integrating mobile technologies into mental health treatment frederick muench, ph.d....
TRANSCRIPT
About Me/Disclosures
• I am the Director of Digital Health Interventions at NSHS and founder of the company Mobile Health Interventions. I am the PI on two mobile intervention studies. I also teach a class at NYU called crafting mindful experiences.
Conflicts
• I own a text messaging company for health behaviors (again).
• I consult with mobile health companies to help them build interventions.
• I have no financial conflict of interest with any product mentioned in this presentation.
Mobile Adoption• 88-95% mobile phone use, including low income & disenfranchised
groups
• No Digital Divide!
• 99% are SMS ready
• Over 65% (2-14) smart phone adoption for first time in, expected to skyrocket.
• Mobile will become the most common way of accessing the Internet
• 55% of mobile users use their phone for some kind of health (mostly fitness)
• Mobile will be a term of the past as mediums merge – connected and personalized health.
Why Mobile?
What, Why, How, When & Where 24/7 access to increase salience of change goals in-vivo:• Assess & monitor using multiple mediums (active & passive)• Tailor & intervene/adapt care (just-in-time)• Triage & crisis intervention• Network and alert supports
Data Download• Improve data quality, display and monitoring, EMR integration,
dashboards, research, etc.
Support Your Work
• Between session support, homework adherence, psychoeducation, engagement, self-monitoring, appointment attendance, etc.
Capabilities…
Voice & Text IVR, reminders, emotional tone, environmental scanning, natural language processing, repeated brief assessment.
Camera/Video Telepsych, modeling, environmental monitoring.
Accelerometers/ Gyroscope/Activity
Behavioral activation, relapse, side effects, sleep.
Geolocation Triggers, activity scheduling, etc.
Capabilities…
Ambient light & sound sensors
Understand environment and world around your client.
Proximity sensors Other phones, social gathering.
Barometers Detect altitude and predict weather
Analytics Phone checking, social interaction, on-off, sleep
Galvanic Skin Response, Temperature, Heart Rate
Variability (Add-ons)
Physiological reaction and arousal, Predict outcome, Relapse & Side effects.
Data Skinner BoxWebsite/Mobile Hit Lever Press
Page View Duration Presses per Lever
Bounce Rate Escape Attempts
Click Path Maze Path
IP Geolocation Maze location
The Skinner Box of Today
Empirical DataIt’s coming….. I promise…. I don’t know what it will say!
TONS ON ASSESSMENT! (EMA, Diary, Add-on Sensors, Conext Sensing)
Very little on mobile applications:• Pilot studies on development with small N’s (This is the same bullet point from last
year)• Mobile Apps generally better than nothing
By far, the most on text-messaging:• Appointment adherence, HIV medication adherence/general medication adherence, Smoking,
Depression, Sexual Information, Alcohol Use, Weight loss, Diabetes & Asthma monitoring, Eating Disorders
• Recent article – SMS better than app for smoking cessation and patients prefer messaging.
• It’s not about a message – but proactive engagement!
Tailored, personalized, just-in-time, help messages, social, self-monitoring.
High level of client acceptability in mobile - clients want to stay connected
Mobile assessment – the one place we are ahead of the game!
Therapists MatterDigital x Alliance
Homework and self monitoring are enhanced when there is accountability.
Mohr, D. C., Cuijpers, P., & Lehman, K. (2011)
Dashboards
Care Integration
• Touch Points in Care: Which technologies can you integrate in different points in care.
• The goal of this is to highlight technologies that may be useful in different points of care. I will focus less on actual targeted apps and more on general features of technology that may be helpful at these different points.
• Enhancement Models vs. Supplemental Models• Avoid overchoice…
Care Integration
Consent
• Consent (What you need to know)
• Many forms of digital communication
• For the purposes of the consent, digital communication should probably refer to all forms of computer, mobile, tablet, wireless, and/or device related communication as well as the type of communication (SMS, email, video, dashboard).
• You can pick and choose the components.
• Your consent form can be digital and you can add a consent form quiz into your services.
Consent Topics
Ryan will discuss HIPAA and Security (External Access to Digital Data, forms of safe and unsafe communication, social network specific communication, etc.)
• Missed communication interaction likelihood (I may miss your SMS)
• Non-communication hours (you can call but I will not be there)
• Communication medium limitations (facial expressions)
• Emergency Communication (digital is secondary)
• Client Training (Phone safe, phone sharing)
• Client Responsibility (Stop and Start, Secure, Costs)
• Inappropriate Timing
• Technology Outages
• Digital communication may be part of the health record
Facilitating Treatment Initiation with DHTs
• Screening forms
• Appointment scheduling
• What is your presence?
Treatment Entry
• Digital assessments• (1) collect more
information, efficiently, • (2) to capture more
sensitive information such as sexual and drug use behaviors,
• (3) to improve diagnosis and trigger personalized care plans based on this objective data,
• (4) to continually analyze follow-up data using predictive modeling
Survey Monkey is now HIPAA compliant
Enhancing Care
• What increases engagement in care• Early alliance• Service availability• Barrier reduction• Low burden• Cost• Collaterals and peers• Appropriate feedback• Gains/efficacy building• Proactive outreach (email, sms, app based communication,
voice). Individuals want to connect early in care.• Listening (through devices; warning)
• Clients are usually motivated early in tx
Audio and Video Supplements
Audio & Video• Education: Technology-based educational
orientations (e.g. orientation videos) are as effective as in-person orientations for many health and behavior problems and improve overall outcomes compared to no orientation control groups. (e.g. Healthclips)
• Audio and Videos have tremendous potential beyond education (e.g. skills training (goanimate, xtranormal), relaxation/mindfulness (e.g. UCLA Meditations).
Diary Tools: Think Beyond the Label
Diary Tools: Think Beyond the Label
Collect, Day One, Momento, Askt
“Anonymous” Tools
Supplements
It is not a supplement if you already do it but just do it badly.
• Activity and Physiological• Mindfulness/Relaxation• Sleep
• Sync with apps, HR and other monitors, track activity, motion, elevation, temperature, HR and more.
• Great for continuous tracking. Terrible for lost data from charging as not on phone.
Sleep Apps (e.g. Sleep Cycle, Sleepbot, Fitbit)
Relaxation/Mindfulness Applications
GENERAL
• Software-Hardware limitations/malfunctions
• Too much data
• Bad data
• Development concerns
• Lost phones/devices
• Limited proactive use
• Regulatory/ HIPAA
• Unclear empirical data
• Confidentiality & Privacy
Obstacles to Integration CLINICIAN
• Cost
• Native Applications/Other
• Technology Integration
• Scope of Practice/Time
• Increased Accountability
• Reimbursement
• Technology Knowledge
• Consent
• “But that’s what I do”
Dashboards
Continuing Care
2010 Data* Addiction Provider (N=34)
Patient(N=49)
Would Use SMS System 87% 98%
Provider Alerts 80% 78%
Specific SMS Alerts 8% ---
When would a system like this be most helpful?When treatment begins 27% 34%
During course of treatment 51% 22%
After treatment 11% 44%*
Treatment Completion
Referrals to websitesSocial support groups onlineClosed ongoing groups (personalized)Ongoing SMS programsOngoing appsJust ending….
Fred’s Thoughts
In 5-10 years: • There will be no workshops like this one. You will go to a workshop on OCD
and 40% of the workshop will be about technology applications for treating OCD.
• If you do not integrate technology into your practice you will equated to todays Freudians.
• It will affect jobs and prosperity for some mental health professionals but not replace us and we have to adapt to this changing reality not fight it.
• It will mostly change in-person assessment and diagnostics because it will do a remarkably better job of static and continuous assessment.
• We will have to figure out how to manage our time better. • More people will seek care before serious problems begin to occur which
will boost prevention interventionists and engagement into the system. • It’s effects will be moderated by severity of illness – stepped care. • Longer-term effectiveness will be mediated by human connection and how
it fosters human connection. • Although we can visualize the benefits right now, we have no clue about
the long-term unintended consequences (dehumanization, trivial reward based culture, monitored culture).
