For the last two years, Dimagi has invested in developing digital solutions to help expand mental health care. This was initially based on an intuition that we could make a substantial and unique contribution in this neglected area, despite there being limited demand for digital platforms for mental health at the time. Even though nobody was asking us what we could do in mental health, we suspected it as an area where we had a substantial contribution to make.
We are now in a better position to articulate this contribution, though we still see ourselves at the early stage of a long-term effort. Our hope is that our impact will follow an exponential curve in which we contribute to more people having access to quality behavioral and mental health care. Our aspiration is to eventually reach a very large number of people, and through our technology help them get better access to mental health care -and particularly make a difference in Lower and Middle Income Countries (LMICs), where the inequalities are greatest. Envisioning exponential growth is helpful to motivate ourselves towards the enormous contribution we can make in the long term, as well as the significant investment and time it will take to get there.
Why digital solutions for mental health can make an enormous contribution
It is not difficult to see the potential contribution of offering digital solutions to improve mental health care given the staggering unmet need, the increased efforts to meet this need, and the high likelihood of digital being integral to delivering and scaling effective mental health interventions.
There is growing recognition of mental health challenges across all populations, and there are great inequities in both burden of disease, and ability to access care.
- The WHO reports that depression alone impacts 280 million adults worldwide, and that greater than 75% of those that need depression treatment in LMICs receive NO care.
- The inequities are clear. This powerful article from Science reports how people in poverty have 1.5-3x higher rates of mental health conditions in any given location. People with depression earn lower wages, and economically disadvantaged populations are more likely to experience mental health conditions.
- Mental Health intersects with other clinical and health outcomes as well, frequently in both directions exacerbating negative outcomes. For example:
- Pregnant people who are depressed are less likely to adopt healthy behaviors which in turn leads to worse newborn health and nutrition.
- Individuals treated for HIV or TB are less likely to take their medications if they are experiencing anxiety.
- People with depression are more likely to develop Type 2 Diabetes according to Mayo Clinic.
Globally, we are seeing an upswing of attention to mental health needs. It is often recognized now as a crisis both revealed and exacerbated by the COVID pandemic. This is particularly true among young people, as 75% of all mental ill health starts by age 24. While the lack of mental health care in LMICs remains stark , it is encouraging to see increasing attention and resources for global mental health. For example, the WHO’s Special Initiative for Mental Health, the Lancet Commission Report on Global Mental Health, and United for Global Mental Health have all been developed in the last few years.
An important insight that we’ve gained is that there are fairly straightforward yet effective methods for preventing and treating mental health conditions. While many people experience mental illnesses that require sophisticated care from specialists, there are far simpler interventions that work relatively well for the vast majority of the population. An analogy can be made to the power of protocols for classifying and treating children with symptoms such as fever, coughing, and diarrhea. While some of these children need to be referred to physicians, most can be managed by non-specialists following relatively simple protocols to provide routine care.
One might imagine that mental health care is always more complicated, but there are many straightforward treatments that are helpful to the majority of cases. The EMPOWER program, with whom Dimagi works in India, has shown that non-specialist providers (NSPs), can be trained in a matter of weeks to provide 1-1 counseling that will have a high success rate on moderate to severely depressed clients. Almost everyone reading this article could do so, by taking their short training course. The surprise is not that you become a specialist from a short course, but rather that the skills one can learn in a week, turn out to be surprisingly effective for what a wide range of people need.
A lot of the most effective wellbeing methods that build resilience and protect mental health are also relatively straightforward. Building resilience can be as simple as taking walks, practicing brief mindfulness exercises, connecting with friends, or improving hydration. For example, the Resilience Collaborative helps address burnout in workforces by building such skills.
This insight is important to Dimagi because it suggests several pathways to expanding mental health and wellbeing, each of which will require digital support.
- Training and supporting large numbers of NSPs to provide mental health care. While this pathway is not easy by any means (including the challenge of finding a cadre of workers that are not already overburdened and under-supported), it is immeasurably less daunting than having to train and deploy a large number of specialists. As described more below, we see a clear role for digital technology to make this expansion of care possible.
- Using digital agents to deliver or augment psychological interventions. In the extreme, there are conversational agents such as Woebot and Wysa that can deliver fully automated treatment. The success of these systems is not due to having achieved remarkable progress in Artificial Intelligence (AI), but rather from crafting engaging and interactive systems, for delivering relatively straightforward psychological treatments. As AI advances though, we may well see more advanced therapy offered by computers. Even so, we expect it to take several decades before such solutions can reach our target population. In the meantime Dimagi is more interested in hybrid approaches, in which digital agents amplify human-delivered careor fully automated systems, to promote wellbeing or build resilience. This is in place of treating mental health conditions such as depression or anxiety with a fully automated approach.
How Dimagi can contribute to the use of digital solutions in mental health
Almost all initiatives for expanding mental health care we have encountered are emphasizing, or at least exploring, how to best leverage digital solutions. The COVID pandemic forced many organizations to experiment with digital, and accelerated the efforts of others.
Even though many organizations are developing digital solutions of their own, Dimagi has an important role to play. Indeed, we want to do what Dimagi does best in all the areas we work in–create more efficient and effective reuse of digital components across projects, programs, and organizations. One hundred mental health care programs each developing their own tech is inefficient and far less effective than creating a common adaptable platform, that can be used across these initiatives. Dimagi’s core competency is creating digital products or platforms that have versatile use across a myriad of implementations. To our knowledge, no other organization is focused on the goal of creating a comprehensive set of reusable digital components that mental health efforts can use, to amplify their impact.
We expect our solutions to include a wide range of digital components and adaptable, open-source digital content. It will include:
- Mobile apps (on our CommCare platform) to support the various models of mental health care delivered by non-specialists, such as 1-1 counseling or group therapy.
- Functionality for ensuring the quality of 1-1 counseling by NSPs, such as we are developing with EMPOWER (Harvard Univ), Sangath (India) and the University of Toronto, funded by Grand Challenges Canada.
- Methods for adapting open source content, such as the Resilience Messaging Program, and embedding them in engaging self-guided apps.
- Specialized approaches and content for important subgroups, such as adolescents, or frontline workers experiencing burnout.
- Digital components that promote general mental wellbeing, including promoting daily practice of techniques such as mindfulness, breathing exercises, or grateful reflection.
Everything we build will be designed to work globally. While all of our solutions will be designed to operate in LMIC environments, they will be highly relevant to underserved populations in high-income countries, and we will develop them in parallel for both settings.
For example, In the US, Dimagi’s Research and Data team is developing a prototype chatbot for patients who are at-risk for, or have a Substance Use Disorder, a common mental disorder worldwide. This prototype supports patient connections to their health team, appointment tracking, goal setting, cravings, wellness check-ins, wellbeing/stress reduction practices, general resources (e.g., housing, food, support groups, transportation, etc.), and connection to immediate care (e.g., helplines, links to service locators, etc.). We expect the work we do here to apply to many contexts across the globe. Our expanding efforts in the United States,include exploring how digital tools can support state governments, in coordinating access to behavioral health care services across facilities, to ensure timely and appropriate care.
As a final example of a reusable component, we are developing what we are calling “PracticePal.” PracticePal is a chatbot to support clients receiving brief psychological or psychosocial interventions. It will guide them to complete activities, and homework related to improvement in their condition, as well as provide basic psychoeducation. Used in coordination with their NSP, we believe this will enhance homework completion, and provide additional support and tools that may improve program outcomes. PracticePal can be used across a wide range of psychological interventions, including ones that utilize 1-1 counseling, group therapy, or even single-session brief interventions.
When will we get there?
Despite the urgency, we can’t offer any quick-fix or magic bullet solutions. If they existed, other organizations would be better positioned than Dimagi to deploy them. Our strategy of building reusable components to augment many other mental health care efforts, is a bet on eventually achieving exponentially growing impact. But it will require some effort and time before we reach the inflection point depicted above. We will also explore direct digital intervention, but that will also take time to develop.
We’re committed to this effort and eager to find even more partners to work with us. Please reach out to us if you have any guidance, content, or interest to work with us. The success of our approach depends entirely on the strength of our partnerships, and our shared commitment to join hands to tackle this large, but not insurmountable, challenge.