Catalytic environments to drive progress in digital mental health research
Creators: name: Florescu, Ana
name: Trust, The Wellcome
Publisher: name: F1000 Research Limited
Year: 2024

description: <i>Version 2 corrections: This version 2 of the report was created to correct a misattribution for E7 on page 30 and factual errors and inconsistencies in describing the relationship between different parties for E15 on page 40.</i><br>
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<b>Executive summary </b><br>
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Digital mental health solutions, including diagnostics, triaging tools, and therapeutics, have the potential to benefit public mental health by offering new solutions for mental healthcare, lowering costs of care, reducing burdens on services, widening access to treatment, and enabling more convenient and personalised care. <br>
While many in the mental health field see this potential, not all digital mental health research successfully translates into impactful solutions. This report highlights five core barriers impeding translation: 

 <b>Constraints in the academic environment and the funding structures that support it</b>, including incentives that favour research outputs over solution development, and skillsets that do not fit with what is needed for translation. 
 <b>Challenges finding a sustainable business model</b>, as each of the main business models have significant challenges and there are many uncertainties influencing business sustainability.
 <b>Challenges in gathering relevant evidence</b>, including limited time and resources, and limited access to real-world testing environments. 
 <b>Challenges interfacing with and embedding within healthcare systems</b>, including understanding what is needed, identifying key decision-makers, ensuring uptake by clinicians, and integrating with existing care pathways and IT systems. 
 <b>Mismatch with user needs, priorities, and realities</b>, derived from factors including limited user engagement, stigma, and a lack of trust.

<b>The landscape of catalytic environments<br>
‘Catalytic environments’ </b>are one potential mechanism for overcoming some of the barriers to developing and scaling solutions. We have defined them as follows: <br>
<i>Digital mental health catalytic environments are organisations or programmes that create and/or directly support projects to develop digital mental health solutions. These projects may be run by the catalytic environment itself, or they may support independent organisations such as companies and non-profits. Though research may be an important part of a catalyst’s work, they aim to go beyond research to build digital solutions that are implemented at scale and have a significant public health impact. </i><br>
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Our research identified 93 example catalysts across 21 countries (see Airtable database for identified examples). Some focus exclusively on digital mental health, others on digital health solutions more broadly. They vary considerably in factors such as the kinds of organisations they are embedded in, the support they offer to solution developers, how they are funded, and how they involve people with lived experience.<br>
To better understand and compare these real-world examples of catalytic environments, we developed a typology based on their key differentiating factors. We noted that catalysts usually take one of two approaches to addressing translation barriers: 

 <b>Support the development of the digital solution inside an academic context, but create complementary structures</b>, such as partnerships with healthcare systems, to address the limitations of research-focused academic settings; or
 <b>Support the development of the digital solution outside of academia, usually in a commercial environment.</b> This may involve moving solutions, knowledge, and/or researchers from an academic context to the non-academic context in order to focus on translation, entry to market, and scale. 

Catalysts located in an academic environment have the advantage of being able to ground solutions in strong research expertise, and to carry out further research on solutions themselves. In addition, academics are not constrained by concerns of short-term profitability. However, there is often a significant mismatch between the incentives, support structures, and skillsets of an academic environment, and what is needed to develop and scale a digital mental health solution. Some experts we spoke to with experience of developing solutions in an academic context mentioned these limitations of the academic environment as a significant constraint for translation.<br>
On the other hand, catalysts working outside of academia have more flexibility to establish the right conditions to support digital mental health solutions; this includes culture, ways of working, incentives, funding structures, and hiring practices. However, they do not by default have the specialist expertise or research infrastructure that catalysts in academic environments have; therefore, they need to take special care to establish their own structures that provide good grounding in science, as well as clinical practice and lived experience.<br>
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<b>The types of catalytic environment</b><br>
In addition to this broader distinction between catalytic environments based within or outside of academic contexts, our analysis revealed numerous different models. To capture these key differences, we developed a framework of six distinct catalyst types, including:

 <b>University research and development (R&amp;D) centre</b>. A university-based centre that initiates and runs R&amp;D projects in digital (mental) health. While led by an academic institution, they may have several partnerships with healthcare system actors or industry, typically on a project-by-project basis to support further development, testing, and implementation activities. Examples include the E-Health Research Center (EHRC) and the Healthcare Technology Innovation Centre (HTIC). 
 <b>University-healthcare partnership</b>. An organisation set up as a partnership between a university and a healthcare system, such that there is deep collaboration throughout the development of interventions. They usually also build partnerships with other stakeholders such as industry, non-profits, and people with lived experience to strengthen solution development and address translation barriers. Examples include MindTech, MindSpot and the eCentre Clinic, Mental Health Research for Innovation Centre (M-RIC), and Eindhoven MedTech Innovation Center.
 <b>Implementation project</b>. Multi-partner collaborations focused on scaling existing digital (mental) health interventions. They are often funded for a fixed period of time and aim to act as a one-time catalyst to drive adoption (often alongside the generation of new solutions). Key stakeholders usually include implementing partners committed to exploring the adoption of existing and emerging interventions. One example is the eMEN: e-mental health innovation and transnational implementation platform North West Europe.
 <b>Independent R&amp;D centre</b>. An organisation that initiates and runs R&amp;D projects in digital (mental) health. While independent from an academic institution, it can have close partnerships with academia, as well as with other key stakeholders including industry, healthcare system actors, or governments. The organising structure of the centres can range significantly, as they have the flexibility to define working structures, incentives and culture. Examples include Orygen Digital and the Wyss Center.
 <b>Accelerator programme</b>. Programmes focused on accelerating existing solutions. They usually recruit startup technology businesses into cohorts lasting from a few months to a year. During the cohort, participants will receive guidance from the accelerator, access to a network of mentors and advisors, and usually funding. They also support cohort members to get follow-on funding through the accelerator’s network of investors. Examples include DigitalHealth.London and The HealthTech Hub Africa.
 <b>Venture builder</b>. Venture builders can be similar to accelerators in terms of structure and support offered, with a key distinction that instead of supporting existing startups, they support individuals to create startups from scratch. We are particularly focused here on a subtype of venture builder that recruits researchers as co-founders, so that they can make use of their expertise to build a science-based business. We note two types of venture builders: <i>founder-first</i> and <i>problem-first</i>. Examples of venture builders include Zinc, Deep Science Ventures, Convergent Research, and Alpha and Koa Health.

<b>Recommendations</b><br>
Our recommendations were developed based on an understanding of the barriers to digital mental health translation and how existing catalysts are tackling these. We drew on ideas from desk research and interviews with experts, including catalytic environment staff. We shaped these recommendations through several iterations with feedback from our advisors, governance group members, and the team at Wellcome. Overall, we make three recommendations for mental health funders interested in supporting digital mental health research translation:

 <b>Fund a venture building programme in digital mental health</b>. This is based on concluding that a venture builder could overcome many of the barriers we have identified and create digital solutions with a high potential public health impact. However, a clear message from experts we consulted was that it is not enough to facilitate the founding of new companies in digital mental health, because barriers around finding a sustainable business model and integrating solutions into healthcare systems can still cause companies to fail later in their development. 
 <b>Drive change in digital mental health markets and healthcare systems </b>responds to these later-stage barriers around finding a sustainable business model and integrating solutions into healthcare systems, and we suggest that this should be supported in parallel to the venture building programme suggested in the first recommendation.
 <b>Create new or modified grantmaking programmes. </b>We also think there may be benefit to funders making changes to existing grantmaking programmes in order to better respond to the barriers we have identified, and this is what we suggest in our final recommendation.

These recommendations can be seen together as a cohesive strategy rather than standalone actions. This is particularly true of recommendations 1 and 2. Driving change in digital mental health markets and healthcare systems in recommendation 2 will facilitate the development and scaling of solutions developed through recommendation 1. Conversely, the venture builders supported in recommendation 1 will develop an understanding of the market and healthcare system barriers that can be addressed through recommendation 2.<br>
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Batty, R., Florescu, A., Gulliksen, E., Wong, A. Catalytic environments to drive progress in digital mental health research. London: Wellcome; 2024.<br>
Corresponding author: Ana Florescu af@science-practice.com