- Psychiatry Advisor

Christoph U. Correll, MD

Expert Perspective
Christoph U. Correll, MD

Expert Perspectives on Technology in Health Care: Part I

Cristoph U. Correll, MD

Hospital and Institutional Affiliations:
Professor of Psychiatry and Molecular Medicine
Hofstra Northwell School of Medicine
Hempstead, New York

Investigator, Center for Psychiatric Neuroscience
Feinstein Institute for Medical Research
Manhasset, New York, USA

Medical Director, Recognition and Prevention (RAP) Program
The Zucker Hillside Hospital, Department of Psychiatry

Question

Can you provide a description of some of the health-related technology that is currently available to providers and their patients?

Answer

Health-related technology has become an important asset and has a lot of promise. Although much of the technology that’s available is more in the general use or research stage, it has real potential to transform clinical psychiatry. Examples are based on the widely available smartphone technology, which allows patients and clinicians to monitor a patient’s behavior either passively or interactively.

With passive monitoring, smartphones now have about 30 or 40 built-in sensors that allow a clinician to look at motion, social interaction, calls, and messages. With global positioning systems, you can see how frequently a patient is leaving the house. Speed can be measured, and there’s something called ecological momentary assessment that enables you to ask patients certain questions during the day: What are you doing right now? Are you alone? Are you with people? How do you feel? Are you anxious? Do you hear voices? Both clinician and patient could become aware that a patient becomes more psychotic when he or she is alone or is more suspicious in a social environment. This information can help target cognitive behavioral therapy, either in person or by using cognitive behavioral therapy modules when a patient experiences a trigger. For example, when they say they are anxious or they hear voices, they are then reminded of certain exercises to perform to distance themselves from the negative thoughts.

Technology can also be used to measure whether people are close to having a relapse. This can be done with a biosignature that has the potential to be individualized. We know that when people with depression experience a relapse, they stay in the house much more. They may have a different pitch and volume to their voice and speak at a different pace when using the telephone. Speech can reveal a lot about how people feel or when they have a manic relapse. In the latter scenario, they would be talking a lot or very fast and making many phone calls, even during the night. Initial data even suggest looking at natural language processing and grammar.

There are also technologies being marketed that measure medication regimen adherence. With MyCite®, individuals wear a patch on their torso or arm that measures skin conductivity, activity, sleep, and heart rate. There is a smart pill with a biodegradable chip in the medication that indicates it has been taken. In this case, it is aripiprazole; when it hits the gastric content, it emits a signal to the receiver on the patch, which is sent via Bluetooth® to the clinical team or is recorded and can be captured later. This process documents whether or not people are adherent to their treatment regimen. You can also use the information to say to the patient, for example, “Look, when you didn’t take the medication your sleep was altered,” or “The next day you weren’t doing so well.”

AiCure® uses artificial intelligence (AI) to see how patients are responding to treatment by having them film themselves taking the medication.

There are more futuristic uses of technology, in which you can use AI to notice when people are anxious or have obsessive-compulsive disorder. They might be creating a hierarchy of fears; for example, they may be thinking of going into or approaching an elevator, perhaps pushing a button and then going in, alone or with a crowd of people.

There are other technologies that use biofeedback in which people try to concentrate, and you try to retrain the brain. You see a brainwave or some other biosignature that helps you hone in on a certain task.

So, there’s a vast array of possibilities, and we are just scraping the tip of the iceberg. Most people don’t even realize what’s already in their smartphones. There is little connectivity between a patient’s use of a Fitbit® or certain apps/having a smartphone and the information entering the clinical sphere; the information that patients gather about their activities and sleep are not directly shared with the clinician.

What I think we will see in the future is a “digital clinic,” in which patients get sensors and fill out questionnaires on their smartphones. There will then be a lot of digital phenotyping that will give us much finer-grained information for the diagnostic process. We’ll get lots of data points, and then we can see how interventions could actually change these behaviors, expressions, thoughts, and emotions.

Question

What are some of the barriers to the uptake of health-related technology and how can they be addressed?

Answer

There is a disconnect between the technology that people are using at home and what clinicians are aware of. The information may not be linked to a medical device or it’s not connected to the clinician. We need more companies to provide simple and easy-to-use app solutions that the clinician can offer a patient that costs a certain amount or is even free. The information must then be transmitted and made visible and digestible. A problem is that there are so many data points and it’s difficult to know how to process them and make them visible so that there is useful information and not just data.

I think we’re on the brink of innovation. There might be products that clinicians and patients don’t even know about that are not approved by the US Food and Drug Administration (FDA) or that their health insurance has yet to cover. We also don’t have efficacy data to show that if you use that app you can predict relapses and reduce their occurrence. So there is a lack of recognition of the possible uses of technology in the healthcare sector. For instance, polysomnography can now be performed at home using a very slim device that senses a patient’s pulse and other physiologic parameters. The information is similar to that obtained in a sleep lab, but it can be collected at home and costs approximately $150 per assessment.

Although it should make things easier on one hand, we have yet to integrate the technology into our daily work because the tools are not that easily incorporated. You have a stethoscope to listen to the heart, but what do we do with all the apps?

Another barrier to implementing health technology is the fear that the human perspective is being taken out of the interaction and the clinician-patient alliance. However, I see technology more as an augmentation of care. Having gathered information beforehand, you can be more efficient and spend more time on things that matter, and you’re not rushing through the information-taking process. Technology can help you gather the information you need efficiently in advance of the patient interaction. But I think we need data to show clinicians that this is better care. It’s not decreasing patient satisfaction, and it’s not more time-consuming. It’s more effective and may increase treatment satisfaction, both for the patient and their family, as well as the provider.

Question

How can technology empower patients to take better control of their disease states?

Answer

We know that when people with bipolar disorder do mood charting, they don’t feel they are the passive victim of their fluctuating emotions and can see how their behavior and activities are affecting their mood. This opens the door to the possibility of patients feeling they can control themselves or helping others aid patients in understanding what is bad and what is good for them, and what needs to be mitigated, stopped, or strengthened.

In addition, when you have these interactive programs, you can do cognitive behavioral therapy, solution-based modules, and mindfulness therapy. The digital solution, or even telemedicine, can be quite helpful in regaining control of treatment and having more therapy at your fingertips. Often, patients need a reminder or prodding by smartphone alarms or devices sensitive to movement, to adhere to treatment.

 

To continue reading about how clinicians can better engage their patients to use health-related technology, as well as examples of successful implementation of technology in psychiatry practice, click through to Part II of this series, “Expert Perspectives on Technology in Health Care.”

Disclosure: Dr Correll has been a consultant and/or adviser to or has received honoraria from: Alkermes, Allergan, Angelini, Boehringer-Ingelheim, Gedeon Richter, Gerson Lehrman Group, Indivior, IntraCellular Therapies, Janssen, Johnson and Johnson, LB Pharma, Lundbeck, MedAvante-ProPhase, Medscape, Merck, Neurocrine, Noven, Otsuka, Pfizer, Recordati, Rovi, Servier, Sumitomo Dainippon, Sunovion, Supernus, Takeda, and Teva. He has provided expert testimony for Bristol-Myers Squibb, Janssen, and Otsuka. He served on a Data Safety Monitoring board for Boehringer-Ingelheim, Lundbeck, Rovi, Supernus, and Teva. He received royalties from UpToDate and grant support from Janssen and Takeda. He is also a shareholder of LB Pharma.