Leveraging Smartphones in Patient Care
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.
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.
Why smartphones?
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.1 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.2-4
Monitoring capabilities
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.5 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.6
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.3,7
Improving outcomes
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.8 A larger-scale study of the FOCUS intervention is currently underway and is already reporting high levels of patient satisfaction and engagement.9,10 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.11
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.12 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.
Personalized mental health care
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.13 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.14
Availability
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.15 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.16
Conclusion
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.
Disclosures:
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.
References:
1. Pew Research Center. Mobile Fact Sheet. http://www.pewinternet.org/fact-sheet/mobile/. Accessed November 1, 2017.
2. Krebs P, Duncan DT. Health app use among US mobile phone owners: a national survey. JMIR Mhealth Uhealth. 2015;3:e101.
3. Kannisto KA, Adams CE, Koivunen M, et al. Feedback on SMS reminders to encourage adherence among patients taking antipsychotic medication: a cross-sectional survey nested within a randomised trial. BMJ Open. 2015. http://bmjopen.bmj.com/content/5/11/e008574. Accessed November 1, 2017.
4. Torous J, Firth J, Mueller N, et al. Methodology and reporting of mobile heath and smartphone application studies for schizophrenia. Harvard Rev Psychiatry. 2017;25:146-154.
5. 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.
6. Moran EK, Culbreth AJ, Barch DM. Ecological momentary assessment of negative symptoms in schizophrenia: relationships to effort-based decision making and reinforcement learning. J Abnorm Psychol. 2017;126:96-105.
7. 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. JMIR Mhealth Uhealth. 2017;5:e18.
8. Ben-Zeev D, Brenner CJ, Begale M, et al. Feasibility, acceptability, and preliminary efficacy of a smartphone intervention for schizophrenia. Schizophr Bull. 2014;40:1244-1253.
9. Ben-Zeev D, Scherer EA, Gottlieb JD, et al. mHealth for schizophrenia: patient engagement with a mobile phone intervention following hospital discharge. JMIR Mental Health. 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4999306/. Accessed November 3, 2017.
10. Scherer EA, Ben-Zeev D, Li Z, Kane JM. Analyzing mHealth engagement: joint models for intensively collected user engagement data. JMIR mHealth and uHealth. 2017;5(1):e1.
11. 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. JMIR Res Prot. 2016;5(2):e77.
12. Ben-Zeev D, Brian RM, Aschbrenner KA, et al. Video-based mobile health interventions for people with schizophrenia: bringing the “pocket therapist” to life. Psychiatr Rehabil J. June 2016; Epub ahead of print.
13. Torous J, Levin ME, Ahern DK, Oser ML. Cognitive behavioral mobile applications: clinical studies, marketplace overview, and research agenda. Cogn Behav Pract. 2017;24:215-225.
14. Franklin JC, Fox KR, Franklin CR, et al. A brief mobile app reduces nonsuicidal and suicidal self-injury: evidence from 3 randomized controlled trials. J Consult Clin Psychol. 2016;84:544-557.
15. Torous J, Roberts LW. Needed innovation in digital health and smartphone applications for mental health: transparency and trust. JAMA Psychiatry. 2017;74:437-438.
16. American Psychiatric Association. App Evaluation Model. https://www.psychiatry.org/psychiatrists/practice/mental-health-apps/app-evaluation-model. Accessed November 1, 2017.
