Can technology transform mental health care?

As with all of healthcare, mental health is using technology to try and fill economic gaps.
By Irv Lichtenwald
11:52 AM
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Any conversation focused on what's great about America usually includes a mention of optimism, hopefulness or some variation on the theme.

Americans generally still believe in a brighter future, and especially the ways in which technology can enable that future. But that sense of optimism contains a kernel of potential disappointment when we ask technology to do too much.

Consider the case of mental health care, a profession that faces massive budget shortfalls.

According to Robert Glover, executive director of the National Association of State Mental Health Program, from 2009 to 2012 states cut roughly $5 billion in mental health services and eliminated about 4,500 public psychiatric beds. As with all of healthcare, mental health is using technology to try and fill economic gaps.

Of the roughly 40,000 health apps available for smartphone, there are about 800 apps oriented around mental health. So, if the key to effective therapy, as most professionals argue, is human interaction, can apps provide any benefit at all? According to David Mohr, professor of preventive and behavioral medicine at Northwestern University, the answer is yes.

"A large body of clinical research shows that web-based and phone applications can treat depression and anxiety," writes Mohr in the New York Times' Room for Debate opinion page. "To be effective, behavioral intervention technologies (B.I.T.s) require repeated use over a number of weeks -- an obstacle because many people with depression or anxiety have trouble staying engaged long enough to make substantial improvements." 

That last part seems relevant and important. If technology shortens attention spans and perhaps makes us less patient, then mental illness would seem to exacerbate that scenario.

"Immersing myself in a book or a lengthy article used to be easy," writes Guy Billout in his landmark 2008Atlantic essay "Is Google Making Us Stupid?" "That's rarely the case anymore. Now my concentration often starts to drift after two or three pages. I get fidgety, lose the thread, begin looking for something else to do. I feel as if I'm always dragging my wayward brain back to the text. The deep reading that used to come naturally has become a struggle."

Studies focused on the use of health apps, the overwhelming majority of which deal with diet and exercise, suggest guarded optimism and unmet potential. In the popular technology vernacular, there is no 'killer app.'

"These findings suggest that while many individuals use health apps, a substantial proportion of the population does not," write the authors of a recent study on health app use in their abstract conclusion, "and that even among those who use health apps, many stop using them."

The idea of staying engaged--of coming back again and again to ideas and ways of thinking that alter perspectives and patterns--seems essential to improved mental health. (Mohr says as much when he references "repeated use over a number of weeks.") But technology seems to create the exact opposite--detachment instead of engagement.

"One of the most significant problems with apps is the high attrition rate: People begin using them but often tire of the required dedication quickly," writes Matthew Hertenstein, an associate professor of psychology at Depauw University, in the same New York Times Room for Debate op-ed. "More important, using an app doesn't allow individuals to deeply connect to other humans – be they therapist or friend."

That deep connection is crucial because, as Galit Atlas, faculty in NYU's postdoctoral psychotherapy and psychoanalysis program, says, "Psychological pain, including depression and anxiety, emerges largely in response to problematic human relations and traumatic history, and it is healed through a human relationship."

While smartphone apps may not provide that human bond, they may still prove useful to mental health professionals because they track our every movement. Writing for thedoctorweighsin.com, John Torous and John Sharp, both physicians associated with Harvard University, suggest that smartphones may be a great source of "passive data" on patients struggling with depression.

"The symptoms of depression can vary greatly between people and are made even more complex by other co-morbid psychiatric conditions … Sometimes worsening depression can also cause cognitive changes so that those suffering do not fully realize the extent of the illness or their symptoms."

Contrast the perspectives on mental health apps with those related to telemental health, the use of telecommunications technology to make mental health services available where few professionals reside. The National Institute of Mental Health reports that half of U.S. counties have no mental health professionals even while the Affordable Care Act's insurance mandates make mental health care more readily available.

According to an article in Behavioral Healthcare, "… patients surveyed have consistently stated that they believe telemental health to be a credible and effective practice of medicine, and studies have found little or no difference in patient satisfaction as compared with face-to-face mental health consultations."

With telemental health, the technology does not seem to be an obstacle. In some ways this seems intuitive. We probably all have the experience of establishing or prolonging strong relationship bonds through technology. Decades ago, a weekly phone call with distant relatives re-established emotional connections. Now, a video chat on Skype bonds service men and women to families back home. Can't a similar relationship be built through regular interaction with a therapist? According to a five-year study of telemental health at the VA, the answer is yes.

And then there are electronic health records (EHRs), by comparison a venerable technology available for mental health care that proliferates in acute care thanks to federal Meaningful Use stimulus. No, EHRs don't give patients an electronic tool with which to heal themselves, if such a thing is possible. They don't readily connect patients who live where there are no psychiatrists and psychologists to professionals where there are many.

But interoperable EHRs do tell an emergency room doctor that the guy who just walked in with a broken arm also suffers from bipolar disorder and might be off his meds. They connect members of a treatment team and save them the hassle of having to assemble paper notes. They make it easier to know what coverage a patient has and what his insurance company will pay for.

Most importantly, given the frequency of co-morbidity in mental health patients, EHRs are the technological enabler of coordination across the continuum of care with the patient and patient's family at the center. It will be difficult to transform the care model and access relevant and timely information without EHRs.

Our relationship with technology is not unidirectional. We use it, and it changes us. But it cannot alter fundamental realities regardless of how hopeful Americans are or how much faith we have in it. More and better technology is not a substitute for adequate funding and coordinated planning, especially when we're talking about the very significant funding issues around behavioral health.

Sure, we can get excited about the newest app and the latest EHR functionality, but we must also maintain a focus on meeting the needs of the mental health professionals committed to keeping our fellow citizens from falling through the cracks.

Even while there is no magic in technology, there is also no reason to believe we can't fix a broken mental health system through hard work, empathy and thoughtful planning. Time and again, our faith in those principles has been rewarded.