Technological

advances in
Psychiatry –
Boon or Bane?

Dr Debasweta Purkayastha
Senior Resident
Department of Psychiatry, SJMCH
Are Computerized therapies the way of the
future?
 Overview
• Current statistics – internet & smartphone
• Introduction
• Use in psychiatry
• Current evidence
• Challenges
• Indian scenario
• Advantages and disadvantages
Worldwide

https://www.statista.com/statistics/330695/
India
 Introduction
• Digital health solutions, also referred to as
“virtual healthcare” or “electronic or e-
Healthcare”
• Significant investments in digital health for
health promotion, facilitating self
management, and improving access to care.
 Introduction
• The rapid growth in the use of smartphones-
new world of opportunities for use in mental
health care.
• Access to mental health care remains limited.
• Potentially reduce the burden of health
systems, empower patients and break barriers
to help-seeking.
• Current WHO policy
 Internet based MH interventions
4 categories:
i) web-based interventions,
ii) online counselling and therapy,
iii) artificial intelligence and virtual reality
therapeutic software, and
iv) other online activities
Internet based MH interventions

Image from Raney et al(2017)

Internet based MH interventions
 Telepsychiatry
• Tele-ECHO (Extension of Community Healthcare
Outcome)
• Either real-time live interaction (synchronous) or
as a store forward approach (asynchronous).
• Emergency psychiatry cases
• Special populations-old age home, disaster
affected areas.
• Remotest areas where health care is sparse
 Telepsychiatry
• No legislation in India concerning
telemedicine and virtual consultation.
• Governed by combination of practice of
medicine and IT with their rules, regulations
or laws.
• Specific laws governing the practice of ‘tele-
medicine’ are needed.
• Guidelines- ATA,APA,ISTeH,AACAP
 Telepsychiatry
• Implementation factor - Primary health care centres are not
yet included in the telemedicine network.
• Man power issues- separate department with dedicated
medical staff, supporting and technical staff
• Attitudinal issues
• Technical difficulties
• Logistic Challenges
• Training of manpower
• Legal and ethical issues- legal responsibility in cases of
medico-legal issues, Security of the data, privacy and
confidentiality.
(Math SB et al, 2015)
 Smartphone Apps for MH
• Developing apps that can collect data using
the sensors built into smartphones.
• These sensors can record movement patterns,
social interactions, behavior at different times
of the day, vocal tone and speed etc.
• Alert caregivers of warning signs.
 Smartphone Apps for MH
• Immediate crisis intervention, prevention,
diagnosis, primary treatment, supplement to in-
person therapy, and post-treatment condition
management.
• In future, apps may be able to analyze these data
to determine the user’s real-time state of mind.
• MHapps - cost-effective and scalable solutions to
addressing the mental health treatment gap.
 Smartphone Apps for MH
NIMH classifies mental health apps into 6
categories :
• self-management
• cognition improvement
• skills-training
• social support
• symptom tracking
• passive data collection
 Games and Gamification
• Enhance concentration, improve retention of
information, facilitate deep learning, and bring
about behavior change.
• Certain studies suggest potential benefits for
psychological and behavioral changes, or
symptom relief with board games or video
games designed for mental health.
 Examples
• CBT based serious games like SPARX .
• CBT and positive psychology based SuperBetter
• Virtual Reality games like “Virtual Iraq” for PTSD
(Exposure therapy)
• Biofeedback-based games like Journey to the
Wild Divine
• Entertainment computer games for mental
health- Tetris
 Digital Medicine System
• 3 components :
a) ingestible sensor,
b) wearable sensor and
c) secure mobile and cloud based apps.
• Aripiprazole
 Virtual Reality clinics
• See patients in person for new intakes
• Prescribe apps monitored by clinicians.
• Virtual reality headsets
• Exposure therapy
 Chatbots
• Software uses AI to simulate a conversation
• Fully automated or with human interface.
• Provide companionship, support, and therapy-
lessens load on therapists.
• People with difficulty of accessibility and
affordability in terms of time, distance, and
finances.
• Eg Woebot is a fully automated conversational
agent- uses digital version of CBT.
 Clinical decision support systems (DSS)

• Secure, web-based software tool designed for

mental health service staff
• Eg : DocuMental
- Diagnostic module
- Treatment module
- History and routine assessment modules
 Technology in Research
• Patient-Centered Outcomes Research Institute
(PCORI)-funded Patient Centered Clinical
Outcomes Research Networks
• NIH’s Precision Medicine Initiative
• Apple’s Research Kit.
• Cost reductions, recruit very large samples in
short periods of time, data collected anywhere
anytime.
• Retention issues/drop outs
 Current evidence
• A meta-analysis of 9 RCTs evaluated the effects of
smartphone-delivered interventions for anxiety
disorders- users experienced reductions in total
anxiety(g=0.33, P<0.001).
• An RCT using myCompass, a self-guided
psychological treatment delivered via mobile phone
and computer, showed significant improvement in
symptoms of depression, anxiety and stress and in
work and social functioning. (Proudfoot et al)
 Current evidence
• A systematic review of 5 studies on using
smartphone apps for schizophrenia- app
retention 92%, and patient-app interactions.
• In Schizophrenia- psychosocial interventions
directly to patients.
 Current evidence
• Apps to monitor patients with bipolar disorder via wearable
sensors (Puiatti et al 2011).
• Birney et al, evaluated a self-guided intervention, using the
MoodHacker mobile Web app to activate the use of CBT skills
in working adults with mild-to-moderate depression, which
reported significant positive effects on depressive symptoms.
• A meta-analysis of 18 RCTs covering 22 mobile apps revealed
that using apps to alleviate symptoms and self-manage
depression significantly reduced patients’ depressive
symptoms compared to control conditions (g=0.38, P<0.001).
 Current evidence
• Zorluoglu et al (2015) have tested a cognitive screening
battery for mobile devices that is able to differentiate
individuals in control and dementia groups for executive,
visual, memory, attention, and orientation functions.
• Larsen et al, identified 24 apps focussing specifically on
suicide prevention, all of which included features
broadly concordant with the evidence base.
• Social media apps eg Twitter app have been analyzed for
suicide risk factors (Jashinsky et al., 2014) and onset of
depression (Cavazos-Rehg et al., 2016)
 Current evidence
• Apps as interventions for smoking cessation (Rubhi et
al., 2016), eating disorders (Juarascio et al 2015) and
alcohol use (Fowler et al 2016).
• Project Evo- a digital treatment (Akili Interactive)-
feasible, acceptable, and efficacious for cognitive control
impairments in children with ASD and ADHD(Yerys et al).
• FDA approved app named ‘RESET’, in a 12-week
multicentric clinical trial of 507 patients, showed
significant increase in abstinence rates in substance use
disorder patients
 Current evidence
• Mobilyze!, an app, in which machine learning models (ie,
learners) predicted patients’ mood, emotions, cognitive
states, activities etc based on at least 38 concurrent phone
sensor values (GPS, ambient light, recent calls) showed
significant reduction in mood and anxiety symptoms. (Burns
MN et al)
• Brouillette et al (2013) - feasibility, reliability, and validity of
a smartphone app for assessing cognitive processing speed.
• Timmers et al. (2014) have shown that smartphones can be
used to assess short term memory outside a laboratory
setting.
 International digital mental health network
(IDMHN)
• To enable the implementation of digital
innovations in clinical practice, facilitating
transformation of current mental health
services to be more personalized and
responsive to patients and healthcare needs.
• Comprises top-level clinicians, regulatory and
ICT experts, genetic scientists, and support
organizations with experience and expertise in
mental health, e-health infrastructures and
decision support systems.
 Guidelines ?

• APA’s smartphone app evaluation workgroup

and the Massachusetts Psychiatric Society’s
Health Information Technology Committee-
app evaluation model- make an informed
decision on whether an app is right for you
and your patients.
• IPS subcommittee 2019-2020
 Challenges
• Cost, speed of implementation, issues of face
validity, and user preferences.
• Poor regulation of quality and privacy
• Inconsistencies in engagement, wrong data entry
• Feasibility of mHealth in psychotic disorders -
symptoms, cognitive dysfunction, or social
isolation reducing technology adoption.
• “Digital divide” – elderly/homeless/ID
Features- Good Mental Health App
1. High patient engagement – (I)real-time
engagement; (II) usage reminders; (III)
gamified interactions
2. Simple user interface (UI) and experience
reduces cognitive load and increases capacity
for learning.
Such as (I) use of pictures (II) reduced sentence
lengths; (III) inclusive, nonclinical language
Features- Good Mental Health App
3. Transdiagnostic capabilities- reducing the
commitment needed to interact with multiple apps
for comorbid disorders.
4. App-based features that enable users to self-monitor
their mood by periodically reporting their thoughts,
behaviors, and actions can increase emotional self-
awareness (ESA).
5. Participatory design process where all primary
stakeholders (e.g., patients, caregivers and clinicians)
are engaged as designers.
 Boon or bane?
Advantages
• Convenience : treatment • Accessibility : in remote
anytime any place, without areas or to individuals in
involving others times of intense need
• Data collection: info from a • Support : 24-h monitoring
large number of individuals and/or intervention support
at the same time and complement usual
• Affordability: cost less or therapy.
free than usual care
 Boon or bane?
Disadvantages
• Treatment tailoring: for all • Effectiveness: Scientific
individuals and for all evidence that this
psychiatric conditions??? technology works as well as
• Privacy: developers need to usual care
be able to guarantee • Overrating: if an app
privacy for users promises more than it
• Regulation: of mental delivers, users may turn
health technology and the away from other more
data it generates needs to effective therapy programs
be developed.
 Indian scenario
• SCARF holds the distinction of pioneering
telepsychiatry services in India.
• Victims of tsunami in December, 2004 in the
coastal districts of Tamil Nadu.
• Mobile (custom built bus)telepsychiatry unit
was implemented for the first time in
2010,Pudukkottai, Tamil Nadu
Indian scenario
 Indian scenario
• Malhotra et al, developed a fully automated, internet‑based,
computerized, Clinical Decision Support System(CDSS) named
“psychiatristonweb”.
• With three interlinked modules for diagnosis, management, and
follow-up.
• Through non specialist, in 3 remote sites (HP,UK,JK)
• The diagnoses generated were reasonably accurate and reliable,
initial trials suggested that the treatments delivered appeared to
be useful.
• An adjunct to existing services or an alternative for nonexistent
services
 Indian scenario
• NIMHANS Virtual Knowledge Network- 2014
• Mission - providing quality care in mental
health by Collaborative learning and capacity
building by using digital technology.
• VKN NIMHANS ECHO, led by expert teams (Hub)
uses multipoint video conferencing to conduct
virtual sessions with community (Spokes) non-
specialist doctors and other primary health
providers.
 Indian scenario
• Train health professionals of Bihar for treating
alcohol dependence and tobacco cessation for
the counsellors working at District tobacco
cessation centres in the state of Karnataka.
• The PCP joined the fortnightly NIMHANS ECHO
sessions from their workplace via internet
enabled devices (smartphone app or laptop)
and discussed the cases
 Smartphone apps in India
• Avaz an augmentative and alternative communication (AAC) tool-
India's first.
• Wysa – AI based chatbot, combines empathetic listening with
evidence-based therapeutic techniques like CBT, meditation and
motivational interviewing.
• Aware - Based in Bangalore, offers unique and guided courses that
help an individual to stay calm, reduce stress and battle
depression.
• YourDost :  IITian, Richa Singh, app that takes care of your wellness
needs academically, professionally and personally.
• InnerHour : self-help app, bank of advice from mental healthcare
experts.
 Smartphone apps in India
• ePsyClinic helps patients undergoing mental health issues
through chat, videos, or calls.
• Headspace: mindfulness app that has a series of cartoons to
illustrate meditation principles, built-in “SOS Sessions” in
urgency and emergency.
• MoodTools - combat negativity and alleviate feelings of
depression, helps you fill up questionnaires, maintain a
journal emotions.
• MoodKit is an iPhone app that focuses on the social, physical
and mental faculties of your being.
• Happy Being - self-improvement app with personalized
guided meditations, assessments, and activities. By means of
a tracker, the app helps people set, prioritize and achieve
goals.
 e-Maanasi
• Introduction of IT solutions in-patient care provision such as
reminders by text messages through cell phones.
• Develop and Scale the e-Maanasi (Electronic Mental Health
Management System) software application for connected patient
care management.
• Integrate smartphones and tablet computers with the e-Maanasi
Application. These smart phones/tablets would be used by
caseworkers / health workers at the field during their visit to
remote villages.
• Use of interactive video conferencing facility for remote
diagnostics by specialist doctors with the “Maanasi Clinic” on
every clinic day.
Caregiver’s perspective in India

Sinha Deb K et al,2018

 Future of Digital Psychiatry

Bhugra D, Tasman A, Pathare S, Priebe S, Smith S, Torous J, et al. The WPA-lancet psychiatry commission on the future of psychiatry. Lancet Psychiatry (2017) 4(10):775–818.
 Take home message
• The health care providers need to remain
current on the state of science regarding these
tools, allowing safe and ethical integration to
improve delivery of care.
• These modalities are 'clinician extenders' (not
'replacers').
• Scope for research
 References
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