⚡️ Apps Won't Solve the Mental Health Crisis
On telehealth and techno-fixes
Happy almost-holidays, y’all! We’re back with another great essay released from Kernel Issue Two: a deeply researched piece on the weird confluence of pill-pusher startups, TikTok ads, and the bio-psycho-social model of mental illness.
To read all our released content, visit kernelmag.io. To support the hard work that went into this, please purchase a print copy of the magazine. It’s the last week to order in time for the holidays, and Kernel makes a pretty good gift, if we do say so ourselves :)
Apps Won't Solve the Mental Health Crisis
By Lily Lou
Originally published in Kernel Magazine Issue Two
Scrolling through my TikTok For You Page, aesthetic slice-of-life vlogs, comedy videos, and occasional discourse on social justice issues are interrupted by ads from mental health apps.
With Done, there is no waitlist and you can get an appointment as soon as next week!!
With @BetterHelp you don’t have to go through it alone.
Get mental health care for depression, anxiety, and ADHD online with @getcerebral.
Cerebral, an online mental health startup specializing in prescribing medications, dominates the space for mental health app advertising by far—and social media advertising in general. According to Pathmatics, a digital marketing and analytics company, from January to May 2022, Cerebral was TikTok’s third largest advertiser, spending $13.3 million on ads and making 1.3 billion impressions. The company also spent $4.7 million on Instagram, where its ads made 581 million impressions.
Cerebral’s ads make use of digitally native advertising tactics, often employing internet lingo and mimicking popular video styles like captions. They involve everyday people talking about their experiences with the service, but even videos with celebrity endorsements—from people such as Simone Biles, who is Cerebral’s Chief Impact Officer—are shot on phones and lightly edited at most. In a video, a man walks as he asks, “Have you ever had a really busy day but you just couldn’t get started? Like, your mind is racing, but you just can’t get out of bed. And you get more anxious by the second.” In the background, you can hear wind rustle into his microphone. He tells viewers, “Look, there’s nothing wrong with you. You’re not lazy and you’re not dumb. You just have ADHD paralysis.”
At the time I saw this ad, I often had these symptoms but was certain I didn’t have ADHD. I was working a job I didn’t like, and after leaving the job for something more fulfilling, I stopped feeling unmotivated to do anything. I wasn’t alone. As my friends and I graduated into a pandemic and worked tedious entry-level jobs that felt unimportant or like busywork—if we were lucky enough to find work at all—many of us felt unusually down or anxious. It felt inappropriate to hear a stranger in a TikTok ad diagnose me, an unknown viewer with whom he had no connection, with ADHD paralysis based on a symptom that felt so widespread. In Lost Connections: Why You’re Depressed and How to Find Hope, Johann Hari cites “Disconnection from Meaningful Work” as one of the causes of depression and anxiety. He notes that “twice as many people hate their jobs as love their jobs,” citing Gallup studies from 2011 and 2012 that found 63 percent of workers were “not engaged” in their work, and an additional 24 percent were “actively disengaged.” The pandemic has worsened America’s mental health crisis, with 41.5 percent of adults reporting recent symptoms of anxiety or depression, up from 36.4 percent, and the proportion of mental-health related emergency room visits for adolescents increasing by 66 percent.
Mental health apps purport to solve these problems, promising to increase accessibility to mental health treatment by lowering wait times and improving affordability and convenience. A report from Deloitte suggests that there may have been up to 20,000 mental health apps in 2021. That year, mental health apps raised $5.1 billion in funding, up from $2.7 billion in 2020 and $1 billion in 2019. Startups focusing on mental health nearly doubled the amount they received in 2020 and received $3.3 billion more than other digital health ventures, such as ones focusing on diabetes or primary care, in 2021. The outcomes from mental health apps are often reported by the apps themselves to investors, tracking profitability and impact as metrics, which influence how much funding goes into the apps.
The technological approach to mental health, which often relies on “data,” perpetuates an emphasis on quantitative results and streamlined processes. A press release reads:
“Cerebral’s success stems from its hyper-focus on quality and efficiency. Spearheading longitudinal data collection in behavioral health, the platform tracks clinically proven symptom-based ratings on a monthly basis as well as client-reported satisfaction. Its ability to collect and leverage data enables Cerebral to overcome one of the biggest challenges in mental healthcare today: lack of visibility into quality and outcomes.”
This “hyper-focus on quality and efficiency” has been accelerated in healthcare more generally by technology. During the Industrial Revolution, the assembly line sped up manufacturing processes and boosted factory output. Rather than workers being present at each step of creating a product, which often required more expertise, they could now focus on a specific, repetitive task. Within the healthcare field, this phenomenon, called task-shifting, has also become more common. Rather than professionals with higher qualifications performing all aspects of medical care, some tasks are shifted to lower-paying roles that require fewer qualifications. The division of medicine has led to tasks being siloed to keep costs down; psychiatrists focus on tasks that require MDs, like prescribing medicine, while social workers and clinical psychologists deliver therapy. Technology can aid task-shifting, standardizing the performance of certain tasks and allowing tasks to be performed by technical assistants. There have even been apps created to work without human intervention, like WoeBot, which lets users perform cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), and dialectical behavior therapy (DBT) on themselves.
The World Medical Association’s resolution on task-shifting notes that while task-shifting can improve medical care in areas with physician shortages, it also has the potential to decrease the quality of care through reduced patient-physician contact and fragmented service. This can lead to increased risks of incorrect diagnosis and treatment and fewer patient follow-ups. The philosophies behind technology, which often focus on scale and consistency, amplify issues seen within task-shifting but are often fundamental to business models and profitability. In fact, since many of these startups exist primarily to make a profit, they cut corners when attempting to scale business models. Within the realm of telehealth therapy, this means less investment in training qualified therapists and patients not receiving the help they need. BetterHelp’s 2018 terms of service note that they are not responsible for verifying the qualifications of any of the app’s counselors; instead, “it is your responsibility to conduct independent verification regarding any Counselor that provides you with Counselor Services.”
For telehealth prescription management, profit models can incentivize clinicians to overprescribe addictive medications — so much so that some major pharmacies no longer fulfill prescriptions from specific telehealth startups. “Adderall can be a potentially addictive substance,” said Dr. Sulman Aziz Mirza, a psychiatrist specializing in adult psychiatry, child and adolescent psychiatry, and addiction medicine. “You push something out there that you know you're going to get a result from, and they're going to need even more of it and they're going to keep coming back.” The Department of Justice is currently investigating Cerebral for violating the Controlled Substances Act for overprescribing stimulants, and many employees, including a former Cerebral executive, have spoken out about being pushed to prescribe medicine at the expense of patient safety. This is especially concerning as many mental health apps target adolescents and exploit users’ trust and lack of alternatives, leading to both overdiagnosis and misdiagnosis.
Online discourse on mental health, which tends to flatten complex narratives, has ballooned in a wormhole of pandemic-induced doomscrolling. In the blog I learnt I had ADHD from TikTok, Dasha Romanowski writes that before consuming TikTok discourse on ADHD, she felt restlessness from working in an office all day and attributed it to laziness: “I accepted that this must be what adult life is, this constant, inescapable sense of drowning, and that I was just being lazy.” But, through “[consuming] TikToks about ADHD in women,” she learns that ADHD is associated with behaviors like “finishing people’s sentences and having to set at least ten alarms to wake up.” Cerebral’s TikTok advertisements parrot user-generated content with their solutions to these common behaviors: Look, there’s nothing wrong with you. You’re not lazy and you’re not dumb. You just have ADHD paralysis. Like in the TikTok discourse videos, these mental health startups often adopt reductive narratives and treatment models of mental health care that don’t account for the interplay of social circumstances. Instead, patients are often immediately prescribed medicines, making them even more dependent on the services.
Like in the TikTok discourse videos, these mental health startups often adopt reductive narratives and treatment models of mental health care that don’t account for the interplay of social circumstances.
Since 1997, drug companies have spent billions of dollars annually on advertisements for individualistic solutions to mental illness. These ads tend to elide situational and environmental factors that also contribute to mental illness. For example, discourse on mental health often ignores systemic causes like economic instability or racial violence. Unhoused people are twice as likely to have mental health issues than the general population; 47 percent of homeless women — twice the general population — are likely to have major depressive disorder. Poverty is highly correlated with mental illness. Black and minority ethnic communities have higher rates of mental health issues.
It’s hard to not be depressed if you’re experiencing something like financial insecurity or systemic racism, or even mundane situations like working a bullshit job. Modern life is riddled with challenges. The Centers for Disease Control estimated in 2011 that almost a quarter of Americans suffer from a mental illness, and that half of all U.S. adults will have a mental illness in their lifetime. The “chemical imbalance” theory of mental health, which hypothesizes that depression is caused by having too few or too many neurotransmitters, focuses on individuals and has long been debunked as the only cause of mental illness. This isn’t to say antidepressants and other medications don’t work. But if we want to accomplish anything beyond alleviating mental illness in individual people, we must tackle it on a larger scale. Today, most psychiatrists follow a bio-psycho-social model of mental illness, which attributes mental illness to a mix of biology and social and psychological factors. However, due to financial incentives, few psychiatrists offer therapy or forms of treatment other than prescription medicines.
Medicalization has become a trend across the United States, despite most people preferring alternatives. This is often because alternatives are costly and inaccessible and people tend to receive mental health treatment — usually in the form of prescription medicine — through community and primary care doctors. Demand for therapy has outpaced supply. Nearly one in three clinicians said that it could take at least three months to get an appointment or that they didn’t have room for new patients. In rural areas, access is even more difficult — 80 percent of rural counties in the US do not have a single psychiatrist.
The toll of mental health apps existing within a system where they need to prove their profitability to survive makes mental health treatment worse for everyone. It means therapists are juggling many patients at once and working within a model of gig labor, sometimes getting paid based on words sent and read via text messages, as BetterHelp does. It means advertising that often preys on adolescents, like Cerebral suggesting unhealthy eating is a symptom of ADHD. It means violating user trust, such as Crisis Text Line selling data to their for-profit spinoff to train AI customer service software without their users knowing. This problem isn’t unique to technology, though the tech industry exacerbates it through scale and emphasizes an individualistic perspective of treatment. Solutions that follow the bio-psycho-social model of mental illness require more thoughtfulness, and won’t generate profit as efficiently as quick fixes involving technology, like medicalization.
But rather than relying on tech companies to save us individually, we need to fix the systems that lead to these problems in the first place.
These apps have no doubt helped some patients. One comment on a BetterHelp ad reads, “The only reason I use it is because I don’t have any other way to get therapy.” But rather than relying on tech companies to save us individually, we need to fix the systems that lead to these problems in the first place. Healthcare solutions should not aim to profit from broken systems at the expense of adolescents who may stumble upon sinister ads. We need to think about the alternatives that exist beyond flashy new apps, efficiency, and profit models. We need to look for alternatives that don’t just mitigate, but actually get to the root of our problems and challenge the oppressive systems of power that make us all more miserable.
Lily Lou (she/hers) is a front end developer for Rest of World based in Brooklyn, New York. She enjoys joining book clubs and sometimes writes.
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✍️ Care under Capitalism
By Ash Band
A community response to Lily’s essay
Taking BART home from work the other day, I noticed a poster for a movement called “Kaiser Don’t Deny”. Kaiser Permanente is the largest managed care organization in the United States, operating in 8 different states. This summer, more than 2,000 mental health therapists went on strike at the company "for as long as it takes to make Kaiser fully staff its clinics and end dangerously long wait times for therapy.” It brings to mind a conversation I had with a coworker, in which he told me about the One Medical membership in San Francisco. For $200 a year, members get “healthcare, without the headaches”—essentially a premium version of modern healthcare—24/7 on-demand video chatting with professionals, same or next day appointments. My coworker described the experience of going to the doctor with One Medical as “how you wish going to the doctor was”. Their homepage advertises “Appointments that start on time.”
Reading Lily’s essay, I realized that mental health care under a hyper-capitalist environment results in the same tiering of quality and access as with other basic human needs, such as housing, healthy food access, and water. In many cases, the tech industry is the vehicle which allows this tiering to occur. People at the top enjoy not only access to the goods, but a premium version of this access if they are willing to pay more while those who can't afford it either don't have access at all, or receive a level of care so inadequate as to cause even more negative effects than they started with in the first, as with addiction caused by overprescription of medication or misdiagnoses through reductive narratives, as Lily pointed out.
Perhaps the lowest tier of mental health care are the apps, with chatbots like WoeBot at the very bottom, where patients manage their mental health themselves, for free. Under Talkspace's model, you can pay more for more of a relationship with your therapist, with the lowest subscription plan limited to chat. A friend who used Talkspace through the Messaging Therapy subscription never saw her therapist, and told me her chats were often riddled with typos and occasionally didn't make grammatical sense. She said it felt very impersonal and would not use it again unless put in a similar situation, where she could not turn to other alternatives for financial and emotional support.
While companies like One Medical attempt to solve the access-to-care issue, they approach it the way white feminism approaches feminism—improving conditions for the people who already have it the best, in this case, those who can afford to pay an extra $200 a year for a first-class health care experience. In order to improve the conditions of mental health care, we must fight to improve the quality of care for those for whom "healthcare without the headaches" is not the main issue demanding attention, simply just "healthcare.” We need to improve not just access to care, but raising the standards of what counts as care.
In a depressingly pessimistic view, this type of change cannot happen as long as the incentives of the overall system are profit and hyper-growth. Rather than devoting time and money to causes such as Kaiser Don't Deny, the incentives of capitalist society instead route the necessary resources towards finding product-market fit in the failings of our current health care system through companies like Cerebral and BetterHelp.
Mental health apps highlight the irony of venture-backed “Tech For Good” companies—where the problem they are trying to solve is often exacerbated or even created by other venture-backed companies in the first place. Facebook knows that Instagram has a negative impact on adolescent girls. Even if their mission is positive in comparison to other tech companies, without a shift or removal of profit incentives, how revolutionary can we really expect these mental health apps to be?
🌀 microdoses
The newsletter
is an excellent source of nuanced and lightly contrarian essays on mental health and modern culture. This one on the BuzzFeedification of mental health feels especially salient to the way that companies like Cerebral use diagnostic-cum-identity categories to target their ads.- explores the limits of "human-centered design" in improving health-tech's quality and accessibility. (The company she works at, FirstHand, helps people experiencing serious mental illnesses navigate the healthcare system. They only work with folks on Medicare and Medicaid, and they’re hiring in a bunch of technical roles. Not sponsored!)
One of my favorite creative projects of the last year, “the sound of love” by Chiara Amisola, was written up in The New Yorker. Grab tissues and melancholia.
💝 closing note
We’re excited to announce that we’ve nominated “all the better to see you with,” a short story by
, for the Pushcart Prize.In this story, which was originally published in Kernel Magazine, Adora skillfully paints a picture of our relationships to each other and to technology. The Pushcart Prize is an award that recognizes the best poetry, short fiction, and essays published in small presses. You can read “all the better to see you with” online or in print.
Take care,
Jasmine & Reboot team
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