From the Editor
A few weeks ago, a patient’s daughter called. She was deeply concerned: the patient was acting differently, she explained. “He’s sick again.” She noted that he was starting to go on long walks at night, and to different neighbourhoods – something he does when he’s starting to get ill with his bipolar. She feared that, without a change in medications and careful follow up, he would end up in the hospital again. As a psychiatrist, that type of information can be invaluable – a clue that a patient is doing less well.
Could technology help us find clues for emerging illness, maybe even before family members or patients themselves?
This week, the first selection weighs this question. Harvard University’s Dr. John Torous considers big data and mental health. In his essay, “Your Smartphone Will See You Now,” he reviews current trends and writes: “I predict that this technology will have an enormous impact on psychiatry.”
In the second selection, we consider a new paper that looks at the costs of homelessness in Canada. As part of the work of At Home/Chez Soi, the authors answer a basic and important question: what are the costs of homelessness?
Please note: there will be no Readings for the next two weeks.
Digital Psychiatry and Care
“Your Smartphone Will See You Now”
IEEE Spectrum, July 2017
Zach has been having trouble at work, and when he comes home he’s exhausted, yet he struggles to sleep. Everything seems difficult, even walking—he feels like he’s made of lead. He knows something is wrong and probably should call the doctor, but that just seems like too much trouble. Maybe next week.
Meanwhile, software on his phone has detected changes in Zach, including subtle differences in the language he uses, decreased activity levels, worsening sleep, and cutbacks in social activities. Unlike Zach, the software acts quickly, pushing him to answer a customized set of questions. Since he doesn’t have to get out of bed to do so, he doesn’t mind.
Zach’s symptoms and responses suggest that he may be clinically depressed. The app offers to set up a video call with a psychiatrist, who confirms the diagnosis. Based on her expertise, Zach’s answers to the survey questions, and sensor data that suggests an unusual type of depression, the psychiatrist devises a treatment plan that includes medication, video therapy sessions, exercise, and regular check-ins with her. The app continues to monitor Zach’s behavior and helps keep his treatment on track by guiding him through exercise routines, noting whether or not he’s taking his medication, and reminding him about upcoming appointments.
While Zach isn’t a real person, everything mentioned in this scenario is feasible today and will likely become increasingly routine around the world in only a few years’ time.
So opens a new article by Dr. John Torous on digital psychiatry.
Dr. Torous notes the limitations of psychiatric care today. A patient with, say, depression is referred to see a psychiatrist but “those who are physically disabled, elderly, living in rural areas, or suffering from additional mental illnesses like anxiety disorders may find it difficult to get to a doctor’s office.” He also notes how limited an assessment actually is – dependent on the patient to provide information on symptoms, when the patient may not even realize that she or he has depression.
Tapping the literature, Dr. Torous argues that smart phones and other devices can provide data allowing clinicians to diagnose patients better.
He highlights a few examples:
- “By correlating patients’ smartphone-derived GPS measurements with their symptoms of depression, a 2016 study by the Center for Behavioral Intervention Technologies at Northwestern University, in Chicago, found that when people are depressed they tend to stay at home more than when they’re feeling well.”
- He notes similar work done for those with bipolar. “The Monitoring, Treatment, and Prediction of Bipolar Disorder Episodes (Monarca) consortium, a partnership of European universities, has conducted numerous studies demonstrating that this kind of data [on activity and movement] can be used to predict the course of bipolar disorder.”
- “Where GPS is unavailable, Bluetooth and Wi-Fi can fill in. Research by Dror Ben-Zeev, of the University of Washington, in Seattle, demonstrated that Bluetooth radios on smartphones can be used to monitor the locations of people with schizophrenia within a hospital. Data collected through Wi-Fi networks could likewise reveal whether a patient who’s addicted to alcohol is avoiding bars and attending support-group meetings.”
Dr. Torous goes on to argue that digital psychiatry will be able to do more than just help with diagnosis. He sees it assisting in the treatment of patients, too. He touches on a couple of examples. VR is already being used for anxiety disorders. He also discusses e-therapies. “Today, therapy requires visiting an office, but it can be just as effective to conduct the session via computer or smartphone, and it’s more convenient for the average patient.”
He ends on a positive note:
I predict that this technology will have an enormous impact on psychiatry. It cannot happen soon enough. One in five people around the world will suffer from a psychiatric illness over the course of a lifetime, but far fewer will seek or receive professional help. According to the World Health Organization, this year depression moved past hearing loss and vision problems to become the leading cause of ill health and disability worldwide.
A few thoughts:
- This essay is well written and thoughtful.
- The studies cited in this essay aren’t amazing. The 2016 study, for example, has an n of just 40. We will accept, then, that there is a literature on technology and psychiatric care – but a young and evolving literature.
- But the larger point is sound. The way our patients interact with the world – where they go in the days prior to appointments, who they talk to that morning (and the rate and tone of their voice), what websites they looked at in the waiting room, etc. – is a rich dataset that could be tapped in the future. To tie back to my introductory comments, patients are generating “clues” – or, really, data – all the time, it’s just that so often we don’t have access to that information. It’s become trendy to speak of AI and the impact on patient care (in psychiatry and outside of psychiatry). Dr. Torous makes a good point about the potential of big data to transform care.
- It should be noted that Dr. Thomas Insel, the former director of National Institute of Mental Health, is now heading up a start-up hoping to convert big data into better clinical outcomes. You can read more here: https://www.nature.com/news/former-us-mental-health-chief-leaves-google-for-start-up-1.21976.
Homelessness and Costs
“Costs of services for homeless people with mental illness in 5 Canadian cities: a large prospective follow-up study”
Eric A. Latimer, Daniel Rabouin, Zhirong Cao, Angela Ly, Guido Powell, Tim Aubry, Jino Distasio, Stephen W. Hwang, Julian M. Somers, Vicky Stergiopoulos, Scott Veldhuizen, Erica E.M. Moodie, Alain Lesage, Paula N. Goering for the At Home/Chez Soi Investigators
CMAJ Open, 19 July 2017
An estimated 35 000 Canadians are homeless on any given night, and over 235 000 experience homelessness over the course of a year. In some jurisdictions, the discussion has shifted toward how homelessness can be ended rather than on how to manage it. Ending homelessness will require resources in the form of targeted prevention interventions, development of affordable housing and a variety of housing and support programs such as Housing First, in which homeless people are offered immediate access to permanent housing together with long-term, individualized support. Arguments for additional government expenditures on programs to end homelessness can be better framed if the costs of maintaining the status quo are well understood. To this end, estimates of the costs of homelessness are needed.
Limited information is available on the economic costs that homeless people engender in Canada.
Eric A. Latimer
So begins a new paper by Latimer et al.
At Home/Chez Soi has been a remarkable effort, covering five cities, and exploring different aspects of homelessness and Housing First. Needless to say, past Readings have highlighted the work.
This paper seeks to answer a simple question: what are the costs associated with homelessness?
The paper is readable; let me provide only a quick summary:
- The authors drew on the At Home/Chez Soi data.
- They calculated “unit cost” in terms of health care and non-health care expenses (hospitalizations, substance treatment, etc.).
- Statistical analysis was done, including a regression analysis.
What did they find? Needless to say, they find a range of costs, associated with need, care, and geography. See figure below.
Assuming that the cost of medications is similar across cities, the annual costs to society of homeless people with mental illness averaged about $59 000 in Canada’s 3 largest cities, about $49 000 in Winnipeg and about $33 000 in Moncton. Annual costs were highly variable across participants, ranging from -$15 530 to $341 535 when earnings were subtracted from health, social and justice services. Spending on different kinds of services also varied greatly across cities.
A quick thought: In public discussions, people ask about the costs of housing the homeless. This analysis illustrates the high costs of homelessness itself. (What are the costs of not housing the homeless?)
Past Readings on At Home/Chez Soi can be found at my website (the digital archive for the Reading of the Week). See: http://davidgratzer.com/uncategorized/reading-of-the-week-housing-first-and-at-homechez-soi/ and http://davidgratzer.com/uncategorized/reading-of-the-week-ending-chronic-homelessness/.
And there are great resources on the web, including atthe Mental Health Commission of Canada’s website.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.