An evolution in fighting mental illness
This year’s mental health month has seen a number of voices engage in the conversation, some expected (the National Alliance on Mental Illness), and some not so expected (Burger King).
As healthcare investors for over 20 years, our firm wanted to take time as the month comes to a close to reflect on a few (by no means comprehensive) developments we’ve encountered that offer hope in tackling the epidemic. These ideas come from academia, industry, and non-profits, important given the scale of the challenge (one in five Americans experiences a mental illness in a given year). They span the full spectrum in fighting the disease, from unpacking mysteries in the underlying biology to rethinking mental healthcare across the broader healthcare system.
Better defining the biology of mental health
Mental health faces hurdles at the biological level that set it apart from other groups of diseases. It’s diagnosed not through a definitive test but by a series of symptoms. Very little has been understood about the underlying biology in psychiatric illness, and clinicians lack the biopsies, ultrasounds, and genetic tests that shed a clear light on disease as they do in other conditions.
The result is a broad categorization and diagnosis for people with vastly different genetic makeup and biomarkers. This certainly adds to the complexity around diagnosis and detection, but perhaps offers an even bigger obstacle when it comes to developing drugs. Drug development is already a field marked by failure (9.6% of drugs make it from Phase 1 to FDA approval), but only 5% of depression drug programs make it from Phase I through FDA approval, the lowest success rate for any single disease category tracked by BIO.
We recently backed a new player in the space, San Francisco-based BlackThorn Therapeutics. The company is developing new molecules for psychiatric conditions, starting with a clear acknowledgement that conducting clinical trials on patients with very different underlying neurobiology will result in a great response by some and no response by others in trials, dwindling the drug candidate’s already paltry chance of success. BlackThorn is working to better define disease cohorts with imaging technology that maps the brain circuits of patients displaying symptoms, locating receptors within those circuits as drug targets, and identifying what it calls digital biomarkers that define these patient populations. It applies AI and data science to increase understanding of patient populations at scale. The end goal is a molecule is tested on more homogeneous groups of patients who share underlying neurobiology and are more likely to respond.
In parallel, the medical community at large is further unraveling the mysteries surrounding the biological root of mental illness, as a recent issue of Harvard Medical Magazine highlighted. These include new discoveries of genes influencing schizophrenia, imaging studies unveiling how the brains of those with schizophrenia and bipolar disorder produce more oxidative stress, and an increased understanding of the role maternal immune response and microbiome plays on offspring being born with autism and neurodevelopmental abnormalities.
Unconventional and population-focused services
The complexity around psychiatric drug development means services and direct interaction with patients play an incredibly important role. For the reasons outlined above, we’ve generally been wary of investing in mental health treatments at the molecular level but have worked repeatedly in the services space. We’ve backed psychiatrist-entrepreneur Richard Kresch, founder and CEO of behavioral health hospital groups Ascend Health and US HealthVest, comprised of 15 psychiatric hospitals, with more in the works. He focuses on geographies throughout the country that are short on treatment beds and tailors services accordingly to the diverse needs of those communities.
Technology has allowed for the scaling of mental health services, even if the exact form factor has changed over time. Years ago, we invested in a company called Free & Clear, which offered cognitive behavioral therapy delivered through phone calls to help people quit smoking. In the smart phone era, the FDA has cleared an app from the startup Pear Therapeutics, for the treatment of substance and opioid use disorders.
The non-profit space has also been a particularly important and creative source of population-focused services. We recently learned about The Phoenix, an organization that seizes on the community — and dare we say, “cultiness” — that can be found in fitness as a source of good for those recovering from addiction. It operates its own gyms and offers programming in partnership with other facilities, only charges its members a “fee” of 48 hours of continued sobriety, and is staffed by trainers who themselves are recovering from addiction (Boston Magazine has a great profile on them). The Soldiers Project, meanwhile, enlists licensed clinicians and associate therapists to offer pro-bono counseling to post-9/11 war veterans for as long as they need it, regardless of tenure or discharge status.
Delivery of care and integration with the broader health system
While specialized organizations are on the frontlines of providing care to underserved groups, it’s equally important to tackle mental health from a systemic level. In this respect, Quartet Health, another portfolio company of ours, is on a mission to treat mental health like any other “physical health” condition — integrated with primary care. Its platform of software and services sits within a PCP’s electronic medical records to flag patients likely facing mental health conditions and quickly connect them with dedicated mental health specialists for these patients.
The aim is to shrink the timelines needed for patients to see specialists, by easily showing caregivers in network and offering alternative (and more accessible) options such as telehealth. Quartet sells its platform to health insurance companies and providers, and counts Sutter Health, Blue Cross North Carolina, Highmark, and Horizon Healthcare among its customers. This provides the company with a large claims database that its engine crawls to identify patterns in healthcare treatment and undiagnosed mental illness. The promise for payers is that getting out ahead of mental healthcare helps with associated co-morbidities and reduces expensive and unnecessary downstream costs. Quartet’s service has shown a 15–25% decrease in ER visits and acute inpatient stays for systems utilizing it.
Perhaps less obviously, Quartet’s approach to treat mental health illness like everything else plays an important role in busting the stigma around it. The perception that mental illness is a moral failing prevents many from seeking care, and Quartet’s emphasis on the primary care context shows that treating an illness of the brain doesn’t have to be all that different from, say, looking after your cholesterol.
Given the scale and reach of mental illness in our world, it’s easy to feel hopeless in response. But impossible is where the science, philanthropic, and VC communities thrive, and where we’ve made important advances before. As the authors of the BIO report on the state of depression drug development pointedly said: “looking back decades ago, cancer was also a poorly understood and monolithic disease, with only limited, toxic chemotherapies available. Today we view cancer as more than 80 distinct indications, each with many subsets correlated to DNA mutations.”
Imagine a world where we understand and treat mental illness with the granularity and nuance that we now see in oncology. We think it’s possible and that pioneers from every corner need to press on in getting there.
We’d love to hear about other advances you are seeing that help us move towards this goal. Let us know in the comments.
The fine print