Part 1 - Rising Automation in Mental Health

Although ‘mental health’ is often presented as a purely technical or clinical issue, it is highly political. Controversies abound, including over the language used to describe the issue,²⁵ the experts who should respond to it,²⁶ the distribution of resources to help those in need,²⁷ the use of forced psychiatric intervention by the state and other forced interventions in the name of care,²⁸ the expansion of psychiatric and psychological ideas to public understandings of human distress and wellbeing,²⁹ and the socio-political conditions that contribute to profound distress and mental health crises,³⁰ to name a few contested issues. It is in these political, regulatory, and epistemic struggles that new ‘digital mental health technologies’ appear.

According to prominent reports, algorithmic and data-driven technology is expanding rapidly in mental health settings. Prominent mental health practitioners and professional associations present algorithmic and data-driven technologies as a way to address the ‘global mental health treatment gap’.³¹ It can bring about ‘radical change’, some argue, with the potential for ‘scalability’ of interventions and unconstrained reach that ‘can help reach billions of people.’³²

Several governments have embraced digital technologies in mental healthcare as a cost-effective, accessible alternative or supplement to face-to-face support. In 2017 in the United Kingdom (UK), for example, former Prime Minister Theresa May announced ‘a £67.7million digital mental health package.’³³ In the US between 2009-2015, the National Institute of Mental Health funded $445 million worth of projects concerned with ‘technology-enhanced mental health interventions’.³⁴

Market interests also play a major role in advancing the proposed digital turn in mental health.

Thoughtforms by Dr Kellyann Geurts and Dr Indae Hwang in Science Gallery Melbourne’s MENTAL. Photo by Alan Weedon

Global digital health market [US]$118 billion worldwide

A White Paper published by the World Economic Forum states that: The global digital health market has been valued at [US]$118 billion worldwide, with mental health being one of the fastest-growing sectors.

US$1.8 billion in venture-capital funding in 2020

Businesses in “digital behavioural health” reportedly raised $1.8 billion in venture-capital funding in 2020, compared to $609 million in 2019.³⁵

Gobal mental health software market: US$4,585m by 2027

According to market speculators, Zion Market Research, the ‘[g]lobal mental health software market [is] expected to generate revenue of around US$4,585 million by end of 2026.³⁶

Global digital health market expected to reach US$660 by 2026

This growth is mirrored in the ‘global digital health market’ more broadly, which Statista.com suggests will increase to around US$660 billion dollars by 2026.

10,000+ mental health apps

Over 10,000 apps concerned with mental health are now available for download and use.³⁷

Major technology corporations – who happen to be also the largest corporations in the world – have increasingly turned their attention to healthcare activity, with each major firm now appointing chief medical officers and a large staff of physicians and clinicians. This financial activity concerns not just the monetisation of data concerning mental health and the expansion of mental health services online—but also in related areas concerning ‘wellness’, digitised social and health care, emotion and affect recognition, and so on.

The scale of activity across government and industry is reflected in an expanding body of research, much of which occurs at the intersection of commercial activity and scientific knowledge-making. Lines of accountability across these clinical and commercial domains are not yet clearly defined.³⁸

Hence, caution is required in interpreting the global picture of digitised mental healthcare. There at least four reasons for this. First, speculated market value is precisely that— speculated. And those doing the speculating often have vested interests. Examples include technology developers wishing to attract capital, technology vendors seeking to sell products, and corporate services wishing to garner government contracts to build and deliver technological services. Narratives play a strong role in speculative bubbles around new technologies,39 and there are many who stand to gain by painting a picture of a rapid and inevitable technological expansion in mental health services and elsewhere. This hype can even be fuelled by humanities scholars who repeat sensational claims about technical feasibility to attract research funding.⁴⁰>

Second, governments investing in ‘emerging technologies’ that are often described in terms of their groundbreaking and revolutionary potential, stand to gain from appearing innovative. Narratives of innovation can be misused in mental health sectors that are commonly painted as broken and crisis-ridden. Innovation-speak may distract from longstanding problems with existing mental health policies and practices and the potential need for major investment or restructuring to fix them.41 Narratives of technological innovation may also detract from broader policies that are toxic to public mental health, such as rising inequality, poor housing, unemployment or employment precarity, pollution and lack of green space. We discuss over-simplified narratives of technological problemsolving later in the report (page 77).

Third, many of the technological claims being made about algorithmic and data-driven technologies in mental healthcare are promissory – that is, they haven’t been proven. They lack robust evidence to back them up, particularly to show how they work in applied and real-world settings. In one of the largest surveys of the field, the James Lind Alliance concluded that ‘the evidence base for digital mental health interventions, including the demonstration of clinical effectiveness and cost effectiveness in real-world settings, remains inadequate’.⁴² Despite this sober finding, and others like it, the flurry of market, government and research activity may falsely suggest an inevitable march of progress toward highly effective and widely adopted digital tools

Finally, as we will discuss shortly, the very people who are supposed to gain from these technological developments – namely, people with lived experience and psychosocial disabilities – are concerningly absent from much of the research and discussion on these topics.⁴³ Where input from this (diverse) group has been sought for mainstream research or where members of this group have led commentary, the general response appears to be one of ambivalence, with support in some areas through to serious concern in others—though by no means an outright rejection (page 37). As we stress throughout the report, the concerns they raise are not to dismiss the aspirations of those wishing to use technologies in good faith efforts to improve care, and nor is it to uncritically reject technology as necessarily bad or a sure path to a dystopian future. Instead, we aim to express concerns as clearly as possible and promote a sober view of the role of computer technology, with its capacity to simultaneously enable and threaten.

1.1 What are the different ways technology is used in crisis support and mental health care?

There are various uses for algorithmic and data-driven technology in the direct provision of mental health care. All are bound up in the contemporary communications eco-system of smartphones, linked devices, and the massive flows of data they enable. Functions within health systems include:

These categories are framed in terms of healthcare systems. There may be good reasons to advance other ways of categorising. For example, technologies that analyse data concerning mental health are appearing outside healthcare services; for example, in criminal justice agencies, online advertising firms, insurance companies, education settings, employer hiring practices, and so on.⁴⁴ Case studies throughout the report will illustrate this expansion

Some technologies are well-established. Others are exploratory or experimental. Navigating these expanding technologies, including distinguishing which technologies are widely used, which are experimental, which ones are even technically feasible, and which ones are merely sensational and unrealistic, is not always easy. However, certain social, ethical, legal, political and economic themes tend to recur across the range of technology types and the conditions of their usage

1.2 Benefits Noted in Research

There are several benefits of digital initiatives in the mental health context that are broadly discussed in academic and ‘grey’ literature:

These are just some of the benefits advanced in the scholarly literature. Some clinically oriented research institutes espouse the benefits of digital forms of mental health care in addressing ‘serious access gaps [to mental health-related] education, prevention and treatment services’.50 We will elaborate on some of these apparent benefits throughout the report, while also attending the risks, challenges, issues, and so on, that may run counter to this optimistic picture of digitally-enabled support.

Photo by Efe Kurnaz on Unsplash.