From the Editor
Social media. Bots. VR.
When I applied to psychiatry residency programs in my last year of medical school at the University of Manitoba, none of these were mentioned when we talked about mental health care. But technology is changing our world. We are seeing a digital boom in mental health care – or is it really a digital mirage?
In the first selection, we move past the big rhetoric with a thoughtful paper by Dr. John Torous (of Harvard University) and his co-authors. In World Psychiatry, they review the literature and make insightful comments about the potential and reality of digital mental health care. “It now seems inevitable that digital technologies will change the face of mental health research and treatment.” We discuss the paper and its implications.
Woebot: Too cool to be clinical?
If the first selection considers cutting-edge technology for bettering patient care, the second is very different. Dr. Thomas E. Smith (of Columbia University) and his co-authors study “the strength of associations between scheduling aftercare appointments during routine psychiatric inpatient discharge planning and postdischarge follow-up care varied by level of patient engagement in outpatient psychiatric care before hospital admission” in a paper for Psychiatric Services. Spoiler alert: there are no chatbots mentioned. “Discharge planning activities, such as scheduling follow-up appointments, increase the likelihood of patients successfully transitioning to outpatient care, regardless of their level of engagement in care prior to psychiatric inpatient admission.”
Selection 1: “The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality”
John Torous, Sandra Bucci, Imogen H. Bell, et al.
World Psychiatry, October 2021
Mental health problems impact over one billion people worldwide annually, with depression representing the leading cause of disability across the globe. The World Health Organization’s Mental Health Gap Action Program (mhGAP) outlines evidence-based interventions to address this global crisis, yet acknowledges that barriers include lack of available services and funding.
The extent of these barriers, even for high-income countries, is highlighted in a December 2020 report from the US government, which indicates that offering evidence-based mental health care in the US alone would require an additional 4 million trained professionals.
The rapid international growth in access to and capabilities of digital health technologies (DHTs) presents a feasible route towards augmenting traditional mental health care and bridging the gap between the need for treatment and the capacity to deliver it. In this paper, we consider DHTs to be innovations beyond electronic medical records or classical telepsychiatry, to instead focus on the recent developments in smartphone apps, virtual reality, social media, and chatbots.
While the integration of these DHTs into mental health care began somewhat slowly, restrictions driven by the COVID-19 pandemic have sparked a paradigm shift as assumptions, interest and utilization of digital health have undergone a fundamental transformation.
So begins a paper by Torous et al.
They write about software and hardware advances allowing our digital moment. And, yes, they note how the widespread ownership of smartphones: “76% of people in advanced economies and 45% in emerging economies owned a smartphone, with recent data from the US showing that ownership rates may be as high as 70% even among people with severe mental illness.”
The paper focuses on three areas: social media, chatbots, and VR.
“Frequently accessed via smartphone apps and connecting people from their own devices to global networks of friends, information, and health resources, social media can represent both a means to quantify mental health as well as a source of both positive and negative interactions.”
They make several points:
- “Increasingly, research suggests that absolute screen time or exposure itself is not strongly associated with adverse mental health outcomes. This is in marked contrast to the more popular conception that screen time and social media use is detrimental to mental health.”
- “Patterns of social media use may represent a means to detect worsening of mental health symptoms. For example, changes in the content and style of social media posts may offer an early warning sign of relapse in schizophrenia.”
- “Social media, combined with natural language processing methods, also offer a practical means to understand population‐level mental health trends. For example, an analysis of 60 million Twitter posts in March‐May 2020, as compared to one year prior, was able to detect pandemic‐related increases in coping mechanisms. These methods have also been employed in studies exploring psychosocial reactions to the COVID‐19 pandemic, as well as the effects of psychiatric medications.”
- “Social media can also be used as a therapeutic tool. Novel research using carefully curated and monitored social networks as interventions has shown promise in youth with diverse mental health needs. For example, the PRIME app is designed to help people with schizophrenia through the promotion of functional recovery and the mitigation of negative symptoms (e.g., amotivation) through a supportive and personalized network.”
“Conversational agents, such as Apple’s Siri or Amazon’s Alexa, have become common in the digital marketplace. Termed ‘chatbots’, the use of these conversational style interfaces offers an intelligent, automated system for detecting and responding to immediate mental health needs. Chatbots have the look and feeling of interacting with a human, despite being run by an automated software program. Thus, chatbots or ‘robot therapists’ have become a galvanizing force for those seeking to automate therapy where software programs listen and respond to people’s mental health needs.”
They make a few points:
- “Research has found that some people feel more comfortable conversing anonymously with a chatbot, and that this may open up the possibility to improve detection of distress and in turn provide momentary interventions to those who feel less comfortable with face‐to‐face contact.”
- “Chatbot interfaces have become a key feature of many commercially available mental health apps. However, their evidence base is not well established.”
- “Across two recent systematic reviews, 24 studies investigating chatbots for health care were identified. Of the 11 trials targeting mental health problems, most were for depression, with a smaller number targeting anxiety, schizophrenia, post‐traumatic stress disorder (PTSD), and autism spectrum disorder. Only two randomized controlled trials were included, and, while some mental health benefits from chatbot interventions were indicated, the types of benefits observed were not consistent across studies, which were further limited by small sample sizes, short duration, and a lack of follow‐up data.”
“Virtual reality involves an immersion in an interactive, computer‐simulated environment via a headset. The ability to create and control exposure to real‐world environments presents important opportunities for mental health assessment and treatment.”
They make several points:
- “Controlled exposure to anxiety‐inducing stimuli within a virtual environment offers a safe, convenient and accessible medium to deliver exposure‐based behavioral treatments.”
- “A recent meta‐review of 11 meta‐analyses, covering predominantly anxiety disorders and PTSD, found that effect sizes for virtual reality exposure treatments were overall moderate to large, and were typically maintained at follow‐up.”
- “A smaller number of trials have been conducted for other psychiatric disorders, with emerging evidence that virtual reality treatment may be effective for depression, schizophrenia and eating disorders.”
- “However, in the studies that have compared virtual reality to traditional treatment, there was little evidence for superior efficacy.”
- “Fewer studies have explored virtual reality treatments beyond exposure therapy, with the exception of skills training, which has also demonstrated positive results…”
The paper continues by looking at specific classes of disorders, and the evidence is mixed. For example, there is evidence for self-management in mood and anxiety, but they note: “most apps for depression (63%) and anxiety (56%) had no active users for the one‐month period under review.”
The paper closes with several recommendations on strengthening the digital experience and impact.
A few thoughts:
- This is a good paper.
- The paper is well written and well researched – with over 250 citations and stretching to almost 12 000 words in length. Wow.
- Though this summary covers important points, the actual paper is nuanced and thoughtful – and worth reading.
- While the authors enthuse about the potential of new technology, they are balanced and careful. For example, they write about digital phenotyping – the concept that active and passive data (like global positioning system and voice tone) could be collected in real time, allowing us to better understand a person and her or his illness experience, and potentially diagnosing problems long before an appointment is made in a clinic. But they also note the reality: “less than 2% of apps on the commercial marketplaces appear to leverage digital phenotyping potential…”
- Of course, even in these early days, we shouldn’t minimize the changes that have occurred. Our patients and their families are increasingly interested in apps and other digital interventions.
- Dr. Torous’ work has been featured in past Readings. In a Quick Takes interview, he discusses apps. Asked about doctors and app recommendations, he comments: “There are a lot of apps out there, so it can be hard to pick the good ones. But imagine if a patient came to us and said, ‘I’m interested in an antidepressant,’ or ‘I’m interested in therapy.’ And we said, ‘That’s great. Go find one…’” Highlights can be found here: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-are-those-with-mental-illness-at-more-risk-of-covid-also-a-podcast-on-apps-qt-and-horton-on-advocacy-doctors-macleans/
The full World Psychiatry paper can be found here:
Selection 2: “The Effectiveness of Discharge Planning for Psychiatric Inpatients With Varying Levels of Preadmission Engagement in Care”
Thomas E. Smith, Morgan Haselden, Tom Corbeil, et al.
Psychiatric Services, 23 June 2021. Online First
High rates of failed care transitions after inpatient psychiatric care are a critical quality concern. In the United States, 42%−51% of adults and 31%−45% of youths do not attend mental health visits within 30 days after discharge. Failed care transitions increase the risk for relapse, hospital readmission, homelessness, violent behavior, criminal justice involvement, and all-cause mortality, including suicide.
Routine discharge planning, including scheduling an outpatient appointment with a community-based psychiatric provider before discharge, significantly improves the likelihood of patients attending visits after discharge. Recent analyses of the sample examined in the current study described patient, hospital, and service system characteristics associated with patients receiving routine discharge planning practices and have documented that, after controlling for a range of these characteristics, patients who had an appointment scheduled prior to discharge had a significantly greater likelihood of receiving timely outpatient psychiatric care.
An important factor to consider, however, is the patient’s history of engagement in outpatient care. Patients who were not engaged in psychiatric care before admission are much more likely to fail to transition to outpatient care after inpatient psychiatric discharge. Hospital providers may administer less discharge planning for patients known to not follow up with care or when patients are being discharged against medical advice or are otherwise refusing outpatient follow-up. It is important to know whether routine discharge planning practices are effective and should be encouraged for these patients.
So begins a paper by Smith et al.
Here’s what they did:
- The authors drew on New York State Medicaid and other administrative databases.
- They considered inpatient care from 2012 to 2013.
- Outcomes: attending an outpatient appointment within 7 days and 30 days.
- “The sample was stratified by whether patients had high, partial, low, or no engagement in outpatient psychiatric services in the 6 months before admission.”
Here’s what they found:
- The final study sample included 18 793 psychiatric inpatient admissions involving 18 793 unique patients.
- Patients tended to be 36+, White and male.
- “Scheduling an outpatient appointment as part of the patient’s discharge plan was significantly associated with attending outpatient psychiatric appointments, regardless of the patient’s level of engagement in care before admission.”
- “The differences were most pronounced for patients who had not received any outpatient care in the 6 months before admission.”
- “When an appointment was scheduled, these patients were three times more likely to follow up with care within 7 days and more than twice as likely to follow up within 30 days than were patients without a scheduled appointment.” See graph below.
A few thoughts:
- This is a good paper.
- A three-word summary: discharge planning works.
- There is much to like here, including the use of a large database.
- Like all papers, there are limitations. The authors note: “Potential limitations to this study included the possibility that unmeasured variables, such as transportation constraints, may have affected attendance at outpatient appointments.”
- A comment on the lack of access of mental health care services: “Only 42% of patients admitted to inpatient psychiatric units were highly engaged in outpatient psychiatric care in the 6 months before admission.”
- The contrast between the two selections this week is palpable: one focuses on the high tech, while the other is decidedly low tech. Yet both offer important innovations in mental health delivery.
The full Psychiatric Services paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.