Theory of Next by Antler India | Episode 03—Mental Wellness Tech

Highlights From Transcript

[00:00] - A message from team Antler India

[02:07] - Introduction

[03:55] - The Mental Wellness Spectrum

[12:06] - Identifying the main challenges: SPACE (Social Stigma, Practitioner Supply, Access, Continuity, Efficacy & Measurement Gap)

[19:33] - Mental Wellness Tech: State of Affairs

[24:18] - Areas of Opportunity for Founders

Transcript

Introduction

Nitin Sharma: Hi everyone, and welcome to the next episode of Theory of Next. I am Nitin, Co-founder and Partner at Antler India. As you know, we started Theory of Next to build our theses in public. We're one of the fastest-growing global venture platforms at the earliest stage. And it's really important for us to be at the cutting edge, talk about interesting new ideas and spaces, and especially zoom into ideas that can be built for the globe from India. We covered Electric Vehicles and DAOs in the first two episodes. And today, we're going to go into a new topic that is close to our minds and hearts. What if I told you there was a space where everyone in the world could be potentially a consumer? And while $600 or $700 billion of venture funding went into a variety of startups last year in 2021, this space actually attracted only about 5 billion. Although that doubled from $2.5 billion the year before, and it's estimated to be close to a $400 billion market right now. We're talking about Mental Health. Today, we're going to cover the landscape of Mental Health. What are some of the systemic challenges that exist? And most importantly, what opportunities are there for founders to build amazing companies?

Welcome to Theory of Next.

So, today we're going to talk about a topic that's close to both our hearts and our minds, that's Mental Health. And, from a VC perspective, it always strikes me that this is a very unmet human need at scale. When you think of various human needs, some connecting with people, you have social networks. When you think of mobility, you have the likes of Uber. But there isn't actually a giant Mental Health company or platform still.

So, that's always intrigued me and we're going to dive into this topic and, to do that, I want to introduce my good friend and colleague Nandini, who's also our Program Director at Antler India and also our resident expert on this topic. So, Nandini, welcome to Theory of Next.

Nandini Vishwanath: Thank you, Nitin.

Nitin Sharma: And let's start talking about the size of this problem.

Nandini Vishwanath: It's a staggering number actually. 10.7% of the world's population struggles with some mental illness or the other.

And that translates to about one in 10 people struggling with mental disorders. And this is obviously on a spectrum. So, these disorders range from depression, anxiety, schizophrenia, you know, and a whole lot of others. In India alone, the stats are quite abysmal. 46 million of us struggle with depressive disorders and about 49 million people cope with anxiety disorders.

What people don't realize, however, is that mental illness or mental health is universal across all people. We're all on that spectrum. So, the addressable market is everyone.

Nitin Sharma: And even the numbers, you mentioned the 10, 11%, that's at any given time. So, even in a more sort of a state where you need help, pretty much everyone in the population will go through a phase in life where they need a mental health intervention.

Nandini Vishwanath: Yes.

Nitin Sharma: So, this spectrum that we talked about Nandini, I think it would be helpful for the listeners to flesh this out a little bit. So, what exactly is this spectrum?

The Mental Wellness Spectrum

Nandini Vishwanath: Sure. Broadly, there are four states in Mental Health. There's Flourishing, which is characterized by positive Mental Health.

Nitin Sharma: Things are going well.

Nandini Vishwanath: You're able to cope even if things are not going well.

Nitin Sharma: That's the key.

Nandini Vishwanath: Second is Moderate Mental Health. This is characterized by reversible disorders.

Things like stress, your work stress, things like that. Then there's Languishing Mental Health, which creates significant functional impairment. And then the fourth one is probably, you know, it is probably defined by degrees of severity there. And it's a spectrum by itself, which has Mental Disorders, clinically diagnosed Mental Disorders.

And probably for purposes of this conversation, we should keep the clinical Mental Disorders outside of this conversation. It requires medical help, professional help, sometimes medication. Tech can only solve for it in a very limited way.

Nitin Sharma: Yeah, I think that's important to point out that it's outside the scope. And if anybody is in that phase, we do not believe that tech is today able to solve any of it. They absolutely need to seek attention of clinical help. And so, what you're really saying is, Flourishing is, things are going well, you are able to cope with the negative stimuli. Moderate is when you are facing some trouble. And if that becomes intense and sustained, that's the third one? Which is Languishing.

Nandini Vishwanath: Yep. Why this is also important is that a majority of the population, all of us, oscillate between Moderate and Languishing. The solutions may overlap, but the situations are quite different. The larger question really is, how do we prevent people from moving towards suboptimal Mental Health and keep them in the Flourishing state? And that is really the goal for all mental health startups.

Nitin Sharma: So, we just established that spectrum. One of the questions for somebody who is looking at the space, or is aware of the space in general, is that there are lots of products out there. Lots of approaches have been tried, and I think it would help to contextualize those things across the spectrum a little bit. So, if you start with Flourishing -

Nandini Vishwanath: So, if you start with Flourishing and Moderate, we call it Preventative or Self-care. And there's a lot of, like you rightly pointed out, a lot of mental wellness applications. Tracking habits, sleep, productivity, meditation, yoga. There are companies like Insight Timer, Headspace, Calm.

Nitin Sharma: Most of the unicorns that people think of when it comes to mental health. There's another category that has to do with B2B, et cetera, which we'll come to, but this is the part that most people associate with. Like mental health unicorns, meditation, static content.

Nandini Vishwanath: Yes, because these also offer your micro doses on a daily basis. And that's exactly what folks in the Flourishing spectrum are able to do, right. There's also hardware & wearables, that's you know, gaining popularity. Watches, trackers that can track your biometric monitors and that data with actionable outcomes can be very valuable for that.

I think the next state which is Languishing and Moderate mental health.

Nitin Sharma: Where you need help. Where you need a therapist or you need another source of help.

Nandini Vishwanath: Absolutely. Right? And we can start off with talking about peer to peer counseling. Peer to peer help, actually not counseling. Because, this is essentially talking to an external person, a third person, who is willing to listen to you. And this again serves as micro-doses, some affirmations maybe, not necessarily talking to a therapist. When you have to talk to a therapist, there are other options. For example, Telehealth has gotten very popular over time, in the last couple of years, where a software platform connects therapists to his or her patients.

Nitin Sharma: And that's the other very common

Nandini Vishwanath: very common, increases access. but it's not the end there, right? There's also CCBT - Computerized Cognitive Behavioral Therapy. Which is one of the most popular principles in counseling psychology.

Nitin Sharma: And maybe it helps to explain what CCBT is.

Nandini Vishwanath: Absolutely. It forms the foundation of anything to do with counseling. It's highly structured. These conversations start with a goal. So, it's not like you can go to a therapist and meander about and talk about everything that affects your life.

We're talking about the current problems. We're probably talking to them about what happened in the past. Essentially, when you're facing those problems, figuring [out]. It's a very collaborative approach as well between the therapist and the person.

Nitin Sharma: And I think the key is to get to understanding some root thoughts that are causing the problem and re-wiring them and asking questions.

Nandini Vishwanath: It's not really dwelling on the past, but really saying, how are you coping with that currently? And what techniques are you learning to cope with it when it comes back again?

Nitin Sharma: So CBT has existed in counseling for a long time. It's a very popular technique. But now, what you are saying is CCBT, that's making this into a tech product.

Nandini Vishwanath: Yes. It makes it a tech product because it connects again, it's like a software where, you know, it connects the therapist to the patient. You don't have to go on the couch, for instance. Digital Therapeutics is focused on evidence-based therapy, which again is based on the principles of CBT. Both of these programs, focus on behavioral program change, don't medicate, have very definite outcomes that have to come out of it.

Nitin Sharma: Where do things like bots, therapy bots fit in? Is that CCBT or?

Nandini Vishwanath: It's probably Top of the Funnel. And depending on the severity of your symptoms, ideally, you'd probably start with a bot, which is essentially like a listening service in many ways.

And then depending on how severe your symptoms are, you would probably graduate to therapy.

Nitin Sharma: And sometimes on the tech product side, you start with a bot that is trying to take CBT and putting it into a bot. Essentially, using NLP and AI to simulate a therapist, taking the same principles you've been coded in CBT, and then the other platforms connecting you to therapists.

And of course, within that, there is sort of more computerized CBT and sometimes just Digital Therapeutics. Got it.

Nandini Vishwanath: Yeah.

Nitin Sharma: And so that's the Assistive part, and then we have some other stuff also that, that falls on that spectrum, right? Which includes things like psychedelics.

Nandini Vishwanath: Yeah, it's interesting that in the West right now, with cannabis and CBD oil being used extensively for anxiety. There's a lot of work happening there. Regulations are not withstanding.

Nitin Sharma: Yeah, unfortunately, or fortunately, I guess we can't talk much about this. But I think it's safe to say, from a tech or venture perspective, that the efficacy of those things is definitely being proven in the West, and it's a matter of time. Seems like some psychedelics are going to be mainstream at some point.

I think there are also opportunities on the provider side or the practitioners side.

Nandini Vishwanath: I think that's a much neglected space right now. There's a full stack opportunity right there to handle everything from infrastructure, the way you take notes, it's very antiquated right now, payments, tracking of appointments and scheduling. One of the biggest problems they face is churn. One of the biggest problems they face is the patient doesn't have the right expectations set. All of this can be solved with some tech.

Nitin Sharma: I think we are not going to go into detail on that, but it's actually a really interesting vertical SaaS opportunity for someone to build from India for the world. It's like we have sizable businesses serving vet clinics and fitness studios.

Like, we have our investment in Bookee for example. Similarly, isn't there a good vertical SaaS play for the therapist population abroad?

Nandini Vishwanath: The market right now in India, might be tad small, for now. But so it is certainly something to watch out for.

Nitin Sharma: So, Nandini, we've established, number one, this is a very universal problem. Everyone can be a customer.

You've established that it is a very multi-faceted topic, where you have so many different pinpoints and interventions are potentially possible. And we've also established that there have been a lot of different approaches. It's been a hybrid of, sort of, software and tech-enabled involving people, et cetera. And yet one question is why do I want to see more scale from a business or a startup perspective?

And there are some elements which are probably common to global mental health startups, with some specific to India. So, that's the question people have been covering recently. Why don't mental health startups reach scale in India. What do you think is the reason?

Identifying the main challenges: SPACE (Social Stigma, Practitioner Supply, Access, Continuity, Efficacy & Measurement Gap)

Nandini Vishwanath: I think there are five reasons that I can think of, right. Let me just quickly acronym it to SPACE so that folks can remember.

Nitin Sharma: SPACE?

Nandini Vishwanath: SPACE. S stands for Stigma, Social Stigma, all of us know it, feel it. P stands for Practitioner Supply. A stands for Access. C stands for Continuity Issues. E for Efficacy and Measurement Gap issues.

And let's go one by one. Social Stigma. We all know it exists. We all don't like it, but we all still feel it. It is getting better. Internalized stigma, for instance, affects treatment outcomes. Even if you're able to approach someone, you constantly continue to berate yourself for doing that. It's certainly changing, but it's only changing in the last couple of years.

Otherwise, you don't want to talk about who you're going to be meeting. I read this very interesting anecdote once that, in the U.S., some women park their cars or take a cab to visit their therapist, not take their cars, because they don't want people to see that they park it outside a therapist office.

Nitin Sharma: I imagine that's probably much worse in India.

Nandini Vishwanath: Yes. And there's also this fact that just blew me away. That the gap between when there's onset of symptoms and from when you take treatment is actually is an average of 11 years in a country like the U.S.

Nitin Sharma: 11 years?

Nandini Vishwanath: 11 years.

Nitin Sharma: By which point you have probably moved on that spectrum to a much worse state.

Nandini Vishwanath: Yeah. That brings me back to our next point, which is Availability of Practitioners.

Right. There's a severe shortage in India for qualified, licensed therapists. And there are multiple reasons for that, right? There's one, training infrastructure is terrible in India. We lack training infrastructure. One. Health is a state subject, which essentially means different states look at training infrastructure differently, there's no standardization. Because there's a clear lack of awareness of mental health or acceptance that this is like very normal illness or disorder that people can do, people don't choose it as a career option.

Nitin Sharma: That's really unfortunate because I think in the ranks, stack ranking of specialties, unfortunately this is last one, one of the 'lower ranked' ones. Although, that is also changing.

And people know that therapists and psychiatrists, especially in bigger cities are actually making good incomes, but there's a huge supply issue.

Nandini Vishwanath: For a hundred thousand people in India, we are at 0.75 therapists and the entire ecosystem of clinical psychologists, psychiatric nurses, counselors, everything stands anywhere between a 7,000 to a 9,000 number for a country with a large population.

Nitin Sharma: I think it's something like seven to eight, 9,000 psychiatrists. And then if we include psychologists, I think 20, 30,000 something in that range, right?

Nandini Vishwanath: It has to be at least 8x to 10x of that. Considering it's a growing disorder and people are seeking help.

Nitin Sharma: So, 0.75 for one lakh people. Less than one professional.

Nandini Vishwanath: Yes. The challenge also, the other point here is also that by the time people realize that they're struggling with something and by the time they come to seek help, and that gap is really high. They are in such a bad condition, that it takes that much more time to solve it, which also means therapists in India are going through a burnout. Things that we don't talk about enough, especially in this context.

So, it's just like you rightly said, vicious cycle.

Nitin Sharma: So, there's a stigma of Practitioner Access. But when you say A for Access, that has to do with cost as well?

Nandini Vishwanath: Cost, affordability, and you've crossed the bridge of saying, 'Hey, I need help'. But you don't know where to go.

Nitin Sharma: But the affordability is more a perception. I would venture to say that, except of course the vast majority of people who would find healthcare unaffordable in general, the cost of a session is what it ranges, I guess, 500 to 2000 rupees per hour?

Nandini Vishwanath: Yeah, the average is about 1,500 to 2,000 [rupees]. So, the cost is definitely getting better. There are services that are doing pay-as-much-as-you-want kind of services that have started. So, people can pay less than that.

Nitin Sharma: But, I think from a startup perspective, we see a number of these counseling startups, I guess one challenge is just on the unit economics.

Let's just say a thousand to keep numbers simple, a thousand rupees, that means if you're acquiring a customer for 500 rupees, and you're making a margin of even, I don't know what, 20% or so per session

Nandini Vishwanath: You are not even looking at the other infrastructure costs, for instance.

Nitin Sharma: You're looking at multiple sessions to break even and that seems likely, but we know that there is significant churn.

Nandini Vishwanath: There's multiple sessions, there's significant churn, because expectation setting is not right. There's this feeling that, you know, as soon as I go to a therapist, things will get better. And it's a long-drawn process. It's not a short-term process.

Nitin Sharma: Majority of the customers, they don't

Nandini Vishwanath: Feel unmotivated, dropout. There's no continuity in treatment that comes to the point 4, which is C for Continuity. There is no concept of interoperability in this ecosystem, right? Like if you go to a doctor for a physical illness, you can get your medical records.

Nitin Sharma: Portability of records.

Nandini Vishwanath: But with this, there's no, it's very difficult to do that, because

Nitin Sharma: If notes are not digitized, they don't get transferred.

Nandini Vishwanath: Exactly. Confidentiality is there. Data privacy.

Nitin Sharma: So yeah, I mean, it looks like systemic problems for why pure sort of counseling, connecting to a therapist platform can potentially not scale beyond a point easily in India.

Nandini Vishwanath: There's also efficacy and measurement gap solutions, which is the other point. The last reason why I think scale is a challenge is that there is no standard. There's no accepted standard across the country. These result in, you know, like I said, several counselors don't really rely on the right kind of evidence-based therapy. Because of the shortage of counselors, what has ended up happening is that a lot of people, English speaking folks, think that they can help people, admittedly with right intent, but they don't use the right methods. Which again leads to, treatment outcomes are not as promised.

Nitin Sharma: It's all a vicious cycle because it goes back to the volume of supply, quality of supplier, matching, continuity. Yeah, lots of challenges.

Nandini Vishwanath: Yes.

Nitin Sharma: I like this framework spaces or SPACE. And if this is the response to why haven't Mental Health startups scaled in India specifically, it's the right reasons. And yet it strikes me that as a VC firm or anyone looking at new innovation, you have to sort of, take a step back and go back to that spectrum, and look at the broader Self-care part of it for opportunities that might be more scalable because, the biggest thing that I think could change the space is the increase in the supply, but there are some systemic reasons why that wouldn't be. I think you mentioned 0.75 for one lakh people in India, which is, when compared to about 34 or 40 in the U.S., for example. Therefore, huge gap. There will always be systemic challenges. So, maybe we can look at that Self-care bucket and see if there are billion dollar ideas there.

Mental Wellness Tech: State of Affairs

Nandini Vishwanath: I do think that there is a lot to be done in the Preventative care or Self-care space. The challenge, however, those spaces are filled with the gamut of mental wellness tech apps, right? Meditation and habit building, that we spoke about earlier. The challenge is, there's no differentiation between any of these apps and there's a lot of clutter in the space.

The other part of this is that there's a content play here. Content by itself can be commoditized. So, it's not really sustainable in the long run. What I'd love to hear from you Nitin, is what are the opportunities that you think would be in this space?

Nitin Sharma: Yeah. So, before we go there, maybe just to summarize what people have thrown at the problem is that, like you said, content can be monetized. Second is, this guided meditation as an approach.

And I actually feel that, as interesting as Headspace and Calm are as successful businesses because of high subscription revenue, I don't think meditations is a habit that people can develop. It's a very hard thing to develop. So, it's almost like a placebo effect for a lot of people, but I don't know if that actually changes mental health for a lot of people, unless your intrinsic motivation is very high.

Nandini Vishwanath: The other element of it is that people who are proactive about taking care of themselves, right. There's a multitude of things that they can do beyond just meditation. Right? There's a lot of gaming that they can do. They can just get involved in that, it helps them ease their everyday stress.

Nitin Sharma: Yeah. And then you could argue that it's a more holistic thing. They just take better care of themselves outside. But, so this content is meditation, which is probably overdone at this point in a way, you could argue. And then, there are of course, some very interesting startups in India who are trying that, but I think the real opportunity is what doesn't exist today. And to imagine that. And of course, there's also a bucket of what I would call non-serious frivolous kind of things, like, you know, there are apps that think that just because you're journaling or, recording your moods, or, scanning your finger and all of that, that can also be in better mental health, but not sure any of that is efficacious.

Nandini Vishwanath: It also creates a new market of people who want to try these things, right? People who have tried meditation, it's hard. The amount of churn with those apps is very, very high. But across age groups, across nationalities, and therefore this is an opportunity for founders in India to build really for the world.

Nitin Sharma: But as we think about expanding that, we should first look at what's out there and let's just summarize that, right. So you've got Content Approaches.

Nandini Vishwanath: and you've got Static Content Approaches, which are just affirmations on a regular basis. Gratitude apps, for instance.

Nitin Sharma: Somewhat commoditized.

Nandini Vishwanath: Yes. So, there is Guided Meditation.

Nitin Sharma: That's the second.

Nandini Vishwanath: Lots of tech apps focusing on that.

Nitin Sharma: And we think that's actually not sufficient because it's a hard habit to develop for most people.

Nandini Vishwanath: It's a hard habit to develop, and it's not differentiated enough from each other, right. Everyone's focusing on the same market of people.

Nitin Sharma: Yeah. And these are fantastic subscription businesses, let's not forget that. They are actually great venture outcomes. And it's entirely possible that some of the meditation apps in India become sizeable, but it seems like because there is actually a little bit of churn, or not enough habit formation, and it's not a natural thing. There is a ceiling. So that's the second.

Nandini Vishwanath: And then the third is Chatbots. The Chatbots have worked well for most part and have been defining Mental Health in India, at least for the past couple of years. And we've moved on from there now because it's lack of personalization, but Chatbots continue to actually help a lot of folks who are okay talking to a bot.

Nitin Sharma: But I think the question there is, have they become venture scalable? Because to some extent, monetization, retention, is still the issue there.

Nandini Vishwanath: Retention is an issue because it's all anonymous.

Nitin Sharma: Yeah.

Nandini Vishwanath: Continuity, that we spoke of earlier, becomes an issue.

Nitin Sharma: And then you have a miscellaneous bucket of things, which I would call non-serious or frivolous, which have everything to do with mood tracking, games, some content recommendations, et cetera. I guess, no, one's done a good job there.

Nandini Vishwanath: Yeah. I think the key is that there's a lot more space to do more innovative things from a product point of view, and we've focused, all our efforts are focused on just these three or four areas and there's a lot more.

Areas of Opportunity for Founders

Nitin Sharma: Yeah. So, which is a great segue into what is our thesis?

So, Nandini, we've covered the spectrum, the problems, the challenges. And now, I think it's the most important, the most fun part, what are the opportunities for founders that are listening to this right? So, what's our thesis? And I think we discussed that, what's come out from what we just discussed is, new products around the folks who are actually in the Flourishing or the Moderate, self-care stage.

That's probably the first huge opportunity, right? And it fits really well when building something from India for the world, perhaps not being so constrained by the challenges in India itself. And so people would wonder what kind of products don't exist today. And of course, our job is not to be too prescriptive, but let's flesh out some general principles of what doesn't exist.

So, what would you say, there aren't enough things that have actually captured real cutting-edge research in this area and embed it into a wonderful product.

Nandini Vishwanath: Yeah. I think it's the huge scope of using principles of other products and using intense and psychological research and UX, seamless UX to create products for the world, right? Gaming, for instance, is a great place. People using VR headsets and VR setups is a great space to think about. A very few products that have come out in these spaces. Product innovation is going to be the key and how you  differentiate yourself from the rest of the clutter is going to be very, very important.

Nitin Sharma: So it sounds like, you know, it's sort of a combination of two or three things. CBT is one thing, but there are lots of other areas in psychology,

Nandini Vishwanath: Evidence-based therapy is great.

Nitin Sharma: Or thinking about mapping your life in various domains or mapping your goals,

Nandini Vishwanath: Milestones and accomplishments

Nitin Sharma: Milestones and accomplishments, marrying that science with what's worked really well for things like Duolingo or any app.

Nandini Vishwanath: Those nudges that make you want to do better.

Nitin Sharma: That nudges, feedback loops and behavior change.

So, and then of course personalizing this as much as possible. So, we cannot imagine it specifically, but somewhere in this, I think we believe there is a huge product opportunity.

Nandini Vishwanath: Yeah. And that it can be available, you know, off your mobile phone, in an app, easily accessible, 24/7, solves for all the external bottlenecks that you're faced with the practitioner-led.

Nitin Sharma: I think if I was not an investor, I'd probably be looking at this as its one of the best areas to build because of the size of the opportunity and the market.

Nandini Vishwanath: And there's a place to build incredibly fun stuff. But there's one thing that we should remember, however, is this is a double-edged sword. If more and more people are going to rely on their mobile phones, this is going to happen in those devices, isolation increases, dependence on devices increases. As long as there's a good balance, that is important.

Nitin Sharma: So you're saying on one hand, we need a new product that really helps people solve problems for their mental health. At the same time, you're still pushing people back to the devices and these devices and social networks are actually, we didn't talk much about it, but they are the biggest causes of these issues that people face.

Nandini Vishwanath: Yes. I think the real value is in building with a full-stack approach. Because that allows you to identify, control, evaluate, and build on a patient's experience end-to-end, right. And the biggest space here, that I see, is in the workplace mental health space. And that's a great, big, SaaS B2B opportunity out there.

And in the West companies like Lyra, Modern mental health, have actually made an impact, have been successful venture outcomes in this space.

Nitin Sharma: Yeah. So in fact, the three largest categories currently globally sort of unicorns, although we don't really like that classification, are meditations apps, therapy connection marketplaces, and workplace mental health types of companies.

Nandini Vishwanath: They've actually shown the way by saying it's possible and doing that, right. And I do think Indian workplaces are ready now. They may not have been ready a couple of years ago, but yeah, because now when you look at all your founders and all your CEOs, organizations talking about offering that space to employees, remote work has taken a toll, COVID obviously has accelerated this to a large extent. The upside is very high. Like you have high focus, high productivity environments, the employee feels cared for, right. And if I have to really talk about the startup point of view, talent requires a strong culture and capital is just not enough anymore. And this is part of all of that, right. Founders, however, have to show quantified outcomes here and show that there is the efficacy of this treatment for organizations to pay a subscription fee for a SAS product. It's also important because this covers the entire spectrum for any employee you could fall into, you could be, you could be in the Flourishing state, you could be Languishing, you have ready-access, ready-access to therapists. It's very important because it takes a long time to get to therapy.

Nitin Sharma: And I guess this is done without employees being conscious of whether the employer knows about them accessing this.

Nandini Vishwanath: There's a lot of data, privacy issues still to be solved, but they're solvable issues.

Nitin Sharma: Right.

Nandini Vishwanath: And of course, anonymous, anonymity is still possible here,

Nitin Sharma: Right. Okay, so that's the B2B full-stack approach. What about B2C?

Nandini Vishwanath: I think there is an opportunity there as well.

Nitin Sharma: Full-stack?

Nandini Vishwanath: Full-stack. You own the patient's experience end-to-end. Holistic companies look like successful companies in this space, in a B2C space.

Nitin Sharma: You would imagine a D2C brand that is focused on this?

Nandini Vishwanath: Yeah, let's think about it, right. That the Top of the Funnel has a Chatbot. And then this is possibly a D2C element to it, and then you hand over the patient when the symptoms become severe, there's a robust referral process there. So, you're actually building for the entire spectrum of a patient experience. This does seem like a little premium.

Nitin Sharma: So, you are imagining a D2C brand that might control the supply chain and training of therapists that maybe, that’s not a marketplace.

Nandini Vishwanath: It's not a marketplace, you have access to them whenever you want. Solves for the five problems that we identified.

Nitin Sharma: And potentially you can have D2C extensions around.

Nandini Vishwanath: You can have D2C extensions, you can do a subscription play here, lots of upselling play.

Nitin Sharma: Is that too premium for India?

Nandini Vishwanath: I think the top 1%, you know, the Cred crowd, as it's popularly called, would possibly find this very useful. It is clearly for people who find mental health valuable, who are proactive about wellness, and that is an increasing market in India for sure.

Nitin Sharma: I think it’s essentially a Digital Therapeutics company essentially, with behavior modification and, it's because enough people might care about this as this is a lifelong subscription, 5-10 years. Could be quite interesting from a lifetime value to CAC perspective.

Nandini Vishwanath: It solves the continuity problem for patients as well. Interestingly, the acquisition, the merger between Headspace and Ginger in the US is also possibly a great indicator of things to come.

Nitin Sharma: Makes sense. So, three part thesis. Build products from India for the world that don't exist, we imagine everything from behavioral modification, science, UX, et cetera. Then you were saying for the assistive part, B2B and B2C, both full-stack offerings to solve for the constraints required on this framework of SPACE that you came up with.

But, Nandini, at the end of the day, right, people still need serious help. And until that supply of trained or effective professionals increases, there's too much suffering. Yeah, so how do we solve supply?

Nandini Vishwanath: Supply, unfortunately, this is the big issue. It takes five years for someone to graduate with a degree in psychiatry, and we don't have enough of them as we discussed earlier, right. This is a problem that the government and infrastructure should solve. It's not a venture-backable problem, honestly. But I do think it's time to start thinking of alternative ways to build capacity. Now that could mean alternative certification courses that people can take. I also think that peer to peer help is going to increase overtime and those services and those products can be built out. What could be interesting is that just as we have paramedics that hold space until, you know, you reach a trauma center with physical health problems. I think there is space to build para-professionals for mental health that can hold space, that can help people. And depending on the severity of symptoms, can hand them over, talk about the right time to hand over.

Nitin Sharma: So, what you're saying is like supply pieces primarily, one is functional. Some of these peer communities that have come up with anonymity and also social listening and some new platforms that we've met in India who're trying to encourage people to become listeners and maybe make some money as well, but that's not the primary motivation. And some of those people could then graduate into making this a side hustle or a career choice and we should be very clear, they are not licensed professionals meant for you, if you have serious issues, but there is an entire layer you're talking about where supply could be expanded.

And I guess there is no choice, but to expand capacity in those ways. Yeah. That makes sense. So, I think this is a good point to sum up. Those other three points in our thesis, right. And I'm sure both of us and the entire team at Antler, first of all, we believe in this issue.

We want to do our best to de-stigmatize this. And, certainly look forward to hearing from many founders in this space.

Nandini Vishwanath: I think, if you're a founder building in this space, our ears are open. We have personally experienced therapy and have benefited from therapy. This is something we're incredibly passionate about. So, if you're someone building in this space, these three thesis should grab your attention. Ping any of us, write to us, we're happy to have a chat. And let's start talking about the size of this problem.

Nandini Vishwanath: It's a staggering number actually. 10.7% of the world's population struggles with some mental illness or the other.

And that translates to about one in 10 people struggling with mental disorders. And this is obviously on a spectrum. So, these disorders range from depression, anxiety, schizophrenia, you know, and a whole lot of others. In India alone, the stats are quite abysmal. 46 million of us struggle with depressive disorders and about 49 million people cope with anxiety disorders.

What people don't realize, however, is that mental illness or mental health is universal across all people. We're all on that spectrum. So, the addressable market is everyone.

Nitin Sharma: And even the numbers, you mentioned the 10, 11%, that's at any given time. So, even in a more sort of a state where you need help, pretty much everyone in the population will go through a phase in life where they need a mental health intervention.

Nandini Vishwanath: Yes.

Nitin Sharma: So, this spectrum that we talked about Nandini, I think it would be helpful for the listeners to flesh this out a little bit. So, what exactly is this spectrum?

The Mental Wellness Spectrum

Nandini Vishwanath: Sure. Broadly, there are four states in Mental Health. There's Flourishing, which is characterized by positive Mental Health.

Nitin Sharma: Things are going well.

Nandini Vishwanath: You're able to cope even if things are not going well.

Nitin Sharma: That's the key.

Nandini Vishwanath: Second is Moderate Mental Health. This is characterized by reversible disorders.

Things like stress, your work stress, things like that. Then there's Languishing Mental Health, which creates significant functional impairment. And then the fourth one is probably, you know, it is probably defined by degrees of severity there. And it's a spectrum by itself, which has Mental Disorders, clinically diagnosed Mental Disorders.

And probably for purposes of this conversation, we should keep the clinical Mental Disorders outside of this conversation. It requires medical help, professional help, sometimes medication. Tech can only solve for it in a very limited way.

Nitin Sharma: Yeah, I think that's important to point out that it's outside the scope. And if anybody is in that phase, we do not believe that tech is today able to solve any of it. They absolutely need to seek attention of clinical help. And so, what you're really saying is, Flourishing is, things are going well, you are able to cope with the negative stimuli. Moderate is when you are facing some trouble. And if that becomes intense and sustained, that's the third one? Which is Languishing.

Nandini Vishwanath: Yep. Why this is also important is that a majority of the population, all of us, oscillate between Moderate and Languishing. The solutions may overlap, but the situations are quite different. The larger question really is, how do we prevent people from moving towards suboptimal Mental Health and keep them in the Flourishing state? And that is really the goal for all mental health startups.

Nitin Sharma: So, we just established that spectrum. One of the questions for somebody who is looking at the space, or is aware of the space in general, is that there are lots of products out there. Lots of approaches have been tried, and I think it would help to contextualize those things across the spectrum a little bit. So, if you start with Flourishing -

Nandini Vishwanath: So, if you start with Flourishing and Moderate, we call it Preventative or Self-care. And there's a lot of, like you rightly pointed out, a lot of mental wellness applications. Tracking habits, sleep, productivity, meditation, yoga. There are companies like Insight Timer, Headspace, Calm.

Nitin Sharma: Most of the unicorns that people think of when it comes to mental health. There's another category that has to do with B2B, et cetera, which we'll come to, but this is the part that most people associate with. Like mental health unicorns, meditation, static content.

Nandini Vishwanath: Yes, because these also offer your micro doses on a daily basis. And that's exactly what folks in the Flourishing spectrum are able to do, right. There's also hardware & wearables, that's you know, gaining popularity. Watches, trackers that can track your biometric monitors and that data with actionable outcomes can be very valuable for that.

I think the next state which is Languishing and Moderate mental health.

Nitin Sharma: Where you need help. Where you need a therapist or you need another source of help.

Nandini Vishwanath: Absolutely. Right? And we can start off with talking about peer to peer counseling. Peer to peer help, actually not counseling. Because, this is essentially talking to an external person, a third person, who is willing to listen to you. And this again serves as micro-doses, some affirmations maybe, not necessarily talking to a therapist. When you have to talk to a therapist, there are other options. For example, Telehealth has gotten very popular over time, in the last couple of years, where a software platform connects therapists to his or her patients.

Nitin Sharma: And that's the other very common

Nandini Vishwanath: very common, increases access. but it's not the end there, right? There's also CCBT - Computerized Cognitive Behavioral Therapy. Which is one of the most popular principles in counseling psychology.

Nitin Sharma: And maybe it helps to explain what CCBT is.

Nandini Vishwanath: Absolutely. It forms the foundation of anything to do with counseling. It's highly structured. These conversations start with a goal. So, it's not like you can go to a therapist and meander about and talk about everything that affects your life.

We're talking about the current problems. We're probably talking to them about what happened in the past. Essentially, when you're facing those problems, figuring [out]. It's a very collaborative approach as well between the therapist and the person.

Nitin Sharma: And I think the key is to get to understanding some root thoughts that are causing the problem and re-wiring them and asking questions.

Nandini Vishwanath: It's not really dwelling on the past, but really saying, how are you coping with that currently? And what techniques are you learning to cope with it when it comes back again?

Nitin Sharma: So CBT has existed in counseling for a long time. It's a very popular technique. But now, what you are saying is CCBT, that's making this into a tech product.

Nandini Vishwanath: Yes. It makes it a tech product because it connects again, it's like a software where, you know, it connects the therapist to the patient. You don't have to go on the couch, for instance. Digital Therapeutics is focused on evidence-based therapy, which again is based on the principles of CBT. Both of these programs, focus on behavioral program change, don't medicate, have very definite outcomes that have to come out of it.

Nitin Sharma: Where do things like bots, therapy bots fit in? Is that CCBT or?

Nandini Vishwanath: It's probably Top of the Funnel. And depending on the severity of your symptoms, ideally, you'd probably start with a bot, which is essentially like a listening service in many ways.

And then depending on how severe your symptoms are, you would probably graduate to therapy.

Nitin Sharma: And sometimes on the tech product side, you start with a bot that is trying to take CBT and putting it into a bot. Essentially, using NLP and AI to simulate a therapist, taking the same principles you've been coded in CBT, and then the other platforms connecting you to therapists.

And of course, within that, there is sort of more computerized CBT and sometimes just Digital Therapeutics. Got it.

Nandini Vishwanath: Yeah.

Nitin Sharma: And so that's the Assistive part, and then we have some other stuff also that, that falls on that spectrum, right? Which includes things like psychedelics.

Nandini Vishwanath: Yeah, it's interesting that in the West right now, with cannabis and CBD oil being used extensively for anxiety. There's a lot of work happening there. Regulations are not withstanding.

Nitin Sharma: Yeah, unfortunately, or fortunately, I guess we can't talk much about this. But I think it's safe to say, from a tech or venture perspective, that the efficacy of those things is definitely being proven in the West, and it's a matter of time. Seems like some psychedelics are going to be mainstream at some point.

I think there are also opportunities on the provider side or the practitioners side.

Nandini Vishwanath: I think that's a much neglected space right now. There's a full stack opportunity right there to handle everything from infrastructure, the way you take notes, it's very antiquated right now, payments, tracking of appointments and scheduling. One of the biggest problems they face is churn. One of the biggest problems they face is the patient doesn't have the right expectations set. All of this can be solved with some tech.

Nitin Sharma: I think we are not going to go into detail on that, but it's actually a really interesting vertical SaaS opportunity for someone to build from India for the world. It's like we have sizable businesses serving vet clinics and fitness studios.

Like, we have our investment in Bookee for example. Similarly, isn't there a good vertical SaaS play for the therapist population abroad?

Nandini Vishwanath: The market right now in India, might be tad small, for now. But so it is certainly something to watch out for.

Nitin Sharma: So, Nandini, we've established, number one, this is a very universal problem. Everyone can be a customer.

You've established that it is a very multi-faceted topic, where you have so many different pinpoints and interventions are potentially possible. And we've also established that there have been a lot of different approaches. It's been a hybrid of, sort of, software and tech-enabled involving people, et cetera. And yet one question is why do I want to see more scale from a business or a startup perspective?

And there are some elements which are probably common to global mental health startups, with some specific to India. So, that's the question people have been covering recently. Why don't mental health startups reach scale in India. What do you think is the reason?

Identifying the main challenges: SPACE (Social Stigma, Practitioner Supply, Access, Continuity, Efficacy & Measurement Gap)

Nandini Vishwanath: I think there are five reasons that I can think of, right. Let me just quickly acronym it to SPACE so that folks can remember.

Nitin Sharma: SPACE?

Nandini Vishwanath: SPACE. S stands for Stigma, Social Stigma, all of us know it, feel it. P stands for Practitioner Supply. A stands for Access. C stands for Continuity Issues. E for Efficacy and Measurement Gap issues.

And let's go one by one. Social Stigma. We all know it exists. We all don't like it, but we all still feel it. It is getting better. Internalized stigma, for instance, affects treatment outcomes. Even if you're able to approach someone, you constantly continue to berate yourself for doing that. It's certainly changing, but it's only changing in the last couple of years.

Otherwise, you don't want to talk about who you're going to be meeting. I read this very interesting anecdote once that, in the U.S., some women park their cars or take a cab to visit their therapist, not take their cars, because they don't want people to see that they park it outside a therapist office.

Nitin Sharma: I imagine that's probably much worse in India.

Nandini Vishwanath: Yes. And there's also this fact that just blew me away. That the gap between when there's onset of symptoms and from when you take treatment is actually is an average of 11 years in a country like the U.S.

Nitin Sharma: 11 years?

Nandini Vishwanath: 11 years.

Nitin Sharma: By which point you have probably moved on that spectrum to a much worse state.

Nandini Vishwanath: Yeah. That brings me back to our next point, which is Availability of Practitioners.

Right. There's a severe shortage in India for qualified, licensed therapists. And there are multiple reasons for that, right? There's one, training infrastructure is terrible in India. We lack training infrastructure. One. Health is a state subject, which essentially means different states look at training infrastructure differently, there's no standardization. Because there's a clear lack of awareness of mental health or acceptance that this is like very normal illness or disorder that people can do, people don't choose it as a career option.

Nitin Sharma: That's really unfortunate because I think in the ranks, stack ranking of specialties, unfortunately this is last one, one of the 'lower ranked' ones. Although, that is also changing.

And people know that therapists and psychiatrists, especially in bigger cities are actually making good incomes, but there's a huge supply issue.

Nandini Vishwanath: For a hundred thousand people in India, we are at 0.75 therapists and the entire ecosystem of clinical psychologists, psychiatric nurses, counselors, everything stands anywhere between a 7,000 to a 9,000 number for a country with a large population.

Nitin Sharma: I think it's something like seven to eight, 9,000 psychiatrists. And then if we include psychologists, I think 20, 30,000 something in that range, right?

Nandini Vishwanath: It has to be at least 8x to 10x of that. Considering it's a growing disorder and people are seeking help.

Nitin Sharma: So, 0.75 for one lakh people. Less than one professional.

Nandini Vishwanath: Yes. The challenge also, the other point here is also that by the time people realize that they're struggling with something and by the time they come to seek help, and that gap is really high. They are in such a bad condition, that it takes that much more time to solve it, which also means therapists in India are going through a burnout. Things that we don't talk about enough, especially in this context.

So, it's just like you rightly said, vicious cycle.

Nitin Sharma: So, there's a stigma of Practitioner Access. But when you say A for Access, that has to do with cost as well?

Nandini Vishwanath: Cost, affordability, and you've crossed the bridge of saying, 'Hey, I need help'. But you don't know where to go.

Nitin Sharma: But the affordability is more a perception. I would venture to say that, except of course the vast majority of people who would find healthcare unaffordable in general, the cost of a session is what it ranges, I guess, 500 to 2000 rupees per hour?

Nandini Vishwanath: Yeah, the average is about 1,500 to 2,000 [rupees]. So, the cost is definitely getting better. There are services that are doing pay-as-much-as-you-want kind of services that have started. So, people can pay less than that.

Nitin Sharma: But, I think from a startup perspective, we see a number of these counseling startups, I guess one challenge is just on the unit economics.

Let's just say a thousand to keep numbers simple, a thousand rupees, that means if you're acquiring a customer for 500 rupees, and you're making a margin of even, I don't know what, 20% or so per session

Nandini Vishwanath: You are not even looking at the other infrastructure costs, for instance.

Nitin Sharma: You're looking at multiple sessions to break even and that seems likely, but we know that there is significant churn.

Nandini Vishwanath: There's multiple sessions, there's significant churn, because expectation setting is not right. There's this feeling that, you know, as soon as I go to a therapist, things will get better. And it's a long-drawn process. It's not a short-term process.

Nitin Sharma: Majority of the customers, they don't

Nandini Vishwanath: Feel unmotivated, dropout. There's no continuity in treatment that comes to the point 4, which is C for Continuity. There is no concept of interoperability in this ecosystem, right? Like if you go to a doctor for a physical illness, you can get your medical records.

Nitin Sharma: Portability of records.

Nandini Vishwanath: But with this, there's no, it's very difficult to do that, because

Nitin Sharma: If notes are not digitized, they don't get transferred.

Nandini Vishwanath: Exactly. Confidentiality is there. Data privacy.

Nitin Sharma: So yeah, I mean, it looks like systemic problems for why pure sort of counseling, connecting to a therapist platform can potentially not scale beyond a point easily in India.

Nandini Vishwanath: There's also efficacy and measurement gap solutions, which is the other point. The last reason why I think scale is a challenge is that there is no standard. There's no accepted standard across the country. These result in, you know, like I said, several counselors don't really rely on the right kind of evidence-based therapy. Because of the shortage of counselors, what has ended up happening is that a lot of people, English speaking folks, think that they can help people, admittedly with right intent, but they don't use the right methods. Which again leads to, treatment outcomes are not as promised.

Nitin Sharma: It's all a vicious cycle because it goes back to the volume of supply, quality of supplier, matching, continuity. Yeah, lots of challenges.

Nandini Vishwanath: Yes.

Nitin Sharma: I like this framework spaces or SPACE. And if this is the response to why haven't Mental Health startups scaled in India specifically, it's the right reasons. And yet it strikes me that as a VC firm or anyone looking at new innovation, you have to sort of, take a step back and go back to that spectrum, and look at the broader Self-care part of it for opportunities that might be more scalable because, the biggest thing that I think could change the space is the increase in the supply, but there are some systemic reasons why that wouldn't be. I think you mentioned 0.75 for one lakh people in India, which is, when compared to about 34 or 40 in the U.S., for example. Therefore, huge gap. There will always be systemic challenges. So, maybe we can look at that Self-care bucket and see if there are billion dollar ideas there.

Mental Wellness Tech: State of Affairs

Nandini Vishwanath: I do think that there is a lot to be done in the Preventative care or Self-care space. The challenge, however, those spaces are filled with the gamut of mental wellness tech apps, right? Meditation and habit building, that we spoke about earlier. The challenge is, there's no differentiation between any of these apps and there's a lot of clutter in the space.

The other part of this is that there's a content play here. Content by itself can be commoditized. So, it's not really sustainable in the long run. What I'd love to hear from you Nitin, is what are the opportunities that you think would be in this space?

Nitin Sharma: Yeah. So, before we go there, maybe just to summarize what people have thrown at the problem is that, like you said, content can be monetized. Second is, this guided meditation as an approach.

And I actually feel that, as interesting as Headspace and Calm are as successful businesses because of high subscription revenue, I don't think meditations is a habit that people can develop. It's a very hard thing to develop. So, it's almost like a placebo effect for a lot of people, but I don't know if that actually changes mental health for a lot of people, unless your intrinsic motivation is very high.

Nandini Vishwanath: The other element of it is that people who are proactive about taking care of themselves, right. There's a multitude of things that they can do beyond just meditation. Right? There's a lot of gaming that they can do. They can just get involved in that, it helps them ease their everyday stress.

Nitin Sharma: Yeah. And then you could argue that it's a more holistic thing. They just take better care of themselves outside. But, so this content is meditation, which is probably overdone at this point in a way, you could argue. And then, there are of course, some very interesting startups in India who are trying that, but I think the real opportunity is what doesn't exist today. And to imagine that. And of course, there's also a bucket of what I would call non-serious frivolous kind of things, like, you know, there are apps that think that just because you're journaling or, recording your moods, or, scanning your finger and all of that, that can also be in better mental health, but not sure any of that is efficacious.

Nandini Vishwanath: It also creates a new market of people who want to try these things, right? People who have tried meditation, it's hard. The amount of churn with those apps is very, very high. But across age groups, across nationalities, and therefore this is an opportunity for founders in India to build really for the world.

Nitin Sharma: But as we think about expanding that, we should first look at what's out there and let's just summarize that, right. So you've got Content Approaches.

Nandini Vishwanath: and you've got Static Content Approaches, which are just affirmations on a regular basis. Gratitude apps, for instance.

Nitin Sharma: Somewhat commoditized.

Nandini Vishwanath: Yes. So, there is Guided Meditation.

Nitin Sharma: That's the second.

Nandini Vishwanath: Lots of tech apps focusing on that.

Nitin Sharma: And we think that's actually not sufficient because it's a hard habit to develop for most people.

Nandini Vishwanath: It's a hard habit to develop, and it's not differentiated enough from each other, right. Everyone's focusing on the same market of people.

Nitin Sharma: Yeah. And these are fantastic subscription businesses, let's not forget that. They are actually great venture outcomes. And it's entirely possible that some of the meditation apps in India become sizeable, but it seems like because there is actually a little bit of churn, or not enough habit formation, and it's not a natural thing. There is a ceiling. So that's the second.

Nandini Vishwanath: And then the third is Chatbots. The Chatbots have worked well for most part and have been defining Mental Health in India, at least for the past couple of years. And we've moved on from there now because it's lack of personalization, but Chatbots continue to actually help a lot of folks who are okay talking to a bot.

Nitin Sharma: But I think the question there is, have they become venture scalable? Because to some extent, monetization, retention, is still the issue there.

Nandini Vishwanath: Retention is an issue because it's all anonymous.

Nitin Sharma: Yeah.

Nandini Vishwanath: Continuity, that we spoke of earlier, becomes an issue.

Nitin Sharma: And then you have a miscellaneous bucket of things, which I would call non-serious or frivolous, which have everything to do with mood tracking, games, some content recommendations, et cetera. I guess, no, one's done a good job there.

Nandini Vishwanath: Yeah. I think the key is that there's a lot more space to do more innovative things from a product point of view, and we've focused, all our efforts are focused on just these three or four areas and there's a lot more.

Areas of Opportunity for Founders

Nitin Sharma: Yeah. So, which is a great segue into what is our thesis?

So, Nandini, we've covered the spectrum, the problems, the challenges. And now, I think it's the most important, the most fun part, what are the opportunities for founders that are listening to this right? So, what's our thesis? And I think we discussed that, what's come out from what we just discussed is, new products around the folks who are actually in the Flourishing or the Moderate, self-care stage.

That's probably the first huge opportunity, right? And it fits really well when building something from India for the world, perhaps not being so constrained by the challenges in India itself. And so people would wonder what kind of products don't exist today. And of course, our job is not to be too prescriptive, but let's flesh out some general principles of what doesn't exist.

So, what would you say, there aren't enough things that have actually captured real cutting-edge research in this area and embed it into a wonderful product.

Nandini Vishwanath: Yeah. I think it's the huge scope of using principles of other products and using intense and psychological research and UX, seamless UX to create products for the world, right? Gaming, for instance, is a great place. People using VR headsets and VR setups is a great space to think about. A very few products that have come out in these spaces. Product innovation is going to be the key and how you  differentiate yourself from the rest of the clutter is going to be very, very important.

Nitin Sharma: So it sounds like, you know, it's sort of a combination of two or three things. CBT is one thing, but there are lots of other areas in psychology,

Nandini Vishwanath: Evidence-based therapy is great.

Nitin Sharma: Or thinking about mapping your life in various domains or mapping your goals,

Nandini Vishwanath: Milestones and accomplishments

Nitin Sharma: Milestones and accomplishments, marrying that science with what's worked really well for things like Duolingo or any app.

Nandini Vishwanath: Those nudges that make you want to do better.

Nitin Sharma: That nudges, feedback loops and behavior change.

So, and then of course personalizing this as much as possible. So, we cannot imagine it specifically, but somewhere in this, I think we believe there is a huge product opportunity.

Nandini Vishwanath: Yeah. And that it can be available, you know, off your mobile phone, in an app, easily accessible, 24/7, solves for all the external bottlenecks that you're faced with the practitioner-led.

Nitin Sharma: I think if I was not an investor, I'd probably be looking at this as its one of the best areas to build because of the size of the opportunity and the market.

Nandini Vishwanath: And there's a place to build incredibly fun stuff. But there's one thing that we should remember, however, is this is a double-edged sword. If more and more people are going to rely on their mobile phones, this is going to happen in those devices, isolation increases, dependence on devices increases. As long as there's a good balance, that is important.

Nitin Sharma: So you're saying on one hand, we need a new product that really helps people solve problems for their mental health. At the same time, you're still pushing people back to the devices and these devices and social networks are actually, we didn't talk much about it, but they are the biggest causes of these issues that people face.

Nandini Vishwanath: Yes. I think the real value is in building with a full-stack approach. Because that allows you to identify, control, evaluate, and build on a patient's experience end-to-end, right. And the biggest space here, that I see, is in the workplace mental health space. And that's a great, big, SaaS B2B opportunity out there.

And in the West companies like Lyra, Modern mental health, have actually made an impact, have been successful venture outcomes in this space.

Nitin Sharma: Yeah. So in fact, the three largest categories currently globally sort of unicorns, although we don't really like that classification, are meditations apps, therapy connection marketplaces, and workplace mental health types of companies.

Nandini Vishwanath: They've actually shown the way by saying it's possible and doing that, right. And I do think Indian workplaces are ready now. They may not have been ready a couple of years ago, but yeah, because now when you look at all your founders and all your CEOs, organizations talking about offering that space to employees, remote work has taken a toll, COVID obviously has accelerated this to a large extent. The upside is very high. Like you have high focus, high productivity environments, the employee feels cared for, right. And if I have to really talk about the startup point of view, talent requires a strong culture and capital is just not enough anymore. And this is part of all of that, right. Founders, however, have to show quantified outcomes here and show that there is the efficacy of this treatment for organizations to pay a subscription fee for a SAS product. It's also important because this covers the entire spectrum for any employee you could fall into, you could be, you could be in the Flourishing state, you could be Languishing, you have ready-access, ready-access to therapists. It's very important because it takes a long time to get to therapy.

Nitin Sharma: And I guess this is done without employees being conscious of whether the employer knows about them accessing this.

Nandini Vishwanath: There's a lot of data, privacy issues still to be solved, but they're solvable issues.

Nitin Sharma: Right.

Nandini Vishwanath: And of course, anonymous, anonymity is still possible here,

Nitin Sharma: Right. Okay, so that's the B2B full-stack approach. What about B2C?

Nandini Vishwanath: I think there is an opportunity there as well.

Nitin Sharma: Full-stack?

Nandini Vishwanath: Full-stack. You own the patient's experience end-to-end. Holistic companies look like successful companies in this space, in a B2C space.

Nitin Sharma: You would imagine a D2C brand that is focused on this?

Nandini Vishwanath: Yeah, let's think about it, right. That the Top of the Funnel has a Chatbot. And then this is possibly a D2C element to it, and then you hand over the patient when the symptoms become severe, there's a robust referral process there. So, you're actually building for the entire spectrum of a patient experience. This does seem like a little premium.

Nitin Sharma: So, you are imagining a D2C brand that might control the supply chain and training of therapists that maybe, that’s not a marketplace.

Nandini Vishwanath: It's not a marketplace, you have access to them whenever you want. Solves for the five problems that we identified.

Nitin Sharma: And potentially you can have D2C extensions around.

Nandini Vishwanath: You can have D2C extensions, you can do a subscription play here, lots of upselling play.

Nitin Sharma: Is that too premium for India?

Nandini Vishwanath: I think the top 1%, you know, the Cred crowd, as it's popularly called, would possibly find this very useful. It is clearly for people who find mental health valuable, who are proactive about wellness, and that is an increasing market in India for sure.

Nitin Sharma: I think it’s essentially a Digital Therapeutics company essentially, with behavior modification and, it's because enough people might care about this as this is a lifelong subscription, 5-10 years. Could be quite interesting from a lifetime value to CAC perspective.

Nandini Vishwanath: It solves the continuity problem for patients as well. Interestingly, the acquisition, the merger between Headspace and Ginger in the US is also possibly a great indicator of things to come.

Nitin Sharma: Makes sense. So, three part thesis. Build products from India for the world that don't exist, we imagine everything from behavioral modification, science, UX, et cetera. Then you were saying for the assistive part, B2B and B2C, both full-stack offerings to solve for the constraints required on this framework of SPACE that you came up with.

But, Nandini, at the end of the day, right, people still need serious help. And until that supply of trained or effective professionals increases, there's too much suffering. Yeah, so how do we solve supply?

Nandini Vishwanath: Supply, unfortunately, this is the big issue. It takes five years for someone to graduate with a degree in psychiatry, and we don't have enough of them as we discussed earlier, right. This is a problem that the government and infrastructure should solve. It's not a venture-backable problem, honestly. But I do think it's time to start thinking of alternative ways to build capacity. Now that could mean alternative certification courses that people can take. I also think that peer to peer help is going to increase overtime and those services and those products can be built out. What could be interesting is that just as we have paramedics that hold space until, you know, you reach a trauma center with physical health problems. I think there is space to build para-professionals for mental health that can hold space, that can help people. And depending on the severity of symptoms, can hand them over, talk about the right time to hand over.

Nitin Sharma: So, what you're saying is like supply pieces primarily, one is functional. Some of these peer communities that have come up with anonymity and also social listening and some new platforms that we've met in India who're trying to encourage people to become listeners and maybe make some money as well, but that's not the primary motivation. And some of those people could then graduate into making this a side hustle or a career choice and we should be very clear, they are not licensed professionals meant for you, if you have serious issues, but there is an entire layer you're talking about where supply could be expanded.

And I guess there is no choice, but to expand capacity in those ways. Yeah. That makes sense. So, I think this is a good point to sum up. Those other three points in our thesis, right. And I'm sure both of us and the entire team at Antler, first of all, we believe in this issue.

We want to do our best to de-stigmatize this. And, certainly look forward to hearing from many founders in this space.

Nandini Vishwanath: I think, if you're a founder building in this space, our ears are open. We have personally experienced therapy and have benefited from therapy. This is something we're incredibly passionate about. So, if you're someone building in this space, these three thesis should grab your attention. Ping any of us, write to us, we're happy to have a chat.