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Dr. Torous looks at the pros and cons of digital psychiatry with the goal of framing the opportunities and challenges for the year ahead.
Dr Torous is a Clinical Fellow in Psychiatry at Harvard Medical School and Senior Resident at the Harvard Longwood Psychiatry Residency Training Program in Boston. He is the Digital Psychiatry Editor for Psychiatric Times. Twitter: @JohnTorousMD
It was a busy year for technology in health care, especially digital mental health. While some things were far too ahead of their time (like the quickly cancelled digital health primetime TV drama Pure Genius),1 there were many important successes, as well as areas for further improvement. Here we look at five examples that demonstrate how digital psychiatry excelled in 2017 as well as five areas of less success with the goal of framing the opportunity and challenges for the year ahead.
We witnessed advances in new technologies like chatbots for mental health, the scaling up of research efforts on smartphones and sensors for monitoring psychiatric symptoms, new changes in app regulations from the FDA, a series of encouraging digital mental health pilot studies, and exciting efforts by industry partners.
1. Therapeutic interactions. This summer Amazon reported that one of the most frequently asked questions to its Alexa devices was “Help me relax.” While Alexa is certainly not a therapist, conversational agents and chatbots helped deliver support and novel therapeutic interactions via voice software. Woebot made the news for its research-informed approach and positive public reception.2 Researchers like Adam Miner3 of Stanford also reminded us that using chatbots in mental health, or conversational artificial intelligence as he labels this group of technologies, is still complex but holds tremendous potential that will likely only expand in 2018.
2. Research. While the sequencing of the first genome was an exciting scientific breakthrough, today genetic studies require large samples from thousands of patients to make health discoveries. Several new large-scale digital mental health studies using smartphones and wearables were established this year. The UCLA Depression Grand Challenge plans to enroll 100,000 participants and will incorporate digital mental health monitoring (in addition to genetic analysis).4 The National Institute of Health (NIH) All of Us Study (also known as the Precision Medicine Initiative Study) created a custom mood monitoring smartphone app that will be used in studies seeking to recruit up to a million participants.5 We will hopefully see the early results of some of these large-scale efforts, and many other huge ongoing trials, in 2018.
3. Regulation. With over 10,000 mental health apps-and little regulation of claims made by these apps-it is no wonder many have called this space the Wild West. While the FDA has taken a largely hands-off approach to health apps, one did receive FDA approval for marketing as a medical application in 2017.6 This will undoubtedly pave the way for many more mental health apps to follow suit in 2018. Another notable move by the FDA was the creation and start of a digital health software precertification pilot program, a “tailored approach toward digital health technology by looking at the software developer or digital health technology developer, rather than primarily at the product.”7 Pilots companies include Apple and Samsung, among others, and the results of this pilot will have important implications for how the FDA approaches apps-implications we will learn about later in 2018.
4. Pilot studies. The scope and potential of digital mental health is still being defined. In 2017, numerous impressive pilot studies highlighted the evolving role of technology in clinical care. The iBobbly study from Dr. Tighe and the Black Dog Institute team in Australia demonstrated how an automatically delivered therapy program via a tablet device could reduce suicide rates in rural and indigenous populations.8 A study by Moran and colleagues of the University of Washington in St. Luis demonstrated how smartphones can help capture new clinical data like real time and real world cognitive state in schizophrenia, and how that new information can improve understanding of patients’ symptoms.9 A look at registered mental health app clinical studies shows that there is plenty of research in the pipeline and lots of new results will be forthcoming in 2018
5. Industry. Both small startups and large tech giants made impressive efforts in digital psychiatry in 2017. Notable events include Google offering the internet browsing public the PHQ-9 depression screening scale when searching for depression and then referring the person, with a screening score, to the National Alliance of Mental Illness (NAMI) website.10 In November 2017, Verily started a study called Project Baseline, with the goal of learning more about how smartphone predict mood and behavior, and that is actively reciting online right now.11 The American Psychiatric Association hosted an Innovation Zone at its annual meeting where startups and psychiatrists met, mingled, and even co-created ideas for new ventures in the Innovation Lab, organized by Dr. Vasan of Stanford.12 The Innovation Zone is back on for the 2018 annual meeting and likely to be even larger.
Room for improvement
Sadly, not everything was positive for digital psychiatry in 2017. The year 2018 should address continued data breaches, release harmful apps on the commercial marketplace, ensure privacy protections for consumers using apps, address gaps in usability of health technology for those with mental illnesses, and improve rates of technology adoption by the mental health field.
1. Safety. If the foundation of all health care-especially mental health care-is trust, then digital mental health needs to ensure that user data is kept safe and secure. Thus in 2017 when hackers posted highly confidential psychotherapy records from a Maine clinic on the dark web with the tagline “everything confessed/discussed in complete privacy is in here for thousands of patients”-the impact of hacks became very real in the mental health field.13 On top of this, the number and scale of national health care data breaches in 2017 put many on edge about the security of digital data-and set the agenda for 2018 to do a better job. Interest and examples of blockchain technology will mature in 2018 and begin to offer a new tool in the battle against hackers.
2. Potentially harmful apps. Available in app stores in 2017, these apps encourage users to self-harm and even commit suicide. Some teens and young adults appear to have downloaded some of these apps.14 While not as immediately harmful, many mental health apps on the commercial marketplaces continue to make false and unsubstituted claims that may lead users to experience harm or wrong advice in addition to wasting their time. The American Psychiatric Association is working to help clinicians and patients make more informed choices and find better apps, with app evaluation efforts expanding in 2018.15
4. Ease of use. The more we learn about mobile health technologies like smartphone apps and wearables, the more it becomes clear that for they are not always designed for use with patients with disabilities. The need to make mobile health more engaging become a buzzword in 2017 as numerous studies, and companies, struggled to keep people using their apps and wearables for more than a few days or weeks. Luckily organizations like Natalia Mental Health Foundation are supporting research efforts at Dartmouth to make digital technology more usable and engaging for those with mental illness18 and the Society for Behavioral Medicine is also aware of the issues at hand, and planning to bring their full expertise and skills to bear towards novel solutions we should see in 2018.19
5. EHRs. Foundational aspects of digital health are not yet fully working. Despite the potential of digital psychiatry, its critical to remember that for it to impact clinical care it needs to delight and engage not only patients but clinicians as well. A recent government report found that only ~ 61% of psychiatrists used electronic medical records (EHRs).20 This low number likely represents that fact that many EHRs were not designed for mental health, remain clunky to use, and may not enhance the therapeutic relationship between clinicians and patients. That said, a new wave of more usable and mental health focused EHRs will continue to develop in 2018.
Capturing a full year of digital psychiatry in a brief article like this is a nearly impossible challenge, but the selected examples shared here offer a glimpse of some of the highs and lows for the field in 2017. Going forward, there is much to look out for in 2018 and Psychiatric Times will be there to report and bring the newest insights directly to you.