Digital health graphic (Photo credit: Adobe stock photos)
Photo credit: Adobe stock photos

In 1992, researchers equipped anxious drivers with some of the earliest mobile phones and studied whether talking to a therapist while driving busy Los Angeles freeways could reduce anxiety and it did. It turned out this real time therapy delivered via telephone—telepsychiatry—was effective. This was one of the first studies to highlight how psychiatric care could be provided on the go and mobile. This early demonstration of mobile telepsychiatry was well ahead of its time 24 years ago, illustrating how the synergy of mobile technology and telepsychiatry continues to hold great potential for the future of psychiatry.

 

The potential

But what is this potential? To fully understand the power in combining telepsychiatry and mobile technology, we need first to explore the background of each. While the name telepsychiatry reflects those original efforts to deliver psychiatric services via telephone, telepsychiatry today is delivered more often through a variety of digital technologies, especially video conferencing. As video technology has become common in everyday life—thanks to increasing quality, decreasing costs, and greater availability (consider how much time you spend in front of screen today!)—the ability to deliver telepsychiatry has also become commonplace.

Numerous research studies have demonstrated that psychiatrists can make accurate diagnoses and provide the same quality of care with telepsychiatry as would be received during in-person face-to-face visit. Clinical studies have also shown that every patient population—be it those who are younger or older, anxious or paranoid, living in rural environments or busy cities—can benefit from telepsychiatry services.

 

Reach

This ability of telepsychiatry to offer a new means to access and receive psychiatric specialty care is very timely as we are recognizing the need for expanded access to mental healthcare services. Psychiatric conditions like depression, anxiety, and schizophrenia are among the most common and disabling illnesses in terms of disability, personal suffering, lost productivity, healthcare cost, and caregiver burden.

With up to one in five suffering from a diagnosable mental illness, demand for psychiatric services continues to far exceed our ability to deliver face-to-face care. Telepsychiatry can help increase the reach and multiply the ability of a single psychiatrist to serve even more patients in need. For example, a psychiatrist can now personally treat and manage a patient who previously could not access care because she lived in a rural area 100 miles away from the nearest mental health provider. Also, a psychiatrist can provide expert treatment recommendations for challenging clinical cases through telepsychiatry sessions without having to physically travel around the city or state, meeting with healthcare providers and patients.

The fact that these telepsychiatry services can be delivered at lower costs than face-to-face care also means that limited funds for mental health may be used to reach even more patients and expand care. The recent wave of new private companies offering telepsychiatry services and major healthcare insurers providing telepsychiatry benefits to members is testament to the potential of telepsychiatry.

 

Digitally enhanced care

Telepsychiatry in 2016 can incorporate something that was not possible on those Los Angeles freeways in 1992. While early mobile phones were simplistic, unreliable and rare, today’s smartphones are intelligent, consistent and nearly ubiquitous. There is tremendous interest in smartphone apps, wearables, and sensor technologies sourcing and providing digital real-time patient data into the clinical visit. At the same time that telepsychiatry is helping to expand access and lower costs of psychiatric care, new digital tools are emerging into the psychiatric world. The rapid rise of mobile health has reached every area of healthcare including psychiatry. We need now to combine emerging mobile patient technologies into telepsychiatry.

Consider that even when a patient is able to have a thirty-minute appointment with a psychiatrist every week, for 99.7% of that week, the psychiatrist is not observing the patient or seeing how their mental illness is impacting life outside of the single office session. Now, the ability to easily report symptoms in real time to a smartphone or have sensors on a fitness tracker record sleep and activity patterns offers a plethora of valuable clinical information.

Researchers are already studying if the GPS signal from smartphones may provide information about risk of depression; phone call and text log information can predict relapse in bipolar disorder; and voice data can inform who is at the highest risk of developing schizophrenia. While much of this mobile data is still of unclear clinical meaning and validity with the need for further research, the potential to collect real-time, objective, and personalized behavioral data for psychiatry seems bright.

Of course, there are significant ethical questions regarding digital data collection and other barriers. One is how can psychiatry best incorporate and use real-time data in clinical practice. Nevertheless, passive patient data collected automatically by smartphone and active data entered by the patient and transmitted to the clinician’s dashboard provides an incredibly rich enhancement of clinically useful information for the digitally informed patient and clinician to put to good use.

This is where the combination of telepsychiatry and mobile mental health technologies holds tremendous potential. The intersection of these two tools could be a new model of care—more accessible and affordable, while also more personalized and responsive care. Offering such individualized care on a population level may seem paradoxical, yet it actually exists at the evolving intersection of new mobile technologies and existing telepsychiatry services.

 

When mobile mental health meets telepsychiatry

Enable psychiatrists to utilize telepsychiatry at the exact time to deliver the exact care to the right patient

Imagine the scenario of a patient with bipolar disorder using a smartphone app that can record data of her anonymized phone call patterns, daily brief voice samples, and measurements of sleep quality. For the last week, the app has detected that the patient is sleeping less, speaking more rapidly and pressured, and making many more phone calls than her average. The app data suggests the patient may be at risk of relapse into a manic episode and needs evaluation as soon as possible.

How is the patient going to receive that evaluation? The patient may be inclined to disregard these emerging signs and symptoms of a relapse. Her appointment with her psychiatrist may be a ways off and an emergency room visit may be the only viable option—if the patient would actually go. What if the patient already had telepsychiatry services and from home, or even on the go on a smartphone, and thus could in real time partake in a digital telepsychiatry video visit with her psychiatrist who knows her well and, receiving notification of her condition, makes an assessment and together formulates a plan.

Now imagine that pertinent clinical information is automatically transmitted to the psychiatrist’s dashboard who reaches out to the patient and arranges a rapid face-to-face reevaluation. The psychiatrist orders an increase in a medication that is delivered to the patient right away; makes sure there is someone else home to keep an eye on how she is doing; prioritized sleep; makes a safety plan together; and schedules an in-person visit the following day—likely avoiding the patient having to be hospitalized for a more significant manic episode. Mobile mental health data could thus enable the psychiatrist to utilize telepsychiatry at the exact right time to deliver the exact right care to exactly that patient who needs clinical attention the most. By pairing innovative real-time data collection with affordable and portable clinical care, personalized psychiatric care offered at a population level is very possible indeed.

 

Takeaway

This combination of telepsychiatry and mobile health technologies offers the tools to realize a new paradigm in the delivery of psychiatric treatment. But tools alone are not sufficient and real change will require the commitment of patients, psychiatrists, researchers, payers, and policymakers to work together towards aligning real-time digital mobile data with evolving telepsychiatry care models. While still a challenge to implement in clinical practice, the pieces are now all on the table and waiting for us to begin to put the puzzle together—finally connecting them into a new picture of how we care for and serve those with mental illness more effectively than ever before. Much has changed since mobile telepsychiatry was born on the Los Angeles freeways in 1992. Now, in 2016, although traffic there is worse, we are ready to fully realize and implement its broad potential—nationally and worldwide.

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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