Mental Health’s AI Revolution: What It Means for Patients & Providers

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Mark Masselli ( 00:05 ):
It used to be patients would sit on a couch and talk with the Dr. Freud type, but in the future, will be
able to talk to a computer that will help them navigate their emotions. Is technology part of the answer
of treating depression and anxiety?
Dr. Jodi Halpern ( 00:20 ):
The majority of apps that people are using for mental health are not called mental health bot. They're
called wellness apps, or even companionship apps. So most of what we know come from those apps,
rather than from the few more recent mental health companies.
Margaret Flinter ( 00:39 ):
Our guest is Dr. Jodi Halpern, a psychiatrist, a noted author, and co-founder of the University of
California's Berkeley group for ethics and regulation of innovative technologies, and we're talking to her
about the promise and the peril of the technology revolution and what it means for mental health
treatment.
Dr. Jodi Halpern ( 00:57 ):
So I don't think it's so much bad actors, it's that the US has always lagged compared to Europe and
regulation, but we are seeing good uses like the National Health Service, and there are going to be
companies here that are developing technology very similar to help listen in on primary care calls and
detect depression and anxiety, and inform the provider during the calls of very serious things that they
might be missing.
Margaret Flinter ( 01:23 ):
This is Conversations on Healthcare.
Mark Masselli ( 01:34 ):
Well, Dr. Halpern, welcome to Conversations on Healthcare. We're really looking forward to this exciting
conversation.
Dr. Jodi Halpern ( 01:41 ):
Thank you.
Mark Masselli ( 01:44 ):
We want our audience to have a better understanding about what apps and kind of technology are we
talking about. And does the research show they work?
Dr. Jodi Halpern ( 01:56 ):
All right, well first of all, in my work, I'm not just looking at apps that call themselves mental health apps,
because in order to avoid any very expensive requirements of going through FDA approval, the majority
of apps that people are using for mental health are not called mental health bot. They're called wellness
apps, or even companionship apps. So most of what we know come from those apps, rather than from
the few more recent mental health companies. And let me say a few things because I know that you
both, your group has interviewed many people on digital health more generally. I'm specifically talking

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about therapy bots that replace psychiatrists, psychotherapists. There's a lot of work in digital health
that you've covered on your show, and the use of AI for medical records, the use of AI for diagnostics
and mental health as in other parts of medicine is a whole different thing that's well underway and quite
advanced and showing a lot of promise.
( 03:00 ):
But the very new thing in just the past few years, because of the loneliness and mental health crisis,
both in this country and the world, which is really something that needs attention, is that there are
people who see this as a big business opportunity and have been developing AI related services,
especially bots, and now increasingly we'll talk about how they operate, to provide mental health
services. So you can break it down if you want me to address each of those things in turn.

Mark Masselli ( 03:32 ):
Oh, that would be great.

Dr. Jodi Halpern ( 03:32 ):
What we know is we have very little data on the empirical outcome of using a bot and no human for
your mental health care. Using, again, AI assisted care, first of all, using digital mental health... The
biggest study just came out in nature last week that used actually AI machine learning to analyze
outcomes in digital mental health. That's when people use... They basically send digital messages to a
genuine human and they do therapy through digital messaging or just through messaging. And that, we
have data showing, can be effective. And this study, which JAMA just put out had, let's see, 166,000
clients. So it was the big study. And sorry, it's JAMA that just came out with it last week. And so if you
have a real therapist that you contact in a digital way just through text messaging, that may be helpful
on a regular basis with anxiety, with mild to moderate depression. So that data-

Mark Masselli ( 04:42 ):
That's human to human, but through text message.

Dr. Jodi Halpern ( 04:44 ):
Digital. Purely through text. You can never talk to the person. You can never see them on Zoom or
anything, but that seems like the fact that there is another human there and you know it, there seems to
be effectiveness there. And of course, you both also know from all your work, that using Zoom for
therapy during COVID, we have a lot of that data, and that has been effective as well. But I'm specifically
targeting this big business investment, six and a half billion dollars in expected profits in using bots to
replace humans and therapists. That's what I'm specifically writing a book about, Engineering Empathy,
and focusing on and doing research on because that's the new big area. I'll say one other thing. I
mentioned the mental health and loneliness crisis. I know you've covered it, but new data came out
yesterday, but just generally in this country, we know from a Harvard study that came out in 2022 that
36% of all American study suffer from extreme loneliness, and 61% of young people and 51% of mothers
with young children.
( 05:56 ):
That's a huge amount of extreme loneliness. We know that there's been a worldwide 25% increase in
serious mental health issues, serious depression and anxiety. And that kind of increase worldwide
statistically is just unbelievable. If we cured the three largest cancers in the US, we would only get a 2%
change in mortality. So to have a worldwide increase of 25% in mental health diagnoses is astounding.

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So there is a huge reason that we care about getting to many more people. And we also know, and
you've covered, that access to care is very limited. So I understand very much the need to use
technology. The question is how best to use it.

Margaret Flinter ( 06:41 ):
Well, Dr. Halpern, you've said a lot there, and I will sort of make the obvious connection that if 36% of
the adult population suffers from loneliness and isolation, that children and adolescents and large
numbers do, and that 26% I think it is of people in America, adult Americans have a diagnosable mental
health condition each year, and yet we hear workforce, workforce, workforce, workforce as a huge
issue. We all get, if we want to help, we have to find some new ways to help alone, in combination in
certain situations. And we really appreciate the great work that you're doing here. What I want to ask
you, and there's so many things we want to talk about, but we had a chance to speak with the surgeon
General, Dr. Vivek Murthy as a guest on our program and in another forum, and he talked so profoundly
about this as a public health crisis, and he was particularly focused on it as children.
( 07:41 ):
And I wonder if you could just speak maybe for a moment about the degree to which we're looking at
this with children in adolescents, this possibility of these alternative technologies, as well as adults. Any
particular concerns there? Is there as much research going on with children and adolescents as there is
with adults?

Dr. Jodi Halpern ( 08:00 ):
That's great. I'm glad you asked me that because that's the area that got me to really become more of
an advocate and get involved in doing press interviews, is my concern about what is happening
regarding children. So I said 61% of adolescents and young adults, we have that data now, suffer from
extreme loneliness in the United States, two-thirds. And the only country with data like that is South
Korea. What does the US and South Korea have in common? Our children spend eight to 10 hours a day
on online social activities. This is in addition to doing their homework online. So they basically are either
gaming or on social media as far as I can tell, every minute they're awake, unless they're really not
sleeping.

Margaret Flinter ( 08:44 ):
Also a problem.

Dr. Jodi Halpern ( 08:46 ):
Well, no, it's related. It's extremely related, because a lot of my work has been showing how as a
psychiatrist who's also studied neuroscience, the mechanisms that social media for-profit companies, all
the large companies, which any two of which have more money... And the seven largest companies,
media companies, digital companies, Google, Meta, et cetera, any two of them have equivalent money
to the whole federal government, so their power to determine and keep us from having regulation is
very, very large. So we're the most unregulated country compared to Europe and some of the Asian
countries that have anything like our scope. And one of the things that the UK did years ago was
regulate marketing to children for social media and gaming and the technology that gets kids addicted,
which is irregular rewards. It's the same thing that gets us addicted. In fact, Instagram uses it, which
most people don't know.
( 09:45 ):

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Instagram doesn't... Every time you put up something, a picture, it doesn't just give you back your likes.
It saves them up in bundles and gives them to you irregularly the way slot machines work in Las Vegas.
And that technology, which we saw the patents for 10 years ago and started talking about then, that
develops dopamine surges that get you addicted. So the fact that we're all addicted to our phones,
addicted to social media, and addicted to gaming is not accidental. It's not accidental. It's the marketing
model of those companies. And I am seeing the same marketing model in the relational support bots for
children. And so that is what concerns me. Because it's one thing to say we need to get mental health
resources that use technology into the schools for kids. We do. We do need to help kids. And kids are
comfortable with technology. So if we have ways of them connecting with real humans or other kids, or
using some online technologies that I'll describe that don't make you addicted in the same way, that
would all be very useful.
( 10:50 ):
But we actually have a good series of reviews by business reviewers, including the Harvard Business
School has a letter that's very in depth from an engineering and business expert on how one of the most
important mental health companies that has gone through the FDA and is held up as a role model, how
their business model is giving the app free to kids in schools, the app that just has a bot. You never talk
to a human because it's quote a sticky technology, and therefore children will get used to going to a bot
rather than a human for mental health and they'll grow up to be adults who are used to only using bots.
And so it's a very good business model for a company. So there's a for-profit motive in getting this even
from very professionally endorsed companies that are for profit, if they are for profit in the mental
health sphere.

Mark Masselli ( 11:46 ):
I want to pull the thread on that, because to some degree or another, there are a group of people who
think generative AI is ray of innovation, but we're in early stage, right? And it will get more
sophisticated. It will get more user-centric. And obviously it's not a magic wand. We have issues on data
privacy and informed consent, on bias mitigation and the like, but if it were nonprofits who were doing
this, or are there any examples of nonprofits who've entered this field? Can't help but think there must
be social entrepreneurs who were thinking about this technology to do good and to design it. So
anything on the horizon? I obviously understand your focus on there are some bad actors who his
intentions are to hook people in it, but it seems that there's a real... Post pandemic, there is a shortage
of behavioral health providers.
( 12:52 ):
Also, we're looking at the data sets that most half of the behavioral health providers have some burnout
associated with them. So we have a paucity of providers, and we have this enormous, you laid out the
numbers very nicely, numbers of people who were impacted who need support. So I guess I'm trying to
figure out do you see any roadmap? I think you're trying to lay out the guardrails hopefully in your book,
and I want to hear more about the book, but guardrails about, hey, be careful here. But is there a
pathway perhaps for using this technology in a progressive and supportive way?

Dr. Jodi Halpern ( 13:34 ):
Definitely. Definitely. And I did start out with in a way the concerns of the business models that we
currently do not regulate. And really, it's not... By the way, I don't even think it's bad actors. I think it's
the way the United States compares to Europe in our lack of a regulatory standard and seeing regulation
as negative as opposed to helping... My field, we also started at Kavli Center at Berkeley for science

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technology and ethics where we work with scientists and engineers and show how good regulation
actually can further the good use, and the further development and advancement of technology for
good purposes. So that's what my whole life is actually devoted to, is finding out how to use the best
cutting edge science and technology to go forward. But I will say that in the UK, there's been excellent
regulation which has allowed already for better uses.
( 14:29 ):
And one of the main uses in the UK... As we all know, large language models like ChatGPT, they only
emerge onto the scene about a year ago, which is amazing because they've influenced so much already.
Machine learning was influencing of these products for many years. But the National Health Service is
the first to institute on their... A large scope of calls that come in for primary care appointments, they're
using a large language model to listen in with the provider on the call because we all know that, well,
people in health know about 75% of primary care visits, people might have a mental health need. And
they're very often undetected because people don't come right in and say, "I'm depressed," or "I'm
suffering from really severe anxiety." And as humans, because doctors and nurses and primary care
providers are so busy, and because of burnout being so high, also over 50%, we miss a lot. We all miss a
lot.
( 15:32 ):
The thing is there's nothing perfect about human providers, to say the least. And so having AI listen in
and use large language models to detect depression and anxiety is a wonderful use potentially. I just
want to say one thing. Also, my opinions on the evidence that exists about what might be harmful or
what might be good, the most important thing we need, and it's what I'll talk about before we finish
today, is we need to require post-marketing research in all of these things, which the FDA... I'm very
involved in the fields of gene editing and neurotechnology as well. Those are the three arms of the
institute we co-founded, neurotechnology, gene editing, and AI and the histories of regulation in these
different fields and helping advance them. And what we're seeing is a real lag in AI. But for gene editing,
we have post-marketing research requirements, because some of the things that can emerge with gene
editing, you just can't know in a one or two year trial.
( 16:33 ):
And that's definitely true for AI because it's changing so rapidly. So I think that if we had the kind of
post-marketing research attached to, even a... It doesn't necessarily have to be only public entities that
create these services, but if they were regulated, as all kinds of private entities that do research in this
country, medical research, are regulated by Congress to have IRBs, which are these institutional review
boards that I've said we should have for AI. We should have IRBs where we have... It could be a private
entity or a public entity. But if they're doing something highly innovative, that we don't know how it'll
affect people because it's changing rapidly and we are changing rapidly, we should have requirements
for post-marketing safety research findings to be publicized. So I don't think it's so much bad actors is
that the US has always lagged compared to Europe and regulation.
( 17:29 ):
But we are seeing good uses like the National Health Service, and there are companies here that are
developing technology very similar to help listen in on primary care calls and detect depression and
anxiety and inform the provider during the calls of very serious things that they might be missing.

Mark Masselli ( 17:48 ):
And they're also very good for note taking, so there's more human to human contact. Simple low
hanging fruit, but important ones.

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Dr. Jodi Halpern ( 17:55 ):
That's the most important thing. You might've covered it on the show already. But if your listeners do
not know, as you two know, that providers are spending two and a half hours every night when they
could be with their kids patching up on their notes. And I think everyone who goes to a doctor these
days knows, or a nurse, knows they don't look us in the eyes because they're so nervous about getting
everything on the record. And I really care about burnout, especially after COVID. Many of my dear
medical students... I've been training the most empathic medical students, and I've worked with some
nurse practitioners through the years who are the most empathic providers you could ever meet, and
they are burned out. So if we could help just use large language models to do the medical records, just
that alone would be a huge, huge positive change.

Margaret Flinter ( 18:45 ):
Well, I can tell we're going to have to have a lot of conversations with you over the next year or two
because you're touching on so many issues of concern to us. And I think you did a good job of talking
about the post market evaluation and research as well. Very, very important, so thank you for hitting
that. I want to ask you about something that I think is... It pops up. It's bothersome. Is it urban legend or
is it real? Can bots go rogue, advise people to harm themselves or others? And I think maybe more an
issue from my point of view is, can they detect that somebody is at risk of hurting themselves or hurting
others through language? And is there a system to alert beside hang up and call 911, which is not always
going to be the right answer? Tell us a little bit about that. And how much assurance do we have that
this is part of what the tech companies are looking at making sure they've got control of?

Dr. Jodi Halpern ( 19:44 ):
Margaret, you and I are totally on the same wavelength. You just basically described the exact set of
concerns I have, which is not the rogue examples, which I'll go over. There are some rogue examples.
And there's times where the large language models have gone crazy and told people to kill themselves.
And one man in Belgium did, and his wife, they have young children, is suing that company. We've seen
there was an anorexia website where the large language model was put onto the site and immediately
went rogue with certain folks and told them how to lose more weight. So large language models are still
early enough... And this was actually six months ago. They're young enough in their technological
development that some of them have glitched and done these crazy things. But we also unfortunately
know that mental, there's some awful mental health providers, although at least they lose their license
if they do terrible things.
( 20:43 ):
But it's not so much the dramatic rare glitches, it's the everyday problem which is incredible to me,
which is that none of the mental health services that I have reviewed, and I could definitely be missing
ones, but I'm talking about the actual ones that call themselves mental health providers and that are
FDA involved in FDA approvals, they basically... As soon as a person mentions suicidality, they basically
sign off and tell you to call 911. And it drives me crazy because we don't have the data yet, but there's
got to be high risk to people because of that. So one of my biggest pet peeves is that those companies
need to do something more of a warm handoff at that point. But one thing, and this has to do with the
marketing, which we can talk about more or less, they market to people as your trusted companion,
your empathic... One reason I got involved is because I study empathy.
( 21:39 ):

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And people ask me, "Are they really empathic?" No, they're not really empathic. They're machines that
simulate language, but they feel useful to people and they're marketed as your most trusted
companion, your therapist who you can really rely on. People do really rely on them. And then they talk
about suicidality, and they're dumped. So my number one thing isn't the dramatic, there'll be lawsuits
for the dramatic cases, but it's going to be a very big problem. That's why post-market research is so
important. We need to know what happens to those people. And I really can't feel comfortable with
them not having actual human handoffs at those points.

Mark Masselli ( 22:23 ):
Doctor, you're an expert in ethics, and I think most of us saw the highlights of the recent Senate hearing
with social media executives. The accusations were really jarring. They're accused of promoting
pedophilia, among other things. You live and work in the Bay Area, which is the center of that tech
industry. I'm wondering if you have a sense of the tech sector having a heart? And does it have the
ethics it abides to?

Dr. Jodi Halpern ( 22:50 ):
Well, first of all, let me say that about those hearings were very painful because there were families
there who've lost their children, which any of us who have raised a child, or have not, it's heartbreaking.
I am not as concerned with the dramatic... Well, I don't know enough about... I have not studied the
extent of pedophilia and things like that, but the point I brought up much earlier about most of these
sites being engineered to create addiction is a big cause of children becoming more isolated and
suffering from worse depression. So I do think that the social media and gaming sites, no matter
whether they have terrible things like pedophilia or just everyday gaming and social media, they're using
that dopamine releasing irregular reward system that makes a child or adolescent addicted. And those
addiction models then prevent the child from having enough real lifetime that might be helpful for their
mental health.
( 23:52 ):
So that's the way I think about the risks of those companies, which are very serious, I think. But in terms
of a positive future, of how do we make sure tech has empathy, has a heart, has a ethics, that's what I'm
devoting my life to at this point. So we have two things. You mentioned one group that I've been
involved in, co-founded at Berkeley. But the bigger thing we did is we created a center, an international
center now, the Kavli Center for Ethics Science and The Public. And we have these three areas of science
and technology, neurotechnology, gene editing, and AI. And we have 10 fellows in our first year that
started, but they're here about a year and a half now. And these are postdoctoral researchers or senior
graduate researchers, students and postdocs who are... Several of them are in AI. They are the
engineers that will develop the new technology or in neurotech or gene editing, and they have choose
to do this fellowship with us so that they have built in professional commitments to thinking about the
societal, public and ethical implications of their work.
( 24:57 ):
And our ideas to create a cohort of people like this, and to grow it and grow it and grow it. And that's
what I'm devoting my time to now, is trying to develop people who, from the very beginning of their
professional formation as engineers, have this as part of being a good engineer.

Mark Masselli ( 25:15 ):
Can you tell us a little bit about the book you're working on right now?

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Dr. Jodi Halpern ( 25:19 ):
Well, I'm early in the stages of the book Engineering Empathy, and I've covered some of the things that
we're looking at, but I'm particularly interested in... Some of it has to do with having studied empathy
itself in clinical care for 30 years. I'm very aware of what helps patients. And what doesn't I've come up
with through the years in various research studies, sometimes in collaboration with neuroscientists,
sometimes in collaboration with medical educators or sociologists, is a very robust model of empathic
curiosity in care, that what patients really want is their doctor or nurse to listen to them and see them as
an individual with particular and specific hopes and fears. And what's interesting to me is that AI can,
with large language models, simulate some of that. So some of what I'm studying is, what are the
therapeutic benefits of having that simulated? What are the limitations of it?
( 26:21 ):
Another thing that I'm studying, which is a little bit off topic for today, but it's relevant I think to things
that you cover is... And it's relevant to burnout in clinicians, actually. We've done the research. We did
big analysis after COVID. And one of the things, just having to operate under such difficult conditions
during COVID where nurses and doctors risk their health, but also there was no way to have empathic
ties. One nurse practitioner who is a big part of my work, she was having to talk to the relatives that
weren't allowed to be in the rooms with their patients at the same time as she was directing the bodies
to be stored outside. There were so many causes of burnout during COVID. But a huge cause of chronic
burnout that was worsened is what we talked about, which is doctors not getting to really make eye
contact or clinicians with patients.
( 27:11 ):
And what we've shown is that that actually makes practice less meaningful for the clinicians, that they
are burning out in part because they need to be empathic with patients to find their work meaningful.

Mark Masselli ( 27:24 ):
That's right.

Dr. Jodi Halpern ( 27:24 ):
I say it like it's a huge discovery. You're both nodding because you both are great in the clinical realm, so
you know this is true. So one of the concerns I have is what's happening to the clinicians when they do
other things, but when they're not providers of empathy. And then our big concern that's the bigger
one, is what happens to us as a society when empathy becomes something we can just easily outsource.
Does it become like Google Maps where none of us have a sense of direction? Do we all lose our
empathic curiosity about each other? So some of the topics that I'm interested in.

Margaret Flinter ( 27:56 ):
I wonder if I can... I'm just going to get a question that you maybe can answer in a short way, and we'll
get you back for a longer conversation. But obviously as a primary care system, as a community health
center and the other organizations that we've built, we often talk about, and in fact, health disparities
are at the center of the work that we do, health disparities, the need for equity and thinking about that
in everything we do. Is anybody thinking about that in the AI mental health space?

Dr. Jodi Halpern ( 28:27 ):

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Yes, they're thinking about it. In fact, we wrote a paper that was used in a bunch of scientific journals
after we published it in one because... It's getting a lot of play because it was in response to a Wall Street
Journal editorial. So our paper came out in '21, and I think the editorial was in late 2020, maybe early
'21. And the editorial said that having mental health bots do the intake, just mental health bots or apps,
would help with health equity because they could be cheap and used a lot. Health equity... One of the
causes of inequity is economic disparities. There's also racism and all kinds of causes of health inequities.
And we pushed back. I co-authored with an anthropologist, Julia Brown, because what we looked at was
what makes people having initial primary care conversation then willing to seek services.
( 29:24 ):
And we looked at the work that shows that if you are from a disadvantage racialized minority, if you're
from a group that doesn't normally, not... A lot of black patients and participants, but there's also a lot
of Asian patients and participants are not comfortable with being referred from a primary care phone
call to see a mental health person. All kinds of groups have all kinds of issues, and all kinds of individuals
have those issues. So we are concerned that if there's not a human warm handshake here, just like we
need a warm handoff, a very warm handoff when people express suicidality, we think, again, that having
bots help just like they are with the National Health Service. Maybe that can allow practitioners with less
mental health training initially, although that's important. I don't want to devalue good, extensive
training and experience, but there's ways of using the technologies as companions and aids. But we
think that people who've been disadvantaged in the health system might particularly want human
contact at some point.

Mark Masselli ( 30:31 ):
Great. Well, Dr. Halpern, thank you so much. And I think Margaret was right. We're going to need to be
having you back a couple of times to help people understand. And I think this has been very helpful for
so many who were interested in this topic. I want to thank you for joining us. Thanks to our audience for
being here. Be sure to subscribe to our videos on YouTube and find us on Facebook and X with our
account name CHC Radio. As always, you can go online to chcradio.com to sign up for email updates.
You can also share your thoughts and comments about this program. And again, Dr. Halpern, thank you
for your groundbreaking work. We're looking forward to your book and to continuing this conversation.

Margaret Flinter ( 31:13 ):
This copyrighted program is produced by Conversations on Healthcare and cannot be reproduced or
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The views expressed by guests are their own, and they do not necessarily reflect the opinion of
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