A digital cure for India’s mental health crisis

Just two months into the existence of Juno Clinic, it was evident the company’s business model wasn’t going to cut it. Founded in January 2016 by Davman Technology Services, Juno was meant to meet a pressing and widespread health need—that of accessible, affordable psychotherapy.

To do this, it aggregated independent mental health professionals—psychologists and psychiatrists—on an online platform, making them accessible both offline and online. With $2.4 million in funding from individual investors including Atul Nishar, the founder of Hexaware Technologies & Aptech Computers, Juno was one of the first chains of its kind in the country.

The opportunity couldn’t have been more apparent. Conservative government estimates state that nearly 15% of India’s adults need active interventions for one or more mental health issues. The World Health Organisation (WHO), meanwhile, states that one in four people globally may be affected by mental disorders.

And while a huge market of potential patients awaits these mental health interventions, the supply side of the equation is horribly skewed. In 2017, Anupriya Patel, minister of state for health and family welfare, painted a grim picture of the mental health care situation in the country. In response to a question asked by a minister in India’s lower house of Parliament, the Lok Sabha, Patel stated there were just 3,827 psychiatrists and only around 898 clinical psychologists in the country. As against a requirement of 13,500 and 20,250, respectively.

According to the WHO, access to treatment is grim with a treatment gap of up to 95.7% for depression in India

Depression treatment gap

According to the WHO, access to treatment is grim with a treatment gap of up to 95.7% for depression in India

Set against a backdrop so stark, Juno seemed destined to succeed. It saw itself as a solution, not just to access, but to a critical factor preventing people from seeking mental health care in India. The stigma around mental illness. By allowing people to seek help remotely and discreetly, mental health issues could finally be addressed.

But Juno, and other startups such as HealthEminds and ePsyClinic which began with similar marketplace-based models, have been forced to rethink their approach entirely, scale down considerably, or become bootstrapped, respectively. They underestimated just how ingrained the stigma dogging mental illness is. Indians are still reluctant to take the plunge and get diagnosed, find a professional therapist, and open up to a stranger, however qualified. At least not en masse. Not yet.

The struggles of these startups are indicative of the prevailing attitudes in the country regarding mental health issues and the difficulties in controlling the quality of therapy in a marketplace. But this isn’t to say there isn’t a market for mental health care in India at present. Bengaluru-based Cadabams Mental Healthcare Services and 1to1Help, for example, have steadily grown to annual revenues of Rs 22.5 crore ($3.2 million) and 12.1 crore ($1.7 million), respectively, for the year ended March 2018.

Both 1to1Help and Cadabams have very different models. The former, started in 2001, provides psychologists for wellness programmes run by large Indian and multinational companies. Founded in 1992, Cadabams, on the other hand, operates an inpatient psycho-social rehabilitation centre for various mental health issues like alcohol de-addiction and drug abuse. In both cases, patients can avoid paying out of pocket—through insurance, in the case of Cadabams, while employers pay for 1to1’s services. The other obvious commonality is that both are strictly offline.

It would be easy to simply chalk this down to an online versus offline battle, but it’s more complicated. A number of app-based mental health startups have popped up over the last few years, rapidly gaining popularity. They do not just offer therapy as a service but as a product, too. Apps like Touchkin’s Wysa and Mindcrescent’s InnerHour, which are seeing thousands of downloads each day, with Wysa claiming a user base of over 1 million.

Different strokes

Most accepted modern treatment options for mental disorders are pharmacotherapy or medication; physical activity; activity therapies like occupational therapy; expressive therapies like music, art and dance therapy; and psychotherapy

It may still be early days, but what accounts for these wildly differing fortunes that have seen apps become ubiquitous while marketplaces have struggled?

Juno’s journey

Two months in, Juno went from aggregating independent therapists to hiring them. A senior executive with Davman points to various quality issues the company faced with its original approach. At the service level, doctors would show up late, not take electronic notes, and their training wasn’t standardised.

While psychiatrists, he adds, are trained in medical colleges, psychologists simply hold a master’s degree in psychology, with no standard levels of quality. He had other concerns, too, like ensuring the privacy of the patients was protected since therapy is very sensitive. He asked not to be named as the company is currently planning to raise a new round of funding.

As of May 2018, in its quest for growth, the company had hired around 50 therapists, opened four physical centres, and was conducting 4,500 sessions a month till May last year. This wasn’t Juno’s redemption story though. This was it finding its feet.

Juno’s expenses for the year ended March 2018 stood at Rs 9.25 crore ($1.3 million), while its revenue for the same period stood at just Rs 1.6 crore ($229,146). Realising its cash burn was unsustainable, the business shut down all but one of its physical centres, shifting all of its sessions online today. While Juno is today down to just 1,600 sessions a month, the senior executive claims that the company is now operationally break even, with revenue remaining at around last year’s levels. The Ken could not independently ascertain this as the company hasn’t filed its results for the year ended March 2019.

Learning from mistakes

Juno’s journey is a decent example of what works and what definitely doesn’t when it comes to mental health care businesses built primarily on providing access to experts. For one, the common startup practice of burning cash in the quest for growth simply doesn’t work in a space this nascent and with as little societal acceptance.

Cricketer Robin Uthappa-backed HealthEminds, for example, which followed a similar model to Juno’s original curated marketplace approach also struggled to grow. One of its investors and advisors, Vishal Pereira, director of CreedCap Asia, said that two challenges for HealthEminds were the pressure from VC backers to grow too much too soon. While it struggled to meet its targets in terms of sessions, growing the supply in a country starved of mental health professionals also proved difficult.

Unlike Juno, which decided to scale down and grow organically, HealthEminds gave up the ghost. Earlier this year, it shut down commercial operations, although it is still run on a very small scale by its co-founder, Dr Sunita Maheshwari.

Pereira and the senior Davman executive both agree that online counselling removes the stigma associated with therapy. Additionally, says Pereira, if a company ends up empanelling therapists—psychiatrists, psychologists and counsellors—with vernacular language capabilities, the market for online therapy is big.

While Davman has survived, there are still obstacles in its journey. First, psychotropic drugs a psychiatrist would prescribe to a majority of her patients cannot be prescribed online. This takes away from the legitimacy of the service.

Then there’s the unwillingness to pay out-of-pocket for therapy. This is high in a primary care setting among patients who can afford it. While patients at an organisation like Cadabams usually have acute mental disorders and paid inpatient care is imperative, this isn’t the case for online services. Earlier this year, the insurance regulator asked insurers to cover inpatient mental healthcare, meaning centres like Cadabams are likely to gain further impetus. Meanwhile, 1to1Help sees traction as organisations are far more willing to pay for these services than individuals.

Investment in inpatient mental healthcare

In October last year, Rangsons Healthcare tapped into the inpatient mental healthcare market by inaugurating India’s first chain of super specialised neurocare centres for treating depression—‘Mindful TMS Neurocare’

An app a day

Even as the likes of Juno buckle down for a slow, uphill trudge forward, a series of app-based mental health startups are rapidly gaining traction. Healthtech startup Touchkin claims to have 1.2 million users for its mental health app Wysa, and says it is adding between 2,000 to 3,000 people every day. Mindcrescent, meanwhile, claimed to have 350,000 downloads of its Inner Hour app in a year, averaging out to roughly 1,000 sign-ups a day. Both apps are free and are used both within and outside India.

According to Ramakant Vempati, co-founder of Touchkin, apps that offer therapy as a product as well as service have a better chance of getting used because the demand for therapy alone is very limited in India.

Founder of Tata Trusts-funded app Trust Circle, Sachin Chaudhry recalls his brother’s schizophrenia diagnosis at the age of 12. The first obstacle in getting treatment, he believes, is awareness, the second is screening and the third is diagnosis. Treatment of the mental disorder comes after. Apps, therefore, are a great tool. They can be downloaded for free, and users can gauge their mental health based on some rudimentary in-app tests.

The focus, says Chaudhury, is on prevention and early intervention for all, not just those who are sick. It is through the layers of products—called tests, smiles and connect on the app—that one finally gets to the paid feature to access therapy—care. Between tests and care, is a spectrum of tools that help the user become more aware of their emotions and then connect with a group.

“Once people see how stressed, depressed or anxious they are, they can decide what to do with that information. Emotional graphs and mood monitors create awareness of emotions,” says Chaudhry, explaining the Trust Circle’s functioning. This awareness could, one day, lead to treatment.

Wysa, on the other hand, is promoted as a 4 AM friend and an artificial intelligence life coach. A bot where one can ask questions and receive suggestions. For instance, says Smriti Joshi, even though Wysa’s model is not very precise as it is still evolving, the bot is based on cognitive behaviour therapy (CBT), dialectical behaviour therapy (DBT) and motivational interviewing that have all proven to be effective in a wide range of disorders. Joshi is the chief psychologist at Wysa. Wysa also has tools targeted to curbing other negative feelings and thoughts. Mostly audio-based, these are usually less than 15-minutes-long.

A screenshot of Wysa app

In the first study to assess the effectiveness of Wysa app, researchers concluded the app helped in average mood improvement. However, more research is required to validate these initial findings in much larger samples and across longer periods.

Inner Hour, on the other hand, has developed programmes like a 28-day plan for management of anger, stress, worry, etc. This includes certain activities along with a chatbot meant for immediate support.

Two screenshots of InnerHour app

Support systems, not solutions

Joshi believes that online tools could indeed play a part in treating mental disorders. However, she is quick to admit that no tool on Touchkin’s Wysa can guarantee treatment or management of these mental disorders. However, using these tools regularly can help build positive coping skills to help manage difficult thoughts or emotions. It can offer wellness to those who do not have any mental disorders, but for those with mental health issues, it serves as a support to weekly sessions with a trained therapist.

Joshi says that once Wysa is downloaded, it first assesses the user’s mental health. Based on this, the app may suggest the person seek professional medical help instead. Unfortunately, says Joshi, most people do not heed this advice. Instead, they choose self-help tools on the app alone or in combination with text-based access to psychologists.

However, Wysa’s approach of suggesting offline therapy is not the norm in India. In January 2019, National Institute of Mental Health and Neuro Sciences (NIMHANS) reviewed 278 free apps for depression. A little over a third of these encouraged users to seek professional help.

Joshi talks to between 40-50 people every day via the app. “We ask them if they are professionally diagnosed, what are the barriers in them accessing professional help, and if we feel they need it, we encourage them to seek professional help,” says Joshi. By her estimates, about 75% of people she speaks to do not realise the intensity of their condition, lack social support or cannot afford therapy.

The appeal of these product-driven apps lies in the fact that they are constantly available and largely free to use. More importantly, they also get rid of the awkwardness of opening up about one’s issues with another person—mental health professional or otherwise. Most people that Joshi talks to do not talk about their emotions even with friends or family because they feel judged.

The fear of judgement, says Joshi, is a major reason many patients including Wysa users find it hard to seek daily therapy. An app, however, can create build trust and help people get used to sharing emotions. It can break barriers of loneliness and circumvent stigma.

Filling in

According to Amit Malik, who practised as a psychiatrist in the UK before founding Mumbai-based Mindcrescent, apps can also help mitigate the shortfall of mental health professionals. Online self-care programmes, says Malik, can develop scale and impact for a large sub-segment of this population early in their illnesses.

With the therapist-patient ratio askew, Malik believes that online products or tools intelligent enough to personalise therapy programmes can provide high-quality help and convince people of the value of therapy. All the while keeping costs low and providing help to millions of people who would never otherwise get it.

Touchkin, for instance, despite its vast reach, has hired only 7 psychologists for their ‘life coaching’ subscription service. It is a text-based chat service with a psychologist, who replies within a day.

But can these online services—either apps or e-clinics like Juno—replace the need for offline therapy entirely, though?

Mumbai-based clinical psychologist Dhruvita Mehta, who practices independently and with Juno Clinic, does prescribe some self-help tools that are offered by Wysa as well to her patients. But she says they aren’t enough on their own. “I would not want to use all the tools for all people. Some I would suggest becoming part of a group, some to try a new hobby or get a new job. Therapy is customised according to people,” she says.

Still, Mehta feels that platforms like Juno Clinic that offer professional therapy via audio-visual means online can be effective when the mental disorder is in the mild to moderate range. At Mehta’s clinic, however, 90% of patients are on medication prescribed by psychiatrists. This means they have acute mental health issues and need offline therapy sessions. Self-help tools or even online sessions can only do so much for them. “All of this helps, but mostly after people have been in therapy for two to three months,” she adds.

Still, the demand for Juno’s online sessions is organically growing between 10-15% every month, says the senior Davman executive quoted earlier. This executive hopes an inflexion point will come someday, exponentially growing the demand for therapy and allowing for a business with an offline and online presence to be built. Until that time comes though, a faceless world of self-help chatbots, audio programmes and tools will have to do.

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