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Dr. Nandi:
“So, there’s an app for that.” You’ve heard it before, right? There’s a smartphone app for almost everything, and most important in the last few years, there are apps, smartphone apps, that actually allow our GI patients to access all sorts of nontraditional therapies, such as cognitive behavioral therapy, mental health therapy. These are resources that we often do not provide for our patients in the clinic.

Welcome to IBD Crosstalk for GI Insights on ReachMD. I’m your host, Dr. Neil Nandi. And joining me to discuss this and more is Dr. Megan Riehl. Dr. Riehl is an assistant professor and very importantly an embedded GI psychologist at the University of Michigan.

Dr. Riehl, welcome to the program.

Dr. Riehl:
Thank you so much for having me.

Dr. Nandi:
Absolutely. You are one of our gurus when it comes to how to get our patients access to mental health resources in the GI clinic. First off, could you give us kind of a broad overview of mental health as it pertains to our GI and IBD patients and what kind of health resources there are out there?

Dr. Riehl:
Yes. And, you know, thanks for just initiating this conversation because you’re so right. It’s an ongoing conversation that is important for our patients to hear from their gastroenterologists and really to normalize these kinds of discussions. In our IBD patient populations, we see higher prevalences of depression and anxiety, and I think the unique aspect of these mental health mood symptoms are that they can come from kind of general life stress, and then they also can come from having a complex disease that requires a lot of interaction with the medical system. It impacts your quality of life in terms of day-to-day functioning, and so sometimes we can understand how having IBD alone can lead to some symptoms of anxiety and depression. So, knowing that it’s common and knowing also that those symptoms can have a pretty tremendous impact on the actual disease functioning, we have to identify resources to help patients manage these symptoms.

Dr. Nandi:
When I think about the practicing clinician out there, how many times in this modern day where we have access to electronic health record and our patients have access to us—right? And so, if you’re wondering why you as a clinician have a role here, it’s to help your patient develop resilience and get access to mental health.

What does it mean about resiliency? What is resiliency for a patient, Dr. Riehl?

Dr. Riehl:
Well, resiliency is something we all have, and what we’ve learned is that it can be a really protective factor for patients with IBD. So, for example, if we think about a challenge—so, getting to doctor’s appointments or taking a new medication—that’s a bit scary, engaging in healthy nutrition and exercise, all of these kind of lifestyle factors, how we approach it, how we approach difficulties in our health is really driven by resilience. And it’s a psychological factor that is also modifiable, so we can help empower patients to use the resiliency that they already have to problem-solve and address difficulties in their disease course, but we can also teach strategies and skills with resiliency. Dr. Laurie Keefer has some fascinating research in this area. And really, we apply different cognitive behavioral acceptance and commitment-based therapies. We apply interventions to help draw out and amplify resilience, which can really be helpful in terms of IBD outcomes, quality of life, and even disease course. So, it’s an interesting factor that packs a lot of power with it.

Dr. Nandi:
So, what are the different resources? What are the different applications that might be available for IBD patients, for instance?

Dr. Riehl:
Yeah. This is a really exciting time for really the innovation of technology-enabled solutions, is kind of how we think about it. And so, I like to think beyond just an app. So, you know, you as a provider may make suggestions in terms of some of these products that are becoming available, but they really can start conversations on a more frequent basis around how a patient is doing.

So, you know, depending on how you want to use some of these technology solutions, that kind of guides the pathway of what you suggest. So, for example, Trellus Health is a solution for increasing resources for patients with IBD. It is a product that includes a smartphone app but also a platform that can be accessed on the computer. And it’s not just mental health resources, but it also connects a patient with kind of a wraparound service that you, as a gastroenterologist, continue to maintain your treatment plan. And then also, they have a whole basically resilience-based curriculum that helps to teach different cognitive behavioral strategies, learning different kind of psychoeducational kind of facts and figures around what it means to have IBD. And so, it’s one of those products that is a little bit different from just prescribing so to say an app and, you know, maybe not following up with the patient again about it.

There are other products like Nerva is a gut-directed hypnotherapy app that while it’s mostly targeting patients with IBS, irritable bowel syndrome, I find it can be an excellent strategy to connect patients that have IBD to a gut-directed hypnosis product that can really serve as another skill; a strategy that teaches deep physical relaxation. And it’s certainly something that is not going to hurt the patient with IBD who may also have some functional bowel overlap.

So those are really just two products in a sea of products that are becoming available. And I could probably talk, you know, for several hours about other things, but I’m just giving you two examples here.

Dr. Nandi:
For those just tuning in, you’re listening to GI Insights IBD Crosstalk on ReachMD. I’m Dr. Neil Nandi, and I’m speaking with Dr. Megan Riehl on different smartphone and digital-based apps that bring mental health resources to our IBD patients.

Now, Megan, are there any other types of creative ways that you have seen technology used for patients when it comes to mental health in GI?

Dr. Riehl:
Yeah. You know, again, it’s these products all have a different kind of go to market business strategy, and that’s where as both a clinician and a patient having conversations around what is it that you’re looking for for a patient. So, you know, in your instances, if a patient is established with you, you’re probably looking for resources that can help support, and there are lots of things. There are things that can track how much vitamin D a person thinks they’re getting out in nature or there’s an app called Mahana, which again, it’s focused on IBS, but it’s a prescriptive digital therapeutic that you as a provider writes a prescription, the patient then has access to this digital app, and they can learn cognitive behavioral strategies to help manage their IBS.

And when we think about why we’re using them, if a patient doesn’t have access to a GI psychologist, that’s where we really see a ton of benefit because you’re still getting some of these evidence-based strategies. And instead of not having access to anything or even, perhaps, utilizing it while you’re on a waitlist to see a GI psychologist, it really helps the patient to learn more about their diagnosis, feel that you as a gastroenterologist hear that perhaps they’re looking for new tools and resources and strategies to help them manage, and you’re able to make some of these other suggestions.

Dr. Nandi:
Let me ask you a fanciful question, Megan. If you could think 10 years from now if an IBD patient walks into the inflammatory bowel disease center at the University of Michigan, what would the ideal care plan for a patient be like when it comes to mental health and well-being?

Dr. Riehl:
A destigmatized patient that walks in and openly is talking about the complexities, the nuances, the psychosocial factors, and they’re having these conversations with their gastroenterologist, the nursing staff, the dietitian, the psychologist, that we all are aware that, you know, our mood impacts us, and it impacts how we engage with our health. And so, I really look forward to the day where patients have better access to strategies that can be implemented, that the level of education, that these companies can provide to referrers, is also going to help with that and I think, as a psychologist, you know, there’s something about also being in person with someone and so maybe that also is that we increase access to our behavioral health services by spending, you know, a couple sessions with the patient and then we supplement with different digital therapeutics and technology solutions.

Dr. Nandi:
I guess let me ask you now, how much do these cost approximately? I won’t hold you to the, to the dollar or cent. Are they affordable? And is there insurance coverage for these apps?

Dr. Riehl:
Well, the answer is different by product. Some like Mahana is going the route of using insurance, and so it’s still in its infancy. So even myself, I’ve had one or two patients that I’ve worked with a gastroenterologist to walk through the process, and they did describe it as pretty seamless on both the provider side and the patient side. The Trellus Health is an example of down the road I think their business model is to try and get insurance coverage, but for right now, I think they’re typically offering an entry of free and then about $60 a month for all of the resources. And so, if I use just that as an example and we compare to paying out of pocket for mental health treatment if it’s not covered or buying different apps it certainly adds up, and so to use products that are very well created by experts in the field and know that you’re getting a very good product, I do find them to be a good investment in your health.

Dr. Nandi:
Fantastic. How common is it for, you know, to have a GI psychologist in a clinic or an academic center?

Dr. Riehl:
It’s a growing field. A few years ago, there were not many, but there are approximately, you know, 420-25, we’ll just say under 450 that we know of. So, we’ve had to get very creative, and that’s where I think the technology solutions are going to help. Many, many IBD centers recognize that they can’t be an IBD center unless they’re incorporating mental health providers, so I think it’s a very exciting field to go into, and again, if I think about that 10-year mark, I’m hoping that more and more academic institutions will have this as just the norm.

Dr. Nandi:
I love that. Dr. Riehl, are there any take home points you’d like our audience to take home at the end of this talk?

Dr. Riehl:
Well, I think my two are, you know, look for good products. And I’m the Director of Behavioral Health Services for GI OnDEMAND, which is a joint venture of Gastro Girl and the American College of Gastroenterology, and one of our missions is to really help inform both patients and providers of the kind of crème de la crème products available. And so, if you’re an ACG member, you have free access to GI OnDEMAND, and on that platform we have lots of webinars and mental health resources as well as links to some of these technology-enabled solutions, so when you go there you know that they have been vetted by experts, and that helps to kind of narrow the field in terms of like where do I go to make these recommendations or what’s available.

And then that other point is stay in contact with your patients. If they bring up that they’re using an app for something, ask them how it’s going, are they noticing any changes, or let them know that you have a couple suggestions, and keep that conversation around how they’re using these products open and be aware that, you know, they may need more comprehensive services.

Dr. Nandi:
Thank you so much, Dr. Riehl, for being on our program. I really learned a lot, and I really appreciated having you today.

Dr. Riehl:
Thank you for having me.

Dr. Nandi:
For ReachMD’s IBD Crosstalk, I’m Dr. Neil Nandi. To access this and other episodes in this series, please visit ReachMD.com/GIInsights where you can be Part of the Knowledge. Thanks for listening.