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Reformulate Digital Therapeutics to Boost Population Health
Digital healthcare is on a roll. We were introduced over a decade ago to the tools of “digital therapeutics,” and these platforms are now multiplying as programs for mood disorders and substance use disorders (SUDs) are being joined by other diagnostic conditions like eating disorders. This care modality has matured and is ready for evaluation. Is it on course or in need of corrective action?
Digital products are well represented by eating disorder solutions like Recovery Record and Equip Health. The program offered by Equip utilizes family-based treatment, and it establishes a virtual 5-person care team of therapist, physician, peer mentor, family mentor, and dietician. Equip has raised $75 million in financing since its founding in 2019, and it is contracted with 10 commercial health plans.
Both of these eating disorder programs are focused on connecting the client with others in the recovery process, and this is different from early digital programs that primarily digitized clinical content. The limits of digital and virtual engagement are being pushed now, and the goal is to activate as many facets of the real therapy experience as possible in these formats. How close will this get to the real thing?
This may be the wrong question. The primary goal should not be replicating therapy for the typical patient. If digital modalities can meet the needs of some motivated clients, this is fine. It saves limited therapist resources. However, the bigger concern should be reaching people who are struggling with stigma, inconvenience, and other roadblocks to access.
Digital healthcare could seek to replace existing services at lower cost, but this would be abandoning a more significant task—addressing the varied needs within populations. Issues range from common behavioral health disorders to unhealthy behaviors to health-damaging behaviors (e.g., medication non-adherence). The hope for digital is to address this full spectrum and aid those who get no help today.
Digital therapeutics are best conceptualized as expanding clinical services. This means reaching more people and spurring health improvement activities outside the clinical office. We have dismally low access rates for all types of behavioral issues, and we should ask how digital products can improve population health. When seen from that perspective, our current direction seems off course. How so?
Our digital platforms today are not optimally designed for population health. They are rooted in psychiatry, which is to say, they are organized around diagnoses. Some platforms are dedicated to single conditions like eating disorders and others address multiple conditions. While diagnostic entities are important, this orientation diminishes the value of these platforms for many needy individuals.
Platform users are presumed to know their diagnosis. Otherwise, they can gauge one by answering screening items. Obviously, a screen cannot diagnose. Some platforms supplement disorder-based tools with solutions for stress, but the basic structure is unchanged. Some products go even further in embracing psychiatry. A few digital therapeutic programs today are available by prescription only.
Pear Therapeutics has digital SUD programs available by prescription only, while Happify Health is planning one for migraines. This restrictive approach is not necessary. It is not protecting consumers from danger, and it is unlikely these prescribed modules are especially unique since good cognitive behavior therapy (CBT) tools—key to most modules—are in wide supply. A primary goal seems to be placing the insignia of the medical model on a proprietary product.
The profit motive plays a role too. Digital platforms are reaching valuations in the billions of dollars after only a few years of development. Product uniqueness is a strong marketing message, even if restrictions by prescription do not serve broad population needs. There may be room for all types of products in the marketplace, but excessive medicalization is shaping the industry in critical ways.
Digital tools are needed for a wide spectrum of needs, and clinical disorders are only one part of that continuum. Some people have multiple conditions, others have non- or preclinical problems, and so segmentation by diagnosis is not optimal. A population-based approach realizes there are many naïve users of these tools experiencing vague distress. Categorizing people can be alienating.
Digital products place high value on therapy techniques. Change is assumed to flow from completing therapeutic exercises. Yet research suggests the therapist accounts for more of the outcome than the technique. This should drive how we try to introduce these tools. Let us endeavor to spread them via endorsement of trusted caregivers. Primary care is an ideal launching pad if we want to appeal broadly.
Our field has a choice. We can either follow the psychiatric path from diagnosis to prescription digital therapeutics or take the population health route of fostering curiosity and exploration without diagnostic labels. If the primary problem for our field is access to care, we should be thinking less about crafting therapeutic homework assignments and more about exercises that are enticing and engaging.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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