Next-Level Digital Medicine

“We are living in a crisis right now,” said Adam Gazzaley, M.D., Ph.D., as he launched into his fast-paced, 30-minute PsychBites presentation on Monday afternoon—one of the new session formats introduced at this year’s Annual Meeting. “I know what you are thinking,” he continued to the sea of bemused faces. “Which crisis?”

Gazzaley, the David Dolby Distinguished Professor of Neurology, Physiology, and Psychiatry at the University of California, San Francisco, was referring to a cognition crisis. “How we attend, remember, imagine, reason, and decide,” he said, “are tragically lacking.” More than a billion people globally are experiencing cognitive deficits—whether it’s problems with emotion regulation, attention in children, or memory difficulties in older adults.

While many researchers are looking for new pills to cure our ailing minds, Gazzaley turned to technology—specifically, interactive, immersive technology. His bet paid off in 2021, when Akili, a company he cofounded in 2011, received FDA approval for EndeavorRx, a game-based digital therapy for attention-deficit/hyperactivity disorder. It was the first—and to date only—FDA-sanctioned video game.

Over the next 30 minutes, Gazzaley provided a rapid-fire pitch on how immersive technology could improve mental health in a meaningful way.

The rationale: experiential medicine — “For thousands of years, we humans have been creating and ritualizing experiences—music, art, dance, story, sports, and games—to enrich our lives,” Gazzaley said. These same experiences can also improve anxiety, fear, grief, pain, and other aspects of mental health. “We know that even witnessing a single traumatic event can detrimentally impact a brain for a lifetime. Can a counter-transformative experience work in the opposite direction?”

The science: closed-loop reinforcement — “Think of it as the world’s ultimate personal trainer,” Gazzaley said. While a user is playing the platform-like Endeavor game, sensors continually monitor performance data. The game then adjusts the difficulty, rewards, and sensations (sounds and vibrations) to stimulate key attention-based neural circuits over and over.

The challenge: insurance buy-in — While EndeavorRx launched fairly well (it has more than 30,000 prescriptions to date), it and other digital therapeutics that came to market in the 2020s quickly hit a brick wall toward profitability: reimbursement. (Akili recently received clearance from the FDA to market Endeavor as an over-the-counter therapy for adults, though youth still require a prescription.) “But just last year,” Gazzaley said, “CMS approved three new codes known as ‘G Codes’ that are available as of January and can be used for digital mental health treatments.”

The future: birds, trees, and mushrooms? — While Endeavor was built around fast action and well-honed response times, Gazzaley’s newest company, Neuroscape, is taking it easy. Drawing inspiration from established practices such as Japanese forest bathing, Gazzaley is building multisensory immersion labs that recreate a calming nature journey—complete with sights, sounds, and smells. Similar to Endeavor, biosensors attached to a viewer’s brain and gut provide real-time feedback on stress and emotional state to optimally adjust the nature experience. As might be expected, Gazzaley’s team is incorporating more AI into the experience (both interpretive AI that uses biosensors to guess the user’s emotional state and generative AI to make more personalized imagery).“What emerges here,” he said, “is a dynamic dance between AI and the brain.”

Sometime soon, Gazzaley hopes to add psilocybin to the mix. “Psychedelic molecules stimulate plasticity to shift perception of self and time and place. That’s potent fertilizer for transformative change,” he said. “The problem is, it doesn’t have directionality; the [change] can go either way.” But guided by the right immersive experience, a psychedelic journey might lead to tremendous healing. ■