SCIENCE science.org 27 MAY 2022 • VOL 376 ISSUE 6596 899EDITORIAL
W
hile the COVID-19 pandemic has been a bur-
den for our mental health, it also led to a
surge in mental health care innovation. Ap-
pointments by telephone or video, as well as
web- and app-based tools, have become part
of a digital mental health revolution. Last
year, US venture capitalists invested $5.1 bil-
lion in this area, a fivefold increase from 2019. But is
this surge in activity actually leading to improvements
for those with the greatest needs?
The shift to remote care addressed a pain point of
the brick-and-mortar mental health system: the gap be-
tween the limited supply of providers and the increas-
ing demand for care. Digital mental health companies
made it easier to access a mental
health professional, and the ad-
vent of self-help apps for mindful-
ness and sleep became popular as
consumer products. Better access
to therapy and consumer apps are
undeniable improvements that
could be helpful to millions.
But are these new tools serving
those who need care the most?
Most of these innovations do
little for people suffering from a
serious mental illness, such as
schizophrenia and bipolar dis-
order. Many with serious mental
illness are unemployed, too poor to pay for online ther-
apy, and, often, on the wrong side of the digital divide.
They may not be seeking online therapy and, to be clear,
there is no app for the range of social and medical prob-
lems they face. They endure homelessness, incarcera-
tion, and loneliness. Can there be innovations to engage
them with health care and foster recovery?
To recover, people with serious mental illness need
people, place, and purpose—the “3 P’s”—usually pro-
vided through supports for social engagement, housing,
and employment. During the pandemic, many nonprofit
providers began delivering these psychosocial supports
through tablets and phones. In contrast to the traditional
delivery of these services, tech-enabled services proved
surprisingly efficient and scalable, demonstrating the op-
portunity for innovation to promote recovery. But we are
just beginning to see the impact of high tech linked to
high touch for people with serious mental illness.
Why have investors and entrepreneurs neglected this
need? In the United States, there are 14.2 million people
with serious mental illness, each representing, on aver-
age, a $1.3 million lifetime economic burden on society.In contrast to medical and surgical costs, more mental
health care is covered by federal public insurance ($110
billion) than by commercial or private insurance ($62
billion). Entrepreneurs and venture capital investors
ought to be lining up at the gates of the public insur-
ance system. Except there are no such gates.
The problem is that the health care safety net does
not easily accommodate companies that want to try new
ways to serve these patients, either in-person or digitally.
In many states, this kind of care is carved out from other
government programs and relegated to county agen-
cies. In states where commercial insurers are involved,
they tend to pay for crisis care, brief hospitalization, and
medication management, but not for engagement—en-
couraging people to enter the
system—and recovery. Although
nonprofit organizations and gov-
ernment agencies have issued
grants and launched projects to
stoke innovative approaches, this
temporary funding is not sufficient
to attract startups that depend on
a sustainable and scalable source
of revenue.
Fortunately, there are some
recent changes that promise to
better align the incentives of inno-
vators with the greatest needs in
mental public health. Payers and
providers are focusing on social determinants of health
such as homelessness and poverty. There is increas-
ing awareness of the need for “whole person care” and
recovery services. Most important, public and private
payers are experimenting with reimbursement based
on a commitment to care for an entire population, with
payment dependent on outcomes. This “value-based”
approach encourages entrepreneurs to take risks in
developing new ways to help the safety-net population,
knowing that they can profit if they can achieve better
outcomes at lower costs.
What is ultimately needed is a new kind of public-pri-
vate partnership to expand the scope of care and access to
these resources. With Operation Warp Speed, we saw the
potential of a partnership between government and the
pharmaceutical industry to accelerate the development of
a COVID-19 vaccine. For mental health, a similar partner-
ship is needed between government and the digital health
industry. This partnership could focus entrepreneurs on
the “deep end of the pool” while helping government
agencies to serve those with the greatest needs.
–Thomas Insel*Mental health care 2.0
Thomas Insel
is an adjunct
professor in the
Department of
Psychiatry and
Behavioral Sciences
at Stanford
University School of
Medicine, Stanford,
CA, USA, and is the
former director of
the US National
Institute of Mental
Health, Bethesda,
MD, USA.
[email protected]10.1126/science.add1020*T.I. is an adviser, board member, and/or holds equity interest in Alto Neuroscience, Cerebral, Embodied, Fountain House, Humanest
Care, Koa Health, Mindstrong Health, Owl Insights, Psych Hub, Steinberg Institute, Valera Health, and Vanna Health.
PHOTO: CHRISTINA GRAY
“Most of these
innovations do little
for people suffering
from a serious
mental illness...”