Nidal Moukaddam, MD, PhD

As smartphone ownership has skyrocketed and internet connectivity has become a necessity, patients and clinicians alike have seen the potential of evidence-based digital interventions. However, mainstream clinical practice has been slow to adopt these new technologies. Reluctance to use digital interventions might be related to attitude/familiarity, knowledge, and systemic/liability concerns.

The slow adoption may also be due to a lack of interdisciplinary dialogue between app users (the consumer, the patient, the physician), app makers/designers (engineers, computer scientists, and artificial intelligence experts), and the clinical practitioners. Currently, app and wearables data do not directly correspond to psychiatric diagnoses. Incorporating technology into mental health treatment plans could allow clinicians to work smarter, with continuously updated information. Clinicians and patients would benefit greatly from novel clinical workflows that incorporate apps and wearables as long as they meet confidentiality/privacy requirements. Innumerable patients have phones and other digital devices that could be gathering relevant information, but the information present in those devices has no formal role in clinical practice yet.

Wearables can include shirts, necklaces, headbands, wristbands, watches, shoes, and eyeglasses. They can be used to monitor physiological parameters such as temperature, heart rate, skin conductance, respiratory amplitude, and body movements, which may help monitor disease status.

Flexible biosensing is a rapidly growing industry and area of research. It aims to produce flexible material that can be worn as close to the skin as possible in a noninvasive and unobtrusive manner. These wearables can include physiological signal-monitoring sensors; customized designs with transmitters, receivers, filters, and circuit tracks—all with reduced size, lighter weight, and lower power consumption.

 Biosensing can also be used to measure chemical levels in the body, such as blood sugar, calcium, lithium, and oxygen saturation.

In the field of psychiatry, only the more basic sensing aspects are eyed as adjuncts for information-gathering and digital therapeutics. Yet, even in their most basic form, sensors have the possibility of changing the way psychiatrists monitor their patients’ symptoms. Instead of relying on subjective information from patients, clinicians could gather objective data on sleep habits, activity levels, food intake, medication adherence, and even substance use. Onset of certain troubling patterns or departure from established baseline patterns serve as diagnostic cues. For instance, increases in motor activity (a proxy for agitation) can be a 

Figure 1. Ideal Scheme of Detection and Change-Triggered Action From Wearables

Key to success is the establishment of a clear relationship between the objective measure and the disease or mental health issue. For instance, irregular respiratory amplitude might signal decompensation of asthma. Since the link between shortness of breath and an asthma attack is well understood, a 

 looking at such data could theoretically be implemented.

 Turning to psychiatry, anxiety symptoms can occur in panic attacks and mimic asthma in an individual who has both disorders; in this case, irregular respiratory amplitude could signal worsening in either or both conditions. Interestingly, the wearable itself cannot make this determination and differentiate conditions unless an artificial intelligence algorithm gathers and interprets additional data points. A stepwise approach to this chain of events is portrayed in 

A Closer Look at Smartphone-Provided Information

The data gathered by smartphones are comparable to wearables, because most individuals carry smartphones on them most of the time. Information provided by a phone or a wearable is referred to as passive sensing, requiring no action on behalf of the user. Below is a non-exhaustive summary of phone-measured dimensions. Note that wearable bands used for fitness cover much of the same information but may not share all of it with users.

The most basic data a phone can provide is GPS information. GPS location tracking provides a detailed image of a patient’s routine. Phones can also measure exposure to daylight, which can share information about the patients leaving their home. These 2 data points tell a story of isolation and psychomotor retardation, both potential indicators of worsening depression. Similarly, sleep fluctuations can be detected by examining screen on/off features and accelerometry data.

The use of text/SMS can establish an individual’s sociability baseline. How large is a patient’s social network? How many people do they interact with on a regular basis? How long do their conversations last, and do they prefer phone to text? Deviations from this baseline can be seen in mood disorders (ie, isolation and withdrawal in depression; extraversion and increased sociability in mania); psychotic disorders (ie, isolation and withdrawal with worsening paranoia or persecutory delusions); and anxiety disorders and substance use disorders (ie, calls at erratic times; increased activity; certain suspicious locations). The length and content of verbal and written communication can also be indicative of pathology or relapses.

Lastly, movement anomalies and tremors can also be detected with smartphone-based monitoring and can be useful in assessing medication adherence and effectiveness.

Symptom Monitoring and Privacy and Confidentiality

The potential of technology to detect deviations in behavioral patterns is vast. However, privacy concerns are legitimate, and every effort needs to be made to protect individuals with mental illness, especially because they are a vulnerable population. For instance, could looking at interpersonal communications violate a patient’s privacy and confidentiality? Linguistic analysis and natural language processing indicate high correlations between in-person clinical ratings and blinded ratings based on social media data posts,

 in discriminating unipolar from bipolar depression.

 On Reddit, sentiment analysis, personal pronouns, and semantic category analysis differentiated belonging to a mental health support group versus other nonmental health groups.

 Social media content has been looked at as a 

 Accessing content of social media posts could be valuable in assessing and following mood disorders.

Looking at an individual’s conversations can be helpful in assessment and diagnosis of mood, psychotic disorders, and brain injuries, but carries risk of privacy invasion. Prosody assessment can help diagnose schizophrenia spectrum disorders by clarifying lexical and syntactic information.

 With privacy-preserving measures and no content analysis, our group has proven that depressive symptom severity 

 with decreased text/SMS and call durations and frequency.

 Privacy preserving analyses is more technically challenging, but may be more acceptable to patients in terms of sharing data and allowing speech recordings.

Ecological momentary assessment (EMA) refers to data reported by an individual in close temporal proximity to an event, which can help avoid recall bias. The use of smartphones has allowed EMA collection of feelings, reactions, and other behavioral measures more frequently than before. Answers in response to a prompt asking about mood are useful, especially in correlation with objective data from wearables or phones. In contrast to passive sensing, EMA cannot be collected continuously.

In the field of mental health, EMA is often centered on reports of mood but can also include questions about suicidality, self-harm impulses, hallucinations, substance or alcohol use, physical activity, self-esteem, etc. Both random and scheduled sampling are options, and the more frequent data collections allow for finer granularity in understanding microprocesses that govern emotional and behavioral experiences. EMA can also play a role in shaping emotions or behaviors by increasing awareness and, thus, needs to be studied carefully for potential placebo-like effect.

Choosing the right EMA is crucial to understanding the patient’s experience, just as choosing the right interview question can facilitate therapeutic alliance. In selecting apps,

 it is important to determine the goals. For example, would an event-contingent sampling (ie, asking a patient to log when they have cravings for a substance or urges to hurt themselves) be helpful? Is time-contingent sampling (ie, examining when things happen to rule out adverse effects or explore life occurrences on mood) a more appropriate option? EMA is also used to train artificial intelligence and deep learning algorithms to predict events, such as resurgence of auditory hallucinations or bad mood.

 Once the algorithm is trained, frequent EMA is no longer needed.

Referred to as digital health, the ability to leverage technology for encouraging positive behaviors is an area that could revolutionize health care, especially in psychiatry.

Mental disorders are heterogenous. A divergence can exist between what a patient reports and what the psychiatrist sees (eg, mixed features in a manic episode). The following tips can help fit this phenomenology within EMA and passive sensing findings.

Carefully evaluate prospective apps.The app evaluation model available on the American Psychiatric Association’s website offers a 

 to clinicians wishing to evaluate such applications.

 Specifically, clinicians should consider:

On which platforms/operating systems does the app work? Does it work on a desktop computer?

Has the app been updated in the past 180 days?

Is there a transparent privacy policy that is clear and accessible before use? Does the patient understand it?

Does the app collect, use, and/or transmit sensitive data? How are the data stored, and is storage claimed to be secure?

Is there evidence of specific benefit from academic institutions, end-user feedback, or research studies? (Note: Most apps do not, hence the difficulty in recommending specific ones.)

Does the app have a clinical/recovery foundation relevant to your intended use?

Does the app seem easy to use? How much battery and data does it consume?

Can data be easily shared and interpreted in a way that is consistent with the stated purpose of the app?

Avoid making a diagnosis based on data points from an app.Psychiatric diagnosis is categorical and relies on specific symptoms for a predetermined duration as dictated by the DSM-5 or the International Classification of Diseases, Eleventh Edition. Wearables do not provide a diagnosis, but rather a set of data points. A symptom of depressed mood does not equate to major depression, nor does a hallucination equate to a formal thought disorder. In incorporating findings in your formulation, use the data as part of a full clinical picture. Discuss app findings with the patient while avoiding diagnostic labels.

Think dimensional, not categorical.Symptom remission is the goal of treatment, but symptoms occur along a continuous spectrum. Findings from an app can be invaluable in helping patients move from partial to full remission. For instance, although a patient with depression may present with an improved affect and grooming suggestive of remission, the curves from a mood app show persisting poor functioning and, therefore, incomplete improvement. In this case, the improvement may have reached a certain threshold, which is not enough for full functional recovery. The dimension of depressed mood is distinct from the construct of a depressive disorder.

Apps and wearables generate an overwhelming amount of data that require specialized processing with deep learning algorithms. Clinicians should start with dimensions in which they have been trained, such as psychomotor retardation to agitation, depressed mood, food intake, and sleep. However, it is clear that othertransdiagnostic dimensions can tell a lot about an individual’s functioning, even if they are not part of traditional psychiatric diagnostic criteria. Functional imaging studies have largely moved in this transdiagnostic, dimensional direction, and these include psychological concepts such as impulsivity, compulsivity, sociability, and other biomarkers chosen based on functional connectivity and biomarker data.

 offers an example of dialogue between the categorical and dimensional approaches in psychiatry as mediated by wearable or app-provided information.

Use data from apps in session to discuss progress with your patients.Data collected outside of appointments offer a glimpse into the patient’s real life. In initiating use of any app or wearable, discuss the expectations and lay the foundation with the patient in terms of what the technology can do and cannot do. Then, during a later appointment, ask the patient to show you their mood graphs, and use this information to initiate a dialogue on noted bad days, triggers, sleep pattern deviation, etc.

There is rapid turnover of apps and technology, with few applications withstanding the test of time. As such, it is difficult to recommend any particular application, but it is useful to know the main ones in the field. Examples include Daylio and T2 Mood Tracker for journaling; Woebot, CBT coach, and CBT-I Coach for cognitive behavioral basics and insomnia; and Calm and Youper for wellness. A clinician familiar with an app can better guide the conversation.

Technology can be useful as adjunct to information gathering, diagnostic clarification, symptom tracking, and teaching/reinforcing behaviors for patients with mental illness. Still in its infancy, this exciting field is rapidly growing and holding much promise.

“Julie” is a young adult with depression. Pharmacological management has helped somewhat, but the patient reveals urges to self-harm and continued intermittent depressive symptoms. However, Julie is not fully open about this issue. Financial considerations and transportation issues preclude the addition of psychotherapy and more frequent visits. Interestingly, Julie wears a fitness band. At one of the appointments, you suggest looking at her sleep results and note a particular Thursday and Friday have a more interrupted pattern than other days. Upon closer inquiry, Julie reports alcohol binging on those days.

With this in mind, you suggest she install a cognitive behavioral therapy app for substance use (reSET, which is FDA-approved), and plan for closer follow-up visits.

is associate professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine and Ben Taub Adult Outpatient Services Director, Medical Director, Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis. 

is chair of the Department of Electrical and Computer Engineering and the Earnest Dell Butcher professor of engineering at Rice University.

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2. Mukhopadhayay SC, Islam T. Wearable sensors for physiological parameters measurement: physics, characteristics, design and applications. In: Mukhopadhayay SC, Islam T, eds. 

3. Faurholt-Jepsen M, Vinberg M, Frost M, et al. 

Smartphone data as an electronic biomarker of illness activity in bipolar disorder

Wearable respiration monitoring: interpretable inference with context and sensor biomarkers

5. Kuosmanen E, Wolling F, Vega J, et al. Smartphone-based monitoring of Parkinson disease: quasi-experimental study to quantify hand tremor severity and medication effectiveness. 

6. Kelly DL, Spaderna M, Hodzic V, et al. Blinded clinical ratings of social media data are correlated with in-person clinical ratings in participants diagnosed with either depression, schizophrenia, or healthy controls. 

7. Mariani R, Di Trani M, Negri A, Tambelli R. 

Linguistic analysis of autobiographical narratives in unipolar and bipolar mood disorders in light of multiple code theory

8. Low DM, Rumker L, Talkar T, et al. Natural Language Processing Reveals Vulnerable Mental Health Support Groups and Heightened Health Anxiety on Reddit During COVID-19: Observational Study.

9. Yoo DW, Birnbaum ML, Van Meter AR, et al. 

Designing a clinician-facing tool for using insights from patients’ social media activity: iterative co-design approach

10. Lucarini V, Grice M, Cangemi F, et al. Speech prosody as a bridge between psychopathology and linguistics: the case of the schizophrenia spectrum. 

11. Cao J, Truong AL, Banu S, et al. Tracking and predicting depressive symptoms of adolescents using smartphone-based self-reports, parental evaluations, and passive phone sensor data: development and usability study. 

12. Moukaddam N, Truong A, Cao J, et al. 

Findings from a trial of the Smartphone and Online Usage-based eValuation for Depression (SOLVD) application: what do apps really tell us about patients with depression? Concordance between app-generated data and standard psychiatric questionnaires for depression and anxiety

13. Shiffman S, Stone AA, Hufford MR. Ecological momentary assessment. 

14. Doherty K, Balaskas A, Doherty G. The design of ecological momentary assessment technologies. 

15. Li B, Sano A. Early versus late modality fusion of deep wearable sensor features for personalized prediction of tomorrow’s mood, health, and stress. 

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17. App Advisor. American Psychiatric Association. Accessed January 18, 2021. 

https://www.psychiatry.org/psychiatrists/practice/mental-health-apps

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The first forms of telepsychiatry were initiated as videoconferencing in the 1950s. Its use has steadily increased in recent decades. Due to the 

 pandemic, the majority of outpatient psychiatric encounters in the last couple of months have been switched to virtual in a rushed, desperate bid to keep care going. These virtual encounters have become a necessity to maintain mental health care, but the abrupt change has forced many adjustments for patients and clinicians alike. In this article, we focus on potential reasons why virtual encounters feel different, incomplete, or simply unsatisfying. We hypothesize that the “flavor” of a virtual encounter, just like a traditional one, is a conglomerate of physical/environmental factors, clinician-specific factors, patient factors, and the interactive process that includes both verbal and non-verbal elements. Drawing on 

, we discuss the importance of the frame in interactions, and the impact of a rushed frame shift without preparation or training

 was developed carefully, where patients and supervisees where made aware of the method of treatment in which they would be engaging. In that capacity, telepsychiatry has allowed for treatment and supervision to occur across long distances. This has ranged from a variety of underserved areas—as varied as rural communities not serviced easily by roads, to providing services to crew members of cruise ships. Telehealth now provides a way to maintain connection and treatment while reducing the chance of spreading COVID-19. In order to protect the population quickly, this change was made rapidly and unexpectedly, for patients and clinicians alike.

One way to consider the move from seeing patients in offices, to seeing them from home through computers, is a shift in the frame. 

, an analyst and painter, coined the term “the frame” to represent the different kind of special reality in a therapeutic session (this was inspired by the concept that a different physical frame could change the experience of a painting). Variations in the frame that are introduced by either the patient or the clinician, relate to the work together. Often, changes in the frame are introduced by the patient and explored by the clinician. For example, the two might work to understand why a patient is chronically late or skips sessions. This could indicate, for example, a patient’s fear of discussing painful feelings around the clinician and trying to shift the frame to avoid those feelings.

There are many benefits to this shift in frame with virtual encounters: the main one, of course, is that many are continuing to receive mental health treatment, because clinicians were able to make this change quickly. Telehealth can provide international training, supervision, and treatment, and allows for continuing relationships with patients who relocated, or who are working or training remotely.

Virtual platforms provide HIPAA-compliant chat functions and allow informal discussion of patients between colleagues; providing much needed connection and interaction. Research supports the efficacy of virtual care in maintaining therapeutic rapport and fulfilling patients’ needs. It also demonstrates that remote supervision was experienced as equally effective to in-person supervision. However, the way clinicians conduct their visits is a finely honed technique that takes years to develop. You might change the way you ask questions, the way you sit, or focus on certain mannerisms during a session. These details are all but lost in virtual encounters and most programs lack specific training on connecting through virtual platforms (

In the past, it was felt by many that virtual mental health care was impossible. Treatment outside the office was deemed insufficient; even with video, nonverbal and subtle sensory experiences that the clinician and the patient take in about one another would be missed. Even now, clinicians feel they may miss subtle extrapyramidal findings or environmental cues when looking at a screen. The calm of the clinician or the simmering agitation of a psychotic patient may not be communicated the same way through video. It is easier to immerse oneself in the experience in the room with a patient and have a greater sensory awareness of the interaction.

 depends on the ability for the patient to maintain a connection with and a positive representation of the clinician in their mind. With the clinician not in the room, patients may revert to their default sense of relating to others and themselves, which is likely to be a very negative one.

Much of psychoanalytic literature discusses treatment in the room with the patient. Kernberg spoke to the use of structure and a frame to help patients struggling with a fragmented sense of self and difficulties with emotion regulation.

 The physical presence of the clinician is a part of that structure. The clinician’s presence can demonstrate a commitment to be in the life of a patient. Over time, a patient can develop and internalize consistency and structure into his or her sense of self by utilizing the experience in the room.

McWilliams discusses the need for both stimulating and comforting elements when working with patients.

 Comfort provides a sense of safety and stimulation is used to introduce challenge and complexity so that the patient can grow. The flexibility of providing a variety of comforting and stimulation interventions is shifted in telepsychiatry. As such, the interventions that the clinician provides may have to be amplified in other ways—just as an un-amplified actor on the stage emotes louder than a Hollywood actor.

Elements of the work in the room that convey meaning, such as silence, may be experienced quite differently in a virtual encounter. In the room, a silence can represent a shared moment of understanding, or an acceptance of patients as they are. During a tele-session, silence can be experienced as abandonment, an absence, distraction by the clinician, or even connection issues.

In the office, patients and clinicians have the privilege of a great deal of privacy. The clinician provides a private, neutral space uninhabited by family members or significant others. This level of privacy is now something patients need to create on their own, by finding their own space to meet. Also, most clinicians have a waiting room, a transitional space patients can use as a bridge between their personal lives and their relationship with their clinician. This transitional space is no longer present and can be jarring to patients. Furthermore, literal privacy is also at risk—tele-sessions introduce vectors for security breaches in a way that is different from the safety experienced in clinicians’ offices.

Just as the distance may affect patients in different ways, it can also affect clinicians in various ways. The distance of the treatment may provide a separateness to help contain their own anxiety. It can help the clinician maintain boundaries of feeling undue pressure to do more than they are able, in the session. The distance may also intensify the loneliness and separation the clinician is experiencing in the work (

Setting up a telepsychiatry environment in the current COVID-19 situation involves the basics of a private space with a desk, communication device, reliable internet, and a comfortable chair. Challenges include eliminating background noise and distractions such as interruptions from pets and family members. The goal is to create an environment that feels safe, inviting, and personal, but also allows privacy for both the psychiatrist and the patient. A safe, private, and quiet environment is essential for the patient to benefit fully from the interaction.

Once these elements are met, another struggle is the ability to maintain eye contact and proper attention while completing other necessary tasks such as note-taking or writing prescriptions. Unlike an on-site session with a patient who fully maintains his attention, there are many more distractions available to clinicians that may make it harder to focus. Emails can pop on-screen, messages ding, and cats slink by the camera. It is important for clinicians to establish with the patient, that they may need to type while talking, or that they may shift their gaze to view the patients’ records. Each eye movement made can be more closely scrutinized by the patient. Keeping patients aware of what might be going on allows clinicians to collaborate more and prevents patients from feeling ignored.

Clinicians may also experience fatigue after a long day of seeing patients through telepsychiatry. This fatigue can stem from energy expended to focus on, and be more active with, patients. Clinicians might feel limited in their ability to move in their lives and communities. These constrictions, as well as the effort of simultaneously providing containment of their own anxiety (and that of their patients) can lead to a sense of burden and weight. The clinician may be pressured to provide certainty during such an uncertain time. This can be a weighty burden for the clinician to bear and contribute to fatigue.

Telepsychiatry has highlighted existing health care and socioeconomic disparities. Tele-visits are far more utilized among patients in urban settings rather than those in rural communities, due partly to less reliable technologies such as fast internet access. The lack of an emotionally safe and private space for a tele-psychiatric visit is a major issue for the underserved. When patients cannot access mental health care on a regular basis, they are more likely to wait until symptoms are more severe and present to emergent care.

Tele-visits can be a great relief to those who do have difficulty accessing transportation. Those with financial and mobility issues may have an easier time initiating a session from home. Clinicians may learn more about the conditions and relationships in the home, recognize more of what the sanctity of the office provides to the patient. The socio-economic disparity may add a layer to the frame, by forcing into clearer view the economic hardship patients experience.

From a diagnostic perspective, certain patients may derive greater therapeutic benefit from telepsychiatry, and this area needs to be investigated further in a rigorously scientific manner. For instance, those who have social anxiety disorder or agoraphobia may initially feel more comfortable avoiding direct interaction by using telepsychiatry. However, it may impair their functioning long-term by reinforcing avoidant patterns.

A patient who is aggressive, psychotic, or one who is experiencing significant cognitive decline may be too inattentive or agitated to focus on the camera for a sustained period. It might be hard to get a full clinical picture of someone with schizophrenia if he or she is responding to internal stimuli. However, it might be easier to have a tele-session with paranoid patients if they do not want to come into the office. Patients with borderline personality disorder may feel abandoned by the switch to tele-visits. Conversely, some patients with histories of trauma, feeling unsafe, or feeling criticized by others may find it easier to speak with the distance of tele-visits.

From a physical perspective, both parties will break a barrier that existed before, between personal and professional. For example, the patient sees the clinician’s home in the video feed, or the clinician sees family members or pets whose existence was formerly abstract. This is not new, however; Freud, for example, frequently saw patients in his home in London. The new information gathered may intensify the treatment in new ways and provide different insights and understanding. Perhaps this is simply establishing a different level of intimacy (desired or otherwise) between the patient and clinician.

The are many elements to consider during this massive migration to telepsychiatry. Nonverbal, physical, and socioeconomic factors are all significant considerations of the shift in frame. These factors, combined with the clinical applications of telepsychiatry, affect the experience of the interaction between the patient and the clinician and bring up a range of feelings in both the clinician and patient. For clinicians, being able to address these changes and experience the related feelings fully, can allow them to apply telepsychiatry better. As many more clinicians are becoming more comfortable with this method, more relationships with patients can be forged, maintained, and renewed.

 is Assistant Professor of Psychiatry at the Menninger Clinic, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; 

 is PGY-1 Resident, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; 

 is Associate Professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine and Ben Taub Adult Outpatient Services Director, Medical Director, Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis.

Convergences and divergences in contemporary psychoanalytic techniques

The are many elements to consider during this massive migration to telepsychiatry. Nonverbal, physical, and socioeconomic factors are all significant considerations of the shift in frame.

Nidal Moukaddam, MD, PhD

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