Have you ever woken up in the morning with a sense of dread that is unshakeable? What about paralyzing anxiety where you know you need to get started on your day, but you just. physically. can’t.? 

 

You, dear reader, may not have experienced the above, but I, along with roughly 200 million other Indians have. 1 in every 6^th Indian suffers from some form of mental illness. As someone who lives with low-lying anxiety, I know how insidious and debilitating a mental health disorder can be (despite having only experienced low-level symptoms of the most common mental illness). 

 

Everything that happens to our bodies, starts with our minds. I never truly understood this until I felt like I did not have sufficient control over my own mind. Extrapolate that feeling 200 million times over and you can only imagine the negative externalities that unaddressed mental illnesses have had on our collective consciousness. In case you need data to grasp the gravity of this problem – the WHO estimates that India will suffer a $1 trillion economic loss due to unaddressed mental health conditions between 2012 and 2030. 

 

 

 

Figure 1: India is the Suicide Capital of the World

 

 

At Lightbox, we are in the business of understanding the Indian consumer and her problems, and then investing in the best solutions to counter these problems. The enormous gap between those who are in need of mental health care and those that receive care (ie. “the treatment gap”), at a high level of clinical excellence, is probably one of THE biggest problems we face as a country. It is one that we, as a fund, are committed to understanding, in order to find and back a company that is solving for the crux of the issues at hand – how do we not only reduce the treatment gap but also help cure mental illness at scale? 

 

In our minds, it is not enough to expand access to mental healthcare, but rather, it is imperative to create products and services that can treat mental illness, while adhering to a high standard of clinical efficacy. We believe a curative solution is the way forward because most mental illnesses can, in fact, be managed. The WHO stated “despite the chronic and long-term nature of some mental disorders, over 80% of people with schizophrenia can be free of relapses at the end of one year of treatment with antipsychotic drugs combined with family intervention, and 60% of people with depression can recover with proper combination of antidepressant drugs and psychotherapy.” 

 

The case for curative solutions: 

 

Consumer psychology points to the fact that “messaging” alone won’t push consumers to choose preventive healthcare measures; many need to understand the risks first. Through our research, we realized that adoption of preventive healthcare is often hinged on 1) raising awareness, 2) helping identify mental illnesses and 3) providing a curative solution after identification of the mental disorder. 

 

Therefore, we believe that “cure-ation” (yes, I just made up this word) comes before prevention. It is universally accepted that if you break your arm, you can go to a doctor who is likely to help the healing process, and hopefully fix it. This is a curative solution – even if the doctor didn’t prescribe you medication, he is not merely placing a band-aid on a broken arm (if he is, please change your doctor). Consumers have grown accustom to putting their trust, and therefore their health, in the hands of these widely accepted treatments. 

 

The rise of technology and scientific advancement has also made illnesses, that were at one point fatal, curable today – tetanus, rabies, polio. Over time, the fear and the stigma associated with these diseases have also dissipated. Those who unfortunately contract these diseases no longer have to retreat from society, they are, ideally (and hopefully), able to get the treatment they need. Once these curative treatments were developed, then preventive measures became part of the solution. Similarly, in India, where those who are mentally ill are often forced to retreat into the shadows of society, clinically identifying and then curing mental illnesses needs to be more universally accepted and understood. Only then will a large part of the population take preventive measures more seriously. 

 

Warning! Difficult market dynamics ahead: 

 

Clearly, there is an urgent need for a new solution in India. However, there are innumerable hurdles that afflict the market, which will need to be overcome by companies hoping to create wide-scale impact in this space. These roadblocks can be grouped into 3 buckets – lack of awareness, lack of access, and lack of quality of care – and will be expanded upon further below. 

 

1. Lack of awareness and social stigma 

 

Stigma against publicly addressing mental illnesses is often spoken about in the context of Indian mental health, so I am not going to touch upon it in much detail here. What is less known however is how the regulatory environment has led to a lack of awareness and understanding of the issues at hand. India inherited some colonial era laws related to mental health called The Lunacy Act of 1912 that has contributed to the stigma we have against those suffering from mental illnesses. This Act essentially criminalized those who were mentally unwell. Although the government established an updated version in 1987 called the Mental Health Act, it still criminalized attempted suicide. 

 

It was only in 2017, with the updated Mental Healthcare Act, that the government decriminalized attempted suicide and provisioned to protect the rights of the mentally ill. Keeping this long history in mind, it is no wonder that it takes up to 4 years for the average Indian to seek treatment for mental disorders after experiencing first symptoms. 

 

2. Lack of access to treatment

 

Patients in India are woefully undertreated and underserved. 85% of patients who need access to mental healthcare services are unable to receive care. This is because India has less 5,000 mental health professionals (for a population of 1BN+, shocking I know). The WHO recommends 1 psychiatrist per 8,000 people; in India we have 1 per 333,333 people. Moreover, we only have 43 government-run mental hospitals, which translates to 3 psychiatrist beds per 100,000 people, while Malaysia and China have 25 and 24, respectively.

 

Due to the lack of supply, high-quality mental health care is offered at a prohibitively high cost and only few can afford it. This is because 70-80% of healthcare expenditure is funded out of consumer pockets because of the government’s abysmal healthcare budget, and the millions that remain uninsured. In fact, the government, despite allotting $6MM to the National Mental Health Program in FY19 only spent $650K of the funds available.

 

 

 

Figure 2. Healthcare professionals per 1MM people

 

3. Lack of quality care 

 

To add to all the aforementioned problems, practicing mental health is a poorly regulated field and those who do get access to treatment may come to realize that there are no standard operating procedures across therapists. Patients are often left to navigate the care process alone. Dr. Soumitra Pathare, the director of The Center for Mental Health Law and Policy, often speaks about how there is no particular set of qualifications you need to call yourself a therapist, and although clinical psychologists need a license to practice, there is no standardization of treatment and it is difficult to judge who is abiding by clinical excellence. 

 

When beginning your journey to receive high quality mental health care, a psychologist will work with a psychiatrist to make sure that your diagnosis and treatment plans are in sync. They both should aim to take accountability across the care spectrum – from discovery and treatment to relapse management. Currently, there are only a handful of offline clinics that operate this way, bringing to light how poorly coordinated and fragmented the current care process is. 

 

I know what you’re thinking…enough about the sad state of the market… let’s hear some solutions!!

 

Given the market dynamics mentioned above, it is clear that the system we have in place is unable to deliver effective outcomes, and provide a structured care plan for consumers. Unfortunately, this leaves the onus of managing post-care treatment on patients and their families. 

 

Keeping this in mind, we set out to explore companies looking to solve these pressing issues. Based on our research, we knew that the most important yardstick to measure any mental health company is against the outcomes they are delivering. We looked at companies across four different business models, and have collated some of our learnings below.

 

 

 

Figure 3: Market Map

 

 

 

1. Full-stack offline clinics and facilities 

 

                    Pros

• High quality practicing psychiatrists and psychologists are able to maintain standards of care and clinical excellence – generally these clinics are built around a particular physician’s name

 

         Cons

• Only a handful of clinics have expanded to more than one location because of the limited resources and bandwidth of the popular therapist. When faced with the opportunity to expand, many of the highly soughtafter practioners will increase prices vs. opening up more clinics (this might be an area for b2b companies to solve some pain points…)

 

• IPD facilities and clinics don’t target the top of the funnel – they are not in the business of raising awareness at scale, a process which is needed in India where the incidence of mental illness is high but the education, access and willingness to get treatment is low

 

2. Online and offline marketplaces

 

                    Pros:

• Online marketplaces aggregate independent clinics so that it is easier for the consumer to find and book appointments with psychologists / psychiatrists in their area

 

• These companies have expanded the access to and awareness of mental health treatment, and is potentially a more discrete way to book an appointment (which might reduce the amount of time it takes a consumer to go from experiencing first symptoms to receiving treatment)

 

                   Cons:

• Most marketplaces don’t own the end consumer, but have to spend a lot to acquire them, only to pass them off for a small margin to offline clinics (and with low awareness around mental health treatment, it would require a lot of consumer education = more $$ spent on marketing)

 

• It is difficult for these companies to hold independent practitioners accountable, resulting in unpredictable quality, standard of care and outcomes. For sensitive issues like mental health, your customers need to trust that you are recommending the highest quality of service. If you cannot deliver on that, it leads to low NPS scores, and even lower retention over time

 

• Because of the issues mentioned above, some of these marketplaces realized that they were not achieving profitable unit economics and pivoted from an aggregator to a fullservice model, with their own clinics and therapists. However, with little awareness of mental health treatments, it was difficult for demand to scale in a way that covered their costs (let us not forget the #1 lesson from OYO: scaling efficiently offline is not an easy game to crack, regardless of how much money you have)

 

3. Teletherapy 

 

                    Pros:

• Teletherapy platforms have found greater success in providing access to care at scale. These platforms also reduce waiting times for patients and allow them to access care more frequently

 

• Platforms that have inhouse therapists can not only better control the quality and standard of care given, but they also have better gross margins because they are not acquiring customers on behalf of clinics. Their overhead costs are also lower without the need for physical clinics, and therapists can earn more online, since they can see more patients in 1 day than they can offline

 

• These are curative solutions, especially if they carefully manage the care process for their patients and take ownership over outcomes

 

                    Cons:

• From our research, it became clear that existing teletherapy platforms are unable to address moderate to severe mental illnesses. Mental illnesses can fall anywhere on a scale from low to severe, and broadly speaking, these platforms solve for relatively milder cases such as career anxiety. This reduces the onus of measuring and delivering clinical outcomes on the platforms, once again, leaving those who experience more moderate to severe illnesses to fend for themselves

 

• Teletherapy platforms that don’t have inhouse therapists will face similar issues to those faced by online marketplaces

 

4. Digital products-as-a-service  

 

                    Pros:

• Companies building products, such as, AI chat bots based on cognitive and dialectical behaviour therapy models, is an exciting proposition – it allows for widescale, unlimited and often time anonymous access to care. Some of these apps operate on a freemium model, which gives those who cannot afford treatment a viable place to turn to in times of need

 

• Many of the AIchat bot companies adhere to clinical safety guidelines and are able to provide standard formats of care

 

• Companies like Calm and Headspace also offer great wellness products that broaden the awareness and importance of mental wellbeing, and provide tools that can work in conjunction with curative products and services

 

                    Cons:

• Although chatbots can help promote mindfulness, listen and suggest resources for further help, they are not yet able to handle the depth and diversity of the issues at hand

 

• In fact, most of the apps that we looked at are not positioned as therapy or treatment for mental illness but rather helpful tools to build emotional resilience skills, and therefore are not substantial curative solutions

 

• Monetization of B2C apps that are focused entirely on prevention is difficult in India where 1) the gravity of mental illness is not yet widely accepted and understood and 2) curative solutions are not available at scale. As early discussed, when there is little awareness of the issues at hand, few are going to be willing to pay for a preventive measure. In fact, the most popular mental health app in India, was only able to scale to $80K in ARR in FY18, with 2MM downloads

 

So, none of the solutions above hit a home run for us. Now what? 

 

We want to help solve the messy, tangled, difficult questions that naturally arise when you look for solutions in this industry: how do we create curative and clinically excellent mental healthcare businesses? How do we ensure that we are building programs with a customer-first mindset? Can we build a curative program that is preventative as well?  

 

We may not have the answers to all the questions above yet, but what we do know is that providing customer-centric, curative mental health care requires a company to build for the entire “care continuum”. The care continuum is the process of following the patient from “preventive care, through medical incidents, rehabilitation and maintenance.” Depending on the patient’s needs, a company would provide a variety of solutions at different points in his or her healthcare journey, and this coordinated effort results in better outcomes for patients. 

 

 

Figure 4: The Care Continuum

 

 

 

This flow, from discovery to treatment, maintenance and eventually prevention of other mental illnesses, has been clinically proved to be an effective way of delivering health care. However, building and managing this process is difficult, and requires a thoughtful, innovative approach. 

 

Although we may not have found the best solutions yet, we are excited to continue on our quest to look for companies that are meeting their customers wherever they are in their journey to get well; a company that is providing touchpoints of care across the spectrum and building with an outcome-oriented approach in mind. A healthcare company that builds with an emphasis on the care.