Technological Ventures Offer New Hope for the Future of Psychiatry

Psychiatrists are on the front lines of the troubling state of mental health care in America. Our patients demonstrate the diversity of problems faced in mental health, including poor access, demand that far exceeds supply, high costs, and stigma. As the US population grows, insurance coverage and reimbursements shift, and the cohort of psychiatric providers is unevenly distributed across the country, the supply and demand mismatch will only worsen. Awareness of these limitations often makes it difficult to appreciate that we are also at the front lines of exciting, hopeful new solutions to these problems-as long as we pay attention to the progress happening around us and learn how best to integrate it into our practice.

There is a strong imperative to develop innovative and scalable solutions that address the gaps in access to and quality of care; and solutions are being created by various parties (eg, entrepreneurs, investors, insurance companies, politicians, hospital administrators, and patients). It is now more important than ever that we join forces with stakeholders and share our ideas and expertise to create new ideas that work for our patients and for the systems in which we function.

Brainstorm, the Stanford Laboratory for Brain Health Innovation and Entrepreneurship, is the first of its kind-an academic laboratory dedicated to transforming brain health through entrepreneurship. Brainstorm applies the biopsychosocial model of disease to tackle problems on the systems level. Launched by a founding team of physicians from around the country, we unite the worlds of medicine, business, and technology to foster innovative ventures that optimize health and human potential. We accomplish this through education, collaboration, and creation.

Through research and collaboration with academic and industry leaders, we have found that for an innovative solution to successfully address challenges, it should be safe, effective, accessible, affordable, measurable, and scalable. Technological innovations are rapidly emerging because they are uniquely suited to meet these criteria-and meet them quickly. From the more familiar text messaging, video conferencing, and mobile phone applications to the newer areas of virtual reality, augmented reality, behavior tracking, wearables, sensors, and chatbots-these are the solutions that can change the future of psychiatry.

To avoid any conflict of interest or perception of endorsement in this article, we discuss the technologies in general categories instead of giving specific examples or using company names. Many mental health technological ventures are early stage and are still working toward clinical validation and/or development of a sustainable business model.

Technology as a solution

Accessibility. Technology gets care to patients who cannot otherwise reach care. Whether the issue is transportation, inconvenience, or short-staffing of psychiatrists in a particular geographic location, the problem is the same-patients lack access to quality mental health care. What many people can access, however, is a smartphone, computer, or their local, tech-friendly hospital. Innovators are using tools for patient care that are not very different from the ones we know (eg, FaceTime), which we use to chat with family or friends around the world. Technology is being used to provide app-based therapy, coverage in psychiatric emergency departments, consultation to medical care, and rounds on inpatient psychiatric units-all in settings that previously may not have had access to psychiatric coverage.

Affordability. Digital mental health services provide affordable alternatives to traditional care. They lessen some of the fixed and variable overhead costs of more human resource-heavy solutions, such as office space, waiting rooms, and administrative staff. This means that care can be delivered by providers more efficiently, and it can be obtained by patients more affordably.

Not only are digital solutions less costly to use, they are also less costly to develop. While the average cost of developing a psychiatric pharmaceutical treatment exceeds $2.5 billion, the cost to develop a psychiatric digital treatment can average around $500,000 to $1,000,000.^1,2

Measurability. One of the greatest challenges in clinical psychiatric practice is the lack of objective measurement to inform clinical decision-making. With the use of technology, data previously unmeasured can be captured and meaningful insights can be made on the individual patient level as well as by aggregating data into larger databases referred to as “big data.” Behavioral patterns (eg, a depressed patient whose number of daily steps suddenly declines) are tracked over time as well as deviations from baseline. Such tracking alerts physicians about the recurrence of symptoms between visits and allows for earlier intervention-resulting in improved outcomes.

Scalability. Digital solutions can take ideas that work and replicate them more quickly and effectively than would otherwise be possible. Once there is evidence that a solution works, it can quickly be reproduced and adopted elsewhere without the common barriers of cost and staffing. This ability to scale offers technology the potential to make a population-level impact.

Ongoing considerations

While many technological innovations have successfully met the standards explained above, most have yet to deliver consistently on 2 fundamental criteria of behavioral health care: safety and efficacy.

Safety. Given the complex history of psychiatry, it is important that diagnostic and treatment modalities are safe. Safety has been difficult to control because to date, many novel psychiatric products have been unregulated. However, recent progress has been made on this front. In July 2017, the FDA launched a new pilot effort to regulate digital medical products, the “Software Precertification Pilot Program,” with the goal of “[providing] patients with timely access to high-quality, safe, and effective digital health products.”³ Its effectiveness will be shown in time. Meanwhile, it is our responsibility to make sure that patients are physically safe on the other side of the screen, that we understand the nuances of the liability involved in each encounter, and that we understand the implications of prescribing a digital solution.

In addition to patient safety, it is important to consider the security of patients’ health information. While many technology-based products are HIPAA compliant, some ask users to voluntarily share personal information and may not be held to the same privacy standards.4 It is critical for clinicians to remind patients of these nuances and the associated risks so that patients know what is secure and what is not.

Efficacy. To advance the state of mental health, we need solutions that make a concrete impact on clinical outcomes, social outcomes, and financial costs. Because the digital age is still new, the effectiveness data are not robust. A significant advantage of studying technology is that it is well suited to being analyzed. As digital ideas continue to emerge, clinicians and researchers need to keep an open mind about technology, not only as a means to treat patients but also to critically evaluate and develop an evidence base for future patients.

An overview of the technology landscape

From mobile apps to telemedicine to virtual reality games, new ideas that incorporate technology are emerging daily, and clinicians will inevitably be asked about them. With the vast amount of available digital solutions, it can be challenging to stay informed. One way to conceptualize these solutions is to group them into 3 categories.

Screening, identification, and diagnosis. Psychiatry has primarily relied on clinical assessment and self-report for screening and diagnosis. Unfortunately, this can be a barrier to timely, scalable care as well as prevention and early intervention. According to the NIMH, with today’s screening and diagnostic methodology (as well as barriers such as stigma and access to care), the average delay between the onset of symptoms and intervention is 8 to 10 years.⁵ While statistics like this are inherently multifactorial, digital solutions aim to address these challenges and help clinicians obtain and utilize quality, objective information.

A prime example is digital phenotyping. Digital phenotyping is the process of taking data collected by technology such as sensors and smartphones, and turning data into clinically relevant information. For example, a smartphone can collect information on how much patients are moving around or engaging with others; this information can be collected either actively by direct input from users or passively, by using functions such as the GPS or logs of outbound calls and messages. These data can be used to screen, diagnose, prevent, and treat disease, and researchers have begun to study the accuracy and potential of these tools.

Therapeutic interventions. While not technically a treatment modality, telepsychiatry was one of the first forays into ways of reaching patients for assessment and treatment. Today, through audio, video, and text, clinicians can consult with colleagues or provide care to patients. Telepsychiatry can be equally as effective as in-person treatment in terms of diagnostic accuracy, treatment effectiveness, and quality of care.⁶ Clinicians and patients have mixed feelings about these alternative modes of communication, wondering, for example, how texting affects the patient-doctor relationship. Answers will unfold as the shift toward technology continues and outcomes are better understood over time.

One of the fastest-growing areas in technology has been in cognitive behavioral therapy (CBT), which lends itself well to digital delivery-exercises can be more engaging and interactive in a digital format than in the form of a printed worksheet. A 2014 meta-analysis showed that guided internet-based CBT therapy was equally as effective as face-to-face CBT.⁷ In response to this expanding research area, CBT products have been created in both industry and academia. Educational modules have also been paired with clinicians or non-clinical coaches to guide users through the modules and offer additional therapy. Online or application-based CBT can address many conditions, including depression, anxiety, eating disorders, social anxiety, insomnia, and addiction.

Virtual reality and augmented reality offer a unique opportunity in patient treatments. Virtual reality creates a virtual, computer-generated world for the user to experience using a headset; augmented reality combines the real world with a virtual world to allow users to engage with their environment in new ways.⁸

PTSD and phobias are particularly well suited for virtual reality, which creates a simulated environment. Patients are exposed to traumatic or fearful situations and learn appropriate coping responses. Virtual reality has also been used for conditions such as addiction (simulating a bar to help gain skills to avoid drinking), autism spectrum disorder (teaching emotion recognition), and pain (using distraction techniques, leading to reduced need for anesthesia and opioid medications). A 2015 meta-analysis showed that virtual reality exposure therapy was successful and led to significant real-life behavior changes.⁹

The newest kid on the block is the chatbot-a computer algorithm that uses artificial intelligence to simulate human conversation with patients in a way that is meant to be therapeutic. Just as bots can be used to help people make online purchases, they can be trained to understand emotional responses and react accordingly. So far, chatbots have been used for a range of issues, from delivering CBT for depression and anxiety to reaching out to refugees in Syria.^10,11

Systems of care

Clinical technology is progressing in tandem with structural changes in the mental health care delivery system. The current movement toward value-based care is bringing forth many digital solutions to help increase patient satisfaction, improve population health, and lower the cost of health care. One of the biggest moves from a systems perspective has been in leveraging digital tools to create and improve care coordination.

There are opportunities that startups and traditional companies have been working to identify and address: databases and digital tools to match patients with clinicians, schedule appointments, connect with multiple care providers, facilitate e-prescriptions, manage health insurance claims, and identify users at risk for mental illness or relapse. Care coordination tools have been particularly effective, and the increase in value is seen across several domains.

Concluding thoughts

Technology has the potential to treat patients who currently are unable to access care, to prevent disease, and to provide early intervention and quality treatment-it can be the gateway to psychiatric care. With these new modalities, clinicians are better able to provide quality care to all patients with mental health and other problems. We need to understand emerging technological trends that will lead the way to better health and greater opportunity for our patients to access help.

Disclosures:

Dr. Vasan is Founder and Director of Brainstorm: The Stanford Laboratory for Brain Health Innovation and Entrepreneurship, Chief Resident in Adult Psychiatry at Stanford University School of Medicine, and MBA Candidate at Stanford Graduate School of Business; Dr. Chaudhary is Founding Partner at Brainstorm, Chief Resident in Child and Adolescent Psychiatry at Massachusetts General Hospital/McLean, and Clinical Fellow at Harvard Medical School; Dr. Aragam is Founding Partner at Brainstorm and Chief Resident in Adult Psychiatry at Massachusetts General Hospital/McLean; Ms. Nagpal is Junior Fellow at Brainstorm and Founder of CS+Mental Health; Ms. McKenzie is Junior Fellow at Brainstorm and a student at Stanford University; Ms. Chen is a Scholar at Brainstorm.

Dr. Vasan receives royalties from Wiley as the author of Do Good Well: Your Guide to Leadership, Action, and Social Innovation; Dr. Chaudhary, Dr. Aragam, Ms. Nagpal, Ms. McKenzie, and Ms. Chen report no conflicts of interest concerning the subject matter of this article.

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