Mental Healthcare is in need of disruption. Can tech startups keep India sane?

‍It was a Sunday night when a friend DMed me on Twitter, asking if I was free to call. I offered to text instead. My conversations with friends are limited to texts after 8 PM, as I spend this time with my son, desperately hoping he’d sleep so I can wallow in my Sunday evening anxiety.

He didn’t text back.

A week after that, he reached out again, asking for help in finding a therapist. He didn’t know how to find one, “I don’t move in those circles, you know?”, he said.

It is always great to see more and more people willing to address mental health issues. Yet, as the conversation around mental health slowly expands, it also exposes the reality of crumbling support structures, lowered resilience levels, and the multiple failing points across our public and private healthcare systems. This is disheartening. The process of accepting that one needs help is difficult enough itself, the other steps needed in this journey should not add to the difficulty.

I believe technology can help bridge this gap. The opportunities to innovate, build, and invest in mental health are immense. And the motives go beyond financial ones. Given how pervasive mental health problems are, these products can genuinely change lives. In fact, mental health tech may be one of the most significant spaces of the future. In this piece, I present a deep dive into the future of mental health tech, from the present landscape and the biggest issues to the most exciting opportunities for entrepreneurs to build in.

But first, the basics. Given all the talk around it, what exactly is “Mental Health”?

The ABCs of Mental Health

Mental health, in its widest sense, refers to “our emotional, psychological, and social well-being. It affects how we think, feel, and act.” (mentalhealth.gov). Issues with mental health are far more universal than people realize – one does not necessarily have to be clinically ill to have a mental health issue. In fact, mental health is better represented as a spectrum, and all of us fall somewhere on it (making everyone the Total Addressable Market).

Mental wellness can roughly be classified under 4 segments of this spectrum

1. Flourishing Mental Health - Characterized by positive mental health involving largely stable mood, healthy coping mechanisms, consistent performance, normal sleep patterns etc.

2. Moderate Mental Health - Characterized by common & reversible distress involving irritability, impatience, nervousness, worry, procrastination, forgetfulness etc.

3. Languishing Mental Health - Characterized by significant functional impairment involving anger, anxiety, lingering sadness, tearfulness, hopelessness, worthlessness etc.

4. Mental disorder/ Clinical disorder - Characterized by severe and persistent functional impairment involving panic attacks, depressed mood, feeling overwhelmed, constant fatigue etc.

Prevent and Assist: State of Affairs in Mental Health Tech

Given the wide range of mental states, a one-size-fits-all solution would not work. Therefore, based on the classifications in the spectrum, the solutions that are presently on offer come under two buckets – Preventive Care, and Assistive Care. Roughly, the former covers Flourishing and the lower end of the Moderate spectrum, while the latter is meant for the upper end of the Moderate and the Languishing spectrum. This is what it looks like:

Preventive Care is meant for folks with largely good mental well being, primarily lying in the Flourishing and Moderate segments. Their main aim is to maintain this positive mental state. A major chunk of Preventive care comes under self-care. This includes:

1. Mental Wellness Applications like meditation apps, habit trackers, journaling apps and productivity markers help individual build systems for resilience. These work by ‘micro-dosing’ wellness, nudging us to build habits that will eventually protect one’s mental health from worsening when something goes wrong. They may often seem rather simplistic, doing only one task on the surface, but this habit-building during times of good mental health is precisely what makes these apps successful. Headspace, Calm, Day One, and Pomodoro timer apps fall under this category.

2. Hardware Solutions like fitness watches and other wearables that track your sleep, nutrition, and other vitals have become more accessible in recent years. These allow us to understand the physical manifestations of mental health better, and take steps towards preventive care. The tracked data, along with actionable insights, can be a game-changer. Moreover, acting as affirmative self-care, these devices also ease the burden on already overloaded mental health professionals. Eg. Feel, Oura, Vytal etc.

3. Peer-to-Peer Help is one of the most decentralized solutions to this problem. It can be described as help and support from a patient’s peers, or in simpler terms, people who have been through similar experiences. This support can be in various forms, such as passive listening, active suggestions, and more. However, the challenges with peer to peer help abound, including data privacy issues and achieving scale while maintaining quality. Eg. Talklife, Shimmer, Now&Me, Mindpeers.

While preventive or self-care works for folks in the Flourishing to the low-Moderate range, as we move further along the spectrum, a different level and type of care is required. In fact, for people in the Languishing state, preventive care can lead to a placebo effect, resulting in long term mental health issues. This is where Assistive Care comes in.

1. Telehealth services provide software that allows for a communication interface connecting patients and counselors digitally. The goal here is to be available 24/7, provide unlimited access to in-house counselors, and make sure everyone who needs help can reach out. There are very specific capacity and scaling challenges that these platforms face, especially with a shortage of therapists. Apps such as TalkSpace, Inner Hour, BetterHelp, etc. fall under this category.

2. Computerized Cognitive Behavioral Therapy is an online variant of Cognitive Behavioral Therapy (CBT). CBT is one of the most used, most well researched, and most effective approaches used in counseling. Earlier, this took place offline. Lately, however, Computerized CBT programs have become popular, which involve a series of online sessions and interactive experiences, with “homework” to complete in between sessions. One of India’s earliest mental health startups, YourDost, uses CCBT techniques.

3. Digital Therapeutics are evidence-based therapeutic interventions that are driven by high-quality software programs. They help patients cope with their various illnesses through nudges, recommendations, reminders and alerts. They aren't exclusively used for mental illnesses, but the use case for mental illness is impactful. Eg. Pear, Livongo, etc.

B2B solutions

On the other hand, there are also solutions on the practitioner’s end (Provider’s tools) to provide operational efficiency and solutions on the B2B side, which is also a large category. Here, tools are used to assist businesses with employee mental health, from general mental wellness, to therapy sessions with professionals. Lyra, Modern Health, Wurkwell, SilverOak Health, Happy+ etc. occupy this space.

As one can see in the India landscape, currently, the mental health tech space is fragmented, with apps offering functionality in one or two specific areas such as consultation, behavior change, meditation, etc., as opposed to a holistic, full stack approach. Wider functionality may be key in the future, and I will talk about this in detail later in the thesis.

Furthermore, a lot of applications–Telehealth, CCBT, B2B, and Childcare–all serve as a platform to connect patients with practitioners. Although this is an important function, such apps are limited by the total availability of practitioners, which is an overall supply issue.

Challenges in this SPACE

Given the sheer number of people affected by it, with 56 million cases of depression, and 43 million of anxiety disorders, the mental health space has been given a surprisingly low amount of attention in India. If we look globally, very few countries have adequate infrastructure and policies. While things may look hopeful in India now, with the government announcing the National Tele-Mental Health program in the 2022 Union Budget, the actual allocation of funds is about 0.8% of the Health budget, similarly low as the previous years.

The deficient infrastructure acts as a detriment for those aiming to build in this space. There are primarily 5 issues affecting Mental Health Tech–Stigma, Practitioner Supply, Accessibility, Continuity, Efficacy. This can be remembered through a simple acronym–SPACE.

S for stigma

The stigma against mental health is internalized to the extent that even the most vocal of us are ashamed to openly talk about our problems. There’s a stark difference between how we treat physical illnesses as opposed to mental illnesses–we proudly carry casts, publicly share our experiences with certain common diseases, yet we carry our mental health scars privately. This means that we don’t seek help as soon, as often and as transparently as we need it. And the more we delay help, the more the illness gets aggravated.

P for Practitioner supply issues

For every 100000 people, we have a mere 0.75 mental health professionals in India. Even if we count all the professionals in the system: psychiatrists, psychiatric nurses, counselors, social workers and others, the total number of professionals in India stands at a dismal 9000. We need three to four times the number of mental health professionals to serve our population. Practitioner supply hasn’t gone up in years owing to the poor education and training infrastructure for these courses. Furthermore, students coming out of these colleges aren’t trained in an informed and inclusive way. The salaries aren’t on par with the industry, and professionals are overwhelmed with the sheer number of patients.

A for Accessibility

One can’t just go to any therapist and expect it to work, the patient and the therapist need to be compatible. Patients who’ve crossed the bridge with stigma and are actively seeking help can’t always find licensed quality professionals to help them, especially when one needs to find the “correct fit”. There is no framework present to make this process easier either.

C for Continuity (or the lack thereof)

Lack of continuity is a huge challenge in this space. This is especially true for patients struggling with multiple illnesses. Often, conversations and triggers get repeated, and outcomes are poor or slow. Interoperability between transition from a counselor to a psychiatrist is also lacking, there is no easy way to port a patient and their contexts from one professional to another. Thus, as many as 3 out of 4 patients end up dropping out of therapy prematurely.

E for Efficacy measurement

Ideally, efficacy measurement should help assess whether patients are receiving adequate care that results in progress. These measures help professionals iterate and change treatment options accordingly. Gaps in Efficacy Measurement primarily occur due to the lack of standardized industry-wide means to measure outcomes. Several practitioners, who aren't qualified or licensed, do not consistently adhere to evidence-based guidelines and there is an incredible variance in quality.

Looking Ahead- The Opportunities

The issues in this space also translate to a number of opportunities. While the main issue, that of practitioner supply, needs intervention at the governmental level, technology can still be used to improve the situation.

At the pre-practitioner stage, this can be done through:

1. Product Innovation at the intersection of AI x deep research x gamification x UI/UX

So far, we’ve seen a variety of techniques including meditation, habit building, and digital journaling take center stage in the preventative or self-care category. What one must remember is that app or not, these are hard habits to build. And this space is cluttered at the moment.

We strongly believe that preventive care is important and needs key innovations in product thinking. There is a lot of scope to build at the intersection of design, cutting edge research in psychology and technology to create beautiful and powerful products.

We foresee gamification, incentivisation to encourage habit-building through a set of principles that are evidence-based and rooted in behavioral science. How to personalize this and yet be able to achieve scale is going to be significant. Imagine a video game that uses historical data to identify patterns and develops a highly personalized action plan and nudges you towards self-care. This can get highly addictive and have a powerful impact on your mental health. Needless to say, technology addiction is a double-edged sword. Balance is key, and should be an integral element in this kind of product thinking.

2. Full Stack Mental Health Care

The real value lies in building with a full stack approach. We believe that maximum value accrual happens at scale only when you are able to understand, control and improve the entire span of a patient’s experience end to end.

Both B2B full stack and B2C full-stack are huge opportunity areas in the assistive care space - targeted at people in the middle of the bell curve, where a practitioner may need to get involved.

B2B Full Stack Care

Bringing the patient, the service provider, the insurance company and the employer(s) all on one platform to build a comprehensive service to the workforce with ready and quick access to therapists is the way to go. The success of this approach has been proven repeatedly in the West with companies like Lyra, Modern Health. This ensures that there is data in place (hopefully with the right kind of data privacy rules) to determine further course of action. Since this includes the end to end patient experience, it solves problems of continuity and efficacy measurement as well.

B2C Full Stack Care

The same principle holds here too. We think that companies building in this space have to be holistic. For instance, if you’re building a monitoring product or an app with some content, rethink on how to build a complete solution in itself to help your users manage their illness.

A major problem with mental health products built for consumers is that they fail at accomplishing specific outcomes owing to a lack of continuity or lack of efficacy in measurement. Setting specific goals and being able to nudge the patient towards the next milestone or next set of help can significantly improve the patient experience. Hybrid chatbots and content can be used for the top of the funnel and other services can be upsold after.

3. Innovation in Supply

All this said and done, the big problem of the patient-therapist ratio continues to loom over our heads. It’d be interesting to consider alternative approaches to build a paraprofessional force through certifications, for instance. A large part of preventive care can revolve around peer to peer help and this may require an altogether different approach. In this, individuals can get trained in a variety of skills and techniques to help other patients, who happen to be their peers. This should lead to a more qualified pipeline for therapists and at the same time, everyone who needs help can receive it.

And these merely scratch the surface. As we tread further into this space, newer possibilities will open up for innovation. It is important, however, that as more options surface and people become comfortable with getting help, the stigma decreases further. Suffice to say, mental health tech is just getting started.

At Antler India, we understand the value of mental well-being. We have seen the benefits of therapy and want to be able to help founders looking to disrupt this space. So, if you are building in this space, contemplating building in it, or are interested in brainstorming ideas, we’d love to hear from you and support you!