Episode 19: The Evolution of Telemental Health with Dr. Thomas Insel, author of the eagerly anticipated book, Healing.

Cohost Rebecca Gwilt elbowed her way through the New York Times, The Wall Street Journal, The Atlantic, and NPR to get an interview with Dr. Tom Insel, a national leader in mental health research, policy, and technology

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In this episode you’ll discover:

  • What opportunities exist for digital health companies to increase engagement in mental healthcare

  • How to use the latest technology tools to increase the quality of mental health care (and training)

  • What value-based mental health care can and should look like

Learn more from Carrie and Rebecca: 

Healthcare insights (monthly email) | Telehealth/Virtual Care Mgmt Update (biweekly LinkedIn update)

Website | Carrie on LinkedIn | Rebecca on LinkedIn | NGL on LinkedIn

 

Read the transcript:

Thomas Insel (00:00):

In mental health, unlike the rest of medicine, the people who may need care the most are the ones who are avoiding it the most. So they're not looking for care. And so it's not an access problem, it's an engagement problem, and that's a very different thing.

Speaker 2 (00:13):

You're listening to Decoding Healthcare Innovation with Carrie Nixon and Rebecca Gwilt, a podcast for novel and disruptive business leaders seeking to transform how we receive and experience healthcare.

Rebecca Gwilt (00:31):

Hello everyone, and welcome back to Decoding Healthcare Innovation. So glad that you joined us and I am so glad that I am joined today with Tom Insel. Tom is the former director of the National Institutes of Mental Health. He is a neuroscientist, a psychiatrist who founded the Center of Behavioral Neuroscience at Emory University and then he moved on to Silicon Valley to take on innovation in the mental behavioral health space joining Google and then Mine Strong. And he also, I researched you, sir, launched one of the first venture funds for behavioral health innovation. So I'm hoping you can hear why I was delighted to have him on our podcast. And welcome, welcome, welcome.

Thomas Insel (01:16):

Well, thanks Rebecca. Delighted to be here. So much to talk about.

Rebecca Gwilt (01:21):

Yes. Yes, I will. I try to draw a ring around the subject matter we're going to tackle today, but absolutely, I could talk about this for days and days. And actually the reason why I was hoping you would join me on the podcast is an amazing article you wrote in Stat Health sort of talking about the future of digital health and really the unique attributes of technology that could help us make mental health services better. So I'm excited to dig into that with you.

Thomas Insel (01:51):

Great. Well, let's do that. I mean, I'm in the middle of writing a lot of stuff because I have a book coming out on the 22nd of February, so that's right around now. And it's the book that's called Healing Our Path from Mental Illness to Mental Health. And it covers not just technology, but a whole range of issues around what I call the mental health crisis. Why have we not been done better when we've had so much progress in science? So research has given us just this whole new exciting area for cognitive science and neuroscience and genomics and all that, and huge advances in our understanding of mental illness. And yet we're still seeing people with serious mental illness who become homeless. They're incarcerated, they're out of care. They're dying 23 years early. What's with that? Why this disconnect between our scientific progress and our public health failure? And so that was the basis for the book, and it's also the basis for me, thinking a lot about can technology help to fill the gap? Can that somehow give us the tools to do better for those with the greatest needs?

Rebecca Gwilt (03:06):

Yeah. Well, so I cannot wait to read this book. I'm thinking about the trajectory of your career putting you at this space where you have a pretty unique perspective on this. I usually start these podcasts by sort of saying, how did you get here? Tell me about this journey. So I'd love to, if you just spend a couple minutes, just help me understand how you came from what sounds like an academic and public service position, bringing that all the way through to some of the innovations, and quite frankly, the companies that are tackling this in the private sector and what have you learned along the way?

Thomas Insel (03:49):

Yeah, so I start the book with this story about how while I was at the NIMH, which was 2002 to 2015, part of what you do in those roles is you're a public figure. So you spend some time talking to the public about how you're using the taxpayer dollar to actually provide a public good. And I was in such a presentation mostly with family members in the audience, with, had kids with mental illness. And I was telling them about all the spectacular work that we were supporting the stem cell work at that time showing the abnormal branching in neurons from people with schizophrenia and the work on autism and some really fascinating work that we were doing on epigenetics and stress and depression. I showed this fantastic slide deck, and at the end, some guy gets up and he says, man, you don't get it.

(04:49):

I said, our house is on fire, and you're talking about the chemistry of the paint. Look. He said, I've got a 23 year old kid with schizophrenia. He's been hospitalized five times, three suicide attempts. He's currently in jail or homeless and none of this is going to have any impact on him. And I was sort of taken aback because that's like, wow I hadn't really thought about it in that way. And honestly, that's why you do those presentations is to hear what people are thinking about what's going on. And I began to think so if the house is on fire, and I think it is for a lot of families and a lot of young people with serious mental illness, how do we put it out and what can we do? And it's not just more papers in nature or science. It's got to be something that actually has an impact for those families.

(05:44):

So that was part of the move to Google was to say, can we bring the force of technology, the opportunity with, to be work in a company with big data, deep pockets huge social commitment. Is there a way to do something here that could be exciting? I think it's hard. I think this last five or six years has been, I would call it transformational for the field of mental health, especially during the pandemic. The entire field has moved to telehealth from brick and mortar. We've seen the sweep up of lots of small private practices into huge, massive groups with thousands of individuals. So you have private equity backed efforts to do that life stance, which is now public company probably the most well-known. You've got enormous number of companies that have some of the very recent, that become very big, that are providing more convenient care through telehealth than through platforms that they've built or platforms that they borrowed. It's pretty interesting. So this is a moment of tremendous change, but the question still remains, are we putting out the fire?

Rebecca Gwilt (07:00):

Yeah. Well, wow, that's super powerful. Yeah. Well, so I was going to ask you what has it felt like these last, I would say probably two or three years with the absolute explosion in the number of companies, the amount of services, and frankly the amount of dollars going into remote behavioral health technologies. What is your take on that? It wasn't that certainly the pandemic accelerated these movements, but it didn't start with that. I mean, what is your take on this? We've got Cerebral and Headspace Health and Calm just acquired a healthcare company, and of course there's talk space and better help. I mean, these companies are proliferating, they, they're becoming unicorns in the space. Are they making an impact?

Thomas Insel (07:59):

It's a great question. It's a little early to know. So they've solved a couple of problems. I think they've helped to solve the access problem. So we've known that there was a massive sort of supply demand imbalance here. They've increased supply. Of course, the demand has gone up at the same time during covid. So when you ask are they having an impact, sometimes it's a little hard to know because we don't have all the data in yet. Sure. But I think for me, the big question is are they changing outcomes at a population level? And to be fair, we weren't doing so great before. So the traditional healthcare system that we had, the brick and mortar care, which had some 700,000 people in the workforce doing probably a hundred thousand different things most of it not based on science and almost none of it being measured, so weren't actually capturing outcomes for most people doing psychological care in the outpatient world I don't think that's great.

(09:09):

I don't think it would meet the standards that we have for most of medicine. So we are now in a world where people are doing things that are a little more standardized. They're doing, they're capturing information online they are providing more accessible, more convenient care. So that I would call and sort of chapter one, I think we've done one thing that's really interesting, which is allowing a lot more people to get help, either, whether that's access to medication or access to psychological therapy. I mean, you take it, you mentioned Cerebral. I think they currently have about 150,000 people on their platform, and probably a hundred thousand of those were not in care before. So that's pretty important.

Rebecca Gwilt (09:57):

Yeah, it's absolutely incredible because I studied policy before healthcare policy before I went to law school, and before that I was writing about it for my college newspaper. And there's been a ton of money and a ton of legislation enacted from the policy perspective to increase access to mental health services. And it seems to me that those efforts have been eclipsed by private sector companies that sort of solved this sort of access and labor and pricing issue. Does that resonate with you, or am I too embedded in the today?

Thomas Insel (10:42):

So we're not quite there. I think one of the issues that we should talk a little bit more about is with reference to that man who said that his son had been in jail and made suicide attempts and had been so ill, it's not clear that all those companies that we talked about before are really addressing his needs. So I think a lot of what's happened has provided access to people who are looking for it in mental health. Unlike the rest of medicine, the people who may need care the most are the ones who are avoiding it the most. So they're not looking for care. And so it's not an access problem, it's an engagement problem, and that's a very different thing. So I don't know that we've solved the engagement problem, and I don't know that we've addressed the 14.2 million people with serious mental illness.

(11:34):

The people who are needing help the most often getting at the least not clear that that group of people has been, the outcomes have changed for them based on technology and the digital mental health revolution. It's also, I think it's really important to distinguish not only access from engagement, but access from outcomes. So the key to ask the real, I think to me the question in 2022 has all of this investment altered outcomes at a population level. And I don't think we know that. I mean, that has to do partly with access, a lot more with engagement, and most of all with quality. And it isn't entirely clear to me yet that we've altered the quality of care. We've certainly provided more access to what people used to get in the brick and mortar system, but whether we've improved the quality or whether we've just taken that online, somebody said to me recently complaining about my enthusiasm for digital mental health, they said, oh, that's great.

(12:46):

You're just giving crap at the speed of light. That's terrific. So I take that as a, I hear that and I understand the concern. I do think that we have to focus on for chapter two, the next part of this transformation, we really have to focus on quality and what quality requires is better measurement. And that has been, for the most part, as traditional mental healthcare has been a data free zone. There's no measurement. Less than 20% of providers use measurement based care for anything. They don't measure anything except whether somebody pays or not. So I think getting our telemental health world in this kind of, from moving it from 1.0 to 2.0, the 2.0 will be when we start to embed measurement, and then we begin to learn and then we can improve quality, and then I think we can improve outcomes. Now, to be fair, some of the companies are doing this. A lot of them the ones that you mentioned, Cerebral, G,inger LiRA, a lot of them are already moving into that space.

(13:57):

It's going to be super interesting to see what they're able to do. And I should just add one other thing, Rebecca, is that we're a little behind the game here because this was all done in the UK in 2008, where the entire field of psychological treatments was moved under something called iapt, increasing access to psychological therapies with a whole new workforce. And that workforce was required to measure every interaction and to document exactly what was going on. And sure enough, outcomes got better. They had 7,000 people trained up treating 500,000 people a year, and they're now able to show population level improvements, which is pretty terrific. So we know this should work, but it's not being done yet in the digital mental health space.

Rebecca Gwilt (14:49):

Are there companies that are drawing on that sort of research and the lessons learned from the implementation in Europe to bring it here?

Thomas Insel (15:00):

Well, a lot of it's happening in the UK. So IAPT itself is beginning to move into using more technology. And there's a company that I like a lot, but it's not in the US yet called IESO, I E S O, that's done exactly that, using natural language processing in every interaction to give both the therapists and the patient a measure of therapeutic alliance and a measure of sentiment and a measure of outcomes, all of that. It's not that hard. We know how to do this. They've been doing it for years. But what's so cool about this is they've been able to show, because they treated about a hundred thousand patients and with about 500,000 hours of therapy for which they have a text engine to be able to train people up to get better and better at what they do. And as they do that, the outcomes improve.

(15:47):

It's amazing. They've gone from 46% I think that's 49% recovery remission to about 76%, something like that, remission over the matter of three or four years. And it's just because they use feedback. That's what we do in diabetes. It's what we do in treating hypertension. It's just in mental health. We have not been able to measure and learn from measurement. So we need to start doing that. And my excitement really about the digital mental health space and IESO is a beautiful example, and IAP as an example, isn't just that they've increased access. It's that they've improved quality, and by improving quality, they've demonstrated that you get better outcomes. We know this, we in the rest of medicine, we've just been slow to this party in the mental health space.

Rebecca Gwilt (16:38):

Yeah. Well, and to your point about sort of outcomes that is, and data that is how companies now are moving into with confidence, the sort of value-based payment models without a way to measure or without metrics for what improvement looks like, what quality looks like and what outcomes need to be. It will be hard for payers to, to pay providers of mental health services based on value. Are we going to see in 2.0 that start to happen?

Thomas Insel (17:18):

I hope so. I think that is where we'll need to get to ultimately is we need to incentivize recovery not to incentivize more treatment. Don Burwick who has been in some ways, my mentor these last few years says, until we make a,

Rebecca Gwilt (17:36):

I'm a Don Burwick fan girl, just so you know. An old CMS staffer from the Donnie B days. So please pass it on to him.

Thomas Insel (17:45):

Yeah <laugh>. All right. Well I love so much of what he's written, especially his recent work on the moral determinants of health, which I think is fantastic. But he once said that we've got to get to a point where we make an empty bed worth as much as a filled bed in a hospital. And I think that sort of captures where we need to get to that we need to build the incentives for health, not for illness right now. Absolutely. People get paid for keeping, in a way, especially in mental health, you get paid based on somebody showing up and staying in therapy for as long as possible. That's right. That's right. That's not how you would build the system if you were trying to focus on health instead of sickness.

Rebecca Gwilt (18:31):

Yeah, yeah. Well, and to your point, what a lot of the value-based programs right now are focused on sort of interventions before the really bad stuff happens. And to your point about engagement, that's generally not the, that's generally not what happens in mental health. You go through crisis, you enter therapy, and then you exit therapy perhaps when you're outside of the crisis. But I want to go back, the last thing I want to pick your brain about today is I want to go back to your statement that digital health companies or digital health itself or digital tools have the ability to increase engagement for those who are not aware of therapy or who generally wouldn't seek out therapy. And I think there's a lot of, when I read this article in stat, and for everyone listening, I will put it in the show notes. It's an amazing article, go out and read it immediately twice. But I would love to hear you talk a little bit about how digital health has digital health companies can leverage technology to actually increase engagement in mental healthcare, perhaps for those who are pre-crisis or hopefully never have to experience a crisis because they've had access to the right care.

Thomas Insel (19:52):

So there are a few answers to that. I started a company about two years, actually exactly two years ago, called Humanness Care. Humanness instead of Humanist. Humanness was the idea we had was we really wanted to go after engagement. We saw that as the big problem. And so we looked around and we thought if we could combine Peloton and the Minute Clinic for mental health, we could probably do that. What do people love about Peloton? Well, they love partly the social piece of it, that they come together, there's a good coach who's very enthusiastic, but they also have a chance to engage with others. And it's like a social hour. It's like going to Starbucks on your bike. And so there's a piece of that. So what Humanness did was to create community and to really build out an opportunity for people to connect to each other.

(20:47):

And by the way, what we discovered is that act of helping somebody else is one of the most therapeutic things you can do. There's nothing as powerful. It's more powerful than any medicine, than any form of CBT is phenomenal. And yet our healthcare system never allows that to happen. Almost never. So Humanness said that's one way to engage is to bring people in, not for what's wrong, but for what's strong, help them to actually take their experience and help somebody else. And amazingly, people want to do that. Especially young people really engage in that. The other thing we learned was the current system is so difficult for people to navigate. They seek care and their set, and we tell them, yeah, we'll find a slot for you in three weeks. Mental health is, it's hard enough to ask for help, but when you do finally get to that point, you want help now, not three weeks from now.

(21:48):

So it's no surprise that so few people actually show up in the old brick and mortar world, someone told me that the average number of visits is less than one because people don't actually come after they made the appointment. And if they do show up, most people don't return. It's about 1.4 overall. So we thought we can do so much better. And part of that is being available at the time of need, not at the time when your calendar opens up. So that's the Minute Clinic combined with Peloton as a way to engage. And I think other companies are figuring this out as well, that there is an opportunity to reach people in that way. The last thing I'd say about that is we ought to think about meeting people where they are, because you're absolutely right. A lot of people do not want to come for healthcare, but almost everybody's on social media.

(22:41):

And the question ought to be that's sort of everybody points to social media as the problem for mental health, but I keep asking myself, could it also be a solution? Is there a way to meet people there and provide the care for them on that platform that doesn't look like the kind of care we're used to. It's not kind of traditional mental health care, but it's something that allows people to actually recover and to get on without needing to become right formal patients. I don't know how that's going to work, but it's certainly, I think, worth exploring. I think we have now opportunity that we ought to think about, rather than just blaming the social media companies for wrecking the world, let's ask them to help fix it.

Rebecca Gwilt (23:36):

So I usually end these podcasts with sort of what's one thing that you piece of advice you would give to the listeners who are entrepreneurs, who are launching companies in this space to supercharge their success. But actually, I think everything that you've said today is a piece of advice for those. So I'll just skip that here and tell them, just re-listen to the podcast. And by the book Healing, we'll put a link to the book in the show notes. And then I'd just like you to possibly close with one reminder for the folks out there who are working to create what digital mental health is going to look like in the future, what's one takeaway you might want them to keep in mind as they're building and creating?

Thomas Insel (24:34):

Yeah. I think for me, the biggest epiphany, if you will, has been that again, channeling Don Burwick to realize that mental health is not just about mental health care. And if we really are interested in mental health, we have to think beyond the traditional care system and think about what I call the three Ps people, place and purpose. So creating social support, creating communities, and a place where people can meet and giving people a purpose, giving them something to care about. All of those things are not what we do in the traditional healthcare system. It's what we have to do if we really care about mental health.

Rebecca Gwilt (25:23):

I have to absorb it. I have to absorb it. It has been such a pleasure to speak with you. Thank you. Thank you for spending your time here. If anyone needs to reach Tom or find out a little bit more, we're going to have his information in the show notes. Of course. Share this far and wide, and please go out into the world with kindness and good intention and help us build 2.0.

Thomas Insel (25:51):

Thanks so much, Becca. What a pleasure. Take care.

Rebecca Gwilt (25:55):

Bye.

Mental Health, Digital Health, Value-Based CareNixon Gwilt LawDr. Thomas Insel, Healing, Telemental health