Bad Mental Health App

I saw her come into my clinic office. Four times. Five times. Six times. Each time, she looked distressed. Or tired. Or downtrodden. Or depressed. But rarely happy. Never smiling. No laughing.

She still couldn’t afford the talk therapy that she needed. This talk therapy could have helped her so much; therapy could have helped her improve the way she felt, therapy could equip her with new tools to manage her mood, and therapy—combined with her medication—would give her a higher chance of recovery than taking medication alone.

But she couldn’t afford the cost of it. Or the time. Or have sufficient insurance. She already has tried many medication combinations, which have helped somewhat.

So, I also asked her, “What about a book?” A $9 book that will coach the suffering reader through their emotional troubles? Perhaps offer some inspiration? And techniques to rewire the mind and cast away depressed thoughts?

Ah, but prescribing a book to her wouldn’t be enough. Part of her depression is that her depression has impacted her concentration. To make it through even a single chapter would be an enormous struggle.

So many others like her appeared in my practice. And a majority of times, I felt like they couldn’t get the talk therapy they needed. There is a lot of need for accessible therapies. Yet, where I worked in Central California, it was extraordinarily difficult to find accessible, affordable therapists with space to take new patients. Talk therapists come in all sorts of shapes, sizes, educational backgrounds, and personalities. They include marriage & family therapists, social workers, psychologists, and, of course, psychiatrists—the medically-trained experts of mind, brain, and body. And there are many kinds of therapies. Just like there are many different types of automobiles and dealerships, not all therapy types are right for everyone. But the kind I was hoping to get for my client—widely-available cognitive behavioral therapy (also known as CBT)—was still out of reach, price-wise, for her.

So there we sat, as she twiddled with her phone. Could her phone hold the key to our dilemma? We had no other options available to us.

 

So, what about technology?

Seeing the above scenario play out countless times in my clinic office made me realize that we, medical professionals, really do need to create compelling technology experiences that can make an impact on our patients’ health. And I’m happy to say that this is becoming a reality. Over the past decade, there has been a surge of research, apps, and products that harness interactive, information technologies for psychiatric disorders. And this interest touches so many diagnoses and ailments, for depression, anxiety, post-traumatic stress disorder (PTSD), attention deficit and hyperactivity disorder (ADHD), and—the more debilitating illnesses—bipolar disorder, schizophrenia, and other psychosis illnesses, which we often term “severe mental illness,” or SMI.

And a lot has been written on these disorders in the form of educational books and self-help books. Countless self-help books, for instance, can be converted into engaging, interactive apps. These apps can add exercises that can give feedback, descriptions, and examples that can be illustrated with videos, and connect people with other resources. Virtual reality can be used to transport someone to a completely new environment, great for meditation, relaxation, and exposure therapies—the kind of vivid environments that books must take 1,000 words to describe.

And, best of all, a lot of research has already been done. Virtual reality has been studied for decades. Computerized therapies available on the Internet have been tested as well.

There is a chicken-and-egg problem, though: A lot of these new developments are not widely used. And a lot of researchers do state that caution is needed around this new frontier of apps, devices, and technologies. Take privacy, for instance. Apps that have poor privacy protections may leak your personal information, perhaps even your diagnoses and medications. That means that future employers, insurance companies, and family members and friends could access this information. Apps that have good privacy protections will keep all of this locked away, safe and secure.

Unfortunately, there is no easy way to tell which apps have bad privacy protections or good privacy protections. Even apps that promise to keep information private—and have clear explanations in published privacy policies—can inadvertently leak this information. A recent study in 2015 at the Imperial College London and Ecole Polytechnique CNRS showed that 89% of the apps certified as safe and trustworthy by the United Kingdom’s National Health Service had problems such as not encrypting locally stored personal information, or even transmitting information over the Internet without encryption protection.

This is why healthcare technologies tend to move slower (and cost more) than technologies in other consumer industries. The extra layers of protection needed around these apps require more testing, more development time, and more money. So a lot of researchers and clinicians, including myself, are cautious about recommending these apps.

 

What is the cost of inaction?

However, I often wonder, what is the cost of inaction? Is it better to have something that isn’t the gold standard—perhaps a “silver” or “bronze” standard—than to have no treatment, which is an unfortunate reality for many? The gold standard is frequently out of reach, so why not turn to an imperfect app? In fact, some say that privacy is dead anyways; a research review by Glenn and Monteith states that so much of our diagnoses, health conditions, and personal lives can be reconstructed from our online activity: reading web pages on depression, purchasing books on depression, searching for health symptoms, credit card purchases at an online pharmacy, driving directions to a psychiatrist, or liking a Facebook page on depression. And, of course, placing multiple calls to a psychiatrist or other hotline!

So, I think back to all of those I have seen in my clinic, including the woman I saw earlier, suffering quietly from depression. So we discuss imperfect treatments. The medications don’t always work, and may have side effects. So, too, do these apps have their risks and benefits. But not just that. Books, exercise, classes, physical therapy, and talk therapy each have their own individual upsides and downsides. But all of these risks and downsides shouldn’t stop the development and adoption of these promising new technologies as long as we’re aware of the side effects, which I will discuss in my next article.

Meanwhile, please let me know what you think about using “imperfect apps” instead of letting people go without care at all.


References:
1. Glenn, T., Monteith, S. “Privacy in the digital world: medical and health data outside of HIPAA protections.” Curr Psychiatry Rep. 2014 Nov;16(11):494. doi: 10.1007/s11920-014-0494-4.
2. Armontrout, J., Torous, J., Fisher, M., Drogin, E., Gutheil, T. “Mobile Mental Health: Navigating New Rules and Regulations for Digital Tools.” Curr Psychiatry Rep. 2016 Oct;18(10):91. doi: 10.1007/s11920-016-0726-x.
3. Huckvale, K., Prieto, JT., Tilney, M., Benghozi, PJ., Car, J. “Unaddressed privacy risks in accredited health and wellness apps: a cross-sectional systematic assessment.” BMC Med. 2015 Sep 7;13(1):214. doi: 10.1186/s12916-015-0444-y.
Steven Chan, MD, MBA (@StevenChanMD)

Dr. Chan is a Clinical Informatics fellow at UC San Francisco (UCSF)’s Division of Hospital Medicine, serving as editorial boardmember for the Journal of Medical Internet Research (JMIR) Mental Health, and develops cutting-edge research in the areas of digital mental health, with applications for cultural psychiatry and underserved minority health. Steve’s ideas, thoughts, and research have been featured in JAMA, Healthcare, JMIR (Journal of Medical Internet Research), Wired, PBS, and NPR Ideastream. Steve serves as Vice Chair for the Workgroup on Mental Health & Psychiatric Apps at the American Psychiatric Association (APA), a part of the Committee on Mental Health Information Technology.

1 COMMENT

  1. Sorry – not convinced that “we, medical professionals, really do need to create compelling technology experiences that can make an impact on our patients’ health.”

    I think part of our emotional well-being is being disrupted by too MUCH tech. We’ve become addicted to WMD (wireless mobile devices) and it’s unhealthy. Creating yet another app (among billions) to further cement this addiction is a recipe for disaster. It’s like telling an alcoholic that beer is ok because it’s not bourbon.

    Putting the phone down and reading a book – any book – may just be the perfect Rx. Sure it’s hard to do – because ALL our concentration is being impaired by this addiction. That’s not unique to those with mental illness. In fact, this new addiction may well be at least a contributing factor to the emotional imbalance.

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