On September 16th and 17th, 2022, the Psychiatry Academy at Massachusetts General Hospital hosted the Future of Mental Health Conference (FOMHC). It was co-directed by David Mou, M.D., the current CEO of telehealth firm Cerebral. Mou and conference co-director, Roy Perlis, M.D., moderated discussions among a group of eminent leaders and thinkers in the mental health ecosystem, including: George J. Goldsmith, Chairman, CEO, and Co-Founder, COMPASS Pathways; Corey M. McCann, M.D., Ph.D., former President and CEO, Pear Therapeutics, Inc; Solome Tibebu, Founder of Going Digital: Behavioral Health Tech; Thomas R. Insel, M.D., former Director, National Institute of Mental Health; Maurizio Fava, M.D., MGH Psychiatrist-In-Chief.
The “future” of mental health is of considerable societal importance given the growing footprint of disability from mental distress as a widespread social problem. FOMHC was a sowing ground for the intellectual flora that may significantly shape how psychological distress is conceptualized and addressed in the coming decades. The influential moderators, keynotes, and speakers at FOMHC aim to chart a future of mental health based on the views and strategic plans shared during the conference.
I attended FOMHC with a cache of curiosity that had been incubating since the meeting was announced months prior. I am a “future of mental health” enthusiast and optimist. I’ve interned at a digital therapeutics company and have trained in a psychedelic therapy and research certificate program; I’ve embarked on a dissertation project that utilizes deep learning, the computational workhorse underpinning recent advances in artificial intelligence technology.
The “future” of mental health is often condensed into three primary categories: digital mental health innovation, psychedelic medicine, and data science disruption. The overall vibe of panel discussions and keynotes at FOMHC encapsulated significant optimism and belief in cutting-edge approaches to tackling society’s mental health perils.
Throughout the conference, in the back of my mind, its sanguine temperament was neutralized by a yearlong foray into critical psychiatry literature and discourse. Having started with Anne Harrington’s Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness in the summer of 2021—and countless media and peer-reviewed articles (many on Mad in America), YouTube lectures and interviews, and podcasts in between—I ended up completing Andrew Scull’s Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness just a few weeks before FOMHC, and from those readings evolved in me a fresh interpretation of psychiatry and the broader mental health ecosystem.
Harrington’s Mind Fixers chronicles a century-long procession of experimentation by neuropsychiatrists seeking to uncover biological explanations of mental illness. Scull takes a similar approach and recounts a history of unsettling failed psychiatric cur(s)es, while eloquently illuminating the underpinning racist, sexist, and marginalizing attitudes that drove the enterprise.
As a mental health professional-in-training, I am of the mindset that most people, if not all, can work towards psychological healing and satisfactory quality of life when offered vital resources, an honest appraisal of their mental faculties and situational conditions, and relationship with caring providers and community members who foresee within them growth and healing. (I also accept that some—perhaps many—may not benefit from the aforementioned and prefer indefinite psychopharmacology.)
Critical psychiatry has exposed me to how far off-kilter foundational mental health establishments are from helping people achieve these goals. Psychologist and author Bruce Levine summarizes these deficits across three areas of failure: (1) worsening treatment outcomes despite increased treatment; (2) the invalidity of the DSM diagnostic system; and (3) the invalidity of the chemical imbalance theory of mental illness.
This dichotomy—the anticipation of an auspicious and prosperous future of mental health against a stark reality of a degraded and demeaning current mental healthcare ecosystem—was often difficult to make sense of at FOMHC. Many of the talking points at the conference illustrate this, starting with Insel’s opening keynote.
After highlighting a record year of $5.1 billion invested in digital mental health startups in 2021, Insel referred to these investments as a “whole new engine to disrupt and create new value in mental health.” His point was that the likes of Facebook, Google, and Amazon have employed computational and digital technology—unfortunately, in ways that are aggressive, addictive, and manipulative—to influence human social and economic behavior. Can we not reposition these tools to improve individuals’ and communities’ mental health and quality of life?
Insel was bullish on innovation in mental health, even suggesting that killing some old ideas is vital. Upon noting that the word “entrepreneur” originates from a French word meaning “undertaker,” he states, “we may have to bury some things at the same time and create some novel solutions.” He is forthright with his perspective on a healthcare industry grappling with an intensification of deaths of despair: “There’s sort of a changing culture that we need here.” Instead of focusing on acute symptoms and designing new medications, we should begin to reconceive what patients with chronic mental illness “really need.” Instead of a purely medical model, we should consider aspects of recovery that help people succeed beyond their stint in emergency care and inpatient stays.
Though I hadn’t read Insel’s book Healing: Our Path from Mental Illness to Mental Health when listening to his speech that day, I recalled a comment from a former supervisor who had read the book. My supervisor noted that the tone of Healing suggested a mea culpa from Insel on behalf of an industry of mental healthcare that embraced a hyper biomedical ethos, especially during his years as Director of the NIMH.
Insel was not prepared to fully “bury” some beliefs undergirding a deeply biologically driven mental healthcare system stating, “I believe strongly that the problem is fundamentally medical. It is these are brain disorders.”
It felt like a gut punch when Insel regurgitated bio-reductionist dogma, effectively erasing his more circumspect and human-centered preceding statements proposing “that we go beyond what we’ve locked into for the last five decades, which is a medical model that really does focus on symptoms.” Ostensibly, Insel did not mean going beyond the ideology exalting neural circuits as the principal source of mental anguish. I would have been keen to ask Insel at FOMHC if he’d ever considered that treating mental illness as inherently brain disorders is the very reason why 20 billion NIMH dollars failed to “move the needle” of mental suffering towards mental healing.
Debates about the underlying biological pathologies of mental illness are and will be passionately argued and researched among the elect of academic psychology and psychiatry for decades, even as the body of evidence becomes increasingly more opaque and yields fewer consistent findings. The stakeholders in the mental health ecosystem cannot reasonably be expected to await a seemingly always soon-to-be-discovered biomedical theory of mental suffering. Yet many of the speakers and panelists at FOMHC appeared fully prepared to remain hitched to the side of the biomedical establishment in mental healthcare.
There may be no technologies more disruptive—in society broadly and mental health more specifically—than big data science and artificial intelligence. The latest buzzword, “precision medicine,” is concerned with developing pharmacotherapeutics and biomarkers through big data analytics of biomedical data and deploying discoveries for advanced personalized care.
Precision psychiatry (or computational psychiatry) claims to stride alongside many other medical specialties towards a new path forward in understanding and treating illness. Cancer medicine and precision oncology were referenced a few times during the CNS drug development panel, with the attitude that psychiatry was equally decipherable with computational analysis.
Yet precision psychiatry is unlikely to be the dark horse that springs a lasting neurobiological model of mental illness. Science philosophers Kathryn Tabb and Maël Lemoine critiqued the precision psychiatry concept, frequently referencing the shortcomings of psychiatric hypotheses. They consider the “precision” label as only aspirational for psychiatry: “We think there are reasons to be pessimistic about the possibility of psychiatry’s following in oncology’s footsteps.” Whereas various cancers are localized to specific tumors that genomic mechanisms may further explain, there has yet to be discovered a location within the brain or body where psychiatric illnesses reside. Precision medicine, a science “which is often narrowly focused on genetics,” is not very amenable to a medical discipline that has never fully established a reliable biomarker.
This was of no concern to the “The Future of CNS Drug Development” panelists at FOMHC. The panel was perforated with optimistic rhetoric and conjectures of transformation in biological psychiatry that may rival precision oncology. Each of the panelists were executives at early and growth-stage drug development biotech firms mission-driven to discover compounds and pathological mechanisms towards treating “brain diseases.” The websites of these firms are dotted with language concerning the neurobiological labyrinths that constitute psychiatric conditions. Their claim: By identifying biomarkers indicative of mental illness, and subtypes of various mental disorders, computational scientists can better target depression and pharmaco-molecules that may work better for certain patients.
This is the formula driving Alto Neuroscience, an early-stage biotechnology startup. The founder and CEO of Alto Neuroscience, Stanford Professor Amit Etkin, announced at FOMHC that his company’s sights are set on “treatments that work far better for people far earlier in the course of the illness, and are targeted to their biology, because ultimately, these are biological interventions.” Etkin even hinted at AI ultimately decoding the biological mechanisms of psychotherapy; “psychotherapy, likewise, by the way, is a biological intervention, yet we don’t measure that biology.”
The portents of AI-driven psychiatry advocated by the panelists are increasingly coveted in an industry enduring a years-long deadlock in bringing psychiatric drugs to market. Precision analytics are driving treatment discoveries in cancer, so why not in psychiatry?
John Dunlop, the Head of Research and Development at Neumora Therapeutics, is impressed that “nobody argues with precision oncology,” which collects “tumor biopsies” and deploys big data analytics to “match a molecule or a pathway to a patient population.” “How can we take a similar approach in CNS?” Dunlop asked the audience. As with many endeavors in the AI industry, throw more data at it. By combining brain imaging, genetics, genomics, proteomics, etc., with “deep data science,” the veiled biomarkers of psychiatric illness will surely emerge.
There’s an “amazing opportunity now,” said panel moderator Roy Perlis of the future of CNS drug development, “to move towards new molecules that have new clinical interventions.”
The preceding declarations raise the question of what pathologies the precision scientists on the CNS panel at FOMHC intend to target with state-of-the-art computational methods. Most of the companies on the panel were devoted to the precision paradigm, investigating disorders of the DSM-5, such as schizophrenia and social anxiety disorder.
The DSM is a manual that characterizes collections of psycho-behavioral symptoms at length in seemingly sensible diagnostic categories and is also effective at regulating clinician communication. It does not describe the underlying pathological mechanisms that determine psychiatric disorders or provide objective tests that distinguish them. It is considered by many to be an unreliable and invalid religious manual; psychologist Levine considers it to have no scientific value.
The flaws of the DSM exposes another angle of cognitive dissonance in psychiatry, akin to the muddle of defenses and denials of the serotonin imbalance theory following Joanna Moncrieff and colleagues’ seminal umbrella review. It remains the chief document of the nosology of psychiatric disorders, yet is regularly renounced by the upper echelon of the psychiatry guild. Insel’s tenure at NIMH is marked by his resolution to discard the DSM-5 and reclassify mental disorders within the Research Domain Criteria (RDoC); Allen Frances, Chair of the DSM-IV Task Force, describes himself on the very cover of his book, Saving Normal, as an insider revolting against “out-of-control diagnoses” and the DSM-5.
Given these inconsistencies, precision psychiatry researchers may be embarking on a futile trajectory. What do precision psychiatrists aim to compute when they target a diagnosis such as major depressive disorder? Even if there were an identifiable neurobiological or genetic process underlying an individual’s psychiatric illness, neither the DSM nor any other psychiatric classification system has shown such processes would be homogenous across individuals. Psychiatric constructs fail to meet the basic requirements of precision science (the latest blow to serotonin imbalance theory and a recent preprint supports this assessment).
It was refreshing to hear a cautious tone from Jerrold Rosenbaum, M.D., Director of the Center for the Neuroscience of Psychedelics at MGH, when introducing the panel discussion on “The Promise and Perils of Psychedelics.” Risking marking himself a “crotchety elder,” he bemoaned the media’s dogged campaign to label psychedelics as miracle drugs, referencing a recently published article predicting an inevitable popping of the psychedelic medicine hype bubble. Rosenbaum believes that “researchers and clinicians have an obligation to counter extreme statements” on both sides of the risk-reward continuum of psychedelic therapeutics.
Unfortunately for Rosenbaum, speculation is an incredibly intoxicating passion, and psychedelic medicine may be the most speculative burgeoning commercial enterprise (save for cryptocurrency).
No topic in the discourse of the future of mental health has flown higher than psychedelic therapeutics. Psychedelic medicines have garnered significant venture capital investment and corporate interest with hopes of formulating novel compounds based on unique mechanisms of brain action—or, in some cases, with hopes of patenting and profiting from substances that have been used since the birth of humanity in rituals of life-changing, spiritual experiences. The mystical features of psychedelics are increasingly believed to be capable of curing some of the most debilitating psychological pains. The most optimistic outlook suggests that psychedelics may upend the current dominant frameworks in mental healthcare.
The CEO and founder of a company with one of the largest market caps of psychedelic therapeutics companies, George Goldsmith of Compass Pathways, was a panelist. He touted that his company’s products have been shown to “produce an immediate response, day two after a single psychedelic experience, for patients suffering with so-called treatment-resistant depression,” as well as remission of symptoms in 26% of research participants after three months. Goldsmith admits that their treatments may not be panaceas while still conveying their findings as promising and remarkable.
Elsewhere in psychedelic medicine research, psychedelics combined with intensive psychotherapy—psychedelic-assisted therapy (PAT)—has produced positive results for seemingly intractable psychological impairments. The Multidisciplinary Association for Psychedelic Studies (MAPs)-led phase 3 trials of MDMA for PTSD that found full remission of PTSD symptoms in 67% of research participants all but stamped an eventual FDA approval of MDMA-assisted psychotherapy.
Despite acknowledgement of the need for intensive and tailored psychotherapy in PAT—the FDA would technically approve MDMA-assisted psychotherapy and not just the drug by itself—some of the most celebrated features of psychedelic medicine concern their direct neurobiological effects. In neuroscience circles the term “psychoplastogen” is favored over “psychedelics” as it categorizes them in the neurobiological rather than the psychical. Neuroscientists purport that psychedelics induce a state of neuro-flexibility that allows individuals to achieve mental states and psychological growth that typically requires several years of psychotherapy.
“We have a platform of neuroplasticity protein therapeutics and a foundational set of IP research and strategic hypothesis,” remarked Mark Rus, the CEO of Delix Therapeutics. Delix’s objective, according to their mission statement and Rus’ own words, is to “drive the aforementioned neuroplasticity frontier of research for the purposes of selectively, rapidly, and sustainably rewiring pathological neural circuits across a range of neuropsychiatric and neurodegenerative conditions.”
Despite assorted scientific and regulatory challenges, psychedelics are quickly becoming accepted as the next major psychopharmacological paradigm in mental healthcare by both practitioners and consumers. Discussing the ketamine clinic she directs at MGH, Dr. Cristina Cusin remarked that her “very large clinic is never able to meet the demand of patients because we have a ridiculous waiting list and no place to treat all these patients.” (Ketamine is not approved by the FDA for the treatment of any psychiatric diagnoses.)
It would behoove mental healthcare stakeholders to scrutinize how commercial exploits may influence the development and provision of psychedelic therapeutics. The consequences that big pharmaceutical corporations have imposed on the healthcare system are well documented, particularly in psychiatry. (During his keynote address, MGH Chief of Psychiatry Maurizio Fava’s brief flashing of a sprawling presentation slide containing his lifetime disclosures signified little interest from psychiatry’s academic leadership in disentangling from the interests of big pharma.)
The psychedelic medicine marketplace is becoming an outgrowth of the caustic corporate warzone of the traditional pharmacotherapeutics marketplace. It is a scene where market share, venture capital, and patent filings override whatever lofty mission statement is displayed on a company’s website.
To be clear, psychedelic therapeutics still require careful investigation of their clinical efficacy as they enter mainstream healthcare. Psychologists Michiel van Elk & Eiko Fried classify threats to the validity of psychedelic science as easy, moderate, and hard problems. They contend that the hardest problems in psychedelic science may genuinely threaten the construct validity of psychedelic therapeutics. The powerful psychoactive effects of psychedelics typically reveal to both participants and experimenters which arm participants belong to in a clinical trial, thus undermining blinding procedures, a bedrock of establishing causality in clinical trial design. As with traditional psychopharmaceuticals, determining the clinical efficacy of psychedelic compounds is an exceedingly cloudy endeavor.
Whatever benefit psychedelics may bestow is at risk of sabotage by the voracious capitalistic fervor that pervades the psychedelic medicine enterprise.
Compass and many other psychedelic pharmaceutical corporations are warring for patent rights for various aspects of psychedelic treatment. Despite its use in indigenous and modern cultures for centuries, Compass seeks to patent a synthetic formulation of psilocybin, the active compound in psychedelic mushrooms, and has filed patents for “therapy room décor and drug delivery methods.” Given that some of these patents pertain to features thought to be inherent in psychedelic therapy—for example, Compass has referenced physical touch and sound systems in their intellectual property claims—some have referred to this strategy as patent trolling.
This style of intellectual property jousting raises knotty ethical, legal, and social concerns that may ultimately diminish the accessibility of psychedelics. Because of the DEA’s war on drugs, which has criminalized most classic psychedelics, the transformation of psychedelics from a harshly stigmatized and criminalized class of compounds to a lucrative pharmaceutical product is a sticky ethical and social conundrum. Even more so as treatments may eventually be least accessible to the communities most harmed by the war on drugs. Furthermore, when a pharmaceutical firm aims to capitalize on classic psychedelics, compounds that have been a part of indigenous practices and cultures for centuries, they may be engaging in biopiracy.
Perhaps the most glaring paradox at FOMHC was the event’s management by David Mou, current CEO (and former chief medical officer) of Cerebral, a tele-mental health services unicorn startup. Cerebral has been investigated by the US Department of Justice for pushing stimulant drugs; a lawsuit alleges that Mou’s stated goal was to prescribe stimulants to 100% of Cerebral’s users and that the company ignored patient safety concerns; the company was also forced to remove social media ads that preyed on users with weight concerns to sell stimulant drugs.
Mou, who said that “mental health really is a data problem,” further remarked that “telehealth actually enables for us to gather tremendous amounts of data.” (Among Cerebral’s many misdeeds, they are reported to have irresponsibly shared consumer data with third-party platforms, possibly exposing personal health information.)
Andrew Welchman, Ph.D., is Executive Vice President for Impact at ieso, a technology company developing “AI-enabled, human-delivered therapy.” Welchman’s view of a seamless data-driven therapy model consists of supporting patients by “quantifying what they’re going through, understanding their phenotype, and then making a prediction about what we expect the outcomes of therapy to be.”
Psychedelics and AI are still generally speculative endeavors, but digital mental health is already a fundamental gear in the mental health infrastructure of tomorrow. Good corporate behavior of telehealth firms like Cerebral would be crucial as this infrastructure is fortified.
But Cerebral’s slapdash initialization of their telehealth services echoes the impulsive manner in which therapies for mental illness have been promulgated since the 1800s—catalogued in staggering detail in Scull’s Desperate Remedies. Lay on top of that Silicon Valley venture capital expectations of lightning-quick and titanic profit returns, and Cerebral looks more like a precarious billion-dollar profit vehicle than it does an effective health service.
Cerebral grew to a $4.8 billion operation in less than two years, propelled by an enormous cash dump from the (in)venerable SoftBank investment group. SoftBank’s investment strategy is to make many random investments, expecting a handful of massive hits. Cerebral may still return significant profits to Softbank, but its value as a comprehensive behavioral and psychosocial rehabilitation service is precarious.
Cerebral may have adopted Softbank’s culture of short-termism, whereby short-term hype and profits are prioritized over long-term and durable solutions. This modus operandi is antithetical to the intricate and often prolonged process of psychological and spiritual healing. Cerebral may instead deliver mental health services that John Oliver of Last Week Tonight likens to fast-food restaurants. Perhaps a statement by Mou about Tesla’s full-self driving software illuminates Cerebral’s approach to undertaking complex problems:
“We’re held to a different standard, right? It’s like when Tesla had their self-driving car and killed one person, and it was still 1000 times safer than human drivers. It didn’t matter, it made the cover of every newspaper. So, there is a tax on technology. There’s a tax on innovation, especially in healthcare.”
Governments and influential institutions have deemed the burden of mental suffering and illness a societal affliction requiring the greatest attention, focus, and resources. Exploring progressive and innovative ways to confront a frighteningly complex social problem is commendable, but the history of psychiatric healthcare should inform our present and future endeavors.
The lobotomy, which was still being used into the 1970s, earned its creator a Nobel Prize, while destroying the lives of tens of thousands of vulnerable individuals. The pivotal DSM-III is frequently criticized for originating from the conjectures and squabbles of a small task force of privileged academics.
Humankind’s efforts to understand and heal mental suffering are fraught with remedies initially considered revolutionary but eventually proven to be inadequate or destructive. Many of them were promulgated by a handful of influential opinion leaders. FOMHC embodied this to a degree.
I have been inspired by recent growth of machine learning methods in psychology and mental health research and have enjoyed learning ML coding programs and quantitative methods through my dissertation research. I am motivated partly by curiosity about a trendy and alluring subject (AI), and a desire to present new ideas in mental health scholarship. The attitude towards AI and precision science at FOMHC, however, was mainly abject faith in the customary AI doctrine, being that AI will eventually solve all of humanity’s problems. Eventually.
Upon further reflection since FOMHC, I now wonder if my research contributions are furthering an academic apparatus committed to further reifying biological models of mental illness, propelled by a shiny new toy.
I am hopeful for what cutting-edge data-crunching software may uncover among the countless variables that comprise the human psyche, but how successful can we be if we rely on erroneous classifications from evidence-free diagnostic bibles?
Personal experiences and countless anecdotes have made me optimistic about PAT. Psychedelics have long histories in many cultures of society and are intertwined with a multitude of human experiences extraneous of the biomedical and pharmaceutical industrial complex (e.g., spiritual awakening, coming of age rituals).
FOMHC alerted me to the very real possibility that psychedelics could ultimately become another cog in the vicious dark side of capitalism that perpetrates social ills. Who is to say that voracious capitalistic interests won’t just swallow up psychedelics and transform them into another profit machine inducing psych-iatrogenic harm? Many mental health professionals, no matter how well-intentioned, have eventually become enmeshed in a healthcare system that prizes molecules as the paramount of alleviating psychological pains. Aspiring psychedelic therapists such as myself are vulnerable to experiencing the same fate, no matter how progressive and liberating psychedelic therapies currently appear.
PAT may become a practical alternative to the traditional psychopharmacology regime, offering a delicate blend of psychotropic and psychotherapeutic intervention, but how successful can the enterprise be when some of the main players engage in regressive, hostile corporatism?
A culture of silence was conspicuous at FOMHC. Nothing was spoken of Cerebral’s wrongdoings despite the conference directed by its CEO. A former executive of Cerebral views the company so unfit for the business of telemental health and drug prescribing that he has levied a lawsuit against the company, claiming they “egregiously put profits and growth before patient safety.” But a room full of clinicians who have pledged to do no harm and practice ethical healthcare were unable to have an honest conversation about the conduct of a multi-billion dollar “future of mental healthcare” corporation. I was not courageous enough to speak up at FOMHC—perhaps I should have snatched the microphone from an unsuspecting speaker and went on an uninvited tirade about these matters. In the end, it felt more like colluding with the mafia, pledging omerta to bury crimes.
Lodged in the middle of FOMHC was a keynote from Jim Yong Kim, M.D., Ph.D., former President of the World Bank Group, entitled “Building the Movement for Mental Health Treatment Access: Lessons from Four Decades of Global Health Activism.” Kim recounted persistently negotiating and jostling with governments and healthcare leaders as he and his colleagues fought to transform HIV treatment in poor countries in the 1990s and early 2000s. He likened the current landscape of mental healthcare to those early days of HIV activism, declaring that this is mental health’s moment:
“The point is to look at the situation today and ask yourself in 20 years, what are the things that are happening right now that young people will look back and say, ‘what were they thinking? Can you believe that they let that situation exist?’ I believe that that situation is [currently] mental health. So, for me, this is mental health’s moment.”
Postscript—a few disclosures
- I did not attend the final two panels at FOMHC, occurring on day 2. The panel topics were “Rethinking Access and Quality in Behavioral Health: Perspectives from Payers Panel Discussion” and “Leveraging Data Science to Improve Mental Health.” That said, there was a great deal of discussion at FOMHC not captured in this retrospective.
- I interned at Pear Therapeutics, whose former CEO spoke during the digital therapeutics panel, during the summer of 2021. Pear Therapeutics filed for Chapter 11 bankruptcy in April 2023.
- I am a trainee of the 2021 Boston Cohort of the Center for Psychedelic Therapies and Research (CPTR) Certificate Program and hold an MDMA-Assisted Therapy certificate from MAPS Public Benefit Corporation.
- Audio and transcripts of the keynotes and panel discussions at FOMHC (except those I did not attend) are available upon reasonable request ([email protected]).
- No portion of this essay was written by or with the assistance of generative text software (e.g., ChatGPT, Bard).