The Future of Behavioral Health is Value-Based

For many Americans suffering from mental health issues, finding the right clinician can seem like an insurmountable challenge.  This problem is exacerbated by the lack of clinicians who can serve the staggering number of Americans coping with psychiatric conditions. An estimated 1 in 5 adults in the U.S. have experienced a mental illness, and 1 in 20 experienced a serious mental illness (SMI) in 2020. Indeed, only 46.2 percent of individuals suffering from mental illnesses in this study received treatment.  In our State of Care report we looked at why so few people are able to access care and found that it often comes down to a few key factors: cost of care, lack of providers who take insurance or are in-network, long wait times for an appointment, clinician fit (e.g., cultural, stylistic, etc.), and clinician availability. We examined each of these concerns in depth in our report and in our companion blog post in September, but today we’d like to highlight perhaps the most nebulous and hard to measure of all those issues: clinician fit. Why We Need Clinician Fit Mental health treatment is a very personal process, one that is most beneficial only if a patient is comfortable to fully engage in their treatment. Unlike some medical specialties like surgery or radiology where bedside manner is relatively less important, mental health care requires a personal connection between patient and provider.  This predicament is doubly-true for minority populations, who already suffer from lack of representation among mental health clinicians. Many black, Hispanic, and LGBTQ patients, among others, often report that they are unable to find a mental health care provider who comes from a similar background, or who can relate to their experiences. The mental health care profession is predominantly white, leaving patients from diverse backgrounds at risk of feeling uncomfortable or at least hesitant to begin treatment.  Clinician Matching and How it Can Help This is why it is so important to feel comfortable with your mental health care provider. As digital-only providers are not bound by location restrictions, telehealth companies already have access to a more diverse set of mental health care professionals than brick-and-mortar peers provide. Instead of just matching patients based purely on availability, telehealth companies can take into account patient preferences.  Clinicians can be assigned to patients based on their familiarity with specific conditions like anxiety, bipolar disorder, or schizophrenia. More personal factors like ethnic background, age range, and gender can also be factored in if patients wish. These preferences can be determined by a simple questionnaire. Why it Matters  Improving clinician fit ultimately improves treatment, by helping patients feel comfortable and allowing it to begin more quickly, a critical consideration in serious mental illnesses cases where self-harm is a danger. And, by measuring and tracking how patients respond to providers that more closely align with their preferences, we believe we can make a fundamental improvement in outcomes. Clinician fit is yet another example of how telehealth can be a solution to issues that have been a hurdle for patients and providers alike for decades. With the right tools for patients and clinicians, we can reinvent the field and deliver on our mission to broaden access to  mental health care for all.

Despite Medical Progress, Suicide Remains Difficult to Treat Even as medical care has progressed, one leading cause of death remains tragically high suicide. Despite persistent research over the past decades, suicide rates have only increased , and self-harm remains stigmatized for families and among caregivers.  In some ways, suicide is among the last of the medical taboos, and that makes sense: doctors don’t like to talk about ailments they can do little about. Even at the best hospitals in the world, psychiatrists fail to predict whether a depressed patient will take their own life after leaving the hospital. Studies show that they have just over a 50 percent probability of making an accurate assessment. Ineffective prognosis and treatments make medical professionals reluctant to take on these difficult cases, leaving patients and families even more isolated. A 2019 study found that willingness to treat was significantly lower and the likelihood of referring out was significantly higher among therapists for suicidal patients.”  To make matters worse, medications intended to alleviate depression and other mental health conditions can take weeks to take effect, leaving some patients especially vulnerable as they await the onset of effect. Overcoming Stigma and Developing Proactive Treatment We can and must do better. Suicide is a national emergency. Every 11 minutes in the United States, someone takes their own life, according to the Centers for Disease Control, and suicide rates increased 30 percent between 2010 and 2018. In 2020, suicide was the second leading cause of death for Americans aged 10 to 14 and 25 to 34. Rates of suicidal thinking are even higher. The CDC estimates that in 2020, 12.2 million adults seriously considered suicide and 1.2 million actually tried to take their own life.    Given the pervasiveness of suicidal ideation in the United States, mental health providers must adjust how we treat and think about suicide. In order to help these patients, we have to dismantle the stigma around talking about suicide. This starts with consistent screening for depression during routine physical exams. Removing stigmas starts with the clinician. If clinicians initiate the conversation, patients may feel more comfortable discussing topics they may have otherwise been too nervous to bring up.        In addition to clinicians, our medical system must broadly establish consistent screening for depression just as it’s done for blood pressure, high cholesterol, as well as much more intensive diagnostics like endoscopies and colonoscopies. Depression should be among the first things physicians and nurses ask about during physical exams - and yet often, it's the last. In fact, a panel of medical experts recently recommended anxiety screening for all adults under 65.        Fifty years ago, the diagnosis of cancer was similarly stigmatized, for the same reason that clinicians were not well-equipped to manage these conditions. The advent of new treatments, better outcomes, and advocacy efforts by medical professionals and patients alike changed perceptions about cancer completely. We can similarly change how we as a society think about suicide through a concerted effort to develop better treatments, improve outcomes, and increase awareness and acceptance.         In particular, telehealth offers a much-needed resource to address the current situation by providing access for patients who haven’t been able to seek mental health care in the past, were excluded in underserved communities, or didn’t feel comfortable seeking care. New Approaches Offer Promise As a first step in improving clinical care and outcomes, we need better measures of treatment for suicidal patients, something that is sorely lacking today. Better data, consistent measurement, and more widespread benchmarks would be a helpful first step. Then, we need to develop interventions that can decrease suicidal thinking.      Some developments are promising. New research indicates that even brief regular contacts with patients experiencing severe depression through post-cards, text messages, emails, phone calls or other communication can decrease suicidal ideation.        This approach helped inspire a new paper that I co-authored with colleagues at Harvard on Bibliotherapy. After suicidal patients read brief, first-person narratives about coping with suicidal ideation written by other people who overcame suicidal thinking, the readers themselves experienced lower rates of suicidal thinking. Bibliotherapy is cost-efficient, easy to scale, and a method of treatment Cerebral intends to launch in the next few months. How Cerebral is Making A Difference At Cerebral, we understand just how prevalent suicide is and how difficult it is to treat. And we are committed to taking on the toughest cases and making a real difference for suicidal patients and their families and utilize a comprehensive treatment plan.       Our organizational structure includes a comprehensive Clinical Safety department that includes crisis specialists, psychiatrists, and data scientists. With this crisis response capability in place, our goal is to make sure no one is neglected by the mental health care system and everyone receives consistent, measurable and high-touch interaction.      Cerebral’s data-driven approach is instrumental in improving clinical safety. Each day, Cerebral receives 5,000 to 10,000 patient messages via a chat system available on our website or mobile app. We are using machine-learning to analyze these messages, and we can correctly detect messages with suicidal content with 97% accuracy, and reach out to these patients within minutes.  This system can also serve as a way to connect with patients regularly and keep them close touch with their care team, as each patient message is reviewed and addressed by our patient support team.         Conclusion As the new research indicates, there are reasons to believe we can make progress in combating the scourge of suicide. As a psychiatrist and CEO of Cerebral, I have seen the devastating impact suicide has on individuals and their families firsthand. During medical training, medical students typically wore short white coats while more senior doctors were clad in longer ones, symbolizing that they had already completed the process of learning. At Massachusetts General Hospital, where I trained, all doctors wore short coats to emphasize that real learning never ends. We always practice medicine; we do not perfect medicine. That is the mentality which I bring to Cerebral. In order to improve care for our most vulnerable patients, we need to remain humble, data-driven, and committed to becoming life-long students of medicine. Too much is at stake for us not to try.  Resources: Suicide and Suicidal Behavior Prediction of Suicide Attempts Using Clinician Assessment, Patient Self-report, and Electronic Health Records | Electronic Health Records | JAMA Network Open | JAMA Network  To Treat or Not to Treat: The Effect of Hypothetical Patients’ Suicidal Severity on Therapists’ Willingness to Treat  Facts About Suicide | Suicide | CDC Advancing the Understanding of Suicide: The Need for Formal Theory and Rigorous Descriptive Research Taking care of suicidal patients with new technologies and reaching-out means in the post-discharge period

Millions of Americans who suffer from mental illnesses go untreated. This number has only risen since the onset of the COVID-19 pandemic, with fresh headlines detailing how serious the crisis has become. Just this month, for example, new data released in the American Journal of Preventive Medicine showed that almost 1 in 10 Americans suffer from depression. However, many victims of depression, anxiety, and other mental health conditions are simply unable to access the care they need for their conditions. At Cerebral, the majority of the patients who come to our platform haven’t been able to access high quality care through other avenues. In an effort to bring more attention to this issue, we have published our inaugural State of Mental Health Care report today. Its aim is to take a holistic look at the mental health field and provide Cerebral’s perspective on the potential solutions to our field’s main challenges. The full report can be found here. Barriers to access: why are so few people getting treatment? To compile our report, we evaluated numerous peer reviewed studies and sources of publicly available information. The results paint a stark picture: in 2020, 1 in 5 US adults experienced a mental illness, and 1 in 20 faced a serious mental illness (SMI), but only 46.2% of individuals received treatment. Our analysis has pinpointed five key reasons for why that is: cost of care, lack of providers who take insurance or are in-network, long wait times for an appointment, clinician fit (e.g. cultural, stylistic factors, etc.), and clinician availability, each with varying impact, depending on the individual. Cost of care was the most cited factor among these five. In the US, 10.3% of adults with a mental illness were uninsured in 2020, and for those without insurance, a standard hour-long therapy session can cost up to/more than $250. What’s more, only 56% of psychiatrists accept commercial insurance, compared to 90% of non-mental health physicians. Taken together, these unfortunate circumstances force many Americans seeking mental health care to pay out of pocket. What’s more, the cost is often prohibitive, even for those earning a comfortable living. An estimated 39% of US adults cited cost as a reason for not receiving mental health treatment. Even if an individual can overcome the sheer cost of care, they face additional barriers such as finding an available clinician who is (1) in their area, (2) accepting new patients, and (3) a cultural and stylistic fit. The average wait time for an appointment for new psychiatric patients can range from 25 to 90 days. As of March 2021, an estimated 122 million Americans were living in areas with a shortage of mental health care professionals. About two thirds of these shortages were in rural or partially rural parts of the country. Finally, as of 2020, the American Psychological Association reported that of all American psychologists, only 6.18% identified as LatinX, and only 4.24% identified as Black.To make matters worse, many people also battle with the stigma of admitting to mental health issues and seeking treatment for them at all. Our beleaguered mental health system is not setting our patients up for success. Cerebral’s Mission: Meeting Patients Where They Are  The reality for our patients prior to finding Cerebral is that it has been very hard for them to get help. Of the patients who turn to Cerebral for depression treatment, 76% report symptoms consistent with moderately severe or severe depression. Similarly, of the patients who came to Cerebral for anxiety treatment, 89% report symptoms consistent with moderately severe or severe anxiety. Cerebral’s telehealth model has proven its ability to fill this void. Our fully virtual model allows our clinicians to meet people where they are, vastly expanding the field of mental health care professionals. Patients have an easier time both getting that first appointment and making that personal connection through a tailored matching algorithm where we take into account our patients’ preferences. All the while, they can avoid perceived stigmas by taking appointments from their phone or computer or wherever they’re most comfortable. Above all, we are committed to ensuring that our clinical care is high-quality and equal to or above widely accepted standards of care. We do this by incorporating outcomes measurement into everything we do, something that is sorely lacking in the mental health care field. As an example, we use data science to improve care via a System for Measurement-based Access to Relationship-focused Treatment (SMART) approach. Our platform matches patients in a timely manner with an appropriate care team and care plan based on patient preference and clinical need. In turn, Cerebral is enabled to deliver high-quality care by using actionable data to improve access and therapeutic relationships. Cerebral tracks meaningful and actionable clinical quality indicators in order to monitor effectiveness, efficiency, safety, and timeliness of care. This approach stands in stark contrast to traditional mental health care providers, who have been hesitant to undertake measurement in a rigorous manner. A recent study even reported that 25% of psychiatrists do not use electronic medical records, and opt for paper notes instead. For underserved communities and others, Cerebral’s data-driven approach will also help us set broader benchmarks for care that can improve results in the future. What’s next? Cerebral is making strides every day in closing both the access and quality gap outlined in our State of Mental Health Care report. This is just the beginning, and much remains to be done.. At Cerebral, we are committed to facing this challenge head on, and we will continue to commit to democratizing access to high quality mental health care for all.