Brandon: What's up everybody? Welcome to another episode of Get'n Down With Digital Health. I'm your host, Brandon Worley. Joining me today as always is my fellow co-founder and CEO of Mend, Matt McBride. Matt, what’s up, man? How are you doing? Matt: I'm doing great here. Your intro just always gets everybody excited. Brandon: Just trying to raise the roof, man, and keep people engaged. Matt and I are very excited because we have a very special guest. Dr. Aragam is here with us. She is a psychiatrist at UCSF. Dr. Aragam, welcome. So happy to have you on the show with us today. Gowri: Hi, good to be here, and thanks for the very energetic intro. That's so wonderful. I am so awake now, this is great. Brandon: I achieved my mission. Dr. Aragam, for the audience, if you wouldn't mind, please just introduce yourself and let them know a little bit about your background. Gowri: Well, thanks for having me. My name is Gowri Aragam. I'm an adult psychiatrist, currently an assistant professor of psychiatry at UCSF, and previously at MGH, where I did my training. Just finished up a fellowship at UCSF as well. My past or my career has been also a co-founder of Stanford Brainstorm, which was the first academic lab for mental health innovation, where we taught a course on mental health innovation. We wrote papers, we consulted with tech companies. We were advising startups. We were doing everything we could to really build an ecosystem and bring together the big gap we saw between industry innovators, academics, and clinicians who really understood the space. That's been my passion. I try to do that however I can bridging those gaps. That's the brief version. How was that for an intro? Brandon: No, that was awesome. I know when we first learned about you and your background, what was so intriguing to us is not only are you a psychiatrist, practicing, and helping care for patients, but you have such a deep tech background and a passion for it. The folks who will be viewing this could get a lot of value out of your insights, because (as you know) digital health is just moving so fast now in all of healthcare, but especially in the mental health space. Since you do have that unique background as both a psychiatrist and involved in tech as a consultant in other areas, what are you currently working on? Gowri: I can't say what I'm currently working on, but I can tell you a range of things that I've been working on. Generally speaking, I would say I have, historically at least, worked on either code developing tech-enabled products that companies want to use either for direct healthcare delivery or for general public health education. I've also worked more recently on real nitty-gritty stuff, like figuring out how to best onboard new clinicians to a web-based digital health platform, both in terms of using the interface, making EMRs more user-friendly and useful clinically, also making it easier to onboard people and to provide training modules and resource guides. As you know, there's just been a huge explosion of healthcare delivery platforms and trying to get new providers to be able to deliver those services, helping figure out how to maintain quality as that happens. That's been more recently what I've been working on which is more nitty-gritty but very much necessary. That's a general sense of the general categories of things that I've been involved with. Brandon: In all of that work you're doing, which sounds very exciting, and on behalf of all of us who are trying to move the digital health utilization across more providers, thank you for your efforts. Are there any specific trends that are really sticking out to you that you're noticing? Gowri: It's funny because the idea of trends feels interesting. I've been in this space for about a decade, more intensely for the past 6–7 years. Things that I've noticed over that course of time continue to be similar, but there's just more evolution. Things are getting more evolved in terms of their ability to deliver on the promise. What I've been noticing is there's definitely a push more recently towards youth mental health, which is always an important thing. More recently, it's a lot more money, time, and effort being put into delivering services that are specific for the youth and seeing them as a demographic that requires a particular intervention and approach, which is initially really great. That's all the way from gaming to direct online healthcare services to the in-between time, and really understanding what their day-to-day looks like. That quickly goes on to another thing that I've noticed is just this idea of well-rounded services. I've noticed these kinds of platforms that used to maybe do just therapy, or just psychiatry, or just education, really trying to expand and combine modalities. They're able to provide something for each person that comes into their ecosystem. One person might need therapy, one person might need psychiatry, one person might need coaching, one person might just need some digital tools to help them re-up on their skill building. I've noticed an expansion of these ecosystems within just a particular company, so noticing a lot of companies that are merging, companies that are being bought out, to really facilitate expansion which allows for easier movement for patients, ideally in the future, and makes that care model a bit more seamless. the ideal is what people are looking for, how do you make people not have to leave and then be lost to the wilderness again, and how do you help them stay within and have whatever they need within the service platform that makes sense. Another thing I've noticed is sensors have been around forever. We've all been really interested in sensor technology. It came to my attention specifically in mental health as it pertains to autism and skin sensors. To me now—fast forward many years—that continues to be pushed in the sensor world as it pertains to mental health. That goes from things like heart rate variability and trying to make that a sensor that is a lot more affordable so that people can measure more frequently because we're realizing how much that correlates with anxiety, stress, depression, and chronic medical illness, all the way to people being able to understand. To skin sensors or sleep sensors, how can you measure the depth of our sleep. There's going to be a push towards that. Again, like vocal sensing. By sensing, that's more vocal technology to understand the vocalizations and different elements of a vocal tone, frequency, variability to understand how that correlates with mental illness states or health states. Matt: Let me ask you about this heart rate variability because mine is usually between 40 and 50. I've got a sensor, I can track it just more from a fitness perspective, but how does that correlate? How does heart rate variability provide an indication of how somebody's doing? Gowri: I guess the quickest way I'll put it is that heart rate variability has been found to be a correlate to vagal tone, which is parasympathetic tone, essentially how good your body is at containing to a calmer rest digest state. If anxiety and stress can activate your sympathetic system, to put it simply, then your parasympathetic system helps with calming one down and dealing with that stress. You're not putting your whole body in that stressful state chronically. The vagus nerve is the primary nerve associated with that parasympathetic system and heart rate variability is something that is controlled by the vagus because that has to do with our breathing, how much oxygen we have in our bodies, how well we can deal with that, and how much our heart has to pump to bring us back to an equilibrium state. Long story short, heart rate variability is a proxy for vagal tone. Vagal tone is a measure of how well our parasympathetic system is working to help us stay calm. It can change throughout the day and for people who have high or low ones, you can tell whether or not they're chronically at risk of high stress or not. It's cool because we can measure that now and it's something that people have used, but it's very cumbersome in the past to measure that and really help people in therapy manage their HRV (heart rate variability). It potentially can be a really huge way forward in helping people deal with trauma, stress, anxiety, and all that. Matt: I think there are reliable and accurate sensors now, so that's interesting. Is it prescribed a device, or maybe they have to get their own device, or is this something that is emerging and that all that stuff is still being worked on? Gowri: I can't speak for everything, but right now what we're seeing is there's a general commercial trend toward sensors. A very conducted consumer model. Ideally the goal is for people to be able to get this in the hands of patients, which is the goal in general, how do we actually help people who need the help. I don't see physicians prescribing sensors by any means unless there are some more cutting-edge ones who might and who may have the capability to do that in their practices, for sure. I'm not going to speak for everybody, but I wouldn't say it's widely available yet because I don't think people really know what to do with the data. It's like this is still up and coming. This is something that's relatively new. What do you do with that data? Which is a big question that we're probably going to talk about probably soon in this particular podcast episode conversation. Also in general, what does one do with the data? How do you use that to help the person in front of you? Matt: We'll touch on it a little bit more in some later questions because I've seen it captured through a web camera, which is pretty amazing. I've got the sensor, I can access my heart rate variability, and then I can run a test through my webcam at any time and see and it's pretty darn accurate. There are a lot of cool things like that emerging that we'll see in the not-too-distant future. Gowri: For sure. Brandon: That was a great answer that you gave around the sensors. I know I learned a little bit there, so thank you for that. Clearly, you have a passion for digital mental health and that encompasses a lot of different things, part of which you just elaborated on and some a little bit earlier when you were talking about some of the trends you're seeing and some of the things that you're working on. I'm going to venture to say there's going to be a good part of the audience who will be viewing this who may not have in-depth knowledge of what digital mental health means. If you wouldn't mind for their benefit, could you just define what digital mental health means to you? Gowri: Thank you for saying what it means to me because I don't want to be butchering this and someone’s going to be like that's not what it is. This is so funny that you ask the question because my team, over the course of many years is like, what are we defining this as? Over the course of time, it's become (to me at least and in general) to be services and tools one can use on any mobile or web-based platform. If you can get services using your phone, an app on your phone, on your computer, through a website, and that includes wearables and sensors that usually have some mobile or web-based platform that used to hold their data, make sense of the data, for you to have this dashboard, for you to see what's going on. I simplify it in that way. That's what I have most easily defined digital mental health, to me at least. It encompasses a lot of stuff and a lot of what we see out there in these companies. Does that align with how you all have been thinking about it? How do you define it for yourselves? Matt: Here's how I like to think about it. Mental health is really one of these specialties that can have some digital component every step of the way. You could get all your treatment virtually, whether it's some intensive outpatient therapy, you seeing your psychiatrist, you're getting your therapy, or there are even clinical assessments. There are other types of tools in therapies that seem to be done virtually. I like to think of it as that mental health organizations are really leading the digital revolution, and showing a lot of other specialties and just showing health care what can be done because you could receive care almost 100% remotely. There are a lot of other aspects to it, but I just like to think that mental health is really almost defining what digital health can be. Gowri: To your point, you're talking now about what it looks like to apply those mobile and web-based tools. There is a whole arc of care that you're referring to in terms of identifying who needs help, making the assessment of the said person, following them through, making treatment decisions along the way, making sure they stay engaged all the way through to them experiencing some relief. Then all the interstitial stuff in between. All the communication that happens, all the pharmacy visits that happen, all the medications and treatment plans they have to adhere to. How do you ensure that they stay on the path and what does that look like which leads me to actually, I want to go back for a moment, you mentioned what else I'm seeing in terms of the trends. This is not as much a trend as it is a mandate, but I have also been seeing a lot more of these conversations, which is great around how to do what you just described, Matt, in a way that's actually culturally sensitive and that actually accounts for a person's background, their ethnicity, and where they live. How do you incorporate this idea of making sure something is culturally accessible to someone, because mental health is so intertwined with our daily life, our social lives, our occupational lives, just the fabric of how we go about our day. That inherently is so entrenched in the culture that we have and that we live in as well. I think that's another trend. To your point, digital mental health is a way to use those kinds of technologies to facilitate the entire arc of care, and then ideally actually create new pockets of care and allow a person's life in between visits to also be really meaningful and provide a lot of benefit to them, as opposed to right now which is like a visit, visit, or what had been the case which has been visit, visit, visit, and then dead time in between. Matt: You mentioned this almost tailoring care to a given culture. Is there an example that you could maybe describe to the audience and maybe how it made an impact? I haven't really necessarily heard of that before, so I was wondering if you could elaborate on that a little bit. Gowri: I can give you an ideal example in terms of what people are working towards and how little things have already made a big difference. I'll give you a small example, which is not exactly what I had in mind when I said it, but I'll give it anyway because it counts. For example, in the emergency room that I worked in. It is a county hospital in a part of California where there's a very diverse patient population within the attachment area of that hospital. A huge barrier to care for them had been that they just did not have adequate interpreter services from Spanish through ASL, using sign language. Being able to provide them with the hardware, which was the phone and the video monitor, and then the software, which I guess is the service, which are the people at the other end of the line, was a huge win because we were able to provide interpreter services for people coming in with even languages that were less common in the area. That was a huge win in terms of being able to provide services in a way that you could tell made people feel more at ease. You could tell they were able to speak more openly and were able to actually figure out what was going on. The sad part is prior to that—I hate to say it—there will be a lot of assumptions being made which still are made, to be fair and to be honest, but even more so. A person's inability to communicate in English, for example, would be somehow pathologized in a way that was just really unfortunate and wrong. Now being able to actually communicate with someone in their native language in an effective and seamless way is a huge win. You take that as a small example, but also a big impact of the impact technology, in general, can have on culturally sensitive care. What I was talking about also is expanding. It's like how can you, both literally and figuratively, speak the language that a person is used to speaking in a way that makes them feel more at ease? The way patients felt more easily sitting in the chair and being able to share more openly and feel like they identified with someone in the room or something in the room, which in this case is a voice, and you're seeing more and more platforms coming out with it. One of the first things was a meditation content. Meditation is an inherently non-western tradition. How do you really acknowledge that and decolonize that space and provide options for meditative audio, for example, that call upon various cultures and various religions and with different voices sharing them? That was one of the first things I thought to really speak to particular cultures. There are different ways that mental health issues can show up depending on one's background, so getting more of a sense of making assumptions about how that might happen allows you to provide educational content, but also to ask questions you may not otherwise ask and show certain images you may not otherwise show, in order to build that client and patient rapport. That doesn't mean like totally changing the book in terms of what the tools look like on the back end. It does mean that you are tailoring the design of the said tool to make it feel more comfortable for the person using it, much in the way that interpreter service might interpret English into whatever language it is that the person actually does speak. Does that resonate with you or does that make sense at all? Matt: Absolutely, because we support eight different languages today, some of the most common languages. This is just our notifications, our text messages, our digital forms, our website. We've seen customers that will have high populations of certain folks, like Haitian Creole is one, for example, that we've got everything in that language from the notifications, the website, the forms. In that instance, there's such a population where they may have providers that speak that language, but we've got the ability through telehealth to bring in and connect up any translation service. I definitely think that has been a big one. If you're trying to get mental health help and there's a massive communication barrier, massive language barrier, that just doesn't help. It just adds to the frustration. We've definitely seen that and being able to support multiple languages is something we've taken pretty seriously. Brandon: The only thing I would add to that, too, is an end result of all of these really nice features that these digital health companies have put together. We very commonly see new groups that we partner with going from 40%-, 50%-, 60%-plus no-show rates with in-person visits to single-digit no-show rates. What does that mean? It really means that patients who are seeking care through digital means are getting the care they need more frequently than if they were just going in the traditional in-person setting. Hopefully, that will lead to better outcomes and people just continuing on their journey to wellness even faster. Tons of help that you see from it. Gowri: Absolutely. Sometimes even the small tweaks can lead to such a big impact. We can't underestimate how nervous one feels, including us, when approaching something or trying to engage in something that's meant to help us, but also can be very intimidating and doesn't always treat us with care or kindness. If you add on to all these things that we've been talking about, it's not surprising to people the no-show rate is that high. What I always talk about is when people are thinking about how to innovate in this space—I might be preaching to the choir here. I don't even mean to be preaching. I just want to just say it because it's pretty practical—and to Matt's earlier point and what we're talking about earlier mental health is within the fabric of our lives. It's our emotional state. It's how we interact with ourselves and how we interact with other people and how we make sense of the world. That is a constant in our lives every moment of the day. It will inherently intermingle and coincide and intersect with just the basic needs that we have each day. A lot of these administrative issues that come up, whether it's signing forms, having to physically get somewhere, having to get child care for your kids, things that seem so simple but actually can be very, very difficult, making those things more seamless is inherently improving the well being of a person in our family unit. You're facilitating what you think is a small deal is actually a huge obstacle for this person or family and it ends up facilitating their ongoing, continuous care. We've noticed that even in mental health, sometimes just seeing the person having a touch point frequently can be enough for certain people. Just having that person to go to on a consistent basis can be therapeutic in and of itself. Just the additive effect here and the compound effect of being able to facilitate a lot of these interstitial things for these people and family is somehow underestimated and not talked about enough. I know that's what you're working on at Mend so that's why I bring it up because it can have a really huge impact. Matt: Just to switch gears a little bit from maybe the patient side to the provider side, because our audience is going to be a lot of decision-makers in healthcare and that's who we send the episodes out to. I saw the podcast that you were featured on the Psych Congress Network with Dr. Chan and you were discussing this need for support around digital tools. We've always tried to provide a lot of customer service and support. For patients, it's a little bit easier. Providers don't always have time to really work with anybody on the support side. They're so busy. I was curious, what support do you think is needed and lacking? What would you communicate to the decision makers out there on the support that's needed around these digital tools? Gowri: It's a big question because there are a lot of different ways this answer could go. My team at Stanford had done last year a survey, during COVID, of practitioners that was recently published. It was an attitude towards technology and practice. We asked them a lot about what allowed them to take on telemedicine so quickly during COVID. Obviously, there was an imperative to do so, but what else did the administration do to facilitate that? It's one of the general questions that we asked. If that same support could translate to other digital tools. If they had the same support, would they be open to using digital tools in their practice? What we found was that it isn't totally surprising. It's just more fun to get it through a survey than not. It's that most of the people that we have either spoken to or who took the survey were just overwhelmed by how helpful it was to have various layers of support from their institution, whether from the nitty-gritty of literally, how do I use this? Whereas the customer support for the technology in and of itself to the bigger picture like am I covered? Is this legal? Can I do this? The medical legal aspects of things and making sure they were covered from that front. It ran the gamut in terms of how they felt supported. That was hugely helpful in how quickly people were able to take this on during the pandemic and then ongoing. I think policy-wise, there are obviously leniencies in terms of out-of-state and who you could see and when you could see them and what you could prescribe and all that. Policy-wise, it facilitated telemedicine adoption during COVID. I mentioned this because we can learn a lot from that as it pertains to now moving forward and be like how can we now incorporate digital tools in ways that could be helpful? One of the things I would say is, hey, there's a huge array of tools that are meant to exist within healthcare systems and some that are meant to exist or designed to exist outside of it. Let's think about what tools that actually exist now that people want to incorporate into the medical system and what kinds of tools are appropriate for a hospital versus a clinic versus a group practice versus a purely virtual practice. There are various types of provider spaces that exist and I think it's important to consider what types of technology could be useful for each. Look at anything else that you would say, hey, let's figure out what's most useful in this particular environment. I say all of that for one reason, which is that we got to know, (1) what people actually need, (2) how to best support them from a systems perspective and be able to incorporate those things, and how to make sure they feel safe using whatever it is that they're using. Not only from a medically legal perspective, but also how do they know that it's going to work for their patient or patients are at at risk. That is a huge concern that goes through the minds of any physician or any provider, any clinician—is this thing I'm using going to help this person or harm them that I am with? Then it becomes a huge struggle. Any technology that's being incorporated, people want to use it. They want options for their patients. They want to be able to give them something to use and in the time they don't see them, they want to make sure they come back. They want to see successful outcomes. People are realizing that tech can really enable that, but it can feel like such a huge beast and a huge monster of like, I don't know, there are so many tools, but actually, only a few of those tools are really relevant to your practice and to your patient population. In this particular slice of time, there will be more coming down the pipeline, but let's not get too nervous about those just yet. If you're in practice, sometimes starting small is really the way to go. Before I keep going, does that resonate with you all in terms of what I am getting out there? Or should I clarify and try to say it again? Matt: No, that's helpful. From our perspective, we might think of support as tech support, but then you were mentioning some of the other sorts of legal and compliance support because the pandemic changes everything. Maybe you weren't doing a lot of virtual, now all of a sudden you're doing all these virtual visits and somebody's going to be seen and they're driving their car, they're in the supermarket now. There's a whole different world of scenarios. What about HIPAA? We've definitely encountered a lot of those different things. Even just prescribing controlled substances was something that state laws dictated. That's the message to leadership here. There has to be, of course, the technical support available or the training, and then the legal compliance, maybe clinical support even to make sure that people are doing things according to the law that's safe and going to be effective. That makes a lot of sense. Gowri: It's like who can this be useful for? We triage services all the time. How do you triage tech in some ways because not everything is for everybody, and we know that already from other kinds of healthcare. The same applies to technology. Brandon: I'd love to move in a slightly different direction and really learn a little bit more about your experience doing virtual health. If you wouldn't mind, talk a little bit about how much virtual health you were doing pre-pandemic, then during the pandemic, and how that has evolved into the current state. Gowri: I did no virtual health before the pandemic. I had colleagues who did, who were going in and trying to provide services to more rural areas in emergency rooms primarily, or in-patient hospitals. I myself was not doing any. I thought they were amazing. I was like, oh, my goodness, how cool. They can do this. During the pandemic, I was actually working primarily in an emergency room, so I was not virtual at all. I was fully in-person for that. Then when I switched over to UCSF, I was doing in-patient work. That was not virtual because I was doing consultations but all my out-patient work was virtual. It's 100% virtual in the out-patient world. Now (2022) there's been a push to go to worth more of a hybrid model—some virtual, some not—and now really pushing to get people back into the clinic if they are able and willing to do so. Brandon: You mentioned earlier about gathering some survey information, but have you gathered any survey information or even just general feedback from your patients about their view of virtual care and how it may be different than in-person visits? Gowri: Yes. I asked every single patient of mine how they feel about this because I was just curious. I was working with a population that was (I guess) all adults and a range of ages. I'm not providing therapy. I was providing psychiatric service. I would not say I would apply this to therapy, but in psychiatric services that I was doing, all the patients were very okay with being virtual, primarily because the way that system works is that a lot of them live very far away. A lot of them require assisted transportation to get in. It was more of a risk for some of them to actually come in than it was for them to stay at home, because the risk of a fall or medical complication in transit was non-zero, insignificant. For many of my patients, they actually were very okay with it. On the other end of things, people who were in their car, in class, trying to make ends meet, who had children, I would see many patients when their children were there with them. A lot of people were postpartum patients as well. For the postpartum crew, that was a whole other reason why it was helpful for them to be virtual. It was easy for them to show up. That was the general sense people had, at least for psychiatric services, and it was resoundingly positive. I personally did not hear much on the negative side for my particular patient cohort and from my colleagues as well. There were some, but it was for the most part, on the patient side, positive. Brandon: Now to flip that from the provider side of just the general feedback you got, what feedback did you get? We heard a lot about burnout during the COVID pandemic, providers really just working their tails off to try to care for folks. Do you feel like virtual care has helped improve the potential for burnout? Did it stay the same or do you feel like it's gotten worse? I guess what impact do you feel virtual has had on people and their workloads? Gowri: I'll speak to how I've seen it vary. I have seen some people who would have probably been those people doing virtual pre-pandemic and have been very happy with it, and continue to be happy with it and loving what it gives them in terms of flexibility in their life and location. There are many that have just been like yeah, this is great. I don't want to go back. I have no interest in doing in-person. I really enjoy this and I'm able to see patients I would never be able to see because they live so far away in California. It's a big state. Then I see others who really miss it. They really miss seeing people in person. They miss the jolt of whatever brought them to be in person because it felt much more enriching and much more fulfilling and it didn't feel as draining to be seeing someone in person and not over the screen. I can't tell you what it is about each person that made them like one versus the other at this moment, but I definitely saw that. Others who were noticing that as much as the patients enjoyed virtual, from the mental health perspective, there are still things that are being missed. You can only see someone's eyes up. It's like when you talk to your grandma sometimes or my aunts. I can't see their faces because they don't know where to look at the screen. As sweet and endearing as that is from a clinical perspective you can miss a lot of stuff or seeing somebody only over the phone because they don't feel comfortable using their computer. Voice can tell you a lot, but you're also missing so much by just the observation. The full mental status exam cannot happen when you're only seeing one part of a person's body. There are other doctors who are noticing that there could be a loss clinically from not being able to actually see the person in-person at least every few months if not every single time. So that’s clinically speaking and what I've been hearing from my colleagues and also from myself. Brandon: Thank you. Matt: Well, we've had a lot of great information so far, but now it's time to switch gears and maybe have a little fun. I get to put you both through an optical illusion and see how it goes. This one is from the New York Post. I'll bring up the screen sharing and you're going to see a square move back and forth across the screen. We want to know the color of the square as it moves across the screen. These are always fun. The audience gets to play along and be tortured as well. Give it a second. I'll play the video here a couple of times and see what you think. Gowri: It changes. Matt: You kind of have this beige and this sort of teal. Brandon, what do you think? Brandon: I've done a lot of these things now on these podcasts, so I know there's generally something I'm missing, so I'm trying to outsmart it. It looks like it's changing to me, but if I had to pick one color, then I would say it's the reddish color. Matt: That's pretty good. Check this out. If you were to crop out the squares on the opposite ends, they're actually the same color. Gowri: Oh, cool. Matt: It's called the chromatic induction effect. It's a perceived color shift. Brandon: I definitely saw it going more reddish to bluish, for sure. Matt: It looks like it's changing. There's no doubt. It looks like it's changing colors. Brandon: Definitely. Gowri: Pretty cool. Matt: Crazy. Brandon: Dr. Aragam, thank you so much for your time today. I know Matt and I have really enjoyed this conversation and definitely learned a lot. For all of you watching, I hope you enjoyed this episode as much as we did. Please feel free to hit us up with any questions or comments you might have in the next episode. We'll have another great digital health thought leader for you. Please make sure to like and subscribe. Thank you so much for watching. Again, Dr. Aragam, thank you very much. On behalf of Matt and I and everyone at Mend and the entire audience, have a great rest of your day. Gowri: You too. Thank you to both of you. Have a good one. Brandon: All right, take care.