Devon is depressed. He has not left his home in days, is no longer exercising, and now is sleeping poorly. Thoughts of self-harm have been entering his mind. Everything seems bleak. He feels alone. The depression blinds him to his condition—he cannot see that he needs help. But he is not completely alone. Someone has been noticing and is about to call for assistance.

It has been recording his sleep patterns, physical activity levels, voice, and social data—and the pattern is clear. Devon’s depression is rapidly progressing. He needs help now. The app notifies his clinicians who quickly arrange a video consultation with Devon via a HIPPA secure app. Together they confirm that the diagnosis is indeed clinical depression.

The clinician provides psychoeducation regarding his condition and prescribes the necessary treatment. The clinician provides Devon a medication and an app to track tolerability and the emergence of symptom relief, in addition to a therapy app for his daily use in treatment. Over the next few weeks, Devon begins to sleep better, begins jogging again, and feels brighter and more hopeful about his future.

 

Fantasy or fact?

Is the scenario presented above fantasy or fact? What can, and cannot, smartphone technology and apps do for psychiatric care? It is a question that is increasingly being asked by many people: patients, clinicians, payers such as insurance companies self-insured employer groups, technology companies, and policy makers.

The symptoms of depression can vary greatly between people and are made even more complex by other co-morbid psychiatric conditions. Some of the more common symptoms of depression can include feelings of hopelessness, changes in appetite, lower energy, poorer sleep, troubles with concentration, loss of interests in hobbies or activities, and even thoughts of self harm or suicide. Sometimes worsening depression can also cause cognitive changes so that those suffering do not fully realize the extent of the illness or their symptoms.

 

What can smartphones do to help with depression?

In this series of articles, we will discuss the potential, pitfalls, and current state of smartphone technology, fitness trackers, and apps applied toward various psychiatric illnesses like depression, substance abuse, and anxiety disorders.

Although still surrounded by stigma, depression remains incredibly common and likely affects at least one in 10 Americans during a lifetime. Yet up to 80% of those suffering from depression may not seek or receive any treatment. For most, the treatment is inadequate. How can we reach those 80% and do a better job at restoring a robust sense of well-being? Smartphones, owned by now at least 65% of Americans, offer a novel means to deliver psychiatric services to now a majority of the population.

One of our interests is screening and monitoring. Key to understanding the potential of smartphones for tracking diseases like depression is to first understand the concepts of active and passive data.

Active data is data that users actively enter—like filling out a survey about mood. Passive data is data that is automatically collected without any user efforts, like GPS signal from a phone. Smartphone apps can collect important active data like surveys about depression symptoms. Importantly, they are readily available to collect this data in real time and during real life.

Yet active data is actually only the tip of the iceberg. Utilizing passive data, the smartphone can collect information regarding where someone is, via GPS, how fast someone is moving, via accelerometer, how many phone calls are being made, via call logs, and much, much more.

 

What can this active and passive data tell us about depression?

Like most of healthcare, psychiatry is practiced in a doctor’s office or clinic. But active data, like surveys about mood, offers a wealth of new real time data about symptoms. Now, it is possible to closely trend and monitor symptoms like mood or thoughts of self-harm.

Using passive data, like GPS, can give clues that a person may not be leaving their home and call log data can suggest how social someone may on a day. Thus for a depressed person, active data surveys may report worsening symptoms and passive data may confirm such by noting the person is not leaving their home and now calling fewer friends than usual.

Already, technology can support this type of data collection. But what this means—its true clinical utility—is far from certain. There are actually very few studies where clinicians have tested whether all this app data actually means what we think and hope it does.

How do differences in mobile self-reporting of symptoms, as compared to conveying symptoms directly to a clinician, impact what we tell our smartphones? What does GPS signal really mean about depression and does not leaving the house really point to depression? These are important questions to which we don’t yet have strong answers. Smartphones applied towards psychiatry and depression are so new that we need more time to study them.

 

Questions that still need to be answered

Even if we knew that the smartphone data was clinically valid and meaningful—the next question is what do we do with it. How frequently should we be monitoring this data and where do we draw the line between these apps becoming invasive and a violation of privacy? What are the legal and ethical guidelines for clinicians to access and act on this data? How do we standardize the data so clinicians don’t have to log into 50 different apps to read the data from 50 different patients? These are important questions that need to be addressed before smartphone apps can take on a bigger role in population health regarding the care of depression and so many other conditions in the province of mental health and well being.

Finally, even if we knew the data was meaningful and a clinician could properly access it and reach out to patients in times of trouble—can apps that offer therapy provide treatment and help for depression? Again the answer is we don’t fully know just yet.

A new drug can spend many years in clinical studies before it is ever released onto the market. The Food and Drug Administration (FDA) carefully studies each new drug and only approves those that are safe and will work well. On the other hand, a new therapy app can be made in a matter of weeks and immediately put on the Apple or Android app stores without any oversight or approval from the FDA. There certainly are high-quality therapy apps on the various app stores, but it can be hard to spot them. There is also very little clinical research about these apps—so it is hard to know if they are effective and for whom they are most likely to be effective.

In the case of Devon, we know his smartphone can gather many types of new data for psychiatry. We know this data has the potential to help with screening, diagnosing, monitoring, and even treating his depression. For a disease as common as depression, smartphones could make a huge impact and bring clinical care to so many currently not able to access services. But we still have work to translate this potential into reality.

The technology, smartphones and apps, are the first step but not the only step. Clinical research, healthcare policy, legal precedent, privacy protection regulations, and evidence based clinical guidelines for new models of care delivery are the other key and necessary steps. Together, they may lead the path to a new psychiatry with new approaches for depression and patients like Devon.

John Torous, MD and John Sharp, MD
John Torous MD (L) is a clinical fellow in psychiatry and fourth year psychiatry resident at the Harvard Longwood Psychiatry Residency Training Program. He has a background in electrical engineering and computer sciences and received an undergraduate degree in the field from UC Berkeley before attending medical school at UC San Diego. He has been active in investigating the potential of mobile mental health technologies for psychiatry and helped create his own apps for the iTunes and Android stores, served a principal investigator on a smartphone depression screening app study, and published numerous papers on the topic. He is currently collaborating with the Harvard School of Public Health in assessing the clinical utility of a novel app that collects both active and passive data streams for mental illnesses. He serves as editor-in-chief for the leading academic journal on technology and mental health, JMIR Mental Health (http://mental.jmir.org/), currently leads the American Psychiatric Association’s task force on the evaluation of commercial smartphone apps, co-chairs the Massachusetts ​Psychiatric Society's Health Information Technology Committee, and in 2014 was awarded an Outstanding Resident Award for research by the National Institute of Mental Health. He is an assistant editor for the Harvard Review of Psychiatry and section editor for the Asian Journal of Psychiatry.   Dr. John Sharp (R) is a seasoned medical professional, board certified psychiatrist, best selling author and media expert. He is on faculty at the Harvard Medical School and the David Geffen School of Medicine at UCLA, dividing his time between Boston and Los Angeles. Dr. Sharp is also the Chief Behavioral Health Officer at MDLIVE, a leading telehealth provider of online and on-demand healthcare delivery services and software that benefit patients, hospitals, employers, payers, physician practice groups and accountable care organizations. Dr. Sharp is an elected member of The American College of Psychiatrists and served as a standing member of the Examining Committee of the American Board of Psychiatry and Neurology. He is a distinguished award winning educator and Fellow of the American Psychiatric Association and the Academy of Psychosomatic Medicine. He has been voted by his peers for inclusion in Best Doctors in America for past seven years. His first book, The Emotional Calendar: Understanding Seasonal Influences and Milestones to become Happier, more Fulfilled and in Control of your Life, was published in 2011 by Times Books, an imprint of Henry Holt & Co, and Griffin Press, an imprint of St. Martin's Press. It has been translated into French, Spanish, Turkish, Czech, and Chinese.

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