What is Computerized Cognitive Behavioral Therapy?
Last year’s trend in Apple’s App Store was the rise of self-care apps, a phenomenon that’s in part fueled by the fact that mental disorders are on the rise. This is not because we’re all becoming a bunch of spineless pansies that can’t cope with the stress of all the first-world problems being thrown at us every day, it’s because things are more complicated these days. There are many biological, environmental and experiential factors contributing to mental disorders, some of which can even be economically and politically motivated. Furthermore, a lot of people in mental distress do not have the insurance coverage or the means to seek professional help. Or they don’t want to.
Take Japan as an example. It’s a country that seems idyllic and charming on the surface, but has a strong undertow of mental health problems. There are recluses (hikikomori), people who die from being overworked (karōshi), and a suicide rate among youth that’s higher than it has ever been in the past 30 years. In a society where mental health has been a taboo topic, some people have good reasons to hide their conditions leading to disastrous outcomes for some. The ones that do tell often end up in psychiatric wards at a much higher rate than other countries.
In the US, mental conditions affect one in five people and about 4% of the population is estimated to have a serious mental illness rendering them unable to lead normal lives. These conditions, which include depression, anxiety, bipolar disorder, borderline disorder, and schizophrenia, tend to have an early onset with 75% triggered before the age of 24. Mental illnesses are the leading cause of disability-adjusted life years, accounting for 37% of healthy years lost from non-communicable diseases. Prevalence has been on the rise over the past decades due to misdiagnosis, inadequate drug prescriptions, and a shortage of therapists.
The Lancet Commission on global mental health recommends that mental health be reframed as a fundamental human right, and that the definition be expanded to promote mental well-being, prevent mental health problems, and enable recovery from mental disorders. It’s not just about altruism. Mental conditions are a significant burden on the global economy, and it is estimated mental illnesses will cost the world $16 trillion by 2030 – about the same size as the global trade industry – a cost primarily resulting from lost productivity. The World Health Organization says that two thirds of countries do not cover care and treatment of persons with severe mental disorders.
With a global healthcare system that’s understaffed and underfunded, a large part of the population affected by mental health conditions never gets diagnosed and never receives treatment. It’s also true in the United States, where 60% of Americans with mental issues don’t receive treatment. With a problem this big, technology just might be able to help sort things out.
Computerized Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT) is a group of methods focused on changing unhelpful thoughts, beliefs, attitudes, and behaviors. It’s proven to be useful in the treatment of many mental illnesses including less severe depression, anxiety, post-traumatic stress disorder, substance abuse, eating disorders, and borderline personality disorder. It is also combined with medications in the case of more serious conditions like major depression, obsessive-compulsive disorder, bipolar disorder, and psychotic disorders. The aim of CBT is to disarm our cognitive distortions, inaccurate thoughts that reinforce negative thought patterns or emotions.
The following are some of the more common CBT techniques:
- Writing a journal about moods and thoughts to identify thinking patterns
- Identifying and challenging harmful thoughts
- Imagining feared worst outcomes until their very end
- Breathing exercises
- Progressive muscle relaxation
- Guided meditation
A review of meta-analysis on the efficacy of CBT, published in 2012, has found that these techniques have an overall beneficial effect on mental conditions, and their effect varies depending on the type of mental condition they are applied to.
CBT sessions have traditionally been delivered face-to-face with a human therapist, but their nature also allows for computerized delivery via apps or the web. These new channels are able to widen the reach of CBT to individuals previously unable to take part in them, but since the tools are relatively new, clinical evidence of their efficacy is sparse at the moment. What evidence there is shows significant positive potential. Here are just some of the startups looking to offer computerized CBT solutions.
Don’t Hate the Player, Hate the Game
We covered Akili Interactive Labs in 2017 in our article on “10 Mobile Health Startups Making You Feel Better.” The Boston, Massachusetts startup, founded in 2011, has almost doubled its funding to $140.9 million since our earlier coverage. The company develops therapeutic games for children, delivering sensory and motor stimuli to target and activate specific cognitive neural systems in the brain. Their prescription action video games work with adaptive algorithms automatically, adjusting the level of the challenge to train certain parts of the brain and improve cognitive deficits.
Patient progress is monitored and assessed continuously to provide information on progress to clinicians and caregivers. At the moment, Akili provides a solution to train attention, working memory, and executive function, helping kids and adolescents with attention-deficit/hyperactivity disorder. The treatment candidate has shown positive results in a clinical study environment, and Akili is preparing documentation for FDA approval that would allow the therapy to be prescribed as a stand-alone treatment by physicians. The startup’s development pipeline includes solutions for major depressive disorder, autism spectrum disorder, and multiple sclerosis.
Update 05/26/2021: Akili Interactive has raised $110 million in Series D funding to help commercialize EndeavorRx, its FDA-cleared prescription video game for ADHD, and develop new video game-based treatments for other cognitive disorders. This brings the company’s disclosed funding to around $301 million to date.
Getting Off the Junk
Founded in 2013, Boston, Massachusetts startup Pear Therapeutics has raised $134 million in funding to develop clinically validated software-based therapeutics for multiple therapeutic areas, including severe psychiatric and neurologic conditions. The startup’s two marketed products are 12-week digital CBT programs used in conjunction with outpatient care, treating opioid use disorder and other substance abuse problems. These have been developed in partnership with Dartmouth and marketed with Sandoz, and both received FDA clearance last year.
The ongoing opioid crisis in the US is estimated to have cost the country $1 trillion since 2001 with another $500 billion projected through 2020 unless sustained action is taken. With the dismal rehabilitation success rate of 30% claimed by the therapeutic community, any treatment that decreases the chances of relapse is a huge help. Besides their existing products, Pear Therapeutics has a strong pipeline of therapy candidates for a handful of other conditions including insomnia, depression, schizophrenia, and epilepsy as well.
Update 12/09/2020: Pear Therapeutics has raised $80 million in Series D funding to accelerate reimbursement coverage for its three FDA-cleared products. This brings the company’s total funding to $214 million to date.
Calm the Eff Down, Man
Founded in 2012, San Francisco, California startup Calm has raised $116 million to develop an app offering guided meditations, sleep stories, mindful movement tutorials, and related music. It has been scientifically proven that meditation has enormous benefits to people’s general well-being, including increased immune function and decreased pain, anxiety, stress, and depression – and it even grows the volume of gray matter in the brain for those of us that could use some.
Guided meditations teach users how to practice meditation on a daily basis, and Calm has more than a hundred of them, from beginners’ level to advanced sessions. Calm Body offers 10-minute guided video sessions for mindful movement and stretching, also affecting mental balance. Sleep Stories are soothing tales narrated by well-known actors, helping users fall into a deep sleep. The offering is paired with music to help users focus or relax as necessary. Calm is not a clinically validated service but it does build on proven CBT techniques with a holistic view of mind and body. App subscription costs $13 per month, $60 per year, or $300 for a lifetime membership. The app had 26 million downloads by June 2018, and grows by 50,000 users each day.
Update 12/08/2020: Calm has raised $75 million in new funding at a post-money valuation of $2 billion. This brings the company’s total funding to $218 million to date.
Free Your Mind and Success Will Follow
Founded in 2010, Santa Monica, California startup Headspace has raised $75.2 million to develop an app focused on guided meditation. The founder, Andy Puddicombe, left university to study meditation in the Himalayas becoming ordained as a Tibetan Buddhist monk ten years later. He established Headspace after returning to the secular world, and his startup quickly went viral in the media. Today, the app stands at 31 million downloads and 1 million paying subscribers, with more than 250 companies offering access to their employees. Headspace offers thematic meditation series beyond its progressive learning path including meditations for stress, focus, and compassion.
The company is conducting clinical research studies with more than 35 institutions including Stanford, NYU, and the University of Southern California, to validate the benefits of its guided meditation service, and has already published 16 studies in peer-reviewed journals. Our MBA who helped research this article was able to learn the basics of meditative practice using the app successfully in a short period of time, and can now successfully “mingle” at finance-related networking events without wanting to pull a Peter Pan off the nearest high-rise.
Update 02/12/2020: Headspace has raised $93 million in new equity and debt financing to double down on its pitch to businesses and healthcare practitioners as well as to look at international markets. This brings the company’s total funding to $168.2 million to date.
It’s Like HR, Except it Cares
Founded in 2012, New Yawk, New Yawk startup Happify Health has raised $25.5 million to develop a personalized self-help platform for employers, health plans, and pharmaceutical companies. Happify has been shown in randomized controlled trials and real-world evidence studies to help its users reduce stress, anxiety, and depressive symptoms. The company claims a 25% improvement in depression and anxiety and a 21% improvement in resilience among regular users. Around 86% of regular users experience a noticeable improvement within two months.
The platform provides four-week programs covering a diverse range of topics, science-based activities and games, guided meditations, inspirational content, and a community. The app assesses users and personalizes the experience, measures progress, and provides enterprise insights reporting analytics on the whole population of users. Happify is researching additional applications for efficacy, person-activity fit, and biological mechanisms in collaboration with major universities including Harvard and the University of Michigan.
Update 03/17/2021: Happify Health has raised $73 million in Series D funding to focus on digital therapeutics and patient care delivery. This brings the company’s total funding to $123 million to date.
The rate of people with undiagnosed and untreated mental conditions suggests traditional healthcare systems are too inefficient to handle the problem in the foreseeable future. Digital delivery of these treatments widens their accessibility both from a geographical and a financial perspective. Early clinical trials suggest computerized cognitive behavioral therapy is efficient, and widespread adoption could mean increased welfare for the masses and a previously untapped market for digital healthcare providers – a win-win situation for everyone. Maybe someday, these tools will even become so sophisticated that they will be used to get America’s polarized political parties to have civil conversations with one another again. One can only hope.
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