Psychiatrists are on the front lines of the troubling state of mental health care in America. Our patients demonstrate the diversity of problems faced in mental health, including poor access, demand that far exceeds supply, high costs, and stigma. As the US population grows, insurance coverage and reimbursements shift, and the cohort of psychiatric providers is unevenly distributed across the country, the supply and demand mismatch will only worsen. Awareness of these limitations often makes it difficult to appreciate that we are also at the front lines of exciting, hopeful new solutions to these problems-as long as we pay attention to the progress happening around us and learn how best to integrate it into our practice.

There is a strong imperative to develop innovative and scalable solutions that address the gaps in access to and quality of care; and solutions are being created by various parties (eg, entrepreneurs, investors, insurance companies, politicians, hospital administrators, and patients). It is now more important than ever that we join forces with stakeholders and share our ideas and expertise to create new ideas that work for our patients and for the systems in which we function.

Brainstorm, the Stanford Laboratory for Brain Health Innovation and Entrepreneurship, is the first of its kind-an academic laboratory dedicated to transforming brain health through entrepreneurship. Brainstorm applies the biopsychosocial model of disease to tackle problems on the systems level. Launched by a founding team of physicians from around the country, we unite the worlds of medicine, business, and technology to foster innovative ventures that optimize health and human potential. We accomplish this through education, collaboration, and creation.

Through research and collaboration with academic and industry leaders, we have found that for an innovative solution to successfully address challenges, it should be safe, effective, accessible, affordable, measurable, and scalable. Technological innovations are rapidly emerging because they are uniquely suited to meet these criteria-and meet them quickly. From the more familiar text messaging, video conferencing, and mobile phone applications to the newer areas of virtual reality, augmented reality, behavior tracking, wearables, sensors, and chatbots-these are the solutions that can change the future of psychiatry.

To avoid any conflict of interest or perception of endorsement in this article, we discuss the technologies in general categories instead of giving specific examples or using company names. Many mental health technological ventures are early stage and are still working toward clinical validation and/or development of a sustainable business model.

. Technology gets care to patients who cannot otherwise reach care. Whether the issue is transportation, inconvenience, or short-staffing of psychiatrists in a particular geographic location, the problem is the same-patients lack access to quality mental health care. What many people can access, however, is a smartphone, computer, or their local, tech-friendly hospital. Innovators are using tools for patient care that are not very different from the ones we know (eg, FaceTime), which we use to chat with family or friends around the world. Technology is being used to provide app-based therapy, coverage in psychiatric emergency departments, consultation to medical care, and rounds on inpatient psychiatric units-all in settings that previously may not have had access to psychiatric coverage.

. Digital mental health services provide affordable alternatives to traditional care. They lessen some of the fixed and variable overhead costs of more human resource-heavy solutions, such as office space, waiting rooms, and administrative staff. This means that care can be delivered by providers more efficiently, and it can be obtained by patients more affordably.

Not only are digital solutions less costly to use, they are also less costly to develop. While the average cost of developing a psychiatric pharmaceutical treatment exceeds $2.5 billion, the cost to develop a psychiatric digital treatment can average around $500,000 to $1,000,000.

. One of the greatest challenges in clinical psychiatric practice is the lack of objective measurement to inform clinical decision-making. With the use of technology, data previously unmeasured can be captured and meaningful insights can be made on the individual patient level as well as by aggregating data into larger databases referred to as “big data.” Behavioral patterns (eg, a depressed patient whose number of daily steps suddenly declines) are tracked over time as well as deviations from baseline. Such tracking alerts physicians about the recurrence of symptoms between visits and allows for earlier intervention-resulting in improved outcomes.

. Digital solutions can take ideas that work and replicate them more quickly and effectively than would otherwise be possible. Once there is evidence that a solution works, it can quickly be reproduced and adopted elsewhere without the common barriers of cost and staffing. This ability to scale offers technology the potential to make a population-level impact.

While many technological innovations have successfully met the standards explained above, most have yet to deliver consistently on 2 fundamental criteria of behavioral health care: safety and efficacy.

. Given the complex history of psychiatry, it is important that diagnostic and treatment modalities are safe. Safety has been difficult to control because to date, many novel psychiatric products have been unregulated. However, recent progress has been made on this front. In July 2017, the FDA launched a new pilot effort to regulate digital medical products, the “Software Precertification Pilot Program,” with the goal of “[providing] patients with timely access to high-quality, safe, and effective digital health products.”

 Its effectiveness will be shown in time. Meanwhile, it is our responsibility to make sure that patients are physically safe on the other side of the screen, that we understand the nuances of the liability involved in each encounter, and that we understand the implications of prescribing a digital solution.

In addition to patient safety, it is important to consider the security of patients’ health information. While many technology-based products are HIPAA compliant, some ask users to voluntarily share personal information and may not be held to the same privacy standards.4 It is critical for clinicians to remind patients of these nuances and the associated risks so that patients know what is secure and what is not.

. To advance the state of mental health, we need solutions that make a concrete impact on clinical outcomes, social outcomes, and financial costs. Because the digital age is still new, the effectiveness data are not robust. A significant advantage of studying technology is that it is well suited to being analyzed. As digital ideas continue to emerge, clinicians and researchers need to keep an open mind about technology, not only as a means to treat patients but also to critically evaluate and develop an evidence base for future patients.

From mobile apps to telemedicine to virtual reality games, new ideas that incorporate technology are emerging daily, and clinicians will inevitably be asked about them. With the vast amount of available digital solutions, it can be challenging to stay informed. One way to conceptualize these solutions is to group them into 3 categories.

. Psychiatry has primarily relied on clinical assessment and self-report for screening and diagnosis. Unfortunately, this can be a barrier to timely, scalable care as well as prevention and early intervention. According to the NIMH, with today’s screening and diagnostic methodology (as well as barriers such as stigma and access to care), the average delay between the onset of symptoms and intervention is 8 to 10 years.

 While statistics like this are inherently multifactorial, digital solutions aim to address these challenges and help clinicians obtain and utilize quality, objective information.

A prime example is digital phenotyping. Digital phenotyping is the process of taking data collected by technology such as sensors and smartphones, and turning data into clinically relevant information. For example, a smartphone can collect information on how much patients are moving around or engaging with others; this information can be collected either actively by direct input from users or passively, by using functions such as the GPS or logs of outbound calls and messages. These data can be used to screen, diagnose, prevent, and treat disease, and researchers have begun to study the accuracy and potential of these tools.

. While not technically a treatment modality, telepsychiatry was one of the first forays into ways of reaching patients for assessment and treatment. Today, through audio, video, and text, clinicians can consult with colleagues or provide care to patients. Telepsychiatry can be equally as effective as in-person treatment in terms of diagnostic accuracy, treatment effectiveness, and quality of care.

 Clinicians and patients have mixed feelings about these alternative modes of communication, wondering, for example, how texting affects the patient-doctor relationship. Answers will unfold as the shift toward technology continues and outcomes are better understood over time.

One of the fastest-growing areas in technology has been in cognitive behavioral therapy (CBT), which lends itself well to digital delivery-exercises can be more engaging and interactive in a digital format than in the form of a printed worksheet. A 2014 meta-analysis showed that guided internet-based CBT therapy was equally as effective as face-to-face CBT.

 In response to this expanding research area, CBT products have been created in both industry and academia. Educational modules have also been paired with clinicians or non-clinical coaches to guide users through the modules and offer additional therapy. Online or application-based CBT can address many conditions, including depression, anxiety, eating disorders, social anxiety, insomnia, and addiction.

Virtual reality and augmented reality offer a unique opportunity in patient treatments. Virtual reality creates a virtual, computer-generated world for the user to experience using a headset; augmented reality combines the real world with a virtual world to allow users to engage with their environment in new ways.

PTSD and phobias are particularly well suited for virtual reality, which creates a simulated environment. Patients are exposed to traumatic or fearful situations and learn appropriate coping responses. Virtual reality has also been used for conditions such as addiction (simulating a bar to help gain skills to avoid drinking), autism spectrum disorder (teaching emotion recognition), and pain (using distraction techniques, leading to reduced need for anesthesia and opioid medications). A 2015 meta-analysis showed that virtual reality exposure therapy was successful and led to significant real-life behavior changes.

The newest kid on the block is the chatbot-a computer algorithm that uses artificial intelligence to simulate human conversation with patients in a way that is meant to be therapeutic. Just as bots can be used to help people make online purchases, they can be trained to understand emotional responses and react accordingly. So far, chatbots have been used for a range of issues, from delivering CBT for depression and anxiety to reaching out to refugees in Syria.

Clinical technology is progressing in tandem with structural changes in the mental health care delivery system. The current movement toward value-based care is bringing forth many digital solutions to help increase patient satisfaction, improve population health, and lower the cost of health care. One of the biggest moves from a systems perspective has been in leveraging digital tools to create and improve care coordination.

There are opportunities that startups and traditional companies have been working to identify and address: databases and digital tools to match patients with clinicians, schedule appointments, connect with multiple care providers, facilitate e-prescriptions, manage health insurance claims, and identify users at risk for mental illness or relapse. Care coordination tools have been particularly effective, and the increase in value is seen across several domains.

Technology has the potential to treat patients who currently are unable to access care, to prevent disease, and to provide early intervention and quality treatment-it can be the gateway to psychiatric care. With these new modalities, clinicians are better able to provide quality care to all patients with mental health and other problems. We need to understand emerging technological trends that will lead the way to better health and greater opportunity for our patients to access help.

Dr. Vasan is Founder and Director of Brainstorm: The Stanford Laboratory for Brain Health Innovation and Entrepreneurship, Chief Resident in Adult Psychiatry at Stanford University School of Medicine, and MBA Candidate at Stanford Graduate School of Business; Dr. Chaudhary is Founding Partner at Brainstorm, Chief Resident in Child and Adolescent Psychiatry at Massachusetts General Hospital/McLean, and Clinical Fellow at Harvard Medical School; Dr. Aragam is Founding Partner at Brainstorm and Chief Resident in Adult Psychiatry at Massachusetts General Hospital/McLean; Ms. Nagpal is Junior Fellow at Brainstorm and Founder of CS+Mental Health; Ms. McKenzie is Junior Fellow at Brainstorm and a student at Stanford University; Ms. Chen is a Scholar at Brainstorm.

Dr. Vasan receives royalties from Wiley as the author of Do Good Well: Your Guide to Leadership, Action, and Social Innovation; Dr. Chaudhary, Dr. Aragam, Ms. Nagpal, Ms. McKenzie, and Ms. Chen report no conflicts of interest concerning the subject matter of this article.

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Articles

Technology holds great promise to improve the future of mental health. Here: an overview of the types of techology-based solutions currently available.

Technological Ventures Offer New Hope for the Future of Psychiatry

Depression is the leading cause of disability and a major contributor to the global burden of disease as measured in disability-adjusted life years, according to a report in 2017 by the World Health Organization.

 By 2030, depression is projected to become the world’s largest contributor to disability-adjusted life years.

 Patients with depression are more likely to have chronic comorbid medical conditions such as diabetes and congestive heart failure and are more likely to be nonadherent to prescribed medications. Patients with untreated depression have higher medical costs, worse health outcomes, and lower quality of life than those whose depression is treated.

There are tremendous disparities in the treatment of depression. Racial and ethnic minorities face both practical and cultural barriers to mental health care. They frequently lack the resources to seek help, suffer from language barriers, and hold strong convictions of stigma about psychiatric illnesses. These obstacles lead to under-recognition and undertreatment of mental illnesses. The Surgeon General’s Report considered correcting these disparities a top priority and suggested offering minority-centered services and developing culturally competent care to address the specific needs of minorities.

Research has shown that the mental health care system provides less care to African Americans, who also are less likely to seek mental health care than white Americans. When African Americans seek mental health care, they are less likely to be satisfied with the care they receive-and more likely to leave treatment prematurely.

 This can be explained by a history of mistrust of medical professionals that originated from unethical treatment of racial and ethnic minorities in research and practice, which led a greater proportion of minorities to be skeptical of mental health care. These help-seeking behaviors may explain why African Americans with major depression are more likely to experience higher degrees of functional limitation.

Asian Americans have their distinctive patterns of illness beliefs. When depressed, Asian Americans tend to focus on physical symptoms and under-report mood and anxiety symptoms. They usually prefer to seek help from primary care physicians (PCPs), lay people, and alternative medical practices, and rarely utilize mental health services.

 This help-seeking behavior makes primary care an important setting for identifying and treating depressed Asian Americans, yet depression is frequently under-recognized and undertreated in primary care.

The tendency of depressed Asian Americans to focus on their physical symptoms renders depression particularly difficult to identify in this population. When PCPs recognize depressed Asian Americans, they frequently feel that they lack the cultural understanding to effectively and sensitively communicate to patients about their illness. PCPs worry that informing their patients about MDD may provoke stigma against having mental illness. Under-treatment of depression among Asian Americans remains a significant public health problem in the US.

The Chronic Care Model has been shown to improve outcomes in many chronic diseases, including diabetes, congestive heart failure, asthma, hyperlipidemia, and depression. Proposed by Wagner and colleagues,

 Use of treatment protocols with proven effectiveness for clinical management

 Patient-centered collaborative goal setting

Based on the Chronic Care Model, Katon and colleagues

 designed a collaborative model of treatment of depression in primary care: the PCP and a psychiatrist provide interventions, intensive patient education, and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. This collaborative management resulted in more favorable outcomes for depression and improved satisfaction among patients with MDD.

There are significant cultural barriers to implementing collaborative management of depression for Asian American immigrants. Many of these individuals are unfamiliar with the concept of major depression, have language barriers, and schedule physician visits only if they have physical symptoms. Physicians with inadequate cultural sensitivity may overlook depression among this population. When depression is diagnosed, many Chinese Americans avoid mental health services because of their culture’s strong stigma against psychiatric disorders. To overcome these cultural barriers, the Engagement Interview Protocol (EIP), a culturally sensitive assessment, can be used to explore patients’ illness beliefs, their understanding of the illness, and what they hope to achieve from treatment.

 This information is particularly useful for engaging minority populations.

Telemedicine, in the form of videoconferencing, brings tremendous opportunities to clinical care, education, research, and administration. Psychiatry is an ideal specialty for the application of telemedicine. Diagnostic and treatment information in psychiatry can be transmitted through audiovisual communication where there is a desperate need to extend mental health services to underserved populations in rural and inner-city areas. Telepsychiatry-together with telecardiology, teledermatology, and teleradiology-is considered an important telemedicine specialty. With the increasing availability of broadband systems, whether satellite-based, cable, fiber, or digital subscriber lines, there are more opportunities to provide telepsychiatry services to any place in the world.

In the development of telepsychiatry, areas of investigation have included its reliability, patient satisfaction, effectiveness of communication, and its effect on the clinician-patient relationship. Reliability studies that compared telepsychiatric services with in-person care have shown high interrater reliability across a wide range of psychiatric disorders including anxiety, cognitive decline, depression, and psychosis.

 In general, interrater reliability and diagnostic reliability appear to be excellent with telepsychiatry. Moreover, children, adolescents, adults, and geriatric patients have reported high satisfaction with telepsychiatry.

Based on a meta-analysis of studies that compared in-person psychiatric assessment with telepsychiatry assessment, Hyler and colleagues

 concluded that there was no difference in accuracy or satisfaction between the 2 modalities. They predicted that telepsychiatry will replace in-person interviews in certain research and clinical situations. After conducting a comprehensive review of the literature on telepsychiatry applications, Hilty and colleagues

 found that telepsychiatry is feasible and increases access to care, enables specialty consultation, yields positive outcomes, allows reliable evaluation, has few negative aspects in terms of communication, generally satisfies patients and providers, and is empowering to those who use it.

Culturally sensitive collaborative treatment using telepsychiatry

Telepsychiatry-based Cultural Sensitivity Collaborative Treatment (T-CSCT) uses advanced telemedicine technology to address the growing number of culturally diverse immigrants in areas with little or no bilingual and bicultural mental health services. Adding a culturally sensitive assessment conducted via videoconferencing to Katon’s collaborative care model provides an innovative depression management program to promote culturally sensitive care.

From 2008 to 2013, my team at the South Cove Community Health Center in Boston studied the feasibility and effectiveness of T-CSCT.

 lists the 4 components that were included in the study. Chinese American patients who participated in the study were asked to complete the Chinese Bilingual Patient Health Questionnaire-9 (CB-PHQ-9)

 during their annual physical examination. They returned the questionnaire before their visits, and their PCPs discussed the results of the screening and recommended follow-up and/or treatment when indicated.

Patients who screened positive for MDD (total CB-PHQ-9 score, ≥ 10) were contacted by phone about the results of their screening and were invited to join the study. Patients who consented to join the study were scheduled to have a culturally sensitive psychiatric assessment at the health center via videoconferencing with a bilingual psychiatrist who was physically located at Massachusetts General Hospital.

The Polycom® VSXTM3000 system was installed at the health center recruitment sites and at Massachusetts General Hospital. This standards-compliant compact videoconference system provides excellent audio and video quality. The systems were connected using internet protocol or Integrated Services Digital Network (ISDN) networking. All videoconferences were encrypted using the Advanced Encryption Standard to provide security during data transmission. The transmissions were at 384 kbps with no audio delay.

In 2011, the Polycom videoconferencing systems were replaced by webcams when web-based videoconferencing became available via Skype. The web-based system was inexpensive to install and required less technical support than landlines and ISDN networking. While Skype is free, it is not HIPAA compliant for telehealth; Skype for Business technically has the sufficient encryption needed for telepsychiatry, but it is not free.

Since many Chinese immigrants had low mental health literacy and strong stigma against receiving mental health services, culturally sensitive assessment was performed using the EIP. This semi-structured instrument is designed to bridge illness beliefs of people from diverse cultural backgrounds with the psychiatric framework described by DSM. The EIP includes exploration of the patient’s narratives and illness beliefs, disclosure of the patient’s psychiatric illness in a way that is compatible with his or her illness beliefs, and negotiation of treatment of depression that is agreeable to the patient. Interviewing with the EIP allows clinicians to discuss patients’ illnesses and treatment options using language and a framework that are relevant to the context of their lives and to avoid psychiatric jargon that is unfamiliar to patients.

In the T-CSCT study, specific EIP-based questions were asked to explore illness beliefs (

). With knowledge of the patient’s illness beliefs, the psychiatrist disclosed the diagnosis of depression in ways that were compatible with those beliefs and discussed treatment options.

After psychiatric assessment, patients with confirmed MDD were encouraged to seek treatment from their PCP, who received a letter about the patient’s diagnosis and a recommended treatment plan. Patients could also choose to seek treatment or consultation from a psychiatrist or a therapist.

Care managers were accessible to patients via telephone and served as a link between patients, PCPs, and consulting psychiatrists. They facilitated patients’ depression treatment and coordinated visits with psychiatrists and psychologists. A psychiatrist provided weekly supervision to care managers, as well as consultations with patients and their PCPs.

At the beginning of the study, a bilingual care manager met with patients to establish rapport, explain the role of the care manager, and provide education on MDD. After the initial meeting, the care manager contacted the patient monthly for 6 months using telephone calls to monitor the patient’s depressive symptoms, adherence to medication treatment, management of adverse events, and knowledge of self-management strategies.

T-CSCT is a promising and effective model to improve treatment of MDD for underserved racial and ethnic minority populations. We encourage future replications and testing of this approach to other racial and minority groups with diverse cultural backgrounds who suffer from disparities in depression treatment.

Dr. Yeung is Associate Professor of Psychiatry, Harvard Medical School, Boston, MA. Dr. Yeung reports no conflicts of interest concerning the subject matter of this article.

 World Health Organization. Depression Fact Sheet; February 2017. 

http://www.who.int/mediacentre/factsheets/fs369/en/

 World Health Organization. Depression, A Global Crisis; 2012. 

http://www.who.int/mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf

 US Department of Health and Human Services. 1999. Mental Health: A Report of the Surgeon General–Executive Summary. 

https://profiles.nlm.nih.gov/ps/access/NNBBHS.pdf

 Holden KB, Hall SP, Robinson M, et al. Psychosocial and sociocultural correlates of depressive symptoms among diverse African American women. 

 Williams DR, GonzÃ¡lez HM, Neighbors H, et al. Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the National Survey of American Life. 

 Yeung A, Chang D, Gresham RL, et al. Illness beliefs of depressed Chinese Americans in primary care. 

 Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: translating evidence into action. 

 Katon W, Korff MV, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. 

 Yeung A, Trinh NH, Chang TE, Fava M. The Engagement Interview Protocol (EIP): improving the acceptance of mental health treatment among Chinese immigrants. 

 Hilty D, Luo JS, Morache C, et al. Telepsychiatry: what is it and what are its advantages and disadvantages? 

 Hyler SE, Gangure DP, Batchelder ST. Can telepsychiatry replace in-person psychiatric assessments? A review and meta-analysis of comparison studies. 

 Hilty DM, Ferrer DC, Parish MB, et al. The effectiveness of telemental health: a 2013 review. 

 Yeung A, Martinson M, Baer L, et al. The effectiveness of telepsychiatry-based culturally sensitive collaborative treatment for depressed Chinese American immigrants: a randomized controlled trial. 

 Yeung A, Fung F, Yu SC, et al. Validation of the Patient Health Questionnaire-9 for depression screening among Chinese Americans. 

Telepsychiatry-based Cultural Sensitivity Collaborative Treatment is a promising and effective model to improve treatment of depression in underserved racial and ethnic minority populations. Details here.

Telepsychiatry-Based Culturally Sensitive Collaborative Treatment

It’s been 15 years since I wrote my first article for 

 in 2002, highlighting how technology will affect psychiatric practice. I’ve been fortunate to have written several articles for 

 since then regarding technology and its potential impact on our field. I think it has come full circle now that I am the chair of this Technology Special Report, with contributions from wonderful authors. I believe it reflects the ease of use and the fertile ground for innovation that have made technology the next domain for delivery, access, and improvement of psychiatric care.

The authors in this Special Report illustrate that the technology itself is no longer a barrier toward adoption, and many creative people have found ways to incorporate technology to address a variety of barriers in the clinical care of our patients. Medical informatics has come a long way from a hobby or interest to now being a clinical subspecialty. While there is certainly a need for those who have received their PhD in biomedical informatics or a master’s degree in health informatics to lead our field in academic, industry, or government positions, it is my hope that more psychiatrists will join me in pursuing fellowship training in clinical informatics. This training provides us with the credibility and credentials to innovate with new mediums of social media and smartphones as well as to serve as leaders in the health care enterprise.

I am certain that you will find the articles in this Special Report of great interest. Smartphones are ubiquitous nowadays, and using apps or sensors on the phone will certainly extend the care of the patient in many ways. Telepsychiatry has been tremendous in eliminating the barriers of access to care, especially in populations where the stigma of mental illness prevents patients from going to a mental health clinic. Incubation of innovative technologies in psychiatric care is critical so that great ideas become products we can use to take better care of our patients. Join me in reading this Technology Special Report-I’m sure you will be inspired!

How is technology affecting psychiatric practice and addressing barriers in the clinical care of our patients? 

Introduction: Innovations to Improve Mental Health Outcomes

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.

 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.

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.

 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.

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.

Beyond providing a new window into patients’ lived experiences of mental disorders, smartphones also offer a new portal to receive and access care. The FOCUS Smartphone Intervention study showed that those with schizophrenia who used the FOCUS app demonstrated reductions in psychotic symptoms, depression, and general psychopathology over a 30-day period.

 A larger-scale study of the FOCUS intervention is currently underway and is already reporting high levels of patient satisfaction and engagement.

 A smaller study of the PRIME app demonstrated the feasibility of smartphone tools to improve reward processing impairments, enhance motivation, and improve quality of life.

Smartphones and wearable sensors (eg, fitness trackers) have also been studied as a means to increase physical activity. The potential to help patients engage in healthy activities such as better sleeping, more physical activity, and better nutrition is especially relevant for a clinical population that may suffer from metabolic syndromes linked with antipsychotic medication use. Moreover, if proven to be effective, these lifestyle interventions would likely have immediate benefit across diverse illnesses.

In addition, smartphones can connect patients directly to care by enabling telehealth services via video chat or messaging services. Smartphone-based video therapy (with pre-prepared content) has been successfully studied in schizophrenia using the FOCUS platform as well as in numerous other mental disorders.

 The potential of these smartphone-based tools is also exemplified in their use for disaster psychiatry, where there is an immediate need for emergency mental health services although often no practical means for mental health workers to quickly arrive at the scene of a tsunami or war zone. Smartphone-based therapy sessions and interventions can potentially help fill this void. Such interventions designed and tested in one region of the world can be shared globally with the click of a button, enabling new collaborations and sharing of successful tools.

Combining both the sensing and the intervention abilities of smartphone tools, their potential to deliver personalized mental health care is clear. By automatically collecting real-time information about not only self-reported symptoms but also behaviors (eg, mobility, socialness, sleep patterns), smartphones can enable a more behavior-based (and possibly more objective and accurate) picture of how patients experience mental disorders. This information can be immediately translated into personalized treatment plans in which smartphones help monitor adherence and help deliver elements of care.

Cognitive behavioral therapy is one example of an element of treatment that is increasingly being researched and utilized on smartphone platforms.

 Other applications ranging from making it easier to schedule appointments, selecting the optimal medication, and even seeking to prevent self-harm are all areas of active research.

The clinical evidence for mental health apps is rapidly expanding, and the number available for immediate download on Apple iTunes or Android Google Play is expanding at an even faster rate. While there is no official count of the number of apps that patients can download, 10,000 overall is a reasonable estimate.

 The vast majority of these apps are untested and of questionable clinical validity. But there are also many cases of successful industry and academic partnerships in the mental health app space that reflect synergy of resources and ideas.

The FDA recently announced that it plans to exert increased regulation in the digital health space, which should bring better guidance to patients and clinicians. The American Psychiatric Association (APA) app evaluation framework offers a tool to help make more informed decisions about picking a useful app and can be freely downloaded from the APA website.

Apps for mental disorders remain a nascent but rapidly expanding area of clinical research and care. The potential of these smartphone tools to reach a global population with monitoring- and intervention-based services makes them uniquely suited to address the scale and scope of the worldwide mental health crisis. Considering that smartphones have been in existence only for a decade and have already shown tremendous potential for improving mental health care, their impact on care in the next decade will likely be even more impressive.

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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http://bmjopen.bmj.com/content/5/11/e008574

 Torous J, Firth J, Mueller N, et al. Methodology and reporting of mobile heath and smartphone application studies for schizophrenia. 

 Wang R, Aung MS, Abdullah S, et al. CrossCheck: toward passive sensing and detection of mental health changes in people with schizophrenia. In: Proceedings of the 2016 ACM International Joint Conference on Pervasive and Ubiquitous Computing; September 2016; Heidelberg, Germany: 886-897.

 Moran EK, Culbreth AJ, Barch DM. Ecological momentary assessment of negative symptoms in schizophrenia: relationships to effort-based decision making and reinforcement learning. 

 Bain EE, Shafner L, Walling DP, et al. Use of a novel artificial intelligence platform on mobile devices to assess dosing compliance in a phase 2 clinical trial in subjects with schizophrenia. J

 Ben-Zeev D, Brenner CJ, Begale M, et al. Feasibility, acceptability, and preliminary efficacy of a smartphone intervention for schizophrenia. 

 Ben-Zeev D, Scherer EA, Gottlieb JD, et al. mHealth for schizophrenia: patient engagement with a mobile phone intervention following hospital discharge. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4999306/

 Scherer EA, Ben-Zeev D, Li Z, Kane JM. Analyzing mHealth engagement: joint models for intensively collected user engagement data. 

 Schlosser D, Campellone T, Kim D, et al. Feasibility of PRIME: a cognitive neuroscience-informed mobile app intervention to enhance motivated behavior and improve quality of life in recent onset schizophrenia. 

 Ben-Zeev D, Brian RM, Aschbrenner KA, et al. Video-based mobile health interventions for people with schizophrenia: bringing the “pocket therapist” to life. 

 Torous J, Levin ME, Ahern DK, Oser ML. Cognitive behavioral mobile applications: clinical studies, marketplace overview, and research agenda. 

 Franklin JC, Fox KR, Franklin CR, et al. A brief mobile app reduces nonsuicidal and suicidal self-injury: evidence from 3 randomized controlled trials. 

 Torous J, Roberts LW. Needed innovation in digital health and smartphone applications for mental health: transparency and trust. 

 American Psychiatric Association. App Evaluation Model. 

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

To explore the evolving role of smartphones in psychiatric care, this article focuses on schizophrenia as a disease-specific example of how new research and technologies are already being used to improve care. 

Leveraging Smartphones in Patient Care

Fibromyalgia is one of the most controversial diagnoses in the field of pain management.

 Some health care professionals believe that the symptoms of this disorder are primarily due to mental disorders, while others believe that it is a physical disorder and that any signs of mental disorders are secondary to the pain and other physical symptoms. It is clear that many symptoms of fibromyalgia can also be symptoms of mental disorders, and it can be difficult to differentiate between them.

1. The most current research indicates that fibromyalgia is a musculoskeletal disorder.

2. Which diagnostic screening instruments are considered to be the most useful for diagnosing fibromyalgia?

3. Chronic widespread pain is sufficient to make the diagnosis of fibromyalgia.

4. The diagnosis of fibromyalgia should be made only after other possible etiologies for widespread pain are excluded.

5. Current research indicates that mental disorders may be frequently misdiagnosed as fibromyalgia.

6. What form of therapy has been found to be most efficacious for the management of fibromyalgia?

7. What form of exercise appears to be most effective for the management of fibromyalgia?

C. The most effective form of exercise has yet to be determined

8. Opioids are the most effective analgesics for the management of fibromyalgia.

9. In addition to tramadol, which other medications have been found to be effective for the management of fibromyalgia?

10. What form of psychotherapy appears to be most effective for the management of fibromyalgia?

11. As of yet, there are no good predictive factors to determine which of the recommended therapies is most likely to benefit the individual patient with fibromyalgia.

For answers to this quiz, please see next page.

Although the etiology of fibromyalgia is still unclear, at the present time it is primarily viewed as a neurologic disorder.

Widespread Pain Index and Symptom Severity Scale. These instruments incorporate the American College of Rheumatology diagnostic criteria for fibromyalgia, which are the most widely used criteria.

Although pain in multiple parts of the body is the primary symptom of fibromyalgia, the diagnosis also requires multiple somatic symptoms, including fatigue, unrefreshing sleep, and cognitive impairment.

Because there are no diagnostic tests for fibromyalgia, the clinical diagnosis is based primarily on history and self-report of symptoms. Many other disorders, both physical and mental, can present with the same symptoms of fibromyalgia; it is therefore imperative to rule these out before making the diagnosis of fibromyalgia.

It can be difficult to differentiate depressive and anxiety disorders from fibromyalgia. They can present with symptoms similar to those of fibromyalgia, including widespread pain, and there are no diagnostic tests for them.

In my experience, many patients who actually have a primary mental disorder are given the diagnosis of fibromyalgia, although they do not fulfill the diagnostic criteria for it. There is still a widespread belief that if pain is secondary to a mental disorder, it is consequently not “real.” The outcome is that patients may interpret this as indicating that health care providers may not be taking their pain seriously.

Although all of these therapies have been found to be beneficial for fibromyalgia, the strongest evidence supports the use of exercise.

7. Answer: C. The most effective form of exercise has yet to be determined

As of yet, the most effective type of exercise for the management of fibromyalgia is still unclear.

In general, the opioids appear to be ineffective for the treatment of pain associated with fibromyalgia. The only opioid-containing drug that has been found to be effective for fibromyalgia is tramadol, which contains both an opioid and an SNRI. Studies show that most of the analgesic effect is attributable to the SNRI.

The SNRIs amitriptyline, milnacipran, and duloxetine and the anticonvulsant pregabalin have been found to be most efficacious for the management of fibromyalgia. However, it is uncertain whether these SNRIs are really more effective than other SNRIs, or whether pregabalin is more effective than other anticonvulsants, including gabapentin-or if it is just that they have been studied more than other medications in the same class.

In general, the SSRIs have been found to be far less effective than the SNRIs for any form of pain.

10. Answer: A. Cognitive behavioral therapy

Biofeedback and hypnotherapy have not been found to be especially efficacious for the management of fibromyalgia.

As with most forms of chronic pain, there is very little information as to which treatment is likely to be most effective for an individual patient.

1. Clauw DJ, Hiroshi U. Summary of the Fibromyalgia Research Symposium 2016 in Nagasaki. 

http://journals.lww.com/painrpts/Fulltext/2017/02000/Summary_of_the_Fibromyalgia_Research_Symposium.2.aspx

2. Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. 

3. Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria. 

4. Hauser W, Perrot S, Sommer C, et al. Diagnostic confounders of chronic widespread pain: not always fibromyalgia. 

http://journals.lww.com/painrpts/Abstract/2017/06000/Diagnostic_confounders_of_chronic_widespread_pain_.2.aspx

Take this quiz on one of the most controversial diagnoses in pain management.

THE QUIZ/Fibromyalgia

Each decade, the nation, under the direction of the federal government’s Office of Disease Prevention and Health Promotion, sets public health goals and objectives to strive for with regard to the promotion of health and prevention of disease. The overarching goals of 

Attain high-quality, longer lives, free of preventable disease, disability, injury, and premature death;

Achieve health equity, eliminate disparities, and improve the health of all groups;

Create social and physical environments that promote good health for all; and

Promote quality of life, healthy development, and health behaviors across all life stages.

Tracking and measuring the nation’s health is no easy undertaking. How are we doing?

Vol 34 No 12

Technological Ventures Offer New Hope for the Future of Psychiatry

Telepsychiatry-Based Culturally Sensitive Collaborative Treatment

Introduction: Innovations to Improve Mental Health Outcomes

Leveraging Smartphones in Patient Care

THE QUIZ/Fibromyalgia

Measuring Up on Mental Health?

The Best and Not So Great Articles of 2017

Stress, Neural Plasticity, and Major Depression

Wound Healing

Strategies and Solutions for Switching Antidepressant Medications

The Best of Times, the Worst of Times: 2017

Public Comment Period Opens for First Set of New Proposals to Update DSM-5

Confusing Psychosis with Imagination