Applying Mobile Technology to Mental Health and Substance Use Disorders: The State of the Science

Transcription

1 Applying Mobile Technology to Mental Health and Substance Use Disorders: The State of the Science Lisa A. Marsch, PhD Director, Dartmouth Center for Technology and Behavioral Health Director, Northeast Node of NIDA Clinical Trials Network Andrew G. Wallace Professor Geisel School of Medicine at Dartmouth College, U.S.

2 Acknowledgements Research funded by U.S. National Institutes of Health, NIH Special Thanks to: NIMH U19 MH which supports this research capacity-building webinar series P30 DA NIDA Center of Excellence Grant NIDA 1UG1DA R01DA029630; R01DA021818; R01DA S1; R01DA034279; RC1DA028415; R01DA025072; R41 DA14727; R42 DA14727;R41DA016083; R42DA016083;R41DA023731; RC2DA028967; R01DA015964; R01DA UH2AG052168

3 Disclosure Affiliation with Square2 Systems, Inc.

4 Promise of Applying Technology to Health Digital technologies (web, mobile, cloud, analytics) have transformed our society (e.g., in finance, retail, travel, education, and social relations). Technologies can also enable new models of health care both within and outside of formal systems of care, while increasing the quality and reach of care and reducing costs. Advances in digital technologies have created unprecedented opportunities to assess and modify health behavior and health outcomes at a population level via web/mobile technologies (science-based tools in the pockets of the population)

5 Promise of Applying Technology to Health Reach: Enable widespread dissemination of evidence-based interventions targeting health behavior Quality: Deliver care with fidelity, ensuring delivery of empirically-supported care Personalization: Responsive to each individual s profile of needs, preferences, culture, level of cognitive functioning, etc. Engagement: Offer the potential to enable individuals (and optionally an extended support network) to play leading roles in their own care management

6 Promise of Applying Technology to Health Enable on-demand access to just in time therapeutic support via electronic devices, delivered anytime/anywhere Can prevent costly escalation of health problems and unnecessary healthcare utilization. Reduce stigma and barriers/disparities in access to care endemic to many traditional care models Increase service capacity of systems of care (ability to treat a much larger number of clients with the same number of clinicians) Considerable population-level significance

7 Ubiquity of Technology Access to the Internet and mobile devices has been growing at extraordinary rates. Approximately 93% of individuals worldwide have access to mobile phone services, totaling about 7.5 billion mobile phone subscriptions worldwide (projected at 8.9 billion by 2020) There are over 3.9 billion smartphone subscriptions in the world, and smartphone access is expected to triple globally to 6.8 billion by Internet and mobile access is also high and growing among even the most traditionally underserved and vulnerable populations

8 Promise of Applying Technology to Treatment of Substance Use Disorders Research has demonstrated that technology-based behavior change tools (if developed well and in collaboration with the target audience): Can be highly useful and acceptable to diverse populations Have a large impact on health behavior and health outcomes Can produce outcomes comparable to, or better than, clinicians Increase quality, reach, and personalization of care Can be cost-effective Can be responsive to individuals health behavior trajectory over time

9 Implementation of Technology-based Therapeutic Tools Technology-based behavioral health therapeutic tools may be deployed via numerous flexible models. They may be used along with traditional models of intervention delivery (e.g., offered as an adjunct to existing treatment). In this clinician-extender model, clinicians have the opportunity to extend their reach (e.g., supplement to clinician-delivered treatments)

10 Implementation of Technology-based Therapeutic Tools Alternatively, these therapeutic tools may replace a portion of typical clientclinician interaction. This may allow a treatment program to treat more clients with the same number of clinicians and/or free-up clinicians to have more time to spend with clients in need of more intensive care.

11 Implementation of Technology-based Therapeutic Tools These tools may also be offered as stand-alone interventions. This may be particularly relevant in rural or other settings where access to care may be limited or for individuals who do not wish to engage in traditional models of care. (e.g., 90% of persons with substance use or mental health disorders are not in treatment)

12 Sample Screens from Web-based interactive digital therapeutic for addiction treatment

13 Replacing 80% of addiction treatment with TES is as effective as gold standard clinician-delivered treatment NIDA-funded randomized, controlled efficacy trial (n=135 opioid-addicted adults entering outpatient buprenorphine treatment) (Bickel, Marsch et al., 2008, Exp Clin Psychopharmacol) 12 Standard Addiction Treatment 10 a a State of the Science Therapist-delivered care Mobile Treatment Treatment Weeks b Continuous Abstinence from Opioids and Cocaine

14 Replacing half of clinician-delivered addiction treatment with TES produces markedly better outcomes than standard care NIDA-funded randomized, controlled effectiveness trial with opioid-addicted adults (n=160; 12 month evaluation; (Marsch et al., 2014, Journal of Substance Abuse Treatment) 70% 60% Percent Weeks Opioid Abstinent 50% 40% 30% 20% 10% 0% Web with reduced TAU Treatment as Usual (TAU)

15 TES Effectiveness Trial Data from the same trial showed that opioid-addicted participants with low cognitive functioning, high anxiety, high ambivalence about treatment, heavy alcohol use, and a greater number of prior treatment episodes at treatment entry had better outcomes when receiving TES as part of treatment vs. standard treatment. Technology-based interventions may be useful in minimizing the impact of specific risk factors on treatment outcome. (Acosta, Marsch et al., 2012; Kim, Marsch et al., 2015; 2016)

16 Adding mobile intervention as an adjunct to standard addiction treatment greatly increases treatment retention (Guarino, Acosta, Marsch et al., 2016) Percent Retained % Mobile Intervention 56% Standard Treatment

17 Adding mobile intervention as an adjunct to standard addiction treatment greatly increases drug abstinence 7 (Guarino, Acosta, Marsch et al., 2016) Weeks of Opioid Abstinence Mobile Intervention Standard Treatment

18 NIDA Clinical Trials Network Study (n=507; 10 sites)

19 Web-based treatment for chronic pain among patients with aberrant opioid taking behavior is more effective than traditional models of care (Guarino, Fong, Marsch et al., Under Review) 20 Aberrant Opioid Medication-taking Behavior (COMM) 16 Web-CBT TAU Baseline Wk 4 Wk 8 Wk 12 Post Wk 16 Post Wk 24

20 Web-based treatment for chronic pain among patients with aberrant opioid taking behavior is more effective than traditional models of care (Guarino, Fong, Marsch et al., Under Review) Pain Catastrophization (PCS) Web-CBT TAU Baseline Wk 4 Wk 8 Wk 12 Post Wk 16 Post Wk 24

21 Web-based treatment for chronic pain among patients with aberrant opioid taking behavior is more effective than traditional models of care (Guarino, Fong, Marsch et al., Under Review) Emergency Department Visits for Pain Web-CBT TAU Baseline Wk 4 Wk 8 Wk 12 Post Wk 16 Post Wk 24

22 Web-based treatment for chronic pain among patients with aberrant opioid taking behavior is more effective than traditional models of care (Guarino, Fong, Marsch et al., Under Review)

23 e.g., We have seen similar robust effects in numerous areas of behavioral health and health behavior Promote smoking cessation Increase self-esteem and reduce impulsivity in children Reduce HIV risk behavior Reduce clinical depression Reduce problematic alcohol use among persons with trauma Prevent drug use and risk behavior among adolescents Reduce symptoms and improve functioning among persons with severe mental illness Promote medical regimen adherence among chronic disease patients

24 Transforming HealthCare with Science-based Technology Opportunity for transcend siloed mobile health apps that focus on single disorder to embrace integrated care for the full spectrum of health Address systemic obstacles in delivering science-based approaches to healthcare that transcend disease, population, and context, enabling a generalizable and scalable solution Opportunity to provide unprecedented access to science-based therapeutic tools in many contexts for many populations at scale (pediatric care; primary care; emergency medicine; community reintegration post-incarceration; schools; direct to consumer)

25 Center for Technology and Behavioral Health P30 Center of Excellence funded by the U.S. National Institutes of Health The Center for Technology and Behavioral Health (CTBH) is a national research center designed to use science to inform the development, evaluation, and sustainable implementation of a wide array of technology-based tools for behavioral health (primarily substance use disorders and mental health)

26 Transforming HealthCare with Science-based Technology Expand academic-industry partnerships to engage a broad array of stakeholders in developing innovative, science-based models of healthcare delivery that centrally leverage technology to provide maximally potent, cost-effective, and widely implementable solutions Trial digitally-driven business models of healthcare enterprises in which digital technologies are at the heart of health care operations to provide evidence-based care at scale Employ models that enable ongoing evaluation and rapid iteration in real-world implementation efforts ( learning healthcare system )

27 Transforming HealthCare with Science-based Technology Address systemic obstacles in delivering science-based approaches to healthcare that transcend disease, population, and context, enabling a generalizable and scalable solution Technology as Minimally Disruptive Health Care (to reduce burden of illness as well as burden of treatment) Technology Solutions Direct to Consumer Understanding trajectories of consumer engagement (e.g., consumer adherence vs. strategic episodic use) Opportunities for Global Health

28 Global Applications of Digital Technologies for Mental Health and Substance Use Disorders (Naslund et al., In press, Lancet Psychiatry) Most studies in low- and middle-income countries have focused on feasibility and acceptability of mobile health in areas of: 1) Technology for supporting clinical care and educating health workers 2) Mobile tools for facilitating diagnosis and detection of mental disorders 3) Technologies for promoting treatment adherence and supporting recovery 4) Online self-help programs for individuals with mental disorders (5) Programs for substance use prevention and treatment Opportunity for expanding rigorous evaluation in low- and middle-income countries

29 Recent Publication from Oxford University Press

30 Thank you!