The global burden of mental disorders—whether measured in suffering, disability, economics, or even premature deaths—is staggering. Depression is now recognized as one of the leading causes of disability worldwide, and severe psychiatric conditions such as schizophrenia and bipolar disorder continue to wreak havoc on the lives of individuals with illness, their family members, and communities. With a shortage of mental health professionals who can provide high-quality evidence-based care, especially in under-resourced settings and low- and middle-income countries, there is an urgent need for new solutions to address the public’s mental health needs.
Smartphones offer one promising avenue for deployment of mental health resources and services, given their increasing worldwide ubiquity, ability to collect and monitor information relevant to mental illnesses, and feasibility to augment treatments as well as to offer adjunctive interventions. To explore the evolving role of smartphones in care, this article focuses on schizophrenia as a disease-specific example of how new research and technologies are already being used to improve care.
To understand the role of smartphones in care, it is necessary to first consider why these devices have become a topic of such interest for mental health research. The notion of a digital divide, that patients with serious mental illness such as schizophrenia either did not own or want to use technology in their care has in recent years been replaced. In a manner that is similar to the rest of the world’s population, those with schizophrenia increasingly own smartphones and are interested in using technology for their care. While smartphone ownership is currently 77% in the US, the highest future rates of ownership are projected to be in middle- and low-income countries, which represents a unique opportunity to soon reach the global population suffering from mental disorders.1 In some cases, patients are already turning to smartphone apps to assist with their care, and there is strong evidence that those with schizophrenia find both text messaging and healthcare apps easy to use.2-4
Patients with schizophrenia are able to use smartphones to monitor their symptoms both upon discharge from an inpatient psychiatric hospital as well as during a hospital stay. There is no evidence that using smartphones in clinical care causes harm or is associated with negative outcomes. Ownership of and interest in smartphones for health care are expected to increase as devices become more affordable. Smartphones represent the best, and perhaps only, tool capable of reaching and addressing the global mental health burden.
The potential of smartphone tools is best understood through exploring their ability both to collect (eg, through self-report or passive sensing) and to deliver information relevant for mental health services. Focusing on the sensing side, the embedded sensors in smartphones offer the potential to automatically record and monitor behaviors that could help diagnose or monitor illnesses. For example, in the CrossCheck study, patients who had schizophrenia used a smartphone app that tracked sleep, sociability (from call and text logs), activity (from GPS and accelerometer), and several other features all based on smartphone sensors.5 Sensor data strongly correlated with clinical symptoms (eg, hallucinations) were found to be associated with certain sleep patterns and spending time in noisy settings. Such findings offer us new and unique opportunities to understand how a person’s behavior and immediate environments may contribute to his or her clinical status.
The use of smartphones to monitor for changes in social and mobility patterns in those with schizophrenia may also offer a method to predict relapse or clinical decompensation, although this remains a topic of active research. Smartphones also offer the potential to record other types of symptoms, including neurocognition. Recent research suggests that using smartphones to immediately record symptoms can help compensate for memory troubles and recall bias that some patients with schizophrenia may experience when recounting symptoms during clinical visits.6
Efforts are currently underway to use smartphones to help with medication adherence in schizophrenia. A recent study using smartphone cameras demonstrated feasibility, although currently the evidence is stronger for text messaging to improve medication adherence.3,7
Dr. Torous is a Fellow in Clinical Informatics and Psychiatry, Harvard Medical School, and Senior Resident, Harvard Longwood Psychiatry Residency Training Program, Boston, MA; Dr. Ben-Zeev is Professor, Department of Psychiatry and Behavioral Sciences, Washington University School of Medicine, Seattle, WA. Dr. Ben-Zeev has an intervention content licensing and consulting agreement with Pear Therapeutics.
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