Evolving Psychiatry: Technology for Patient Care

Transcription

1 Evolving Psychiatry: Technology for Patient Care David C. Mohr, PhD Director, Center for Behavioral Intervention Technologies Professor, Department of Preventive Medicine Northwestern University, Feinberg School of Medicine Chicago, IL Julia Hoffman, PsyD National Director of Mobile Mental Health US Department of Veterans Affairs Menlo Park, CA 2015 Otsuka America Pharmaceutical, Inc., Rockville, MD MRC2.CORP.D advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare professional.

2 This program is paid for by Otsuka America Pharmaceutical, Inc. The speaker is a paid contractor of Otsuka America Pharmaceutical, Inc. 2 advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare professional.

3 PsychU Virtual Forum Rules of Engagement: Otsuka America Pharmaceutical, Inc. (OAPI) has entered into collaboration with Open Minds, L.L.C. to explore new ways of bringing/increasing awareness around serious mental illness. OAPI s interaction with Open Minds is through PsychU, an online, non-branded portal dedicated to providing information and resources on important disease state and care delivery topics related to mental illness. One of the methods employed for the sharing of information will be the hosting of virtual fora. Virtual fora conducted by OAPI are based on the following parameters: When conducting medical dialogue, whether by presentation or debate, OAPI and/or its paid consultants aim to provide the viewer with information that is accurate, not misleading, scientifically rigorous, and does not promote OAPI products. OAPI and/or their paid consultants do not expect to be able to answer every question or comment during a PsychU Virtual Forum; however, they will do their best to address important topics and themes that arise. OAPI and/or their paid consultants are not able to provide clinical advice or answer questions relating to specific patient s condition. Otsuka employees and contractors should not participate in this program (e.g., submit questions or comments) unless they have received express approval to do so from Otsuka Legal Affairs. OAPI operates in a highly regulated and scrutinized industry. Therefore, we may not be able to discuss every issue or topic that you are interested in, but we will do our best to communicate openly and directly. The lack of response to certain questions or comments should not be taken as an agreement with the view posed or an admission of any kind. 3

4 Learning Objectives To consider potential advantages that digital technology may offer in the assessment and management of mental illness To review existing technologies including digital psychosocial interventions, mhealth sensors, mobile device applications and telepsychiatry To discuss some of the challenges to the adoption of digital technology 4

5 Overview Digital technologies are intended to address some barriers to psychiatric care 1,2 Digital tools are designed to attempt to capture comprehensive, ecologically rich patient data and to enable in-the-moment interventions 3,4 Digital technologies have the potential to improve medication adherence through real-time monitoring 5,6 Clinical decision support technology is designed to assist physicians in clinical decision-making by providing patient-specific assessments and evidence-based information 7,8 Technology-assisted delivery of psychosocial interventions may increase access to care 9 and can augment traditional in-person psychological services 1 1. APA Council on Psychiatry & Law. 2014; Hilty DM, et al. Telemed J E Health. 2013;19: Ben-Zeev D, et al. Schizophr Bull. 2014;40: Kumar S, et al. Am J Prev Med. 2013;45: Velligan D, et al. Schizophr Bull. 2013;39: Frangou S, et al. Telemed J E Health. 2005;11: Berner ES. Agency for Healthcare Research and Quality Publication No EF. 8. Sim I, et al. J Am Med Inform Assoc. 2001;8: American Psychological Association. Accessed September 30,

6 Digital Technology Is Poised to Become the Fourth Wave of Evolution in Mental Health Care 1890s 1952 Psychoanalysis 1 Psychopharmacology s- 90s Evidence-based practice in mental health care 3, Digital psychiatry 5,6 Suboptimal treatment response remains an ongoing concern 7 1. Gleitman H, et al. Psychology. 8th ed. W. W. Norton & Company. 2011; Ahuja N. A Short Textbook of Psychiatry. 7th ed. Jaypee Brothers Medical Publishers (P) Ltd. 2011; Spring B. J Clin Psychol. 2007;63: APA Presidential Task Force on Evidence-Based Practice. Am Psychol. 2006;61: Kumar S, et al. Am J Prev Med. 2013;45: Mohr DC, et al. Gen Hosp Psychiatry. 2013;35: Lehman AF, et al. Am J Psychiatry. 2004;161:

7 There Are Many Barriers to Access to Optimal Mental Health Care in the United States SHORTAGE OF SHORTAGE OF MENTAL PROFESSIONALS HEALTH PROFESSIONALS 1 1 TRANSPORTATION TRANSPORTATION DIFFICULTIES DIFFICULTIES 2 2 $ COST OF THERAPY 2 TIME CONSTRAINTS 2 FEAR OF CONCERNS STIGMATIZATION ABOUT WHAT 2 OTHERS WOULD THINK 2 A X C LIMITED ENGLISH LANGUAGE PROFICIENCY BARRIERS Thomas KC, et al. Psychiatr Serv. 2009;60: Mohr DC, et al. Ann Behav Med. 2006;32: Bauer AM, et al. Med Care. 2010;48:

8 Digital Technology May Provide New Tools for Patient Assessment and Management mhealth sensors 1 Mobile device applications 2 Digital psychosocial interventions 3 Digital neurocognitive assessments and remediation 4,5 Telepsychiatry 6 Medication adherence technologies 7 Clinical decision support systems 8 1. Kumar S, et al. Am J Preven Med. 2013;45: Ben-Zeev D, et al. Schizophr Bull. 2014;40: American Psychological Association. Accessed September 30, Moore RC, et al. Schizophr Res. 2013;144: Fisher M, et al. Schizophr Bull. 2015;41: APA Council on Psychiatry & Law. 2014; Velligan D, et al.schizophr Bull. 2013;39: Kurian BT, et al. Prim Care Companion J Clin Psychiatry. 2009;11:

9 Limitations of Current Methods of Patient Assessment Inability to capture dynamic processes 1 Current methods cannot record patients symptoms and subjective experiences over time Recall bias 2,3 In retrospective self-reports, respondents usually rely on partial recall when asked to report on past behavior and experiences, which contributes to recall biases Uncertain accuracy Retrospective summary reports are not always accurate in capturing one s most intense, most recent, or variability of experiences and symptoms 1 Information obtained in the clinical interview may also sometimes be inaccurate, with patients minimizing or exaggerating symptoms 3 1. Ben-Zeev D, et al. Schizophr Bull. 2012;38: Schwarz N. In: Stone AA, et al, eds. The Science of Real-Time Data Capture: Self-Reports in Health Research. Oxford University Press. 2007; Vergare MJ, et al. Am J Psychiatry. 2006;163:

10 Digital Technology May Offer Some Advantages for Assessing and Managing Mental Illnesses Gathering more comprehensive data 1 Multiple sensors and modalities may provide more ecologically rich data sets Analysis of real-world behaviors or experiences 2,3 Ecological momentary assessment methods allow assessment of behaviors and experiences in their ecological context Providing in-the-moment interventions 4 Pervasive nature of mobile technologies allows the delivery of interventions in the moment Potential to provide a continuous connection between a care system and the patient Assessment and interventions for treatment adherence 1 Discerning those factors that influence adherence behaviors Providing feedback and support to improve adherence 1. Kumar S, et al. Am J Prev Med. 2013;45: Schwarz N. In: Stone A, et al, eds. The Science of Real-Time Data Capture: Self-Reports in Health Research. Oxford University Press. 2007; Stone AA, et al. In: Stone AA, et al, eds. The Science of Real-Time Data Capture: Self- Reports in Health Research. Oxford University Press. 2007; Mohr DC, et al. Gen Hosp Psychiatry. 2013;35:

11 Mobile Health Technologies (mhealth) Are Designed to Capture In-the-Moment Assessments and Deliver Real-time Interventions Mobile technology based applications and sensors (mhealth) are designed to provide a reliable way to detect changes in subjective state (thought, mood) and physiology 1-3 They can be used to collect data, often in real time 4 Data collected by mhealth can potentially help to inform in-the-moment delivery of tailored interventions 2 Guido Mieth/Getty Images 1. Ben Zeev D, et al. Schizophr Bull. 2012;38: Ben Zeev D, et al. Schizophr Bull. 2014;40: Prociow P, et al. Int J Ment Health Syst. 2012;6:5. 4. Kumar S, et al. Am J Preven Med. 2013;45:

12 Digital Psychosocial Interventions May Bridge Gaps in Care UNMET NEEDS The treatment gap for severe mental illnesses is large 1 Shortage of mental health professionals 2 Multiple factors contribute to limited use of psychosocial interventions 3 Concerns about what others would think Financial concern for patients Time constraints POTENTIAL BENEFITS Increased access to care 4 Convenience 4 Augment in-person services 4 POTENTIAL CHALLENGES Understanding the therapeutic relationship and factors that influence it 5 ; legal, regulatory, and licensure requirements 5 ; emergency management 4 1. Kohn R, et al. Bull World Health Organ. 2004;82: Thomas KC, et al. Psychiatr Serv. 2009;60: Mohr DC, et al. Ann Behav Med. 2006;32: American Psychological Association. Accessed September 30, Sucala M, et al. J Med Internet Res. 2012;14:e

13 Discussion There are lots of apps and treatment websites available. How do we know people will use them? 13

14 Digital Neurocognitive Assessments and Remediation May Lead to Improved Treatment Outcomes UNMET NEEDS Major contributing factors to lack of recovery in patients with schizophrenia are: Impaired insight 1 Negative symptoms 2 Neurocognitive deficits 2 Impaired social cognition 2 Current cognitive remediation therapy programs are heterogeneous in method and effects, and the source of their overall benefits has yet to be determined 3 POTENTIAL CHALLENGES POTENTIAL BENEFITS Standardized administration 4,5 User-friendly format 4 Largely language independent 4 Flexible batteries 4 Automated test instructions and scoring 5 Less resource intensive 5 Do not require face-to-face implementation 6 Reliability and validity of digital assessments, 7 cost, 4 lack of comparison to traditional neuropsychological tests 4 1. Drake RJ, et al. Br J Psychiatry. 2000;177: Lehman AF, et al. Am J Psychiatry. 2004;161: Wykes T, et al. Am J Psychiatry. 2011;168: Levaux M-N, et al. Eur Psychiatry. 2007;22: Silverstein SM, et al. J Clin Exp Neuropsychol. 2010;32: Fisher M, et al. Schizophr Bull. 2015;41: Vergare MJ, et al. Am J Psychiatry. 2006;163:

15 Telepsychiatry May Improve Patient Access to Care and Treatment Retention UNMET NEEDS Access to care Cost and transportation barriers 1 Shortage of mental health professionals 2 POTENTIAL BENEFITS Increased access to care 3 Improved retention 4,5 Outcomes comparable to face-to-face meetings 4,6 POTENTIAL CHALLENGES Data storage and other technical issues, licensing 3 1. Mohr DC, et al. Ann Behav Med. 2006;32: Thomas KC, et al. Psychiatr Serv. 2009;60: APA Council on Psychiatry & Law. 2014; Mohr DC, et al. JAMA. 2012;307: Leigh H, et al. J Telemed Telecare. 2009;15: Hilty DM, et al. Telemed J E Health. 2013;19:

16 Technology May Improve Methods for the Measurement of Medication Adherence UNMET NEED Methods to assess medication adherence are only estimates of patients actual behavior 1 POTENTIAL BENEFIT Potential for improved adherence measurement through a number of technologies Electronic bottle caps and pill containers 2,3 Telemonitoring 4 POTENTIAL CHALLENGES Clinical implementation 5 1. Sabate E. World Health Organization Nakonezny PA, et al. Psychiatry Res. 2008;157: Hayes TL, et al. Conf Proc IEEE Eng Med Biol Soc. 2006;1: Frangou S, et al. Telemed J E Health. 2005;11: Velligan D, et al. Schizophr Bull. 2013;39:

17 To Optimize Clinical Care, Physicians Need Up-to-Date Information Oliver Burston/Getty Images Clinical decision support systems are designed to assist physicians in clinical decision-making by offering recommendations based on patient-specific assessments and evidence-based information 1. Sim I, et al. J Am Med Inform Assoc. 2001;8:

18 Supportive Technology May Inform Decision-making UNMET NEED Clinical practice guidelines are often unavailable in electronic medical record systems 1 POTENTIAL BENEFITS May increase compliance with treatment guidelines 2 Can help reduce inference gap 3 POTENTIAL CHALLENGES Legal, financial, and policy concerns 1,3 ; impact on workflow 4 ; relevance and accuracy of information 1,4 1. Mardon R, et al. Agency for Healthcare Research and Quality Publication No EF. 2. Trivedi MH, et al. BMC Med Inform Decis Making. 2009;9:6. 3. Olsen LA, et al. The Learning Healthcare System: Workshop Summary. The National Academies Press; Berner ES. Agency for Healthcare Research and Quality Publication No EF. 18

19 Discussion How can digital technologies be integrated into care systems and settings? 19

20 mhealth Technologies and Devices Are Still Evolving Emerging nature of mhealth technologies is associated with several challenges Concerns about privacy, security, and confidentiality 1 Patient and therapist familiarity with technology 2 Risk of obsolescence prior to complete validation 1 Data analytics 1 Impact of cultural differences on how patients experience mhealth interventions 3 1. Kumar S, et al. Am J Preven Med. 2013;45: Palmier-Claus JE, et al. BMC Psychiatry. 2013;13: Aguilera A, et al. JMIR Mhealth Uhealth. 2014;2:e47. 20

21 Several Challenges to Adoption of Digital Technology Reimbursement 1 Privacy 2 Security 2,3 Familiarity with technology 4,5 Acceptability 4,6 Implementation in clinical practice 2 1. APA Council on Psychiatry & Law Mardon R, et al. Agency for Healthcare Research and Quality Publication No EF. 3. Kumar S, et al. Am J Prev Med. 2013;45: Depp CA, et al. J Nerv Ment Dis. 2010;198: Palmier-Claus JE, et al. BMC Psychiatry. 2013;13: Musiat P, et al. BMC Psychiatry. 2014;14:

22 Discussion Do digital technologies create an expectation of an always-on healthcare system (increased health care professional burden) or do they lighten the load? 22

23 Summary Digital technology may possibly transform psychiatry by Increasing patient access to care and potentially enhancing costeffectiveness 1,2 Capturing real-time data and delivering tailored interventions 3,4 Optimizing clinical decision-making with evidence-based support 5 To facilitate widespread adoption of digital technology in psychiatry, several challenges need to be overcome, such as Reimbursement 1 Privacy 3,6 Security 3,6 Familiarity with technology 7,8 Acceptability 7,9 Implementation in clinical practice 6 1. APA Council on Psychiatry & Law. 2014; Hilty DM, et al. Telemed J E Health. 2013;19: Kumar S, et al. Am J Preven Med. 2013;45: Ben Zeev D, et al. Schizophr Bull. 2014;40: Sim I, et al. J Am Med Inform Assoc. 2001;8: Mardon R, et al. Agency for Healthcare Research and Quality Publication No EF. 7. Depp CA, et al. J Nerv Ment Dis. 2010;198: Palmier-Claus JE, et al. BMC Psychiatry. 2013;13: Musiat P, et al. BMC Psychiatry. 2014;14:

24 QUESTIONS 32

25 CLOSING 32