Transcript
Announcer:
Welcome to ReachMD. This medical industry feature, titled “Incorporating Digital Tools into Mental Health Treatment,” is sponsored by Otsuka Pharmaceutical Development and Commercialization.
Here’s your host, Dr. Charles Turck.
Dr. Turck:
This is ReachMD, and I’m Dr. Charles Turck. Joining me to discuss how we can usedigital tools in mental health treatment is Dr. Matthew Brams, Assistant Professor in the Division of Psychiatry at Baylor College of Medicine. He’s also Medical Director of the Senior Behavioral Health Unit at OakBend Medical Center in Richmond, Texas, and a psychiatrist at Memorial Park Psychiatry in Houston. Dr. Brams, thanks for being here today.
Dr. Brams:
Thank you! Glad to be here.
Dr. Turck:
So Dr. Brams, let’s start by doing some level-setting. When referring to digital tools, can you share some key definitions we should know?
Dr. Brams:
So, when we talk about digital tools, there are three key terms to know: digital medicine, digital therapeutics, and prescription digital therapeutics. In fact, both the Digital Medicine Society and Digital Therapeutics Alliance have proposed definitions, but in general, Digital medicine refers to software and/or hardware products that measure and/or intervene in human health, such as an ingestible or implantable sensor.1 Then there’s digital therapeutics, which refers to software interventions like apps that are intended to prevent, manage, or treat a medical disorder.2 And last but not least, prescription digital therapeutics are a subset of digital therapeutics that are available by prescription only.
Dr. Turck:
Thanks, Dr. Brams. And with those definitions in mind, can you tell us if digital tools are being used in psychiatric practice?
Dr. Brams:
Yes, so the use of digital tools in psychiatry and mental health treatment is already a reality, even if some of us have reservations about them. But clinicians and patients have become increasingly familiar with technology, and restrictions from the COVID-19 pandemic have resulted in the widespread use of virtual psychiatric services. And it’s important to recognize that digital tools and apps perform or enhance several key tasks in psychiatry.3 They provide cognitive training or motivational support, supplement treatment with drugs or devices, and capture real-time data to potentially help create more effective treatment plans. In fact, systematic reviews have shown significant benefits with digital therapeutic products for patients with serious mental illness, with larger effect sizes reported for programs that provided professional support along with the smartphone app.4,5 What’s also exciting is that clinical research focusing on digital tools in psychiatry is expanding. In February 2022, there were more than 4,000 studies for digital therapeutics listed in clinicaltrials-dot-gov. Of these, more than 850 were mental illness, such as major depressive disorder or MDD for short, substance use disorders, schizophrenia, psychosomatic disorder, bipolar 1 disorder, and general anxiety disorders.6
Dr. Turck:
So then let’s zero in on those digital tools, Dr. Brams. What data or information do you want from a digital tool?
Dr. Brams:
So, in my opinion, it depends on why you’re using the tool. For example, you may want to know if a patient has taken their medication, and that may be sufficient information, especially if the patient has cognitive issues or is often hospitalized. After all, tracking ingestion can help you determine if the patient has symptoms because they’re not taking their medication, if the medication is incorrectly dosed, or if it’s simply not working. But for me, the primary reason to integrate digital tools into my practice is that they allow me to monitor my patient’s mental status. In higher-functioning patients, I can review symptom data over time to assess the patient’s trajectory and then adjust treatment plans accordingly. I can track their activity, rest, and sleep patterns, which might indicate when a patient is becoming depressed or manic. For example, an increase in activity and decrease in sleep might suggest an impending mania, whereas a decrease in activity and increase in sleep might suggest deepening depression. The data are not diagnostic, but they do provide clues as to the patient’s trajectory.
Dr. Turck:
So then once you decide what you want from a digital tool, how do you go about finding the right one?
Dr. Brams:
So first, it’s important to know that finding the right tool is paramount to your patient’s success. That means we must investigate and evaluate various options. To help with that, the American Psychiatric Association developed an app evaluation model that provides a guide for clinicians to assess digital tools. The evaluation model includes considerations for security and data privacy, clinical evidence and benefit, usability, and interoperability, which refers to the ability to integrate the data into the healthcare system.
7Dr. Turck:For those just tuning in, you’re listening to ReachMD. I’m Dr. Charles Turck, and today I’m speaking with Dr. Matthew Brams about how we can use digital tools when treating patients with mental illness.
So Dr. Brams, once you’ve found the digital tool that best suits your and your patients’ needs, how do you encourage patients to use it?
Dr. Brams:
You bring up a good point because engagement with the digital tool is crucial, especially for higher-functioning patients. If they don't agree with the treatment plan and don’t use the digital tool consistently, that tool may not be effective. So to encourage patient engagement, I think it’s important for the clinician to meet with the patient— or caregiver, if appropriate—and discuss the benefit of the selected digital tool, explain how to use it, and offer ongoing support and encouragement. Motivational interviewing can also be helpful here.
Dr. Turck:
Then let’s zero in on that for just a moment, Dr. Brams. Can you tell us about motivational interviewing?
Dr. Brams:
Sure, so motivational interviewing involves three essential components: one, asking your patient open-ended questions; two, listening to their answers reflectively; and three, affirming and summarizing their statements. Motivational interviewing can help patients resolve their ambivalence about using digital tools by allowing them to express their reasons for and against it and how their ambivalence may conflict with their personal health goals. 8, 9,10 For example, if their goal is to “get better” and if using digital tools can help them reach this goal, they can start to understand why change may be necessary. So in my own practice, I use motivational interviewing for two reasons: one, it has an empathic component, and two, it helps resolve ambivalence, which in turn allows for positive movement. I’ll say, “Let’s talk about things that are working well and things that are not working so well.” And after our discussion, we can generally agree on one or two changes. So in essence, your belief in the patient’s capacity for change becomes a self-fulfilling prophecy.9
Dr. Turck:
Now with that being said, Dr. Brams, do you tell patients about your expectations regarding their engagement with the digital tool?
Dr. Brams:
No, I don’t discuss my expectations with low-functioning patients. Instead, I give them a basic overview, and their care provider helps them navigate the digital tool. It’s different, however, with high-functioning patients with MDD or bipolar disorder, also known as BD for short. They want to know about their progress, and they’re invested in getting better. So after I review the digital tool with them, I explain that the features are important to me because they tell me how they’re doing. I tell them that I usually review the data just before or during our session, so that we can see together how the patient is progressing and discuss any issues they might have. I also make it clear that this digital tool is in addition to—not a replacement for—our routine sessions. And if they’re having a psychiatric emergency, they should contact me directly—not via the digital tool.
Dr. Turck:
So let’s bring all of this together, Dr. Brams. Overall, what would you say are the benefits to using digital tools in psychiatry?
Dr. Brams:
The benefits most talked about are increased access to health care and scalability,11,12 but I think there are three additional benefits to draw attention to here. First, for higher-functioning patients with MDD or BD, apps can give me better information about the patient’s mental status between visits. With real-time data about ingestion, rest, activity, or symptoms, I can assess if the treatment plan needs to be modified.12 In essence, it gives me a better picture than a self-report of how the patient has been doing since the last visit. Second, I think apps can serve as transitional objects.12 For example, when I give patients my phone number, they often don’t use it, but it comforts them to know they have it. And in the same way, just knowing that I can “check to see how they’re doing” anytime on the app is reassuring to some patients. And lastly, apps can help strengthen the therapeutic alliance with patients. Some clinicians who have extremely busy practices may not have the time to fully develop empathic connections. In these cases, the data from the app potentially can help the clinician develop stronger relationships, and the data can serve as a focal point for discussing how the patient is feeling and responding to treatment.
Dr. Turck:
And with those benefits in mind, Dr. Brams, what are some of the barriers that can keep us from using digital tools in practice?
Dr. Brams:
I’d say the number one barrier for patients is lack of familiarity with apps or technology in general. But in my experience, once patients are familiar with digital tools, they like them.7, 13 Now for clinicians, I believe the number one barrier is lack of familiarity with the benefits of digital tools. Not only are they unfamiliar with the benefits, but they also think learning about an app is a burden. Other concerns identified in a 2021 survey of clinicians including patients’ lack of comfort with technology, privacy and security concerns, reimbursement and cost considerations, and difficulty integrating into clinical practice and workflows. Now fortunately, education can help address the lack of familiarity with technology and digital tools in mental health.14, 15 Additionally, reimbursement will be less of a barrier in 2022 because the Centers for Medicare & Medicaid Services published a new HCPCS code effective April 1st for reimbursement of prescription digital behavioral therapy.16 But despite that progress, data privacy and security remain a concern, and some clinicians and patients may hesitate to use digital tools until these issues are addressed.17
Dr. Turck:
Thank you for breaking all of that down for us, Dr. Brams. Now we’re almost out of time for today, but before we close, can you share some main points you’d like our audience to take away from this discussion?
Dr. Brams:
Yes, so I think the first main point is that digital tools play an increasingly important role in psychiatry. They can perform or enhance several key tasks, and their ability to monitor patients’ mental and physical status is the biggest reason why I’ve integrated them into my own practice. With that being said, clinicians play a major role in helping patients engage with and benefit from apps, which is why educating clinicians and patients about digital tools is so important in overcoming barriers to their use. I hope that all of the information that I have given has been helpful to move forward with digital tools, but if you’d like to learn more, I encourage you to stay turned for the sister programs on the topics of what digital tools are and how we can evaluate them.
Dr. Turck:
Well with those key takeaways in mind, I want to thank my guest, Dr. Matthew Brams, for helping us better understand how to effectively use digital tools in mental health treatments. Dr. Brams, it was great speaking with you today.
Dr. Brams:
Thank you Dr. Turck! It was a pleasure for me as well.
Announcer:
This program was brought to you by Otsuka Pharmaceutical Development and Commercialization. If you missed any part of this discussion, visit ReachMD.com/industry-feature. This is ReachMD. Be Part of the Knowledge.
References:
- Digital Medicine Society (DiMe) – Advancing digital medicine to optimize human health. (n.d.). Retrieved April 7, 2022, from https://www.dimesociety.org/
- Digital Therapeutics Alliance. (2019). Digital therapeutics definition and core principles (p. 1). https://dtxalliance.org/wp-content/uploads/2021/01/DTA_DTx-Definition-and-Core-Principles.pdf
- Licholai, G. P., & Feuerstein, S. (2021, August). The Expanding Role of Digital Therapeutics in Mental Health. Psychiatric Times. https://www.psychiatrictimes.com/view/the-expanding-role-of-digital-therapeutics-in-mental-health
- Linardon, J., Cuijpers, P., Carlbring, P., Messer, M., & Fuller-Tyszkiewicz, M. (2019). The efficacy of app-supported smartphone interventions for mental health problems: a meta-analysis of randomized controlled trials. World Psychiatry, 18(3), 325–336. https://doi.org/10.1002/wps.20673
- Torous, J., Bucci, S., Bell, I. H., Kessing, L. V, Faurholt-Jepsen, M., Whelan, P., Carvalho, A. F., Keshavan, M., Linardon, J., & Firth, J. (2021). The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality. World Psychiatry, 20(3), 318–335. https://doi.org/10.1002/wps.20883
- Clinicaltrials.gov. (n.d.). Search results for “digital therapeutics” and “mental illness.” Retrieved April 7, 2022, from https://clinicaltrials.gov/ct2/results?cond=mental+illness&term=digital+therapeutics&cntry=&state=&city=&dist=
- American Psychiatric Association. (n.d.). Hybrid psychiatrist-patient relationships: proficiencies for 21st century psychiatry. Retrieved February 19, 2022, from https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Telepsychiatry/APA-Hybrid-Psychiatrist-Patient-Relationships.pdf
- Levensky, E. R., Forcehimes, A., O’Donohue, W. T., & Beitz, K. (2007). Motivational interviewing: an evidence-based approach to counseling helps patients follow treatment recommendations. The American Journal of Nursing, 107(10), 50–58; quiz 58–59. https://doi.org/10.1097/01.NAJ.0000292202.06571.24
- Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). The Guilford Press.
- McCarley, P. (n.d.). Patient empowerment and motivational interviewing: engaging patients to self-manage their own care. Nephrology Nursing Journal, 36(4), 409–413.
- Ng, M. M., Firth, J., Minen, M., & Torous, J. (2019). User Engagement in Mental Health Apps: A Review of Measurement, Reporting, and Validity. Psychiatric Services, 70(7), 538–544. https://doi.org/10.1176/appi.ps.201800519
- Tremain, H., McEnery, C., Fletcher, K., & Murray, G. (2020). The Therapeutic Alliance in Digital Mental Health Interventions for Serious Mental Illnesses: Narrative Review. JMIR Mental Health, 7(8), e17204. https://doi.org/10.2196/17204
- Ruzek, J. (2018, October 15). Bringing Apps into the Treatment Process. One Mind PsyberGuide. https://onemindpsyberguide.org/blog/bringing-apps-into-the-treatment-process/#SeptBlog
- Chan, S., Godwin, H., Gonzalez, A., Yellowlees, P. M., & Hilty, D. M. (2017). Review of Use and Integration of Mobile Apps Into Psychiatric Treatments. Current Psychiatry Reports, 19(12), 96. https://doi.org/10.1007/S11920-017-0848-9
- Torous, J., & Roberts, L. W. (2017). Needed Innovation in Digital Health and Smartphone Applications for Mental Health. JAMA Psychiatry, 74(5), 437. https://doi.org/10.1001/jamapsychiatry.2017.0262
- Reuter, E. (2022, February 25). CMS code seen as major step toward reimbursement for digital therapeutics. Medtechdive. https://www.medtechdive.com/news/pear-therapeutics-cms-code-reimbursement-digital-health/619435/
- Grande, D., Luna Marti, X., Feuerstein-Simon, R., Merchant, R. M., Asch, D. A., Lewson, A., & Cannuscio, C. C. (2020). Health Policy and Privacy Challenges Associated With Digital Technology. JAMA Network Open, 3(7), e208285–e208285. https://doi.org/10.1001/JAMANETWORKOPEN.2020.8285
August 2022 US.UNB.V.22.00006
