integrating mobile technologies into mental health treatment frederick muench, ph.d....

Integrating Mobile Technologies

intoMental Health Treatment

Frederick Muench, Ph.D.fmuench@nshs.edu

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).

Questions

fmuench@nshs.edu

Thank You