Inside and Outside2022-10-16

We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win.

—John F. Kennedy

To understand, track, predict and improve mental health, we need to evaluate what is inside and what is outside. What is outside- speech, other ways of communicating, and actions- are relatively easy to get at, and can be assessed in multiple ways. What is inside- feelings, thoughts, and biological changes- are hard to get at, and there are currently no tools in widespread use in routine clinical practice.

Two decades ago, my colleagues and I set out to do the hard thing, to conquer the inside. Over the years, my teams developed simple and quantitative self-report tools for how people feel and think, validated them in clinical research studies, and bundled them in a comprehensive assessment package, now available in our Life x Mind app, which is the most complete and easy to use clinical-grade fitness tracker for mental health developed to date. We also identified the hidden biological changes, that underlie and precede full-blown disease, and developed panels of blood biomarkers for mental health, and for pain. In addition, these RNA gene expression biomarkers can match people to existing psychiatric medications, and monitor response to treatment, through true pharmaco-genomic approaches (not to be confused with the weaker approaches that are based on DNA testing, which should be properly called pharmaco-genetic). Genomics is easier in terms of testing and screening hundreds of medications for effects on gene expression in cell culture, animal models, and humans. We and others have accumulated large databases. There is nothing comparable yet with other approaches explored for biomarkers, such as EEG and imaging, which are harder to use and less granular for screening the effects of medications at scale. Pharmaco-EEG and pharmaco-imaging are in their infancy.

Taken together, we think that the tools we and others have developed will transform primary care, where most mental health issues are seen first and managed, and subsequently specialty psychiatric care, where there is currently too much reliance on the outside of a patient, done in a qualitative way, translating into suboptimal diagnosis and treatment. And we can get a better handle in the future on the outside, with digital checklists of risk factors, like the one we developed for suicide prevention called SXPrevent, and with machine learning approaches applied to speech, typing, actions, and behaviors, like Silicon Valley giants are doing. One hopes all these tools will be used for to help individuals and for the greater good, as per the Hippocratic Oath that physicians take, and not for discrimination and societal manipulation purposes.

Live. Happier. Longer.