The Dark Ages of Mental Health

Leaning on one of the most overused finance analogies of all time, we are not even in the first inning of the mental health game. Rather, we haven’t even gotten on the bus to go to the stadium for warmups.

After investing $40mm into 31 startups in the mental health space since 2020 at What If Ventures, what I can tell you is that we really know very little, and this is a very long game.

Some people think too much money and too many founders have flooded the space, and maybe that’s true from some people’s perspective, but in reality, it’s going to take centuries to get this right, not just one or two capital market cycles. We’ve only begun to address the problem.

We Are Facing a Crisis

What we do know for sure is that there is a crisis — one in five U.S. adults experience a mental illness each year, and less than half of those who need help are able to get it. The supply of affordable, effective mental health care doesn’t come close to meeting the demand for such care. Demand is increasing rapidly as stigma decreases and people seek to improve their mental health.

Despite the cultural recognition of mental health in recent years and record VC funding in the space, we are still only beginning to fight this fight and we have such a long way to go.

The Dark Ages

Sometimes I think about where we are in mental health care relative to how far we’ve come in other disciplines. For example, let’s look at the human heart. The heart was first discovered in the 2nd century A.D. and we really started to understand it more fully in the 17th century (more on that here), yet still, in 2020, heart disease was the top cause of death in the United States.

Turning to mental health, let’s look at our understanding of the brain in the same context. We’ve known of the brain’s existence in the body for quite some time but started to really have a sense of how it functions in the 17th century. Looking deeper, specifically at mental health, we only identified serotonin — the key hormone that stabilizes our mood, feelings of well-being, and happiness — in the 1930s.

We haven’t exactly been leaning into mental health for the last 100 years, but for argument’s sake, let’s say we are 100 years into solving for mental health. When you compare that timeline to the heart, we’re literally in the Dark Ages (well, actually, just slightly before that as the Dark Ages began around the 5th century A.D.).

What does that mean? It simply means we don’t even know what we don’t know. We’ve just begun to even try to understand the problem.

What We’ve Learned

The sky is not falling. In fact, we’ve made more progress in the last decade of mental health advancements than we made in past centuries of progress in other health indications, in my opinion. Over the last few years, What If Ventures has invested more than $40mm into 31 startups in the space and we’ve learned a lot from our involvement with our portfolio companies.

We’ve learned about the problems, solutions, and the market; the value proposition of various solutions; and the stakeholders in the space, including people who need care, providers, payers, founders, and investors. Below, I’ve summarized a few of the key learnings.

Let’s start with what has not changed since day one: our fundamental hypothesis that the supply of affordable, effective mental health solutions does not come close to meeting the demand for these services. There are nearly 8 billion people on earth, and we all have mental health. We all need some help maintaining that health just as we do with our physical health.

There are not, nor will there ever be, enough therapists and psychiatrists for each of us to get the care we need from the traditional model where we each see a therapist for an hour and maybe get a prescription for an anti-depressant from our psychiatrist. There just aren’t enough providers, and we can’t make them fast enough to keep up with the surging demand resulting from the rapid decrease of mental health stigma that has driven more and more people to finally seek support.

Where will the supply of care come from? It will come from:

• Technology
• Novel therapeutics
• Scientific discoveries
• New business models

This is where venture capital comes into the picture, including us, What If Ventures.

Where Is the Opportunity?

I’ve listed a handful of the categories in which I think we will see major breakthroughs in the coming years based on investing in 31 startups in the space and evaluating over 1,000 businesses in the last two years. This is by no means an exhaustive list, but these are some of the areas we are thinking about daily.

1. Measurement & Testing: You can’t fix what you don’t measure. When I break my ankle, I get an x-ray confirming that it is broken, and then again confirming it has healed. When my mental health struggles, my doctor simply relies on me to answer a few opinion questions about how I feel. Imagine if my orthopedic surgeon based his view of my ankle’s healing progress on how I said I felt one day.
2. CNS Drug Discovery: There has been next to zero progress in psychiatric medications over the last couple of decades. Both digital and small molecule therapeutics have been drastically underdeveloped in the behavioral space. One of the reasons is number one above. The inability for drug developers to measure the success or failure of a drug during development has eroded their motivation to spend money bringing new drugs to market.
3. Business Model Evolution: We need disruption of the business model within behavioral health. What does the business model need to look like? I can’t predict that. But I can say that the way we pay for healthcare today is a problem in the behavioral health space.
4. More Care Capacity and Better Care Delivery: We must create more care capacity and deliver care in a more effective way. There are a lot of solutions in the market that simply shuffle existing care capacity from one platform to another. If you swap the logo on a therapist’s business card from one company to another, then you have not created new care capacity. In fact, when you complicate the workflows of the therapists, you actually create more busywork for them, thus reducing care capacity.
5. Comorbidity With Physical Health Conditions: We see a very high correlation between high-acuity mental health needs and high physical health care costs. When we speak with payers, we find that the most expensive lives they cover often have a very expensive physical health condition comorbid with a high-acuity mental health need. We believe that solving the mental health need as the primary presenting indication will improve physical health, lowering the cost of the physical health need over time. We want to invest in more solutions where the value proposition is based on this understanding.
6. Engagement: We need a lot more innovation in the mental health space, beyond telehealth. Behavior change is really hard to do digitally and at scale. We’ve seen this over and over again with fitness and weight loss apps acquiring users and losing them 30 days later — behavioral health is no different. Creating an app that hijacks the rewards system won’t solve the mental health crisis long-term. We’ve seen a lot of great “front doors” developed, but we’ve not seen many people get better than single digit long-term user engagement.
7. Youth: There is a huge opportunity to help an entire generation begin their journeys into adulthood with positive mental health. Providing care to children and adolescents is very hard. From a business point of view, one of the hardest parts is that the user (the child), the decision maker (the parent), and the payer have different incentives and motivations. Several promising startups are making great progress here and we are excited to see this space evolve. If we can get this right, and we can find a way to teach better coping skills and nervous system regulation at a younger age, then I believe we will eliminate the mental health crisis in future generations.
8. Consolidation: One of the big pain points we hear about from payers is the extreme fragmentation of the vendor landscape in the mental health market. There are a lot of small provider groups, solo practitioners, and a burgeoning supply of startups. Payers would like to see a consolidation of vendors and larger care provider networks. Platforms that can consolidate care without sacrificing quality and accessibility will be something to watch for in the coming years.

Conclusion

There are so many ways to attack the mental health crisis. There are thousands of problems, and even more potential solutions. This isn’t a winner-take-all kind of market or problem set. There is room for everyone and anyone to try to help. That is our focus — getting as many people involved in the development of solutions as possible.

My way of being a part of it is to invest in startups bringing solutions to market. To that end, I created What If Ventures out of my own struggle with addiction and mental health differences. I want to see more innovation, more capital, more business creation, and more people to focus on this problem set. If we can impact those things, then we can find out what solutions work, what solutions don’t work, and we can advance humans toward better mental health together.

I hope you will join us as we work on this mission. There are a number of ways to get plugged in, whether you’re an aspiring startup founder, someone who wants to work in the space, an investor, or someone curious about how to improve your own mental health. Take a look at the links below if you’d like to connect with what we are doing.