Why the next blockbuster in mental health might be a video game

David Keene looks at the difficulties faced in treating mental health patients and how digital technologies are changing the game.

In 1919 a young Dwight Eisenhower participated in a cross-country road trip to deliver tanks from Fort Meade in Maryland to San Francisco. Most of the roads on the journey were muddy, rut filled trails, and after 62 days at an average speed of 5 miles per hour, the convoy finally arrived. Forty years later President Eisenhower signed the Federal Aid Highway Act and created the United States’ interstate highway system. Today, the same trip can be easily completed in 4 days.

A highway is a wonderful example of an enabling technology, an underlying, general purpose entity that supports many – sometimes unexpected – innovations. For example, one could argue, that without a high-speed reliable interstate highway system, we wouldn’t have Amazon. Moreover, first mover advantage goes to those who see the maturation of enabling technologies and can build solutions at their intersection at the right moment.

For digital therapeutics, that moment is now.

When I started in the video games industry, computer graphics were – at best – abstract representations of reality. Over the last 20 years, computer and graphics processors have improved astronomically. These improvements — measured by increased transistor count and power efficiency — have allowed for radical increases in graphic fidelity. To put it simply, my mother can’t tell the difference between real life and a computer image anymore. GPU speed and power efficiency has also accelerated machine learning techniques that were unheard of 10 years ago.

Likewise, the availability of high-speed internet has skyrocketed. Spurred on by the intense bandwidth requirements of digital entertainment, the average data rate in the western world has doubled every 18 months, in lockstep with Edholm’s law, the telecommunications equivalent of Moore’s law. Starlink, a network of satellites being launched by SpaceX, is 30% launched, and when complete will provide high speed internet to the entire planet.

“EndeavorRx has become the first ‘prescription video game’ for doctors to utilise, forcing focus for children with ADHD”

In short, society has created machines with photorealistic graphics and machine learning capability, along with a blindingly fast network to connect them. Beyond video games, cat videos, and increased revenue, what else will we spend this tech treasure on?

Mental health disorders affect one in four people, making them a leading cause of ill-health and disability worldwide. Economically speaking, Americans lose approximately $193.2 billion in annual earnings as a result of unmanaged mental illness, and depression alone cost the global market $1 trillion in lost productivity in 2013. According to a 2018 landmark report by the Lancet Commission, the growing mental health epidemic could cost the international economy up to $16 trillion by 2030, with a dramatic impact on productivity and quality of life.

After early wins in the mental health space in the 1950s and 60s with first generation antidepressants and antipsychotics, the industry has struggled to impact mental health at the same rate as other indications. With the exceptions of Spravato and Zulresso, the last major steps forward in the space were SSRIs and SNRIs in the 80s and 90s.

Why is mental health such a “hard attack surface”, to use a hacker’s analogy? The brain is the most complex system in the body, and we are only now starting to understand the complex mechanisms of communication within. It is as if we are standing at the doorway to a vast server farm of computers, but we don’t know the passwords, have only recently discovered electronics, and we don’t yet have a keyboard.

Luckily, our brains already have sensing and effector capabilities, including eyes, ears, a vestibular system to sense the world and many other ways to interact with the outside world. Our brains are highly optimized to use these systems not just as content to reason about, but also as source data to change how we reason, a sort of meta-cognition system.

The human brain is constantly rearranging how it filters, processes and reasons its input. For example, in 1897, George Stratton created a pair of goggles to invert his vision. After wearing them for several days, his brain adapted to the inverted signal from his eyes to his brain, allowing him to function normally and even ride a bike. This year, Akili received FDA clearance for their digital therapeutic for children with ADHD by forcing the brain to adapt with a cleverly designed video game that forces focus. Our brains are capable of responding to training with plasticity.

This makes Akili’s product, EndeavorRx, the first ‘prescription video game’ for doctors to utilise. The game, recommended for children aged 8-12 years old, sees players piloting a small aircraft through a variety of challenging environments.

Due to their rapid development times, low risk and potential for synergistic effects, digital techniques are an ideal add on to existing pharmaceutical pipelines. Many existing drugs and therapies could see an efficacy or adherence boost by adding a digital combination therapy. Soon, integrated digital medicine will be like having a miniature interdisciplinary team accessible 24 hours a day in the patient’s pocket.

In some cases, a combination approach like this will give radically better outcomes. For example, Medically Assisted Therapy (MAT) in Substance Use Disorder (SUD) is more effective than medication intervention alone but is simply unavailable in many areas. A combination digital medicine approach will make high quality, standardised behavioural interventions available for everyone. In other cases, such as the emerging use of psychedelics for SUD or Treatment Resistant Depression, such after-care, as well as pre-care, is critical.

Perhaps now, more than any time in history, all the conditions are ripe for a massive leap forward in mental health. Who will take up the challenge? Who will invest in the basic science? Who will invest in the clinical trials? I would argue that the pharmaceutical industry is the prime candidate for taking up the mantle of taking on mental health with digital medicine. No other industry has the experience, budget, scientific rigour, and established commercialisation pathways to move quickly, ethically and powerfully into this green field of development.

With every required enabling technology now mature, the next leap forward is imminent – and for the hundreds of millions living with debilitating mental illnesses, not a moment too soon.

About the author

David Keene is CEO of IntroSpect Digital Therapeutics, an ATAI Life Sciences Company