Individualized Intervention to Support Mental Health Recovery Through Implementation of Digital Tools into Clinical Care: Feasibility Study

Myriad digital tools exist to support mental health but there are multiple barriers to using these tools in routine care. This study aimed to assess the feasibility of an intervention incorporating a support role to help the clinical team identify and use technology to promote recovery. The technology specialist intervention is 3 months in duration and comprises four stages: goal setting, researching and evaluating tools, demonstrating and selecting tools, and ongoing support. We implemented the intervention in a community mental health center and a dual diagnosis treatment program, working with eight clients and their case managers. Clients and case managers willingly engaged with the technology specialist and found the intervention beneficial. Integration and collaboration with the care team facilitated implementation of the technology specialist in these real-world settings. Clients reported that the intervention made it easy to try a digital tool. Six of the eight participants stated that they made substantial progress toward their goals. The technology specialist is a promising new role for mental health care delivery to augment traditional services and enhance individualized recovery.

     

Reporting and understanding the safety and adverse effect profile of mobile apps for psychosocial interventions: An update

Recent years have seen a rapidly increasing trend towards the delivery of health technology through mobile devices. Smartphones and tablet devices are thus becoming increasingly popular for accessing information and a wide range of services, including health care services. Modern mobile apps can be used for a variety of reasons, ranging from education for the patients and assistance to clinicians to delivery of interventions. Mobile phone apps have also been established to benefit patients in a scope of interventions across numerous medical specialties and treatment modalities. Medical apps have their advantages and disadvantages. It is important that clinicians have access to knowledge to make decisions regarding the use of medical apps on the basis of risk-benefit ratio. Mobile apps that deliver psycho social interventions offer unique challenges and opportunities. A number of reviews have highlighted the potential use of such apps. There is a need to describe, report and study their side effects too. The adverse effects associated with these apps can broadly be divided into: (1) those resulting from the security and safety concerns; (2) those arising from the use of a particular psycho social intervention; and (3) those due to the interaction with digital technology. There is a need to refine and reconsider the safety and adverse effects in this area. The safety profile of a mobile PSI app should describe its safety profile in: (1) privacy and security; (2) adverse effects of psychotherapy; and (3) adverse effects unique to the use of apps and the internet. This is, however, a very new area and further research and reporting is required to inform clinical decision making.     

Digital technology and clinical decision making in depression treatment: Current findings and future opportunities

Clinical decision making encompasses a broad set of processes that contribute to the effectiveness of depression treatments. There is emerging interest in using digital technologies to support effective and efficient clinical decision making. In this paper, we provide "snapshots" of research and current directions on ways that digital technologies can support clinical decision making in depression treatment. Practical facets of clinical decision making are reviewed, then research, design, and implementation opportunities where technology can potentially enhance clinical decision making are outlined. Discussions of these opportunities are organized around three established movements designed to enhance clinical decision making for depression treatment, including measurement-based care, integrated care, and personalized medicine. Research, design, and implementation efforts may support clinical decision making for depression by (1) improving tools to incorporate depression symptom data into existing electronic health record systems, (2) enhancing measurement of treatment fidelity and treatment processes, (3) harnessing smartphone and biosensor data to inform clinical decision making, (4) enhancing tools that support communication and care coordination between patients and providers and within provider teams, and (5) leveraging treatment and outcome data from electronic health record systems to support personalized depression treatment. The current climate of rapid changes in both healthcare and digital technologies facilitates an urgent need for research, design, and implementation of digital technologies that explicitly support clinical decision making. Ensuring that such tools are efficient, effective, and usable in frontline treatment settings will be essential for their success and will require engagement of stakeholders from multiple domains.     

There is an app for that! The current state of mobile applications (apps) for DSM-5 obsessive-compulsive disorder,posttraumatic stress disorder,anxiety and mood disorders

Mental health apps are viewed as a promising modality to extend the reach of mental health care beyond the clinic. They do so by providing a means of assessment, tracking, and treatment through a smartphone. Given that nearly 2/3 of the American population owns a smartphone, mental health apps offer the possibility of overcoming treatment barriers such as geographic location or financial barriers. Unfortunately, the excitement surrounding mental health apps may be premature as the current supporting literature regarding their efficacy is limited. The app marketplace is littered with apps claiming to treat or assess symptoms, but even those created by reputable organizations or those incorporating components of evidence-based treatments have not yet been validated in terms of their efficacy. This review aims to provide a comprehensive review of the current state of the mental health app literature by examining published reports of apps designed for DSM-5 anxiety and mood disorders, OCD, and PTSD. The breadth of apps reviewed includes those oriented around assessment, symptom tracking, and treatment as well as “multipurpose” apps, which incorporate several of these components. This review will also present some of the most popular mental health apps which may have clinical utility and could be prescribed to clients. While we discuss many potential benefits of mental health apps, we focus on a number of issues that the current state of the app literature presents. Overall there is a significant disconnect between app developers, the scientific community and health care, leaving the utility of existing apps questionable.     

Technology Matters: Digital micro interventions to support parenting: Evaluating time out apps

Digital interventions to support parenting skills are popular but engagement can be low. Digital micro interventions such as apps targeting specific aspects of parenting are a novel development with the potential to overcome this challenge. Time out is an evidence-based component of many parenting skills training programmes and is an appropriate target for digital micro intervention. We describe the eight requirements of high-quality time out according to the literature and how these can be supported by an app. Searches of the App Store, Google Play, and Alexa Skills in the UK identified six apps designed to support time out. Current time out apps all promoted consistency, but they all risked low-quality time out through inappropriate initiation, duration, and termination. Professionals in child and adolescent mental health should explore the details of any digital micro interventions being used by parents for time out and provide appropriate counselling. We recommend that all future digital micro interventions in this area should incorporate evidence-based guidance.     

Review of Use and Integration of Mobile Apps Into Psychiatric Treatments

Purpose of Review

Mental health practitioners should understand the features of current, publicly available apps; the features of novel, research apps; and issues behind the integration of mobile apps and digital health services into clinical workflows.

Recent Findings

The review is based on a research literature and the authors’ clinical and healthcare administration experiences. Articles searched—on telepsychiatry, telemental health, mobile mental health, informatics, cellular phone, ambulatory monitoring, telemetry, and algorithms—were restricted to 2016 and 2017. Technologies are used in a variety of clinical settings, including patients with varying mental illness severity, social supports, and technological literacy. Good practices for evaluating apps, understanding user needs, and training and educating users can increase success rates. Ethics and risk management should be considered.

Summary

Mobile apps are versatile. Integrating apps into psychiatric treatment requires addressing both patient and clinical workflows, design and usability principles, accessibility, social concerns, and digital health literacy.

     

Mobile Mental Health: Navigating New Rules and Regulations for Digital Tools

Mobile health (mHealth) apps are becoming much more widely available. As more patients learn about and download apps, clinicians are sure to face more questions about the role these apps can play in treatment. Clinicians thus need to familiarize themselves with the clinical and legal risks that apps may introduce. Regulatory rules and organizations that oversee the safety and efficacy of mHealth apps are currently fragmentary in nature and clinicians should pay special attention to categories of apps which are currently exempt from significant regulation. Uniform HIPAA protection does not apply to personal health data that are shared with apps in many contexts which creates a number of clinically relevant privacy and security concerns. Clinicians should also consider several relatively novel potential adverse clinical outcomes and liability concerns that may be relevant to specific categories of apps, including apps that target (i) medication adherence, (ii) collection of self-reported data, (iii) collection of passive data, and (iv) generation of treatment recommendations for psychotherapeutic and behavioral interventions. Considering these potential pitfalls (and disclosing them to patients as a part of obtaining informed consent) is necessary as clinicians consider incorporating apps into treatment.     

Smartphones,Sensors, and Machine Learning to Advance Real-Time Prediction and Interventions for Suicide Prevention: a Review of Current Progress and Next Steps

Purpose of Review

As rates of suicide continue to rise, there is urgent need for innovative approaches to better understand, predict, and care for those at high risk of suicide. Numerous mobile and sensor technology solutions have already been proposed, are in development, or are already available today. This review seeks to assess their clinical evidence and help the reader understand the current state of the field.

Recent Findings

Advances in smartphone sensing, machine learning methods, and mobile apps directed towards reducing suicide offer promising evidence; however, most of these innovative approaches are still nascent. Further replication and validation of preliminary results is needed.

Summary

Whereas numerous promising mobile and sensor technology based solutions for real time understanding, predicting, and caring for those at highest risk of suicide are being studied today, their clinical utility remains largely unproven. However, given both the rapid pace and vast scale of current research efforts, we expect clinicians will soon see useful and impactful digital tools for this space within the next 2 to 5 years.

     

Mobile Applications for Mental Health Providers

Mobile devices such as smartphones and tablets have fundamentally changed the ways in which we interact with information. Far more than communication devices, smartphones and tablets are now indispensable tools in the pocket of healthcare providers. Mobile mental health applications (apps) provide instant access to up-to-date information on prevention, assessment and treatment. Self-help apps allow patients to take greater ownership of their own health and well-being. The past decade has seen an extraordinarily rapid proliferation of mobile medical apps. Though thousands of apps now exist, the challenge for healthcare providers and consumers alike has become sorting through mobile apps for those which provide accurate content delivered in the most user-friendly format. This article will review six mobile apps that can assist healthcare providers and consumers interested in enhancing mental health.     

Debate: Supporting the mental health of school students in the COVID-19 pandemic in New Zealand – a digital ecosystem approach

The pandemic is creating unprecedented demand for mental health support for young people. While schools often facilitate mental health support for their students, the demands for online teaching and the uncertainty created by the pandemic make traditional delivery of support through schools challenging. Technology provides a potential way forward. We have developed a digital ecosystem, HABITS, that can be integrated into school and healthcare systems. This has allowed us to deploy specific evidence-based interventions directly, and through schools, to students and to parents in New Zealand during the current pandemic. Chatbot architecture is particularly suited to rapid iteration to provide specific information while apps can provide more generalised support. While technology can provide some solutions, it is important to be aware of the potential to increase current inequities, with those facing the greatest challenges to health and well-being, also least able to afford the resources to access digital interventions. Development of an integrated and equitable digital system will take time and collaboration.     

Lifelong Learning for Clinical Practice: How to Leverage Technology for Telebehavioral Health Care and Digital Continuing Medical Education

Purpose of Review

Psychiatric practice continues to evolve and play an important role in patients’ lives, the field of medicine, and health care delivery. Clinicians must learn a variety of clinical care systems and lifelong learning (LLL) is crucial to apply knowledge, develop skills, and adjust attitudes. Technology is rapidly becoming a key player—in delivery, lifelong learning, and education/training.

Recent Findings

The evidence base for telepsychiatry/telemental health via videoconferencing has been growing for three decades, but a greater array of technologies have emerged in the last decade (e.g., social media/networking, text, apps). Clinicians are combining telepsychiatry and these technologies frequently and they need to reflect on, learn more about, and develop skills for these technologies. The digital age has solidified the role of technology in continuing medical education and day-to-day practice.

Summary

Other fields of medicine are also adapting to the digital age, as are graduate and undergraduate medical education and many allied mental health organizations. In the future, there will be more online training, simulation, and/or interactive electronic examinations, perhaps on a monthly cycle rather than a quasi-annual or 10-year cycle of recertification.

     

Multimodal monitoring and neurocritical care bioinformatics

Neurocritical care bioinformatics is a new field that focuses on the acquisition, storage and analysis of physiological and other data relevant to the bedside care of patients with acute neurological conditions such as traumatic brain injury or stroke. The main focus of neurocritical care for these conditions relates to prevention, detection and management of secondary brain injury, which relies heavily on monitoring of systemic and cerebral parameters (such as blood-pressure level and intracranial pressure). Advanced neuromonitoring tools also exist that enable measurement of brain tissue oxygen tension, cerebral oxygen utilization, and aerobic metabolism. The ability to analyze these advanced data for real-time clinical care, however, remains intuitive and primitive. Advanced statistical and mathematical tools are now being applied to the large volume of clinical physiological data routinely monitored in neurocritical care with the goal of identifying better markers of brain injury and providing clinicians with improved ability to target specific goals in the management of these patients. This Review provides an introduction to the concepts of multimodal monitoring for secondary brain injury in neurocritical care and outlines initial and future approaches using informatics tools for understanding and applying these data to clinical care.     

An exploration of the qualities and features of art apps for art therapy

Using a participatory design (PD) approach, this study explored the qualifying features and qualities of digital art materials, specifically art apps on iPads, for art therapy use. The qualitative study included a questionnaire survey of 4 art therapists using iPads with clients in therapy and four separate focus groups with 15 art therapist participants. The focus group participants engaged in art directives with nine art making apps identified as potentially useful in art therapy. The results revealed that while no single commercial art app satisfied the needs of all art therapists and potential clients, three distinct qualities and six concrete features of an “ideal” art app for art therapy emerged. These desirable criteria of an art app can be used in the future development of a customized art app for art therapy. In addition, these findings may expand the parameters of art therapy's art making practice and artistic vocabulary by illustrating the potential therapeutic and expressive use of digital art media. While the findings reveal unlimited possibilities for the meaningful use of digital art media in art therapy, they also acknowledge how the unique characteristics of digital art media will require carefully considered limitations and restrictions.     

Pushing the quality envelope: a new outcomes management system.

This article is based on the authors' experience in designing and implementing outcomes management systems for large managed care organizations. Topics addressed include design of instruments, use of cost-effective technology, development of computerized decision-support tools, and methods for case-mix adjustment. The case-mix-adjustment models are based on a data repository of several thousand treatment cases with multiple measurement points across the course of treatment. Data from controlled and field studies are described. These data suggest that the outcomes management methods outlined in this article can result in significantly improved clinical outcomes and a more rational allocation of behavioral health care resources.     

Ethical Considerations for Mental Health Clinicians Working with Adolescents in the Digital Age

Purpose of Review

Adolescents’ use of digital technologies is constantly changing and significantly influences and reflects their mental health and development. Technology has entered the clinical space and raises new ethical dilemmas for mental health clinicians. After an update on this shifting landscape, including a brief review of important literature since 2014, this article will demonstrate how core ethical principles may be applied to clinical situations with patients, using vignettes for illustration.

Recent Findings

The vast majority of adolescents (95%) across all demographic groups can access smartphones (Anderson et al. 2018?). Technology use in mental health is also expanding, including a proliferation of “apps.” While qualitative data from technology experts reports overall positive effects of technology (Anderson and Rainie 2018), concern about its potential negative impact on youth mental health remains high, and an association between technology use and depression is strong. Internet addiction, online sexual exploitation, and accessing illicit substances through the “dark net” pose additional clinical and legal concerns. In this context, clinicians have an ethical responsibility to engage in education and advocacy, to explore technology use with teen patients and to be sensitive to ethical issues that may arise clinically, including confidentiality, autonomy, beneficence/nonmaleficence, and legal considerations such as mandated reporting.

Summary

New media and digital technologies pose unique ethical challenges to mental health clinicians working with adolescents. Clinicians need to stay abreast of current trends and controversies about technology and their potential impact on youth and engage in advocacy and psychoeducation appropriately. With individual patients, clinicians should watch for potential ethical dilemmas stemming from technology use and think them through, with consultation as needed, by applying longstanding core ethical principles.

     

A roadmap for implementation of patient‐centered digital outcome measures in Parkinson's disease obtained using mobile health technologies

Obtaining reliable longitudinal information about everyday functioning from individuals with Parkinson's disease (PD) in natural environments is critical for clinical care and research. Despite advances in mobile health technologies, the implementation of digital outcome measures is hindered by a lack of consensus on the type and scope of measures, the most appropriate approach for data capture (eg, in clinic or at home), and the extraction of timely information that meets the needs of patients, clinicians, caregivers, and health care regulators. The Movement Disorder Society Task Force on Technology proposes the following objectives to facilitate the adoption of mobile health technologies: (1) identification of patient‐centered and clinically relevant digital outcomes; (2) selection criteria for device combinations that offer an acceptable benefit‐to‐burden ratio to patients and that deliver reliable, clinically relevant insights; (3) development of an accessible, scalable, and secure platform for data integration and data analytics; and (4) agreement on a pathway for approval by regulators, adoption into e‐health systems and implementation by health care organizations. We have developed a tentative roadmap that addresses these needs by providing the following deliverables: (1) results and interpretation of an online survey to define patient‐relevant endpoints, (2) agreement on the selection criteria for use of device combinations, (3) an example of an open‐source platform for integrating mobile health technology output, and (4) recommendations for assessing readiness for deployment of promising devices and algorithms suitable for regulatory approval. This concrete implementation guidance, harmonizing the collaborative endeavor among stakeholders, can improve assessments of individuals with PD, tailor symptomatic therapy, and enhance health care outcomes. © 2019 International Parkinson and Movement Disorder Society     

The domain management model: organizing care for stroke survivors and other persons with chronic diseases

The US health care system is poorly designed to help patients with stroke and chronic health conditions and their functional consequences. These patients face multiple clinical problems. The Domain Management Model (DMM), based on the biopsychosocial model, describes four domains into which all patient and family problems can be classified. These problems are then managed over time through attention to care processes and outcomes. The use of the DMM in health care may help relieve patient and family suffering, guide resource use more efficiently, and improve satisfaction of health care providers (clinical, administrative, and financial) in treating complex patients with chronic health conditions.     

Use of resampling to select among alternative error structure specifications for GLMM analyses of repeated measurements

Autocorrelated error and missing data due to dropouts have fostered interest in the flexible general linear mixed model (GLMM) procedures for analysis of data from controlled clinical trials. The user of these adaptable statistical tools must, however, choose among alternative structural models to represent the correlated repeated measurements. The fit of the error structure model specification is important for validity of tests for differences in patterns of treatment effects across time, particularly when maximum likelihood procedures are relied upon. Results can be affected significantly by the error specification that is selected, so a principled basis for selecting the specification is important. As no theoretical grounds are usually available to guide this decision, empirical criteria have been developed that focus on mode fit. The current report proposes alternative empirical criteria that focus on bootstrap estimates of actual type I error an power of tests for treatment effects. Results for model selection before and after the blind is broken are compared. Goodness-of-fit statistics also compare favourably for models fitted to the blinded or unblinded data, although the correspondence to actual type I error and power depends on the particular fit statistic that is considered.     

Genetic testing for neurologic diseases. A rose with thorns

Genetic testing for neurologic conditions, including HD, requires that the primary concerns of informed consent, counseling and support, and confidentiality be recognized and addressed. A safe, reliable test should be available to those who want the information and understand the limitations of the testing procedure. However, testing should be in the context of multifaceted counseling, which combines a variety of components. Safeguards for confidentiality should be assured. Predictive testing for hereditary disease emphasizes the need to focus on capabilities rather than disability. This is an extension of the larger reality that continuing advances in health care can extend the length of an individual's life and stave off death without restoring health. Certainly, new developments in molecular biology may provide new tools, but the basic ethical problems are fundamental issues independent of technology. Just as change is not necessarily progress, the application of scientific advances to health care does not automatically benefit humanity. Sensitivity to human needs is the art of applying medical technology.     

Digital phenotyping in Parkinson's disease: Empowering neurologists for measurement-based care

There remains a significant mismatch between the complexity and variability of symptoms and disabilities in Parkinson's disease (PD), and the capabilities of existing validated assessment tools to objectively measure and monitor them. However, with the advances of circuit and sensor technologies, it is now possible to apply the concept of digital phenotyping to PD, providing a moment-by-moment quantification of individual patient phenotypes using personal digital devices, such as smartphones. Such technology holds considerable potential if a patient-centered multidisciplinary team is able to select digital outcomes that are not only clinically relevant, but also provide measurement-based care results that support individual patient clinical decision making. However, it is likely to be a long road, requiring large collaborative efforts to undertake a number of essential steps before full integration and synchronization of these outcomes into patient management platforms that can deliver individualized data to patients, caregivers, and treating neurologists. In the meantime, both neurologists and patients can empower themselves with digital technologies, working as a team to define the ways that new technologies can be most powerfully employed in PD management. Once digital phenotyping becomes feasible and widely adopted in PD communities, it is likely to expand our understanding of individual PD patients' lives and priorities, leading to targeted treatments and better outcomes for PD patients and their families.