Digital Mental Health - UC Berkeley - without hidden - reduced

@StevenChanMD @UCDavisHealth #DigitalMentalHealth #DigitalMentalHealth

#DIGITALMENTALHEALTH @StevenChanMD • @UCDavisHealth THANKS TO JOHN TOROUS, DON HILTY, PETER YELLOWLEES, ARSHYA VAHABZADEH, SHIH-YEE MARIE TAN, APA/SAMHSA MINORITY FELLOWSHIP PROGRAM, UC DAVIS PSYCHIATRY

@StevenChanMD @UCDavisHealth #DigitalMentalHealth

SLIDES

On Twitter, where available. DISCLOSURES

#DigitalMentalHealth

Patient

Provider / Doctor / Nurse

Live interpreter

Collateral Caregivers

Family

IMAGE: : http://www.dentaleconomics.com/content/dam/diq/online-articles/2014/06/vitalsigns.jpg

neutral

Feeling down No pleasure Suicidal plans & intent

unipolar depression

neutral

bipolar hypomania bipolar mania

overexcitement euphoria delusions overactivity

bipolar depression

medicines

talk therapy

calm environment

case management &

support

neutral

1 IN 5 U.S. adults suffer from a mental health condition in a given year.

https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers

OBJECTIVES

1 APPS YOU CAN USE 2 EVALUATING TECHNOLOGY 3 BIG PICTURE TRENDS 4 HOW MIGHT WE

@StevenChanMD @UCDavisHealth #DigitalMentalHealth @StevenChanMD

CURRENT USES

As a communications medium. As an extension of face-to-face clinic. As intervention + new monitoring techniques.

CURRENT USES: AS A COMMUNICATIONS MEDIUM

https://play.google.com/store/apps/details?id=com.doctorondemand.android.patient&hl=en

•  Doctors on Demand •  HealthLinkNow •  American Well •  1docway •  Talkspace •  MDLive Breakthrough

CURRENT USES: AS A THERAPY AND INTERVENTION

•  Self-monitoring activities & moods •  Encouraging therapy homework •  Case management for relapse

T2 APPS (NATIONAL CENTER FOR TELEHEALTH & TECHNOLOGY) ON GOOGLE PLAY

VA APP STORE — MOBILEHEALTH.VA.GOV

11 total mental health apps

VA — PTSD COACH

VA — MINDFULNESS COACH

HEADSPACE MEDITATION

https://itunes.apple.com/us/app/headspace.com-meditation-mindfulness/id493145008?mt=8

http://www.imedicalapps.com/2015/07/anxiety-app-review/

INTELLICARE

https://intellicare.cbits.northwestern.edu — http://clinicaltrials.gov/show/NCT02176226

INTELLICARE

MOODTREK

http://mood-trek.com/moodtrek-for-consumers/

MOODTOOLS

http://www.imedicalapps.com/2015/08/moodtools-no-frills-comprehensive-psychoeducation-psychotherapy-depression-app/

CURRENT USES: INTERVENTION + MONITORING TECHNIQUES

•  Self-monitoring activities & moods •  Encouraging therapy homework •  Case management for relapse •  Immediate intervention at relapse •  Intelligent assessments •  Passive monitoring •  Make it more fun & engaging

CURRENT USES: INTERVENTION + MONITORING TECHNIQUES

Patrick L. Dulin PhD, Vivian M. Gonzalez PhD & Kendra Campbell PhD (2014) Results of a Pilot Test of a Self-Administered Smartphone-Based Treatment System for Alcohol Use Disorders: Usability and Early Outcomes, Substance Abuse, 35:2, 168-175, DOI: 10.1080/08897077.2013.821437

MEDISAFE

http://mood-trek.com/moodtrek-for-consumers/

GOOGLE SEARCH

Google Search app

@StevenChanMD @UCDavisHealth #DigitalMentalHealth @StevenChanMD

CURRENT USES

As a communications medium. As an extension of face-to-face clinic. As intervention + new monitoring techniques.

OBJECTIVES

CHALLENGES OF MOBILE HEALTH: RESEARCH METHODOLOGIES ARE OUTDATED

•  Way too many apps, pilots •  Lack of standardization •  Lack of sound methodology •  Lack of data interoperability & systems

integration

Tomlinson et al., 2013

CHALLENGES OF MOBILE HEALTH: RESEARCH METHODOLOGIES ARE OUTDATED

“The emerging field of mobile health“. Steven R. Steinhubl,* Evan D. Muse, Eric J. Topol. Science Translational Medicine. 15 April 2015

CHALLENGES OF MOBILE HEALTH: RESEARCH USES OLDER TECHNOLOGIES

3-6 y 6-7 y ½-2y

up to 15 years

15 years ago

CHALLENGES OF MOBILE HEALTH: NIH MHEALTH TRAINING INSTITUTE

NIH mHealth Training Institute. See obssr.od.nih.gov

MHIMSS EVALUATION METHODS

http://www.mhimss.org/sites/default/files/resource-media/pdf/HIMSSguidetoappusabilityv1mHIMSS.pdf

Selecting a Mobile App: Evaluating the Usability of

Medical Applications

mHIMSS App Usability Work Group

July 2012

Table 2 – Usability Principle Attribute Checklist Usability Principle

Mobile Design Tenet

Example attributes of a “usable” app

Let data scream

Only information, visual elements and functionality necessary to core tasks and decisions are included. Important information stands out, and function options are easy to understand. The focus is the data. The app has a clear, clean, uncluttered screen design.

Speak my sign

What interface?

Screen metaphors are familiar to everyday life, or commonly expected computer experiences for the clinician. Workflows match the clinical practice needs. The app is intuitive and easy to learn; minimal, if any, training is required. Iconography and symbols speak “naturally.”

Grid it Graphic design and layout have the same look and feel, consistent placement of screen elements (e.g., gutters, columns, margins and captions). Terminology and data entry fields are used consistently. Understanding how one screen works helps you understand how other screens work.

Date your users It’s hard to lose data or destroy time-consuming effort with a wrong tap or wrong choice of buttons. If you make a mistake, the app helps you avoid it or provides a method to recover from errors gracefully (the system is “forgiving”). The app provides informative feedback about actions you are about to take or have taken. The app displays explanatory messages when processing information and describes how long it might take.

Speak my sign

Date your users

The app uses the same words that you use (while providing mapping to standardized codes and terms used for data retrieval). List or entry-form choices are clear and unambiguous. Sentences read like your native language (e.g. English).

What interface?

Get physical

The app minimizes the number of steps/gestures it takes to complete tasks; appropriate defaults are always provided. The app provides navigation options such as shortcuts for frequent and/or experienced users. Navigation methods minimize movements, such as

Simplicity

Naturalness

Consistency

Forgiveness and Feedback

Effective Use of Language

CHALLENGES OF MOBILE HEALTH: EVALUATING APPS

http://www.wellocracy.com — Partners Healthcare

CHALLENGES OF MOBILE HEALTH: EVALUATING APPS

http://www.adaa.org/finding-help/mobile-apps

Presented at American Psychiatric Association Annual Meeting 2015

DATA & PRIVACY OVERVIEW BY GLENN ET AL.

“Predictive modeling, referred to by the advertising community as behavioral targeting, is used to bring specific advertisements to online users based on their perceived interests… Target predicted that a customer was pregnant due to purchasing patterns…”

Curr Psychiatry Rep (2014) 16:494 DOI 10.1007/s11920-014-0494-4

DATA & PRIVACY OVERVIEW BY GLENN ET AL.

“This incident also highlighted that personal health information can be created by combining seemingly innocuous data, and that a predictive model outside of HIPAA protection can cause harm whether or not it is accurate.” — Tasha Glenn, Scott Monteith

Curr Psychiatry Rep (2014) 16:494 DOI 10.1007/s11920-014-0494-4

NATIONAL HEALTH SERVICE — APP STORE RISKS

Huckvale et al. BMC Medicine (2015) 13:214 DOI 10.1186/s12916-015-0444-y

Of 27 apps [using online API’s], 16 (59 %, n = 16/27) allowed unencrypted access. Two apps had critical vulnerabilities which permitted access to user information, including information belonging to other users, without authorization.

Half of apps (50 %, n = 35/70) included strong identifiers in transmitted information. Two-thirds of these (66 %, n = 23/35, 29 % of all apps) sent identifying information without encryption, including email addresses (n = 5), account login details (n = 5), full name (n=2) or date of birth (n=2).

[Of the apps with privacy policies,] for a small number (4 %, n = 2/49) information handling was completely consistent with commitments made by the policy. However, while no apps transmitted information where a specific commitment had been made not to, four-fifths either collected (82 %, n = 42/49) or transmitted (78 %, n = 38/49) one or more data items not addressed by a policy.

THREE KEYS TO INCORPORATING APPS

1  Use reputable institutions & verified developers.

2  Try an app yourself first. If an average person can use it — prescribe it.

3  Informed consent on security, privacy, and lack of testing is key.

OBJECTIVES

FUTURE: INPATIENT�OUTPATIENT�HOME

http://www.tedeytan.com/wp-content/uploads/2011/06/Kaiser-Permanente-Innovation-Journey-11.jpg

WHY SHOULD WE CARE? PATIENTS WILL MANAGE THEIR OWN HEALTH.

“People with psychotic disorders were able and willing to use e–mental health services. Results suggest that e–mental health services are at least as effective as usual care or nontechnological approaches.” Lian van der Krieke, M.Sc., M.A. Lex Wunderink, M.D., Ph.D. Ando C. Emerencia, M.Sc. Peter de Jonge, Ph.D. Sjoerd Sytema, Ph.D. E–Mental Health Self-Management for Psychotic Disorders: State of the Art and Future Perspectives.” Psychiatric Services 65:33–49, 2014; doi: 10.1176/appi.ps.201300050

PEOPLE CAN’T AFFORD MENTAL HEALTH

“According to SAMHSA’s 2014 National Survey on Drug Use and Health (NSDUH), 43.6 million people had a mental illness in the past year. But fewer than half received treatment. That’s one in five Americans over the age of 18.” — Paolo del Vecchio, M.S.W., Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration

http://blog.samhsa.gov/2015/10/05/accelerating-access-to-mental-health-treatment/

Art by Regina Holliday, Stanford Medicine X 2014

http://participatorymedicine.org

Jeana H Frost, PhD; Michael P Massagli, PhD. ”Social Uses of Personal Health Information Within PatientsLikeMe, an Online Patient Community: What Can Happen When Patients Have Access to One Another’s Data” http://www.jmir.org/2008/3/e15/.

WHY SHOULD WE CARE? OUTPATIENT SURVEY

Harvard

LSU New Orleans

UC Davis Sacramento Cty

U Wisconsin, Madison

Harvard

LSU New Orleans

UC Davis Sacramento Cty

U Wisconsin, Madison

State n=106

Private n=108

County n=56

County n=50

36.2 y

39.6 y

44.7 y

43.9 y MEAN AGE

Pending publication. John Torous, MD; Steven Chan, MD MBA; Marie Tan, MD; Jake Behrens, MD; Ian Mathew, BS; Ladson Hinton, MD; Peter Yellowlees, MD MBBS; Matcheri Keshavan, MD.

OUTPATIENT SURVEY STATISTICS

33 25 6 37

53 17 13 17

62 9 17 13

72 16 5 8

0 25 50 75

County 1

County 2

Private

Clinic Type

Percentage

nership and Willingness

Has Sm

artphone and Willing

artphone but Willing

Has Sm

artphone but Unw

illing

artphone and Unw

illing

Has smartphone + Willing

No smartphone + Willing

Has smartphone + Unwilling

No smartphone + Unwilling

county 1

county 2

private

73 16 5 5

59 16 9 15

29 25 11 35

33 18 6 42

0 25 50 75

Under 30

31 − 45

46 − 60

Over 60

Age Groups

Percentage

nership and Willingness

Has Smartphone and W

illing

No Smartphone but W

illing

Has Smartphone but Unwilling

No Smartphone and Unwilling

OUTPATIENT SURVEY STATISTICS

Has smartphone + Willing

No smartphone + Willing

Has smartphone + Unwilling

No smartphone + Unwilling

<30 yo

31-45 yo

46-60 yo

>60 yo

OUTPATIENT SURVEY DISCUSSION

•  58% ownership of smartphones�mirrors national U.S. 58% ownership

•  71.4% psychiatric outpatients are favorable to the idea of using smartphones for MH

•  Age matters: Younger use >> older •  Socioeconomic status matters:

Private insurance >> public patients Pending publication. John Torous, MD; Steven Chan, MD MBA; Marie Tan, MD; Jake Behrens, MD; Ian Mathew, BS; Ladson Hinton, MD; Peter Yellowlees, MD MBBS; Matcheri Keshavan, MD.

OUTPATIENT SURVEY LIMITATIONS

•  Use of app hypothetical; not verified practice •  Selection bias�what about non-volunteers? •  No individual diagnoses •  No control for differences in smartphone

ownership rates in each community

DIGITAL HEALTH OVERVIEW

104 M in the U.S. own smartphones Mobile healthcare & medical app downloads reach 44 M in 2012, rising to 142 M in 2016 McKinsey projects opportunities in global mHealth to be $60 B 19% of smartphone users have health apps

http://rockhealth.com/healthcare-and-digital-health-facts/

DIGITAL HEALTH FUNDING YEAR-TO-YEAR

Technology will change the way we practice mental health.

SPEECH ANALYSIS

EYE & FACE RECO

SMART CLOTHING

INGESTIBLES

Tasha Glenn, Scott Monteith. ” New Measures of Mental State and Behavior Based on Data Collected From Sensors, Smartphones, and the Internet” Curr Psychiatry Rep (2014) 16:523 DOI 10.1007/s11920-014-0523-3

WEARABLE DEVICES

ADVANTAGES OF MOBILE HEALTH: MOBILE

•  Just-in-time context-aware interventions •  Portable � location-independence •  Low-power � low- to middle-income

countries with less-established infrastructure •  Lower cost than traditional desktop

computers

Hilty et al. 2013, Harrison et al. 2011, Klasnja & Pratt, 2012; WHO Global Observatory for eHealth and WHO, 2011

ADVANTAGES OF MOBILE HEALTH: OPPORTUNITIES FOR OBJECTIVE INFORMATION.

FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION.

location

accelerometer

net usage

text analysis

voice pattern

light & imaging

depression

anxiety

stress

suicidality

wandering

smartphones

eye trackers

smart clothing

ingestibles

wearables

FUTURE TRENDS: INTERVENTION + MONITORING TECHNIQUES

AiCure.com - http://files.abstractsonline.com/CTRL/6d/a/1ab/bbf/190/4b6/1a2/5d9/579/e23/0d4/41/g632_4.jpg

Proteus bio-sensor — variant of image from http://www.turkiyegazetesi.com.tr/dunya/70817.aspx

The Colbert Report

FUTURE: GERIJOY

GERIJOY

GEPPETTO AVATARS

http://www.xconomy.com/wisconsin/2014/05/15/geppetto-avatars-aims-to-read-your-emotions-keep-you-healthy/?single_page=true

SPECIFIC PHOBIAS

SOCIAL ANXIETY D/O

ALCOHOL USE D/O

RELAXATION

Psious

Affordable virtual reality can enhance psychotherapy.

FUTURE TRENDS: VIRTUAL REALITY

$40-$350 per unit

Oculus Rift

$40-$350 per unit

Oculus Rift

Springer

FUTURE TRENDS: GEORGIA TECH — GOOGLE GLASS

FUTURE TRENDS: GOOGLE GLASS

Sension. http://www.wired.com/2013/08/catalin-voss/ , http://www.medicaldaily.com/google-glass-vs-autism-how-face-tracking-and-emotion-response-are-putting-18-year-old-catalin-voss

FUTURE TRENDS: GOOGLE GLASS + BRAIN POWER FOR AUTISM

https://developer.ibm.com/watson/blog/2015/03/23/ibm-watson-personality-insights-science-behind-service/

Machine learning & big data to drive population health and individual health.

Dror Ben-Zeev, 2013, at mHealthSummit, Oxon Hill, MD

FUTURE: INSTAGRAM & SUICIDE

Presented 3 May 2014 at American Psychiatric Association 2014 meeting

“Social media may be a tool to identify those at risk for suicide and self-harm, to improve mental health stigma, and to provide valuable mental health resources.” – Arshya Vahabzadeh MD,

Holly Peek MD MPH

www.PosterPresentations.com

AIMS AND OBJECTIVES

METHODS

Quantitative and Qualitative Analysis

DiscussionA Content Analysis and Policy Discussion of Posts Tagged #Suicide on Instagram

Arshya Vahabzadeh M.D.1 Holly Peek M.D. MPH2

1Massachusetts General Hospital and Harvard Medical School, Boston, USA

2Tulane University School of Medicine, New Orleans, USA

INTRODUCTION

References

1. http://www.pewinternet.org/2012/07/11/teens-2012-truth-trends-and-myths-

about-teen-online-behavior/

2. http://www.cnet.com/news/why-teens-are-tiring-of-facebook/

3. Kross E, Verduyn P, Demiralp E, Park J, Lee DS, Lin N Shablack H, Jonides

J, Ybarra O. Facebook use predicts declines in subjective well being of young

adults. PLoS One. 2013 8(8):e69841.

4. Krasnova H, Wenninger H, WidjajaT, Buxmann P. Envy on Facebook: A

Hidden Threat to Users’ Life Satisfaction? 11th International Conference on

Wirtschaftsinformatik, Leipzig, Germany, Feb 27-March 1 2013.

5. Moreno MA, Christakis DA, Egan KG, Jelenchick LA, Cox E, Young

H, Villard H, Becker T. A pilot evaluation of associations between displayed

depression references on Facebook and self-reported depression using a

clinical scale. J Behav Health Serv Res Jul 2012; 39(3): 295-304.

6. Abrutyn S, Mueller AS. Are suicidal behaviors contagious in adolescence?

Using longitudinal data to examine suicide suggestion. American Sociological

Review, published online 14 February 2014.

7. Gould M, Jamieson P, Romer D. Media Contagion and Suicide Among the

Young. American Behavioral Scientist. May 2003; 46(9): 1269-1284.

8. Livingston JD, Cianfrone M, Korf-Uzan K, Coniglio C. Another time point, a

different story: one year effects of a social media intervention on the attitudes of

young people to mental health issues. Soc Psychiatry Psychiatr Epidemiol.

Published online January 9 2014.

Social media is popular among teens, with 80% of those aged

12-17 using social media (1). The posting of photos and videos is

one of the most frequent activities on social media in this age

group (1). Instagram, a picture-based social media platform with

over 100 millions users, is the top photo sharing outlet, with 1 in

10 teens visiting the site each month (2).

Despite its popularity, there is growing concern that some users

of social media experience negative mental health effects (3, 4).

Social media sites have also been shown to elicit high levels of

self-disclosure which include references to health risk behaviors

such as depressive symptoms or suicidality (5). Alarmingly,

media stories have highlighted instances where suicides were

referenced on social media sites before being carried out,

drawing attention to the urgent need to examine these

references.

The influence of suicidal content posted on social media is

concerning, particularly for adolescents as they frequently imitate

behaviors of their peers, a phenomenon known as “social

modeling.” Media research demonstrates that the young are

particularly vulnerable to portrayals of suicide in mass media

(6,7).

Because of the increased rates of self-disclosure, which include

serious imagery or allusions to depression and suicide, and the

vulnerability of adolescents to the suicidal content in the media,

Instagram states that it has a policy of removing content that

promotes suicidal or self-harming acts.

Given the concerns for suicide and self-harm risk for adolescent

users of social media, we performed an exploratory study that

analyzed if Instagram's policy is effective in removing suicidal or

self-harm content, and also to describe the content that is

labelled by users with the hashtag identifier “#suicide".

A search on Instagram was created using the search term

"#suicide" and a content analysis was performed on the first 60

resulting images. These images were quantitatively analyzed by

two reviewers. Content was categorized by the presence of

pictures or quotes and then further subcategorized.

Subcategories included content perceived by both reviewers as

being depressive, suicidal, self-injurious, eating disordered,

reflective, neutral, humorous, or positive. The categories were

not mutually exclusive. The images containing suicidal and self-

harm content were further analyzed for other qualitative themes.

Quantitative analysis revealed 42% of the images contained

pictures and 58% contained quotes. Distribution of the themes

were as follows: 50% depressive; 15% suicidal; 12% self-

injurious; 5% positive; 3% eating disordered; 16% neutral; 3%

humorous; 13% reflective.

Key Findings:

89% of suicidal themed images were either idolizing,

romanticizing, or promoting methodology or locations of

suicide according to the reviewer analysis - factors which

are linked to an increased risk of suicide.

Qualitative analysis for the suicidal theme revealed the

following:

• No images for suicide help resources

• All of those posting were female

• Four images visually demonstrated actual methods of suicide,

two with hanging and two with pill overdose

• Three images demonstrated text only, including a suicide note

and other expressions of a desire to die

• One image of a self-portrait with a suicidal caption

• One image with a humorous overtone

Qualitative analysis for the self-injurious theme revealed the

following:

• No images for self-injury help resources

• All of those posting were female

• All images depicted a variation on the theme of cutting

• Four images showed bleeding cuts, including active cutting

• One image was instructive on the method of cutting

• One image described the cuts as "beautiful“

• One image with an encouraging overtone of healing with self-

injury

Our findings show that Instagram’s policy of identifying “any

account found encouraging or urging users to embrace anorexia,

bulimia, or other eating disorders; or to cut, harm themselves, or

commit suicide” resulting in a “disabled account without warning”

as ineffective. Searching “#suicide” reveals a majority of images

that romanticize and idealize suicidal, self harm or depressive

themes including graphic images that are either instructional or

suicidal acts in progress. Alarmingly, only 5% of the images send

a positive message discouraging suicidal or self-harm behaviors.

Furthermore, absolutely no informational or crisis intervention

resources are provided within the content of the search.

When searching “#suicide” on Instagram, a disclaimer does

appear advising that the searched images may contain graphic

content and gives an option to “learn more” by redirecting to an

outside website for suicide prevention or to alternatively “show

posts.” The option to be redirected to a website is a nominal

effort in promoting suicide prevention in that suicide prevention

information can be easily bypassed by viewing the graphic posts

where no suicide prevention resources are available.

We suggest the addition of suicide prevention information and

resources within the search content rather than an optional

redirection to an outside website. Evidence has shown that youth

are increasingly seeking health information online and through

social media. Social media campaigns can potentially be a

successful tool in learning about mental health symptoms,

reducing stigma and increasing awareness of mental health

services (8).

Given the growing popularity of social media among youth, we

must engage with social media networks and the wider public to

ensure that these issues do not go unnoticed and attempts are

made to remedy them.

Depressive

Suicidal

Self Injurious

Eating DisorderSubstance Use

Neutral

Reflective

Content of #Suicide in % of tagged Instagram

Images (n=60)

Poster wasfemale

A method of

suicideText based

suicidal ideaPhoto based

suicidal ideaHumorous

overtone

Content of Suicidal Themed Images (n=9)

Poster wasfemale

Injury bycutting

Bleeding

cuts/Activecutting

Advice forcutting

Labelling

cutting as

beautiful

Cutting ashealing

Content of Self-Injury Themed Images (n=7)

-Recognize social media is popular among adolescents and is a

vehicle many use for self-disclosure, including references to

suicide and self-harm.

-Recognize the lack of enforcement of the policies aimed at

preventing graphic suicidal and self-harm imagery on social

media sites, such as Instagram.

-Recognize that the exposure to idolized and romanticized

imagery of suicide, it’s methodology, and potential locations are

linked to suicide attempts.

-Recognize that social media may be a tool to identify those at

risk for suicide and self-harm, to improve mental health stigma,

and to provide valuable mental health resources.

Results

FUTURE IS NOW: FACEBOOK BUILT-IN SUICIDE FLAGS

SPARX CBT GAME

Merry S, Stasiak K et al. The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2598 (Published 19 April 2012) http://www.bmj.com/content/344/bmj.e2598. Also covered at http://www.imedicalapps.com/2014/01/video-game-depression-anxiety-kids-diabetes-asthma-linkedwellness/

ADVANTAGES OF MOBILE HEALTH: CAN BE MORE ENGAGING.

Curr Psychiatry Rep. 2014 Dec;16(12):520. doi: 10.1007/s11920-014-0520-6. The use of electronic games in therapy: a review with clinical implications. Horne-Moyer HL1, Moyer BH, Messer DC, Messer ES.

“The use of electronic games in therapy: a review with clinical implications”

Mental health is the new frontier for digital health.

http://www.technologyreview.com/news/541446/why-americas-top-mental-health-researcher-joined-alphabet/

“Technology can cover much of the diagnostic process ... Also, a lot of the treatments for mental health are psychosocial interventions, and those can be done through a smartphone.”

— Thomas Insel, M.D., Sept 21, 2015

Fragmented systems create opportunity for new mental health platforms.

HYPE CYCLE

Source: Gartner: July 2014. Hat-tip to Kathryn Hautanen, MS, SM, MBA , Kaiser Permanente.

expectations

Innovation triggers

Peak of inflated expectations

Trough of disillusionment

Plateau of productivity

THANK YOU Steven Chan MD MBA • UC Davis Psychiatry THANKS TO JOHN TOROUS, DON HILTY, PETER YELLOWLEES, LADSON HINTON, JAKE BEHRENS, SHIH-YEE MARIE TAN, APA/SAMHSA MINORITY FELLOWSHIP PROGRAM.

OBJECTIVES

h/t Nick Dawson

“We can’t…”

“How might we…”

KAISER PERMANENTE INNOVATION

HACKATHONS & CHALLENGES

INTRODUCING

INSTANTANEOUS INTERPRETATION — ANY TIME, ANYWHERE

I’m feeling depressed today.!Me siente depremido hoy.!

Telepsychiatry Synchronous & asynchronous

INSTANTANEOUS INTERPRETATION — ANY TIME, ANYWHERE

Telepsychiatry Synchronous & asynchronous In person

REAL-TIME LANGUAGE INTERPRETATION

UC DAVIS TRANSLATION APP

FUTURE TRENDS: GOOGLE TRANSLATE

FUTURE TRENDS:

FUTURE TRENDS: SKYPE & CLOSED CAPTIONS

2010 U.S. CENSUS

of the population (over 5 years of age) had limited English-speaking abilities. This is nearly the size of Illinois.

REAL-TIME LANGUAGE INTERPRETATION: WHY IS LANGUAGE IMPORTANT?

•  In 2002, approx. 6 million immigrant adults aged 18-64 did not speak English well. More than 2.5 million did not speak English at all.

•  Professionally-trained interpreters are often not available in community-based practices.

•  Failure to use interpreters� – � hospital admission rates – �use of testing – poorer patient comprehension – misdiagnosis and improper treatment

SACRAMENTO COUNTY LANGUAGES

90+ non-English languages, like

Spanish Miao Chinese Vietnamese Tagalog

Russian Ukranian Hindi German Hmong

Patient

Provider

Live interpreter

Patient

Provider

Live interpreter

Patient

Provider

Patient

Provider

Ad hoc

• untrained staff • family • children

Patient

Provider

CAPTIONS

SPEECH

ULTIMATE GOAL

•  Analyze language as data.

•  Create new clinical processes for in-person care and telemedicine.

•  Create a better standard of care with improved interpreting, more efficiently, and less expensively.

PRELIMINARY TRANSLATION TESTS

English Tell me about your girlfriends. They were animals. Pick one, and tell me about her. I met a woman last year; she was a stray cat. Why do you say she was a stray cat? She had no connections. What was it that you were attracted to? Her body. Okay. What kicked in about her personality later? What do you mean? If I met her, what would I notice about her? It's tough to answer. Her attitude. How was that? It was good. What do you think you'll be doing in five years, and what would you like to be doing? I'll probably be dead. I'd like to be a physician.

From Daniel J Carlat’s The Psychiatric Interview 2nd Edition. “Obtaining the Social and

Developmental History." pp.104-105

English Tell me about your girlfriends. They were animals. Pick one, and tell me about her. I met a woman last year; she was a stray cat. Why do you say she was a stray cat? She had no connections. What was it that you were attracted to? Her body. Okay. What kicked in about her personality later? What do you mean? If I met her, what would I notice about her? It's tough to answer. Her attitude. How was that? It was good. What do you think you'll be doing in five years, and what would you like to be doing? I'll probably be dead. I'd like to be a physician.

Bing Translator EN�ES�EN Tell me about your friends. C They were animals. Choose one and tell me about it. P I met a woman last year; It was a stray cat. P Why you say that it was a stray cat? P It had no connection. P What was it that attracted you? Your body. P, C It is ok. He kicked him later about his personality? N, P What do you mean? If I knew her, would count on it it? N, P It is difficult to answer. His attitude. P How was that? It was good. What do you think to be doing in five years, and what would you like to do? I will probably be dead. I'd like to be a doctor.

Odd pronouns Non-sensical

Critical error

English Do you have any thoughts about what might have prompted your wife to call the ambulance? It sounds like you’ve been very sad since your mother’s death, and that her death after so many years of suffering has also felt like a relief. You look very sad. I know you have much to tell me, but I need to shift to getting some basic information. I see you’ve thought a lot about the previous treatment team, but could you tell me when you had that last hospitalization?

From John Barnhill’s “Chapter 1. The Psychiatric Interview and Mental Status Examination”. The American Psychiatric

Publishing Textbook of Psychiatry . 6th Edition.

English Do you have any thoughts about what might have prompted your wife to call the ambulance? It sounds like you’ve been very sad since your mother’s death, and that her death after so many years of suffering has also felt like a relief. You look very sad. I know you have much to tell me, but I need to shift to getting some basic information. I see you’ve thought a lot about the previous treatment team, but could you tell me when you had that last hospitalization?

You have any idea about what could be done for his wife to call the ambulance? C It seems that you've been very sad since the death of his mother, and that he also felt his death after so many years of suffering as a relief. C You feel very sad. I know that you have much to say, but I need to change to get some basic information. I see that you thought much about pretreatment equipment, but could you tell me when was that last hospitalization? N

Bing Translator EN�ES�EN

Non-sensical

Critical error

INTRODUCING

Telemedicine 1999

SPECIALTY CARE VIDEO CONFERENCING

ASYNCHRONOUS TELEPSYCHIATRY

Clinician Nurse, Counselor, Therapist, or Resident

Patient

Video is routed to psychiatrist.

EQUIPMENT IS MOBILE

Cameras

Videoconferencing software

Dedicated speakerphone

ASYNCHRONOUS TELEPSYCHIATRY WORKFLOW

PRIMARY CARE PROVIDER

PATIENT-CLINICIAN“VIRTUAL VISIT”

PSYCHIATRISTVIDEO

CONSULTNOTE

STORE ON VIDEO FILES

STEP 1:Provider refers patientto telepsychiatry.

STEP 5:We measure satisfaction,symptoms & outcomesevery 6 months.

STEP 2:A video of the patientinterview is recorded

STEP 3:Video & history sent securelyto consulting psychiatrist.

STEP 4:The specialist’s consult &recommendations are sentto primary care provider.

ATP SUMMARY OF FINDINGS

Diagnostically reliable across differing language groups with translation

Not suggested for therapy

Can be used for monitoring treatment progress

Easier management/admin/scheduling

Improved communication between patient and reporting provider

THE VCC TEAM

•  Peter Yellowlees MD •  Alberto Odor MD •  Lorin Scher MD •  Michelle Parish MA •  Steven Chan MD •  Breanne Harris BA •  Glen Xiong MD •  Robert McCarron MD •  Andres Sciolla MD •  Anna-Maria Iosif PhD •  Paul Leigh PhD

•  Bill Brady MD and Auburn Clinic staff – UCD PCN

•  Scott MacDonald MD and J St Clinic staff – UCD

•  Communicare FQHC staff •  CHT technical team – George

Wu, Kalim Simon •  EMR Epic team – Mike Minear

and Hien Nguyen MD •  Psychiatry Outpatient Clinic –

Becky Mackey •  Don Hilty MD USC •  Jay Shore MD U Colorado

h/t Nick Dawson

“We can’t…”

“How might we…”

OBJECTIVES

THANK YOU Steven Chan MD MBA • UC Davis Psychiatry THANKS TO JOHN TOROUS, DON HILTY, PETER YELLOWLEES, LADSON HINTON, JAKE BEHRENS, SHIH-YEE MARIE TAN, APA/SAMHSA MINORITY FELLOWSHIP PROGRAM.

#DIGITALMENTALHEALTH @StevenChanMD • @UCDavisHealth THANKS TO JOHN TOROUS, DON HILTY, PETER YELLOWLEES, LADSON HINTON, JAKE BEHRENS, SHIH-YEE MARIE TAN, APA/SAMHSA MINORITY FELLOWSHIP PROGRAM, UC DAVIS PSYCHIATRY & BEHAVIORAL HEALTH CENTER OF EXCELLENCE.

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