Photos by Joel Schnell

A Therapist in Your Pocket

Smart phones and bracelets now support mental and behavioral health

People struggling with mental illnesses face multiple obstacles to get treatment. There’s the process of finding an appropriate provider, then making time for an appointment and figuring out how to pay for it. Minnesota’s mental health system has a well-documented backlog that often leads to a wait for services.

Add to that the lingering stigma around mental health that stops some sufferers from reaching out; others may be too overwhelmed by their illness to take the step.

Several Minnesota startups are on the cutting edge of developing consumer-centric digital tools — online content delivered to apps and tablets, wearable sensors and text-based coaching — to ease the process and make care more accessible.

“This is an exciting time for us; we are doubling and tripling our growth in every metric, from clients served to our revenue,” says Dale Cook, CEO and co-founder of Learn to Live, which provides customized online programs based on the principles of cognitive behavioral therapy, or CBT.

“Over 10 years of psychological research shows that online CBT is as effective as face-to-face therapy for mild-to-moderate sufferers,” he adds. “We’re meeting an important need for folks, but it’s sobering because we see people suffering.”

Founded in 2013, Learn to Live offers three programs targeting users with depression, anxiety or social anxiety. Learn to Live provides them with self-paced online lessons and can augment their experience with social media support groups and coaching from mental health professionals.

“Programs like ours are taking hold in the wellness space,” Cook says, noting that clients include employers, health plans, and colleges and universities. “Employers feel the steep cost of mental health problems in high rates of absenteeism and employees who are less productive because they are depressed or anxious.”

Plus, many workers with comprehensive mental health coverage don’t take advantage of their traditional therapy options.

Cook’s research indicates self-directed offerings like Learn to Live see higher rates of participation.

“We get 25-30% engagement of a population in our clinically appropriate solutions. We know that employer assistance programs that have been around a long time generally get 1-5%. That’s an eyebrow raiser.”

Another online resource called Marbles zeroes in on a narrower target. This peer-to-peer mobile app is building a virtual community of students and young adults who live with depression and suicidal thoughts.

“College has become a pressure cooker, with 1,100 collegiate suicides per year. My big audacious goal is to eliminate it [suicide],” said Real EmPowerment Solutions CEO and founder and Marbles creator Adam Moen, 26, who blogs and speaks as That Mental Health Guy.

Moen, a high achiever from a loving suburban family, found himself feeling overwhelmed and immobilized as he pursued a business degree at the University of Minnesota.

“It wasn’t the academic rigor that broke me. It was the expectations I was dealing with,” he recalls. “It pushed me to a very dark place. I used drugs and alcohol to numb myself and thought about suicide.”

Alarmed by his descent, his parents and friends intervened to get him professional help. As he grappled with his illness, Moen began telling his story on YouTube and was surprised with the appreciative response from other college students.

“That was the turning point. I wasn’t the only one struggling with these thoughts and emotions. I realized I’m not alone when I share my story.”

Moen began leading a support group for young adults through the National Alliance on Mental Illness (NAMI) and started work on the app, produced with a social science researcher at the U. Marbles offers a way for users to build self-awareness by reflecting on how they are feeling and to communicate, whether to share their own distress or to offer their tricks and tips for managing stress to their peers.

“You don’t have to be a trained professional to deliver a human connection to someone who’s suffering,” Moen says. “We have a warmhearted and genuine community giving intellectual, social and emotional support.”

It should be noted that these new tools are unregulated by the FDA. Data on the quality, safety or efficacy of apps and wearable sensors is still emerging. Last year, the American Psychiatric Association set up a Smartphone App Evaluation Task Force to offer recommendations and guidelines for their clinical use. The group is pushing for more clinical research to provide evidence to support their use in the treatment of psychiatric illnesses.

“These apps are a good addition and have a role to play, but they won’t and can’t replace the traditional system,” says Sue Abderholden, executive director of NAMI’s Minnesota chapter. “We need a full range of services and to build up our mental health system.”

NAMI Minnesota has expanded its own online offerings, with web-based support groups targeting rural Minnesota, where providers can be scarce and drives to appointments can be lengthy. But Abderholden believes the new digital options are not adequate for many people who need psychiatric care for diagnoses like schizophrenia and borderline personality disorder. She thinks the online approach works best for those whose mental illnesses are described as mild or moderate.

“If you have a serious mental illness, you need more than an app on your phone,” she adds.

Abderholden notes that the Affordable Care Act and the expansion of Medicaid have given more people mental health coverage; additional people seeking treatment have added to the wait time within the mental health delivery system. She sees digital offerings as bridging the gap while those in need of services are on hold.

Dale Cook believes that innovative approaches have the potential to reach millions of underserved people.

He expects Live to Learn to double its work force and continue to expand its server capacity in the next year to keep up with the new users who are logging on.

“Our method of delivery is highly scalable,” he says. “The powerful thing about CBT, whether digital or face-to-face, is that it provides practical tools that can last a lifetime.


Good Vibrations: How one woman’s struggle turned into a high tech startup

Aneela Idnani Kumar had a secret, one she regarded as so shameful that she kept from everyone. Her mother, sister, college roommates and work colleagues didn’t know it.

Neither did her husband Sameer.

But three years into their marriage, in Aneela’s words, “Sameer caught me.”

He walked in on her as she was drawing on her eyebrows and discovered she was suffering from trichotillomania.

Starting when she was a pre-teen, Aneela struggled with trichotillomania — a hair-pulling disorder manifested in her as an uncontrollable urge to yank out her eyelashes and eyebrows.

It worsened when her father was diagnosed with leukemia and died while she was in high school, and continued as she left home.

“It became my go-to soothing mechanism to relieve stress and tension. Some people go for a cigarette break; I would sit at my desk and pull out my eyebrows,” Aneela explains.

When she came clean to her husband, Aneela, now 36, found sympathetic support as she sought therapy for the first time.

As the couple faced her challenge, they gradually came to see an entrepreneurial opportunity in Aneela’s diagnosis, one that has embedded them in Minnesota’s tech and startup community and led to their acceptance into HAX, a Shenzhen-based hardware startup accelerator program.

Together, with the help of two technical co-founders, they launched HabitAware to help people struggling with Body-Focused Repetitive Behaviors (BFRBs), a category that includes compulsive skin picking and nail biting as well as hair pulling.

It’s not clear if the disorder is set off by genetics, stress or a chemical imbalance. But it takes a psychological toll.

“People are embarrassed that they can’t explain it or stop what they’re doing to themselves,” says Aneela. “You probably know someone who has one of these disorders; 1 in 25 people has this, even though no one talks about it.”

HabitAware’s sleek Keen bracelet resembles a sports activity tracker. Using Bluetooth technology, it can be customized to deliver a vibration to alert the wearer of their often subconscious compulsion. Available in a variety of colors and sizes including one for children, it sells online for $149.

“Psychologists who practice cognitive behavioral therapy hand their clients journals to track their patterns and triggers,” says Sameer Kumar. “This device automates the process and gives real time feedback that brings people into awareness, the first step to control the behavior.”

It was a three year journey from their Aha! moment to producing the wearable tool.

Aneela’s career was in advertising and Sameer, with an MBA from the Wharton School, worked as a business strategy consultant.

“Neither of us have technical backgrounds so we found the right team to bring the idea to life,” he says.

The couple started by attending a local hack day, then began networking with other entrepreneurs working in tech and health care. Working nights and weekends, they built an app and a prototype and took it to a conference for people with BFRBs.

“We got market validation there when we saw people wanted the product and would pay for it,” Sameer said. “We told them we didn’t know when we would ship the product but we got 50 pre-orders. That gave us the confidence to keep pushing.”

Their confidence grew again when they were accepted in the HAX hardware accelerator. The couple spent the first three months of 2016 in Shenzhen, China’s electronics manufacturing center, where they finalized their design, iterated the product and worked on software, packaging and supply chain.

Returning home, they began shipping prototypes to collect feedback and building their Minnesota-based team. According to a January SEC filing, they raised $510,000 of a $550,000 round, with funding coming from a mix of friends and family, angels and the VC firm SOSV which runs HAX.

Aneela was raised on Long Island and Sameer hails from Michigan; his job at Ameriprise brought them to Minnesota five years ago. Now they plan to put down personal and professional roots here.

“HabitAware would not be happening if not for Minneapolis,” Sameer declares. “We got looped in to a welcoming community that exceeded our expectations. We’ve gotten so much support and guidance and that’s what helped make HabitAware a reality.”

Their marketing strategy involves connecting with physicians and mental health professionals who work with people with BFRB’s, and customers who’ve found the Keen bracelet helpful.

“Through the Internet, there are groups and communities for people interested in these topics and they look for support. There’s great word-of-mouth for the product,” Sameer says.

Aneela Kumar can offer her own personal testimony for the Habit Aware tracker.

“My eyelashes and eyebrows are thicker than they’ve been in twenty years,” she said. “When I go to pull, the bracelet vibrates and I pause and work on some deep breathing.”

She finds the best result of her progress is the relief that came with breaking her secret’s vicious circle.

“For years I beat myself up about why I couldn’t stop, which caused more stress and more pulling,” she says. “I see myself in people with the same struggle. It’s our goal to help them use this tool to retrain their brains and take control of these behaviors.”

Mental health in the startup sector: The dark side of entrepreneurship that no one wants to talk about

It was supposed to be a night of laughs and beers under the stars.

Instead, it became a sobering group confession about the stresses and demands facing startups and small businesses.

Last summer, some 85 hard-charging entrepreneurs took a weekend off and headed to a getaway camp in northern Minnesota, sponsored by COCO, the co-working space.

During the day, participants canoed, challenged themselves on a ropes course and hiked the pristine woods overlooking the North Shore of Lake Superior.

In the evening, they settled in to listen to keynote speaker Patrick Rohne, a noted tech writer and entrepreneur.

COCO CEO and co-founder Kyle Coolbroth recalls the audience was overcome with emotion with the topic of the talk.

“He shared his journey about how mental health and depression touched him and his family. It was a big risk but it was raw and honest and it touched a nerve,” says Coolbroth, an entrepreneur himself.

At the conclusion, the speaker asked for a show of hands of people in the room who were also familiar with troubling mood disorders.

“Almost every hand went up,” Coolbroth says. “It was amazing. In the business world, we don’t like to admit these things. It’s looked on as weakness.”

To beat the long odds and make it as a startup, an entrepreneur must be focused to the point of being almost obsessed. It goes without saying that they work punishing hours, put their own—and other’s—capital on the line and must never appear to waver in their public confidence in their venture. It’s a life that can be a prescription for mental health challenges for many of those who are living it.

“Entrepreneurs are often passionate and that’s thought of as a good thing,” says Dan Forbes, who studies the social psychology of entrepreneurship as a professor at the Carlson School at the University of Minnesota. “The passion it takes to get a venture off the ground can be a source of stress. It increases once you employ people and there’s more at risk than yourself.”

The struggles facing entrepreneurs are more than anecdotal.

Research published by the University of California in 2015 showed that 49% of entrepreneurs surveyed dealt with at least one mental illness, including ADHD, bipolar disorder, addiction, depression or anxiety. A study from the Swinburne University of Technology in Australia found that many business owners displayed signs of clinical obsession, including strong feelings of distress and anxiety.

And the Well-Being Index prepared by Gallup-Healthways concluded that entrepreneurs experience more stress and worry on a daily basis than other workers; 45% of entrepreneurs say they’re stressed, three percentage points greater than other respondents.

What’s not clear is whether the stress of the work triggers the mental health issues, or whether personalities that are attracted to the startup life are more likely to have tendencies associated with certain diagnosable disorders.

Regardless, while entrepreneurs must wear a fearless face, statistically, most will experience failure as part of their journey, and that, too, takes a toll.

“We see the successes on the magazine covers, but we don’t see the ones that don’t work out,” Forbes says. “There is grief in the aftermath of a failure. There’s been a major investment of time and money and there’s a mourning process that exists. It’s a painful part of the life of an entrepreneur.”

Forbes hopes that the shame that often accompanies mental health diagnoses will continue to diminish.

“I see evidence that leaders who are quite successful are willing to bring this up and that’s encouraging. It makes it safer for people to be public with their personal struggles,” he says.

He cites former Medtronic CEO Bill George’s discussion of his own use of meditation to relieve stress and Gov. Mark Dayton’s public acknowledgment of his treatment for depression and alcoholism.

Kyle Coolbroth believes that raising the dark topic around the bonfire last summer left some participants more willing to share their vulnerabilities.

“As entrepreneurs, we live in the future. We can see, taste and feel something that doesn’t exist and that the world might not know it wants. That’s lonely,” he says. “We need to promote more empathy to let people know they’re not alone.”