a public health platform that is more ubiquitous than clean water or stable electricity.”

• “True, for most of us, smartphones may seem to be more of a problem than a solution for mental health. Serious concerns exist about their addictive potential and what is now called “surveillance capitalism”—using the data from our smartphones for marketing, often without our consent or knowledge.7”

The smartphone enables 3 innovations that can close the gap: (1) digital phenotyping (data monitoring for better treatment/diagnoses), (2) digital interventions or support (CBT online, or peer-to-peer support), and (3) better care management tools for clinicians.

• “Three innovations can close the gap between population needs and mental health care reach. First, with data from sensors, speech analytics, and keyboard use, scientists are learning how to measure cognition, mood, and behavior passively from the smartphone. This field, called “digital phenotyping,” offers a sort of digital smoke alarm for mental health issues. With appropriate consent and transparency, digital phenotyping can provide ethical and effective biomarkers that predict relapse or recovery, much the way we monitor progress in diabetes or hypertension.”

• “Second, smartphone applications have been developed for interventions ranging from crisis services and peer support to evidence-based psychotherapies. These online interventions have been shown to be equivalent in efficacy to face-to-face treatments. Moreover, online treatments are more convenient and, for many people, more acceptable than brick-and-mortar care.”

• “Finally, smartphones can improve care management by collecting data on service use and coordinating care in real time. Together, these three functions—measurement, intervention, and care management—can generate a learning engine that improves with experience.”

Closing the Gap

To successfully serve the whole population of those who would benefit (eg underprivileged, jail system, school system), and not just those currently in the system, technology must still be combined with “high touch” and compassionate care. 

• “To be clear, the use of digital technology for mental health care is still in its infancy. There are great promises for reducing suicide and preempting relapse, but the clinical utility of smartphone applications remains to be seen. Although I doubt that technology alone can solve the mental health crisis, I believe that by combining high technology and “high touch,” we can begin to close the population health–mental health care gap.”

• “By expanding our field of view to examine population needs rather than only those in the mental health care system, we can reduce morbidity and mortality among most of the people affected, including those in our jails, our schools, and our homeless shelters. By focusing on the diverse needs of people with serious mental illness, a public health approach can build out the framework for recovery, including psychosocial supports and the need for inclusion and equity. By moving upstream to reduce social determinants of disability and relapse, a public health approach can improve outcomes and lower costs for the care of people with serious mental illness. In each of these areas, technology will yield the data, the interventions, and the connectivity, at scale. But high touch will be critical to understand the context of the data and to turn the connectivity into compassion.”

We already have effective treatments based in evidence, and yet people don’t have access. “Closing the gap between what we know and what we do is the most urgent and tractable problem we face in the world of mental health care”

• “Perhaps the most important role for public health is less obvious. If one of the inconvenient truths about mental health care in the United States is that we have a fragmented and chaotic system, one of the inconspicuous truths is that we have effective treatments. In this field, perhaps more than any other area of health care, we need to close the unconscionable gap between what we know and what we do. We know how to help people recover from mood and anxiety disorders as well as psychotic illnesses. We have medications, psychotherapies, and forms of rehabilitation that have efficacy comparable to that of interventions in the rest of medicine. We have the evidence base and the experience to bend the curve on morbidity and mortality. Yet we have not translated this knowledge into an effect on public health. Closing the gap between what we know and what we do is the most urgent and tractable problem we face in the world of mental health care. This is the challenge and the opportunity for public health to bend the curve for mental health. Technology can help.”