Jhilam Biswas, MD

As with any cutting-edge innovation, digital therapeutics (DTx) have their detractors. This is particularly evident when concerned doctors focus upon 

, such as trauma, in which DTx “might not be able to replace face-to-face therapy.”

 What practical considerations arise when the results of DTx interventions are interpreted in forensic as opposed to other medical settings? Using DTx can have variable results, as we will illustrate in 2 vignettes, both of which are composites of actual legal matters involving DTx. Regardless of the outcome of any individual case, it is important to consider how DTx can help physicians make clinical decisions and improve patient care.

Barriers to Treating Psychiatric Disorders in Forensic Settings

Forensic settings can be free-standing, secure medical facilities, or they can be correctional settings in which individuals accused of criminal offenses are housed while awaiting trial. These patients are being assessed for competency to stand trial, criminal responsibility, or other legally relevant issues. They may be receiving psychiatric treatment in order to become competent, or perhaps they are being retained in a forensic setting so they remain competent and legal proceedings will not be delayed any further.

Individuals who have already been convicted may be retained in forensic settings as well. These services are typically delivered in jail and prison environments, and sometimes draw upon the same resources as those used for pretrial assessment. Patient care may focus upon such issues as serious mental illness, anger management, sexual offender recidivism, and societal reintegration. Forensic services can also be rendered subsequent to release in the context of mental health courts, drug courts, and outpatient commitment.

Serious mental illness is significantly overrepresented in jail and prison populations. A recent 

 of reviews on this topic identified, for example, notably high prevalence rates for psychotic disorders (males, 4%; females, 4%), major depression (males, 10%; females, 14%), alcohol misuse (males, 18-30%; females, 10-24%), and drug misuse (males, 10-48%; females, 30-60%).

of jail and prison treatment practices conducted by the Treatment Advocacy Center concluded that

Not only are the numbers of mentally ill in prisons and jails continuing to climb, the severity of inmates’ illnesses is on the rise as well.

Many inmates with mental illness need intensive treatment, and officials in the prisons and jails feel compelled to provide the hospital-level care that these inmates need.

The root cause of the problem is the continuing closure of state psychiatric hospitals and the failure of mental health officials to provide appropriate aftercare for the released patients.

Why does this matter? In no particular order, the nationwide status of mental health services for individuals behind bars is costly, ineffective, and ethically challenging. Approximately 14% of prison health care spending is used for 

 Increasingly, blatant shortcomings in treatment adequacy are leading to 

 Given the procedural as well as budgetary hurdles they face in attempting to wring needed care from minimal resources, doctors can hardly be blamed for focusing on the ethical and medical ramifications of subpar and delayed services for those with chronic and severe mental illness.

How Can Digital Therapeutics Address These Problems?

DTx is not a panacea, but it offers exciting new opportunities for cash-strapped, understaffed, and overutilized forensic operations.

In inpatient forensic settings, DTx enables clinicians to gather more data, which leads to more accurate assessment and more focused treatment. This process also helps correctional staff and court personnel to conduct tracking and feedback functions with pretrial detainees.

DTx allows for real-time risk prediction based upon sensor data and contributes to early detection of evolving mental health conditions. This is particularly important in light of the problems that can emerge when forensic detainees are deprived of services during the pendency of 

 DTx has been shown to reduce variations in inpatient care, and to enable the delivery of more 

Furthermore, DTx has a vital, supplemental role to play in outpatient forensic settings. It assists in keeping patients in the community and out of the criminal justice system, in large part by reducing medication noncompliance for those who have mental illness and a history of violent behaviors during acute exacerbation such conditions. This, in turn, can improve the prognosis concerning both mental illness and medical comorbidities for a particularly high-risk population.

DTx affords better remote monitoring and automatic check-in options for appointments with treatment providers, probation/parole officers, and others, which is a particular boon given how little we otherwise have learned about how individuals with mental 

 Additional benefits include monitoring court-ordered medication, identifying relapse triggers, and providing built-in incentives for compliance-oriented behaviors.

Ten Items to Consider in Using DTx in Forensic Settings

offers a checklist for psychiatric professionals who are considering DTx.

“Drew” is awaiting trial on charges of kidnapping and murder. The judge ruled 6 months ago that Drew was incompetent to stand trial, based upon the opinions of 2 forensic psychiatrists—1 for the defense, 1 for the prosecution—both of whom agreed that the most relevant underlying diagnosis was posttraumatic stress disorder (PTSD). The East Dakota Forensic Psychiatric Center has placed Drew in its Competency Restoration Program.

Numerous problems have arisen. Drew complains that “trying to deal with a machine” while addressing prior traumatic events is “cold,” “boring,” and “impersonal.” When Drew is informed that the doctors who conducted the competency evaluations would have a conflict of interest in providing treatment, and that the office of the only board-certified trauma specialist in the state is located 100 miles away, Drew suggests that “maybe at least one of the guards can read me this stuff instead of my just seeing it on a screen.”

Screen access itself is a problem. The Psychiatric Center’s few available computer terminals are dominated by a combination of court hearings and attorney video conferences. Psychiatric staff actually took up a collection to purchase a smartphone so that Drew could utilize DTx resources on a regular schedule; the device was branded as contraband by prison administrators and never used.

Responding to Drew’s concerns about what sorts of unhelpful disclosure might be occasioned by the Psychiatric Center’s use of DTx, defense counsel are demanding to review the manuals and algorithms for the DTx being utilized. They want to attend DTx-based sessions themselves, and to record them if possible.

Faced with a lagging restoration timeline due to a lack of progress concerning Drew’s PTSD symptoms, psychiatric staff obtained a budgetary waiver that allowed one of their clinical psychologists to receive specialized weekly telephonic supervision from the state board-certified trauma specialist. The trauma specialist also agreed to travel to the Psychiatric Center on a monthly basis to meet with Drew and the clinical psychologist in person. Psychiatric staff remain convinced of the value of DTx, but they recognize that the parties with whom they must collaborate are not yet ready.

“Shawn” is subject to outpatient commitment as part of a diversion program, after pleading no contest to half a dozen different charges of robbery in the first degree. The focus of court-ordered treatment is a combination of anger management, medication compliance, and community living skills. According to the court’s Diversion Coordinator, group therapy alone will not suffice; individual treatment—by DTx, if feasible—will be necessary.

The XYZ Community Treatment Center is a brand-new facility located just outside of Capital City in West Carolina. It has been hiring staff at an impressive pace, but it has yet to develop much of an integrated service team or attract many senior specialists. Groups are filling, but seats in those groups are still available. A licensed clinical social worker is willing to provide individual therapy for community living skills, but she has declared outright that some other source of treatment will be necessary for anger management and medication compliance.

Shawn does not own a personal computer, and Shawn’s defense attorney insists that the public library is not a suitably private venue for receiving DTx services. Although the smartphone Shawn owned prior to his arrest is still functional, it has insufficient memory to handle the DTx programs identified by the Treatment Center Director in consultation with the Court’s Diversion Coordinator.

Fortunately, the Treatment Center’s licensed clinical social worker has been able to obtain funding for Shawn to obtain a smartphone with sufficient memory, a large screen for viewing (since Shawn is also visually challenged), and other up-to-date features. What Shawn has not been able to secure is WiFi access at home, where paid WiFi services are prohibitively expensive, and where the publicly available wireless signal is too weak for DTx to function effectively.

The Treatment Center has a solution. Shawn can use one of the empty offices at the Treatment Center and access that facility’s WiFi free of charge with a special password. The Treatment Center’s licensed clinical social worker has also managed to obtain extra travel vouchers for Shawn to travel to the center for DTx sessions when they do not coincide with a group counseling session or an individual community living skills session. Shawn responds well to DTx, meeting the Treatment Center’s milestones for clinical progress and the court’s requirements for compliance.

In forensic settings, it is important to think of DTx and other technologically informed options as physician extenders rather than as a tool for enabling nonclinical entities to make clinical decisions. In the hands of those with alternative agendas, or of those who might misinterpret psychiatric data willfully or otherwise, digital information can gravely harm individuals and can serve to make a stigmatized population even more vulnerable.

Similar concerns can be—and have been—leveled at every successive innovation in modern psychiatric care. There is no percentage in unthinking technophobia for forensic psychiatric personnel and the systems they support. DTx is here to stay, and the advantages far outweigh the disadvantages for those ready to proceed with due foresight and caution.

is the Director of the Psychiatry, Law, and Society Program (PSLP) at Brigham and Women’s Hospital in Boston, Massachusetts. She is a board-certified forensic psychiatrist with a focus on social systems, cultural dynamics, criminal justice reform, and legal issues impacting psychiatric care.

is the Affiliated Lead of Psycholegal Studies for the PSLP. He is an attorney and board-certified forensic psychologist with a focus on expert witness testimony and trial consultation.

Drs Biswas and Drogin both serve on the faculties of Harvard Medical School and the Harvard Mass General Brigham Forensic Psychiatry Fellowship, of which Dr Biswas is the Co-Director.

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How can digital therapeutics overcome barriers to psychiatric treatment in forensic settings? 

Interpreting Digital Information in Forensic Settings

Nearly 70,000 residents of Ayacucho, Peru, were violently killed  during the campaign of the Sendero Luminoso (The Shining Path). A Peruvian  communist revolutionary movement, the Sendero Luminoso employed guerrilla  terror tactics to fight the government of Peru in the 1980s.The brutality  inflicted on this community continued for 12 years, until the leader of the movement  was captured in 1992. As in other war-torn areas around the world, combat has  come at a steep psychological price. Confronting the trauma experienced through  horrific crimes to their loved ones, many women in this small Andean region at  10,000 ft cope through knitting, doing craftwork, singing, journaling, and sharing  stories of the past and present.

Pictured from Left to Right: Dr Biswas, Dr Bullon, and Dr Abdool. 

As doctors from abroad, we were privileged to join a healing group  called La Asociacin Nacional de Familiares de  Secuestrados, Detenidos, y Desaparecido del Per (or, ANFASEP, the  National Association of Families of the Kidnapped, Detained, and Disappeared of  Peru). This  organization offers war victims an opportunity to confront the trauma, to show  support for each  other, and to commemorate the lives lost by holding  memorial services. The ANFASEP meets in the Museo de la Memoria,  a museum established to chronicle this civil war. The women whom we joined there sat in a  circle with neon-colored yarn in hand and thick double braids beneath their  hats; they told us the stories of their sons and husbands who were lined up and shot  in the plaza or a remote field.

These members demonstrated the importance of collective grieving and are working to incorporate it into their culture. ANFASEP is  one example of the many interconnected communities we experienced during our  weeklong commitment at the clinic in Ayacucho, the poorest region of Peru. As  PGY-2 and PGY-4 residents in the Harvard Longwood Psychiatry Residency Program  in Boston, we followed our attending, Antonio Bullon, MD, high into the Andes  to the mental health clinic where he devotes his time every 6 months. We  discovered that this trip was structured in a unique way that led to an  experience that was culturally enriching and educational. We hope that our  description will help other psychiatrists as they plan global mental health  trips of their own. The main themes include:

•A  structured clinic dedicated to mental health treatment
 •Real-time  attending supervision for residents
 •Clinical staff  committed to patient follow-up when doctors are not available
 •Didactics  for Ayacucho staff regarding management of mental health crises when doctors  are not available

The clinic we worked at in Peru was called Comision de Salud Mental  de Ayacucho (or, COSMA, the Mental Health Commission of Ayacucho). Antonette  Carbon, a Filipina nun with a psychiatric nursing background, started it in  2003. It became her answer to the trauma she witnessed in this community after  the decades of war that ravaged the area. 
 Although no psychiatrists live in Ayacucho, Sister Antonette was  able to recruit Dr Luis Matos from Lima and a group of psychiatric nurses from  the local nursing school. Soon, psychiatrists James Phillips, MD, and Mark  Rego, MD, from Yale University learned of the clinic through the Peruvian  American Medical Society (PAMS), and joined Sister Antonette in the clinic  every 6 months.

A few years ago, Dr Bullon of Beth Israel Deaconess Medical Center,  a native Peruvian who went to medical school in Lima, met Dr Phillips at an  American Psychiatric Association Conference and learned of his work. Dr Bullon  also committed to work for this small but powerful health institution. The  clinic is made up of Peruvian residents who work in the clinic 1 weekend a month  and American psychiatrists who join the clinic for 1 week every 6 months. In  our week at COSMA, we visited with nearly 50 patients; made home visits;  trained staff members on mental health topics, including bipolar disorder,  alcohol abuse, and psychiatric manifestations in organic brain disease; and  visited community nongovernmental organizations (NGOs) focused on alleviating war  victim stress.

Before our arrival, COSMA provided us with an explanation of plans  for the week via e-mail, setting expectations for our trip. From the time we  arrived, not a minute was wasted. Brother Alfredo, who has taken over Sister  Antonette’s work in managing the clinic, gave us a warm welcome tour and  directly took us to a case conference the nurses had prepared to provide more  insight into a particularly complicated patient.

Together with psychiatric nurses, we visited homes of patients the  staff thought would benefit from the mental health system. The nurses would  listen in on our sessions so they could provide continuity for the patients after  we left the country. In the evenings, Dr Bullon arranged for a member of PRAXIS  Ayacucho, a group that helps investigate war crimes, to take us to local NGOs  involved in helping war victims heal from trauma. It was through this connection  that we met the group members of ANFASEP.

The structure of the trip ensured that we received maximum exposure  to Peruvian mental and social health and contributed to the success of our  trip. However, none of it would have been possible without the mentorship we  received. Our attending’s experience and leadership were essential for our  global health trip. Dr Bullon helped translate, supervised our patient care,  and consistently offered us a cultural and historical context to all that we  saw. Each night, we would debrief the interesting and problematic situations we  encountered, and Dr Bullon would offer insights. His understanding of Peruvian  society and geography created a fertile ground for deeper reflection. Most  importantly, he was excited about teaching and left no question unanswered.

Our team was organized so that Dr Bullon saw patients with the 2nd  year resident while the 4th year resident saw patients with a translator. With  practice over the course of working 12 to 14 hours a day for 2 to 3 days, we  were able to interview and treat patients in an unfamiliar culture. The nursing  staff’s knowledge about their patients and their dedication to keep them safe  served as a crucial component to continuity-of-care. They freely shared their  concerns and questions from what they had observed in the patients over time.  This proved invaluable to our treatment of patients with whom our interaction  was only a brief 30- or 60-minute snapshot in time. We worked with translators,  even when translation required a 2-step process (from English to Spanish to  Quechua, the language of the Ayacucho region). Within a few intense workdays,  we began to understand the meanings behind facial expressions, body language,  and tone of voice, which allowed us to relate to our patients as psychiatrists. This  process introduced new profundity to an already rich experience.

We had the opportunity to lead didactic sessions on topics  specifically chosen by staff as part of our work in Ayacucho. These sessions  were conducted with an audience of onsite nurses, social workers,  psychologists, and members of the community. The 2-hour sessions were held  weekday afternoons and included a presentation of topics described above,  followed by a question-and-answer period. Both staff and community participants,  who were able to provide insights on diagnostic and treatment strategies that  might be helpful within the region, enthusiastically attended these didactics.  The clinic in Ayacucho represented a gateway to an integrated care structure,  finely attuned to the needs of the community, despite the limits of medical  services in this area.

As our time in Ayacucho drew to a close, we could not help but  reflect on the resourcefulness of the clinical staff, the resilience of  Ayacucho’s people, and the richness of our learning. During many moments in  patient interviews, it was easy to forget that we were high in the remote  Andes, far from the comforts of Boston. We learned that American psychiatric  training has wide-reaching cultural value. The cultural dynamics certainly  highlighted the influence certain beliefs have on the way patients present.  However, the universality of psychiatric presentations, such as psychosis, OCD,  mania, addiction, and depression, reminded us that psychiatry is a field of  organic disease and that the field must have a secure place in world health  initiatives.

We would like to thank Dr Zeina El Chemali, who  leads the Peace in Medicine Initiative, for her generous support, mentorship,  and funding of our project. Dr El Chemali is Director, Neuropsychiatry Clinics  and Training, Departments of Psychiatry and Neurology, at Massachusetts General  Hospital, and Assistant Professor of Psychiatry at Harvard Medical School,  Boston.

During their time in Ayacucho, these visiting psychiatrists learned that American psychiatric training has wide-reaching cultural value. 

Jhilam Biswas, MD

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