John Torous, MD, MBI

The last year has seen an unprecedented shift in the medical landscape, and mental health care is no exception. Experts look at the evidence and risks of digital tools, apps, telehealth, and other technologies for the treatment of serious mental illness. 

In this video, John Torous, MD, and Sherin Khan, LCSW, briefly talk about their presentation at the 

American Psychiatric Association Annual Meeting

Three New Tools to Augment Care for People With Serious Mental Illness

. Speakers are Sherin Khan, LCSW; John Torous, MD, MBI; Amy Cohen, PhD; Tristan Gorrindo, MD, and Moderator, John Luo, MD. 

Dr Torous is director of the Digital Psychiatry Division, Department of Psychiatry at Beth Israel Deaconess Medical Center, Boston; editor in chief of 

​. Sherin Khan, LCSW, is the Senior Director of Workforce and Organizational Development at 

, Illinois' oldest and largest provider of community mental health services; and Social Work Expert for 

Videos

The last year has seen an unprecedented shift in the medical landscape, and mental health care is no exception. Experts look at the evidence and risks of digital tools, apps, telehealth, and other technologies for the treatment of serious mental illness.

New Digital Psychiatry Tools to Improve Care

Slideshows

Against a sea change in real-world practice of technology in psychiatry, John Torous, MD, MBI, shares what clinicians can expect next.

6 Predictions for Digital Psychiatry in 2021

Experts discuss the latest in digital mental health smartphone apps, digital clinics, and online therapies and telehealth, topics that are especially relevant as we are experiencing a radical transformation of health care.

Most people have access to both the internet and devices that can connect to providers, but do patients have tools to make digital health work for them? We are in a pivotal time now with COVID-19 where we have seen wider access being provided at least in highly populated areas. We are still at the beginning stages as we strive to provide wide access to a lot of different people. 

, is Director of Digital Psychiatry, Beth Israel Deaconess Medical Center, Boston, and Chair, American Psychiatric Association, Health Information Technology Committee. He is the Digital Psychiatry Section Editor for 

, is Clinical Director of the Division of Digital Psychiatry at Beth Israel Deaconess Medical Center, Boston, MA.

 can be properly converted to a new platform in the form of digital technology apps. Additionally, some interventions might be a easier than others. Cognitive behavioral therapy and dialectical behavior therapy are more formulaic and provide homework for patients. Psychodynamic approaches may be more nuanced than some of the shorter term interventions that we are seeing. 

For some patients, it may be unclear exactly what happens in that translation. One useful analogy is comparing a book with a movie. Sometimes, the book is better than the movie; sometimes vice versa. But there is still a lot that we don't know as to why in-person therapy works for some and not for others. The principles are there but we are still learning about the evidence.

Sometimes, the book is better than the movie; sometimes vice versa. But there is a lot we don't know as to why in-person therapy works for some and why digital works for others. In this video, experts discuss the evidence.


Digital Technologies in Mental Health Care

There is a massive effort in the US to curb the spread of 

. But the US has been behind other countries in part because of lack of testing capacity. As testing capacity accelerates, the number of confirmed cases has grown. Singapore and South Korea have flattened the curve more quickly through efficiently identifying cases and exposures and promoting quarantine. This public health strategy, contact tracing, is old but their method is novel. They use phones.

Countries are using Bluetooth or mobility data (eg, Global Positioning System [GPS], cell tower) collected by the phone for contact tracing. One method of contact tracing involves scanning and recording Bluetooth signals from other nearby phones, usually within a 30 feet diameter. The real time data offer a novel means to track proximity and potential interaction with others. Another method for contact tracing involves use of mobility data (often GPS) collected by the phone that allows a digital trail of timestamped locations visited to be easily recreated.

Public health officials can leverage either approach, Bluetooth or mobility, to determine who an infected person may have been in close contact with—and then notify those exposed of possible risk. Countries have taken different approaches in what information they share with individuals identified as being at risk.

, where the age, gender, and location history of those infected are disclosed to those who may have been exposed. On the other end of the spectrum is Singapore, where people are only informed that they may have been exposed. Both South Korea and 

 have been successful in flattening the cure and their use of phone-based contact tracing offers clear potential to better understand how COVID-19 spreads and can be stopped. With increasing interest in using contact tracing in other countries, it is important to understand the potential risks and benefits of use in the US.


During these unprecedented times it is necessary to consider the benefits of disclosure to exposed third parties against the risks of not respecting individual privacy—everyone’s right to control their health information. People are reluctant to share their health information for various reasons, such us harm to one’s reputation, employment problems, and access to insurance.

In the US, health care professionals do not break confidentiality to disclose a patient’s disease status even for communicable diseases like COVID-19 that present a risk to others. One exception is HIV where many state laws encourage or mandate disclosure to public health identities and/or sexual partners. This HIV status disclosure is justified because public health benefits are thought to outweigh the risks to the individual, though this is not without controversy. For COVID-19, one’s personal data (such as age, gender, location, and health status) is shared with others in a public fashion. Yet a discussion about COVID-19 status disclosure does not appear to be happening in many countries where phone-based contract tracing is deployed. In other words, personal data is being shared without the input of people whose information is being shared—in this case those infected.

The current pandemic-related disclosed data can be very sensitive, especially if linked to GPS mobility data collected by phones. Intimate details like where a person sleeps, shops, and even eats can be easily inferred. Later secondary uses of this data can have numerous unintended consequences around employment, social standing, and health insurance coverage. People have already been assaulted because of suspected or confirmed COVID-19—now imagine their home address being shared too. While efforts to deidentify data can be undertaken, history seems to always show that in the near future reidentification is possible. It is assumed that the data are encrypted and secure. But is it? We do not know, key details are lacking.


The legal implications cannot be ignored either; will there be criminal consequences for spreading coronavirus? It may sound fantastical, but in the US there are criminal laws against certain high-risk behaviors that could spread HIV. In Singapore, refusal to share COVID-19 related data requested by the Ministry of Health can lead to prosecution. These consequences have likely led to people avoiding testing or care.

Ethically based solutions offer a path forward. One pathway is to simply ask for 

 to collect data. This could be done in multiple ways including an opt-in system (Singapore) or even opt-out in some circumstances. Although Iranian officials used an opt-in system, the consent was displayed in a non-native language or not at all for many users. Regardless of the system, to respect privacy, it is important that the data collected, shared, and where data are stored is clearly explained to users. Alternatively, it could be an opt-out consent, which may be more coercive because people are less likely to change from the default. If an infected person’s consent is required before his or her data are shared, an opt-in system could be more palatable. Another solution is to aggregate data at the community level to examine trends rather than an individual’s data. This does not necessarily preclude obtaining consent. Although less advantageous for contact tracing, storing contact data on the phone of an infected person rather than a centralized database lets that individual decide whether he or she want to share the data with public health officials.


COVID-19 has spurred many changes leading to wider adoption of various technologies to support public health efforts. But even data collected for the greater good such as phone-based contact tracing can have unintended negative or punitive consequences. There is always a risk when sensitive information is collected. Ultimately, US public health officials must weigh these risks against potential benefits in an informed fashion.

is a Child and Adolescent Psychiatry Fellow, University of California Los Angeles Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA.

is Director, Digital Psychiatry Division, Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. He is Digital Psychiatry Section Editor for 

Articles

COVID-19 has spurred many changes leading to wider adoption of various technologies to support public health efforts. But even data collected for the greater good can have unintended negative or punitive consequences.

A Novel Approach to Contact Tracing

We have all been there. In an idle moment, you instinctively reach for your smartphone to browse your social media feed. The goal is simple: an easy distraction. But the effect is sometimes complicated. Many of us enjoy social media to stay connected with friends, family, colleagues, or groups of individuals with similar interests, but there is inherently an ugly side too. That side where you see something-the perfect family photo, the vacation picture, the promotion of a work accomplishment-and think, “I wish that were me,” can have negative mental health effects.

These double-sided reactions to social media are critical to understand given the high rates of exposure so many people around the globe have to social media each day. In 2018, 

 social media use among internet users worldwide was 2 hours and 16 minutes.

 And, while user retention for most apps over the first 90 days is 

between 10% and 30%, many social media apps have retention rates ranging from 60% to 98%.

 But are they good for us or are they just addictive? Perhaps they are the social-emotional equivalent of eating fast food every day for lunch.

Several lines of research may be relevant in answering this question. For example, 

 would have us speculate that when we are offered highly curated pictures of other people’s lives, we tend to feel worse about our own.

 Similarly, mindfulness, or focusing on the present moment on purpose without judgement, has been found time and time again to be linked to emotional wellbeing. To the extent that social medial calls for a focus on documenting our most precious moments rather than living them, we might expect that users focused on posting pictures or videos of these moments may be a little less present in those moments.

The difficulty in answering this question is that most of the studies evaluating the social and emotional impact of social media have been cross-sectional. They only look at one point rather than how engaging with social media affects users over time. From cross sectional studies, we know some things. For example, more than 1 hour of 

 daily has been associated with worse psychological well-being (

of young adult social media users indicates that those who used a large number of platforms (7 to 11 different social media platforms) were 3 times more likely to have symptoms consistent with a mood or anxiety disorder.

The challenge of these studies is that they do not tell us whether use of social media makes people unhappy. Cross-sectional studies focus on describing patterns observed (for example, that individuals with high amounts of screen time or who use more platforms are more often unhappy), but not why those patterns are observed. From these findings two different scenarios are entirely possible. First, it may be that people who are more depressed use social media more often in an attempt to feel better. Second, it may be that people who use social media more often become more depressed because they are less mindful in their day-to-day lives or are more engaged in destructive social comparison practices. Either explanation, and may others, could be true. A 2019 study analyzed cross sectional data from over 350,000 youths about their well-being and digital technology use. The researchers concluded that the actual negative effects could be much smaller than projected (0.4%).

A study from 2018 looked beyond cross-sectional data.

 The researchers recruited 200 students: 100 were assigned to an app-based intervention intended to reduce use of social networking apps; the other 100 were not assigned an intervention. The app included education on the use of social networking and allowed students to create limits on how often they could use smartphone social networking platforms. The results showed that among students who received the intervention, use of online social networking platforms as well as symptoms of depression and anxiety decreased. Conversely, the group that did not receive the intervention showed no difference in the use of online social networking platforms or in symptoms of depression or anxiety.

The tentative conclusion from this study: less social media use improved emotional health. As scientists, we have to point out that this study was far from perfect. Most notably, there was no comparison between the intervention and control group-which is a key aspect of establishing what caused the observed changes. Also, while the authors reported that the only criteria for participation was being a student at the host university, they imply that the study recruited participants who perceived their use of online social networking to be an addiction. If participation was skewed toward people who viewed their use of online social media negatively, that alone could certainly explain results. The bottom line is that we will need replication of these kinds of longitudinal studies to draw any firm conclusions. Nonetheless this study represents a promising step toward understanding the impact of social media.

So, is social media your best bet for a relaxing way to pass time between meetings or on your morning bus ride? Should parents allow their impressionable teenagers to use social media? We will certainly need more studies to answer this. But it is looking more and more like the answer may be that social media is not particularly beneficial for most of us.

 is Associate Director, Brigham and Women’s Hospital Digital Behavioral Health and Informatics Research Program, Boston, MA. 

 is Director of Digital Psychiatry, Beth Israel Deaconess Medical Center, Boston, and Chair, American Psychiatric Association, Health Information Technology Committee.

This articles was originally posted on February 7, 2020, and has since been updated. -Ed

Daily Time Spent on Social Nerworking by Internet Users Worldwide From 2012 to 2018

Which Apps Retain Their Users-And Which Ones Don’t

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Associations between screen time and lower psychological well-being among children and adolescents: evidence from a population-based study

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Use of multiple social media platforms and symptoms of depression and anxiety: a nationally-representative study among US young adults

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Based on recent data, it is looking more and more like the answer may be that social media is not particularly beneficial for most of us.

Why You May Want to Swipe Left on Social Media

It has been a busy year for digital mental health. While no one knows what 2020 will bring, some themes are sure to continue to shape the field.