digital mental health - uc berkeley - without hidden - reduced
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@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
None.
#DigitalMentalHealth
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
Patient
Provider / Doctor / Nurse
Live interpreter
Collateral Caregivers
Family
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
IMAGE: : http://www.dentaleconomics.com/content/dam/diq/online-articles/2014/06/vitalsigns.jpg
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
time
happy
neutral
sad
Feeling down No pleasure Suicidal plans & intent
unipolar depression
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
happy
neutral
sad
time
bipolar hypomania bipolar mania
overexcitement euphoria delusions overactivity
bipolar depression
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
time
medicines
talk therapy
calm environment
case management &
support
happy
neutral
sad
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
CURRENT USES: AS A COMMUNICATIONS MEDIUM
https://play.google.com/store/apps/details?id=com.doctorondemand.android.patient&hl=en
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
CURRENT USES: AS A COMMUNICATIONS MEDIUM
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
CURRENT USES: AS A COMMUNICATIONS MEDIUM
• Doctors on Demand • HealthLinkNow • American Well • 1docway • Talkspace • MDLive Breakthrough
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
CURRENT USES: AS A THERAPY AND INTERVENTION
• Self-monitoring activities & moods • Encouraging therapy homework • Case management for relapse
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
T2 APPS (NATIONAL CENTER FOR TELEHEALTH & TECHNOLOGY) ON GOOGLE PLAY
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
VA APP STORE — MOBILEHEALTH.VA.GOV
11 total mental health apps
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VA — PTSD COACH
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VA — MINDFULNESS COACH
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HEADSPACE MEDITATION
https://itunes.apple.com/us/app/headspace.com-meditation-mindfulness/id493145008?mt=8
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
MY3
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
SAM
http://www.imedicalapps.com/2015/07/anxiety-app-review/
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
INTELLICARE
https://intellicare.cbits.northwestern.edu — http://clinicaltrials.gov/show/NCT02176226
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
INTELLICARE
https://intellicare.cbits.northwestern.edu — http://clinicaltrials.gov/show/NCT02176226
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
INTELLICARE
https://intellicare.cbits.northwestern.edu — http://clinicaltrials.gov/show/NCT02176226
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
MOODTREK
http://mood-trek.com/moodtrek-for-consumers/
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
MOODTOOLS
http://www.imedicalapps.com/2015/08/moodtools-no-frills-comprehensive-psychoeducation-psychotherapy-depression-app/
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
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MEDISAFE
http://mood-trek.com/moodtrek-for-consumers/
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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.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
OBJECTIVES
1 APPS YOU CAN USE 2 EVALUATING TECHNOLOGY 3 BIG PICTURE TRENDS 4 HOW MIGHT WE
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
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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
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CHALLENGES OF MOBILE HEALTH: RESEARCH USES OLDER TECHNOLOGIES
3-6 y 6-7 y ½-2y
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
CHALLENGES OF MOBILE HEALTH: RESEARCH USES OLDER TECHNOLOGIES
up to 15 years
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
CHALLENGES OF MOBILE HEALTH: RESEARCH USES OLDER TECHNOLOGIES
15 years ago
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
CHALLENGES OF MOBILE HEALTH: NIH MHEALTH TRAINING INSTITUTE
NIH mHealth Training Institute. See obssr.od.nih.gov
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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
v1.0
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
CHALLENGES OF MOBILE HEALTH: EVALUATING APPS
http://www.wellocracy.com — Partners Healthcare
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CHALLENGES OF MOBILE HEALTH: EVALUATING APPS
http://www.adaa.org/finding-help/mobile-apps
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
Presented at American Psychiatric Association Annual Meeting 2015
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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
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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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
NATIONAL HEALTH SERVICE — APP STORE RISKS
Huckvale et al. BMC Medicine (2015) 13:214 DOI 10.1186/s12916-015-0444-y
x79
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NATIONAL HEALTH SERVICE — APP STORE RISKS
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.
Huckvale et al. BMC Medicine (2015) 13:214 DOI 10.1186/s12916-015-0444-y
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NATIONAL HEALTH SERVICE — APP STORE RISKS
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).
Huckvale et al. BMC Medicine (2015) 13:214 DOI 10.1186/s12916-015-0444-y
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
NATIONAL HEALTH SERVICE — APP STORE RISKS
[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.
Huckvale et al. BMC Medicine (2015) 13:214 DOI 10.1186/s12916-015-0444-y
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
OBJECTIVES
1 APPS YOU CAN USE 2 EVALUATING TECHNOLOGY 3 BIG PICTURE TRENDS 4 HOW MIGHT WE
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE: INPATIENT�OUTPATIENT�HOME
http://www.tedeytan.com/wp-content/uploads/2011/06/Kaiser-Permanente-Innovation-Journey-11.jpg
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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/
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WHY SHOULD WE CARE? PATIENTS WILL MANAGE THEIR OWN HEALTH.
Art by Regina Holliday, Stanford Medicine X 2014
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
WHY SHOULD WE CARE? PATIENTS WILL MANAGE THEIR OWN HEALTH.
http://participatorymedicine.org
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WHY SHOULD WE CARE? PATIENTS WILL MANAGE THEIR OWN HEALTH.
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/.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
WHY SHOULD WE CARE? OUTPATIENT SURVEY
Harvard
LSU New Orleans
UC Davis Sacramento Cty
U Wisconsin, Madison
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
WHY SHOULD WE CARE? OUTPATIENT SURVEY
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
WHY SHOULD WE CARE? OUTPATIENT SURVEY
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.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
OUTPATIENT SURVEY STATISTICS
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.
33 25 6 37
53 17 13 17
62 9 17 13
72 16 5 8
0 25 50 75
100
State
County 1
County 2
Private
Clinic Type
Percentage
Ow
nership and Willingness
Has Sm
artphone and Willing
No Sm
artphone but Willing
Has Sm
artphone but Unw
illing
No Sm
artphone and Unw
illing
Has smartphone + Willing
No smartphone + Willing
Has smartphone + Unwilling
No smartphone + Unwilling
state
county 1
county 2
private
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
73 16 5 5
59 16 9 15
29 25 11 35
33 18 6 42
0 25 50 75
100
Under 30
31 − 45
46 − 60
Over 60
Age Groups
Percentage
Ow
nership and Willingness
Has Smartphone and W
illing
No Smartphone but W
illing
Has Smartphone but Unwilling
No Smartphone and Unwilling
OUTPATIENT SURVEY STATISTICS
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.
Has smartphone + Willing
No smartphone + Willing
Has smartphone + Unwilling
No smartphone + Unwilling
<30 yo
31-45 yo
46-60 yo
>60 yo
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
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.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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/
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
DIGITAL HEALTH FUNDING YEAR-TO-YEAR
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
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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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
ADVANTAGES OF MOBILE HEALTH: OPPORTUNITIES FOR OBJECTIVE INFORMATION.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION.
location
accelerometer
net usage
text analysis
voice pattern
light & imaging
mania
depression
anxiety
stress
suicidality
wandering
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION.
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
smartphones
eye trackers
smart clothing
ingestibles
wearables
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION.
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS: INTERVENTION + MONITORING TECHNIQUES
Proteus bio-sensor — variant of image from http://www.turkiyegazetesi.com.tr/dunya/70817.aspx
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS: INTERVENTION + MONITORING TECHNIQUES
The Colbert Report
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FUTURE: GERIJOY
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
GERIJOY
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
GEPPETTO AVATARS
http://www.xconomy.com/wisconsin/2014/05/15/geppetto-avatars-aims-to-read-your-emotions-keep-you-healthy/?single_page=true
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
SPECIFIC PHOBIAS
SOCIAL ANXIETY D/O
ALCOHOL USE D/O
PTSD
RELAXATION
Psious
Affordable virtual reality can enhance psychotherapy.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS: VIRTUAL REALITY
$40-$350 per unit
Oculus Rift
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS: VIRTUAL REALITY
$40-$350 per unit
Oculus Rift
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FUTURE TRENDS: VIRTUAL REALITY
Springer
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FUTURE TRENDS: GEORGIA TECH — GOOGLE GLASS
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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
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FUTURE TRENDS: GOOGLE GLASS + BRAIN POWER FOR AUTISM
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS: GOOGLE GLASS + BRAIN POWER FOR AUTISM
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION.
Dror Ben-Zeev, 2013, at mHealthSummit, Oxon Hill, MD
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FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
TEMPLATE DESIGN © 2008
www.PosterPresentations.com
1
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.
010
2030
4050
Depressive
Suicidal
Self Injurious
Eating DisorderSubstance Use
Neutral
Reflective
Humor
Content of #Suicide in % of tagged Instagram
Images (n=60)
0
1
2
3
4
5
6
7
8
9
Poster wasfemale
A method of
suicideText based
suicidal ideaPhoto based
suicidal ideaHumorous
overtone
Content of Suicidal Themed Images (n=9)
0
1
2
3
4
5
6
7
8
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE IS NOW: FACEBOOK BUILT-IN SUICIDE FLAGS
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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/
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
ADVANTAGES OF MOBILE HEALTH: CAN BE MORE ENGAGING.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
ADVANTAGES OF MOBILE HEALTH: CAN BE MORE ENGAGING.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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”
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
Mental health is the new frontier for digital health.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
Fragmented systems create opportunity for new mental health platforms.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HYPE CYCLE
Source: Gartner: July 2014. Hat-tip to Kathryn Hautanen, MS, SM, MBA , Kaiser Permanente.
expectations
time
Innovation triggers
Peak of inflated expectations
Trough of disillusionment
Plateau of productivity
@StevenChanMD @UCDavisHealth #DigitalMentalHealth #DigitalMentalHealth
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.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
OBJECTIVES
1 APPS YOU CAN USE 2 EVALUATING TECHNOLOGY 3 BIG PICTURE TRENDS 4 HOW MIGHT WE
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
h/t Nick Dawson
“We can’t…”
“How might we…”
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
KAISER PERMANENTE INNOVATION
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
KAISER PERMANENTE INNOVATION
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
KAISER PERMANENTE INNOVATION
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
KAISER PERMANENTE INNOVATION
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
KAISER PERMANENTE INNOVATION
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
KAISER PERMANENTE INNOVATION
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
KAISER PERMANENTE INNOVATION
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
KAISER PERMANENTE INNOVATION
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
HACKATHONS & CHALLENGES
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
INTRODUCING
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
INSTANTANEOUS INTERPRETATION — ANY TIME, ANYWHERE
I’m feeling depressed today.!Me siente depremido hoy.!
Telepsychiatry Synchronous & asynchronous
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
INSTANTANEOUS INTERPRETATION — ANY TIME, ANYWHERE
Telepsychiatry Synchronous & asynchronous In person
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
REAL-TIME LANGUAGE INTERPRETATION
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UC DAVIS TRANSLATION APP
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FUTURE TRENDS: GOOGLE TRANSLATE
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS:
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
FUTURE TRENDS: SKYPE & CLOSED CAPTIONS
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
2010 U.S. CENSUS
4.7%
of the population (over 5 years of age) had limited English-speaking abilities. This is nearly the size of Illinois.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
SACRAMENTO COUNTY LANGUAGES
90+ non-English languages, like
Spanish Miao Chinese Vietnamese Tagalog
Russian Ukranian Hindi German Hmong
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
Patient
Provider
Live interpreter
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
Patient
Provider
Live interpreter
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
Patient
Provider
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
Patient
Provider
Ad hoc
• untrained staff • family • children
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
Patient
Provider
CAPTIONS
SPEECH
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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.
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
PRELIMINARY TRANSLATION TESTS
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.
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PRELIMINARY TRANSLATION TESTS
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
INTRODUCING
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
Telemedicine 1999
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
SPECIALTY CARE VIDEO CONFERENCING
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
ASYNCHRONOUS TELEPSYCHIATRY
Clinician Nurse, Counselor, Therapist, or Resident
Patient
Video is routed to psychiatrist.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
EQUIPMENT IS MOBILE
Cameras
Videoconferencing software
Dedicated speakerphone
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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.
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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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
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
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
h/t Nick Dawson
“We can’t…”
“How might we…”
@StevenChanMD @UCDavisHealth #DigitalMentalHealth
OBJECTIVES
1 APPS YOU CAN USE 2 EVALUATING TECHNOLOGY 3 BIG PICTURE TRENDS 4 HOW MIGHT WE
@StevenChanMD @UCDavisHealth #DigitalMentalHealth #DigitalMentalHealth
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.
@StevenChanMD @UCDavisHealth #DigitalMentalHealth #DigitalMentalHealth
#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.