FIXING A BROKEN SYSTEM

Mental health policy needs to start embracing models and frameworks from other disciplines — in particular, the field of Behavioural Science.

and staying home all day long. Staring at WORKING FROM HOME screens. The blurring of work-life boundaries. Inability to meet up with friends and family. Anxiety about one’s future and financial worries. Uncertainty about when — or if — we will ever return to normalcy. Worries that anxiety is a sign of personal weakness. These are just some of the issues facing citizens around the world during the COVID-19 pandemic.

There is little doubt about the massive scale of mental health challenges brought by the pandemic. Unfortunately, mental health was already a looming crisis before the pandemic, accounting for 22.8 per cent of the global burden of disease. COVID-19 has only accelerated the rate at which this parallel crisis has taken root in our society.

As mental health policy experts and healthcare strategists develop plans to deal with this, we call for a radical rethink of how to help people with their mental well-being. The ongoing conversation in the health policy community in Canada and elsewhere revolves around the need to improve access to mental health services. These conversations often culminate in a call for additional resources — training more providers, scaling up service delivery, and improving the quality and quantity of services offered. In particular, there has been a fair bit of work focused on developing new treatments and therapies, investing in larger programs and policies, designing innovative delivery methods, and increasing the number of clinics, clinicians, and services with an effort to reach a larger percentage of the population.

These efforts focus on the supply side of the equation and are consistent with a quote by Ralph Waldo Emerson: “Build a better mousetrap, and the world will beat a path to your door.” This loosely translates to the idea that if we build better products and services, people will automatically flock to consume them. However, as one of us argued in a recent book ( The Last Mile by Dilip Soman), the ‘better mousetrap’ argument is fallacious because the builders of the new mousetrap haven’t thought of:

a) whether the value they see in the new product is shared

by potential customers; b) what frictions might prevent the conversion of latent

demand into actual demand; and c) how best to solve ‘last-mile issues’ in communicating the

value and facilitating the uptake of the product.

Our collective efforts in mental health care might be falling prey to a similar fallacy. While the work and investment in mental

health infrastructure is laudable, there remains a need to take a broader view of the concept of improving access. Specifically, we must ensure that we do not ignore the demand side of the equation.

For one thing, it is important to identify ‘latent demand’, specifically among citizens who fail to access services even when they would benefit from treatment. Many people with serious mental illnesses who don’t seek help show up when in a crisis that could have been prevented — increasing the stress associated with emergency visits and the high cost of hospitalization.

By attending to the demand side, we can increase the ability of citizens to make informed choices for help-seeking. In order to achieve this, our mental health infrastructure must be designed with human fallibilities in mind and there must be minimal frictions that impede access to the appropriate service. In this article, we offer a new framework for matching demand with supply in the realm of mental health.

The Mental Health Marketplace

Like any other market, the market for mental health services will be best served when there is a match between demand and supply. This matching should occur not only for the volume of services sought and delivered, but across geographies and heterogeneous groups. Obviously, different sub-segments of a diverse population — ethnic minorities, Indigenous Canadians, low-income consumers and other underrepresented groups — will require different volumes and types of support and services need to be culturally responsive to be effective.

At the most basic level, the matching process must attend to structural factors that pose barriers to mental health service use. For example, we must help individuals with minimal fluency in the official languages to be aware that services are delivered in their languages; and for Indigenous people, there is a need to decolonize mental health services and to recognize Indigenous healing traditions. Unfortunately, culturally responsive mental health services are rare.

Two main challenges exist for matching demand with supply. First, there is a need for market development. We must work to convert ‘latent users’ into actual users by designing interventions to ensure that citizens access mental health services at the earliest signs of need, before a crisis occurs. Second, a number of people who recognize the need for services do not access them because of frictions, including complexity of information, clunky processes, lack of access or emotional barriers such as stigma. We must clear these frictions, or, as behavioural scientists say, ‘clear the sludge’. Let’s take a closer look at these challenges.

Challenge 1: Market Development

The act of market development refers to the processes of educating, preparing and organizing the potential marketplace for a new product or service. Traditionally, this includes the development of retail outlets, the communication and education of the value of the product to its potential customers, and the facilitation of sales transactions. The market development for mental health services is no different.

As with many other domains, the principle of ‘A stitch in time saves nine’ also applies to mental health. People that might benefit from accessing services often are unsure that they need it, and therefore procrastinate until they are in crisis. Therefore, one important objective of market development is to encourage people to start accessing services during the early signs of a problem.

Unlike physical health, mental health issues are typically hard to recognize at an early stage. Physical illnesses are preceded by symptoms such as headaches, muscle aches or fevers that people readily recognize. With mental health, these symptoms are typically more ambiguous and not as easy to identify.

For example, if a person experiences stress or anxiety, should they attribute it to a health issue or simply to being unusually busy? Most people do not have the expertise or experience in recognizing mental health problems and may easily misattribute symptoms of psychological distress to external circumstances. Additionally, our society has historically tended to conflate some common symptoms with idiosyncratic or dysfunctional behaviours. Given these challenges, it is easy to see why people procrastinate in accessing services.

There will likely be a further delay in accessing mental health services for the most vulnerable populations if they must choose between treating physical versus mental health problems. People with financial burdens, who live in difficult-to-access areas or do not have paid sick leave have fewer resources to deal with health issues. In the face of constraints, more salient

Unfortunately, culturally-responsive mental health services are rare.

and visible physical health challenges might get precedence over more ambiguous and invisible mental health issues, especially for individuals who believe psychological distress will disappear over time without intervention.

The behavioural sciences offer two potential ways to mitigate these problems.

The first relates to the ‘status quo bias’ — the STATUS QUO BIAS: tendency to speak to default options. A default choice is a choice that people implicitly make if they do nothing. For example, many people choose not to open retirement accounts, get an annual health checkup or consult with their wealth managers because each of these choices involves effort. However, changing the default (without imposing any restrictions on choice) has dramatic effects on outcomes. For example, randomly assigning an annual checkup appointment but giving people the option to reschedule has been shown to increase the likelihood that people will get a checkup. Likewise, defaulting people into opening retirement accounts but allowing them to close the account later increases savings behaviour.

A similar change in defaults for mental health could have positive impacts. Starting from elementary and high schools, we must build a culture in which people are aware of the high prevalence of mental illness (about one in five Canadians experiences mental illness in a given year) and are comfortable with identifying and addressing mental-health challenges. And just as we routinely recommended annual health checkups, we also need to routinely recommend mental health checkups as a default.

Many people with mental illness have problems with motivation and behaviour. When someone experiences depression, they are often lethargic and unmotivated, whereas experiences with mania are often accompanied by engagement in risky behaviour and impaired judgment. Both extremes are related to lower motivations for help-seeking. Therefore, changing the default will likely have a positive outcome for helping people spot challenges early, and will go a long way in reducing the stigma associated with mental health.

A second concept that has DEVELOP A CONSUMPTION VOCABULARY: value in market development is that of a ‘consumption vocabulary’. In the domain of products and services, researchers have shown that the provision of a consumption vocabulary — labels to describe why people like particular products and services — improve the learning of those products and therefore the willingness to engage more with that product category.

Consider, for example, product categories like wine. People often know when they like a particular bottle of wine, but they are unable to articulate why. Giving such consumers labels (indicators of, body, sweetness, acidity) helps them better understand their preference and also engage more to experiment and refine their tastes. A similar approach could be of utility in the area of mental health.

Most individuals are unaware of different forms of mental health challenges. In their minds, anxiety, stress and depression are all part of the same large category of mental illness. Giving people labels to attach to discrete symptoms can help them communicate how they feel in a nuanced fashion, thereby allowing them to recognize the challenges and increase their confidence to speak about these issues with service providers.

Modern-day marketing also effectively harnesses the power of social norms, influencers and word of mouth. In a digital era, many people only share highly curated images of themselves. For such individuals, it is particularly important to cultivate a culture of openness and self-reflection about mental health challenges.

There are also some who share openly about their emotions and daily experiences. Educating citizens to learn to identify symptoms in others is particularly valuable for early intervention for this group, as mental health challenges reduce cognitive bandwidth, which may make accurate self-evaluation difficult. It can be extremely helpful to have a trusted friend, family member or confidante identify signs of distress, reach out and suggest seeking treatment.

Challenge 2: Eliminate Frictions

Even after solving the problem of converting latent demand into actual demand, Sludge can prevent people from accessing a service Sludge is often not intentional, but is a bit like weeds in a garden: Both are initially difficult to spot, need constant clearing up, and ignoring them can result in rampant and uncontrolled growth. Following are four categories of sludge to look out for.

A focus on the supply-side has produced thouCHOICE OVERLOAD. sands of available options for individuals seeking help. However, users often do not know which services can best address their needs. Individuals in distress with limited cognitive bandwidth and motivation may find it difficult to search for and evaluate their options. This state of ‘choice overload’ may lead people to defer making a choice and not seek help at all. Health benefits providers can help their policyholders overcome this obstacle by presenting a tailored list of eligible services, such as a network of eligible therapists and counsellors in a policyholder’s area based on client preferences (e.g. cultural needs).

When a person has to seek services from FRAGMENTED SYSTEMS. two or more providers, care is often not coordinated. A counsellor might recommend consulting for pharmacological intervention to client, but a consultation for medication must be completed with a physician. At this point, it is not only up to the client to seek the physician but also to keep both providers updated regarding any changes in symptoms, side effects or dosages. Another example may be an escalation of illness severity, whereby a client must seek in-patient care but must provide their own clinical history.

Another common source of sludge is exEXCESSIVE PAPERWORK. cessive paperwork. Some plans require a formal diagnosis or a prescription from a physician. For example, Ontario’s BounceBack coaching program — which connects users to a virtual therapist — requires users to enter their primary care provider’s billing number and professional ID. This can lead to procrastination and raises inequity concerns for individuals without a family physician. Furthermore, perceived stigma may also prevent individuals from contacting their care provider to register for this program. Policymakers should identify similar process frictions and streamline the steps involved for registering in their programs to improve ease of access and increase uptake.

Seeking help usually involves interacting with a healthSTIGMA. care provider, which may be difficult for a person if they perceive stigma from the provider, especially if they are already part of an ethnic or racialized minority. Stigma often leads to the avoidance of clinics or other public places where people might be labelled. Policymakers should ensure that individuals at risk or with mild symptoms can self-refer to an appropriate low-intensity service. This would allow them to avoid any potential stigma and make them more likely to access those services, thereby preventing further deterioration, and help close the mental health gap for minority groups.

The Way Forward

As indicated herein, we must think about mental health in much the same way as we think about developing any other marketplace. How can we accomplish this? We have five recommendations.

Many inefficiencies 1. IMPROVE COORDINATION AND OVERSIGHT. and lack of market development arise due to a lack of coordination in the delivery of mental health services across the nation and across multiple entities. If we had a comprehensive strategy for mental health and resources devoted to market development and sludge-reduction efforts, as well as processes for sharing resources across organizations and provinces, we might move towards reducing some of the identified inefficiencies.

Digital tools can overcome 2. EMBRACE DIGITAL SOLUTIONS. many of the structural barriers presented by traditional inperson services, including lack of access, long wait times and stigma. Self-guided digital solutions are suitable for individuals with mild symptoms or those at risk of developing mental illnesses and have been shown to produce modest improvements while protecting the individual from further deterioration. Such solutions might also help to overcome stigma, as individuals do not have to disclose their condition for self-guided treatments. Therapist-guided solutions can be even more effective than self-guided approaches and as effective as traditional in-person services. Therapist-assisted digital solutions may also reduce stigma by removing the individual from the physical presence of the therapist.

Campaigns can increase 3. INCREASE MENTAL HEALTH LITERACY. population-level recognition of mental illness and improve

Most individuals are unaware of different forms of mental health challenges.

understanding of the benefits of treatment. They can also reduce stigma by normalizing mental illness as a common phenomenon that most people will experience in their lifetime and which can be improved with treatment. Campaigns that inform individuals of prevalence and highlight the biological, psychological and social factors contributing to mental illness can also reduce self-blame and stigma. Using a bio-psychosocial model reframes mental illness as a social issue rather than locating the responsibility within the individual. Mental health literacy campaigns can also instill hope by including examples of individuals with mental illness who are living successful lives post-treatment, motivating consumers to act. Furthermore, by improving mental health literacy at an early age, we can normalize the idea of regular mental health checkups as part of everyone’s regular default routine.

As indicated, sludge-reduction efforts can 4. REDUCE SLUDGE. make it easier for people to seek help. Because vulnerable individuals might not know they need help, governments should make validated screening instruments widely available to help citizens determine whether they could benefit from support. Self-administered web-based tools could be completed regularly to help care providers monitor any changes in a patient’s health. Learning from past research, health benefit providers could also automatically assign their policyholders to the next available appointment with an eligible service providing the appropriate level of care, providing an option to reschedule or select a different provider. Finally, as health benefits providers are responsible for monitoring service usage, they are in an ideal position to coordinate such services to enable the integrated and seamless delivery of care.

Despite the fact that social me5. EMBRACE SOCIAL MEDIA TOOLS. dia has been blamed for a variety of mental health problems, it can also be of help in several ways. We know that people tend to look to other people who are similar to themselves or to social influencers (rather than experts) for advice and information. As a result, campaigns by prominent social personalities (both in the physical world, within communities, and on social media) advocating for mental wellness and encouraging help-seeking could be beneficial. In an online context, machine learning algorithms could also help to identify patterns of posting that are indicative of particular problems, and peers (both online and in the community) could be trained to identify patterns of behaviour that signal the need for intervention.

In closing

With the wide variety of technological tools available today, there are clearly many different fronts on which to fight the mental wellness battle. Our roadmap is not meant to be comprehensive, but our point is simple: In order to win this battle, we need to do more than simply deploy more resources. By embracing lessons learned from the Behavioural Sciences and attending to the demand side of the equation, we can increase citizens’ ability to make informed choices for help-seeking — and improve the collective well-being of our society.

Renante Rondina (Uoft PHD in Psychology ‘19) is a Post-doctoral Fellow at Behavioural Economics in Action at Rotman (BEAR). Cindy Quan is a PHD Candidate in Psychology at the University of Victoria and a former research assistant at BEAR. Dilip Soman holds the Canada Research Chair in Behavioural Science and Economics, is a Professor of Marketing at the Rotman School and is the founding director of BEAR. He is the author of The Last Mile: Creating Social and Economic Value from Behavioural Insights (Rotman-utp Publishing, 2015) and co-edited The Behaviourally-informed Organization (Rotman-utp 2021)