Evolving Role of Technology In Behavioral Health and Developmental Disabilities

March 12, 2014

Melissa D. Pinto, Emory University

eSMART-MHWhere technology

and behavioral health research intersect

TechnologyPrepares Americans to

address behavioral health needs

Real Life ImplicationsImproves well-being of

Americans

Objectives• Evolving role of technology based

interventions in Behavioral Health Technology (BHT)

• Benefits and concerns about use of BHT• How BHT impacts the clinical relationship and

care• State of science of BHT• eSMART technology

Who suffers from “Technophobia”?

What is Behavioral Health Technology (BHT)?

• Application of interventions through use of technology to address behavioral, cognitive, and affective targets that support physical and mental health

Types of BHT

• Remote delivery-real-time, time-bound– Videoconference and telephone

• Reduced contact– Internet CBT, email-therapy, automated or

personal text messages– Online chat

How are BHTs Delivered?• Web-based intervention (internet intervention)• Mobile devices (mHealth)• Laboratory• Gaming

Importance of BHT Today

• Growing need • Workforce development alone cannot fully

meet need• Expand capacity and extend reach• Critical shortage of providers, especially child

and adolescent

Importance of BHT Today

• 75% patients identify 1+ structural or psychological barriers to care

• Access more difficult for minority groups and individuals in rural areas

• Potential for totally new interventions

Strengths and Benefits of BHT• Improved Access– Brings service to people (rural)– Overcomes psychological and structural barriers to

care– Convenience and private

• Reduce costs-preliminary findings

Strengths and Benefits of BH Tech• Flexibility– High fidelity and individualized tailoring– Designed for many conditions

• Interactivity and consumer engagement– Incorporates multimedia– Consumer empowerment– Improve continuity and integration of care

Concerns & Barriers of BHT• Will it replace important and needed services?• Will it divert attention from funding for

conventional services?• Will it be costly to develop, implement, and

evaluate?

Concerns & Barriers of BHT• What will happen to the important

therapeutic relationship? How can this happen?

• Will people not get the correct level of service or delay seeking appropriate services?

• Can it be reimbursed? How will this work?

Does BHT Work?Early Findings

• Clinical outcomes similar to face-to-face in adults

• Therapy outcomes diminished in some BHT studies compared to traditional therapies

• Self-guided, self-help just as effective as some traditional approaches

Early Findings• Therapeutic relationship robust to distance,

asynchrony, and limited contact.• BHT offer both traditional therapies on or new

therapies all together?• Mechanism for clinical improvement could be

different in BHT?– Hope, self-efficacy, learned resourcefulness, self-

determination, empowerment.

How does BHT impact therapeutic relationship?

• Therapeutic relationship critical for improved outcomes

• Changing role of the therapeutic relationship

BH Technology

Therapist/Provider

Client

BH Tech/Progr

am Support

Four Types of BHT Interventions• (1) Therapist administered– Clients sees therapist– Technology augments and adjunctive

• (2) Minimal-Contact– Therapist actively involved, lesser

degree typical therapy (≤1.5 hrs)– Therapist assists client with application

of techniques

Four Types of Interventions• (3) Client predominantly independent self-care– Therapist checks-in, teaches how to use tool

• (4) Self-administered therapy– Pure self-help– Therapist may do assessment only– Fully automated system no therapist contact

STATE OF SCIENCE: DELIVERY OF BHT (ALSO APPLICABLE TO DEVELOPMENTAL DISABILITIES)

Extending Therapist Reach: Psychotherapy via videoconference,

telephone, and Instant Message

– May be equally effective as face-to-face

– Acceptable to patients– Increased access to care

• Concerns and Needs– Managing emergencies and crises– Risk for privacy– Diminish therapeutic relationship– Limited pool of providers– Evaluate cost-effective model

Mobile Technology

• Real-world, “in the moment” use• Findings mixed, but some positive for

depression, anxiety, bipolar and schizophrenia• Successful adherence of medication• Collect/track data by sensors and infer patient

state and location for intervention

• Concern and Needs– How interventions can be integrated with existing

care seamlessly– Transition into the medical record if desired– Dissemination and safety of interventions– Protection of data on mobile devices– Blending social media, sensor, and self-report

health

Simulated Places and People

• Immersive virtual reality and exposure therapy– Anxiety disorders

• Avatars – High on empathy and alliance– Deliver health information in nonthreatening

manner

• Concerns and Needs– Cost-effective methods of delivering virtual reality

therapy– Avatars beginning

Gaming• Video, web, & mobile– Role play and support

exploration– Increase therapeutic

alliance and motivation– Fun! Serious games for

health– Most games for children– May increase cognitive

benefits and change neural circuitry

• Needs and Concerns– Efficacy for games on clinical outcomes in early

stages– Reasonable for adults and older adults– Examine how games may work to improve clinical

outcomes • Is it content or delivery or both?

Developmental Disabilities• Most studies using iPod Touch, Pad are

beginning• Little evidence base• 3 popular applications– Proloquo2Go– Pick a Word – Pixtalk

• Most studies among young adults

Autism Spectrum Disorder• Most research in this area– Use robotics, interactive video, handheld and

touch device, internet virtual environment– Interventions address: • Initiate, maintain, and terminate behavior• Recognize faces and emotion• Improve spatial planning, functional activities of daily

living, safety skills, vocabulary, and reading skills, and social participation

– More rigorous research and evidence needed

ESMART-MH

DEMONSTRATION OF ESMART

http://www.youtube.com/watch?v=zcjYYX_GS38

Overview of eSMART-MH Technology• Co-created with

community members

• Starts at the experience of the participant

• Objective: Improve depressive symptoms by self-management in young adults

Overview of eSMART-MH Technology• How can e-SMART help?

o Simulates interaction with health providers

o Practice self-management skills in realistic environment

o Increase confidence and self-efficacy

o Overcomes stigma and traditional barriers

• Uses Cognitive Behavioral Strategy: SBAR3

o S: Share your storyo B: Bring your backgroundo A: Ask for what you want and/or needo R: Review the plano R: Reflect on whether it is “right for me?”o R: Repeat the plan

How can eSMART Improve Behavioral Health?

How can eSMART Improve Behavioral Health?

• Promotes self-management• Mental health education• Empower patients• Validates feelings and thoughts: They

Realize They Are Not Alone

• Consistent access to Internet

• Transition to a mobile platform

• Complete independently

What are the implementation considerations?

eSMART-MH participants show fewer depressive symptoms.

• 30 million young adults between the ages of 18-24

• 1 in 4 of them have a diagnosable mental illness

• Digitally connected:• Spend 25 hours per week

online• 75% use social media• 95% have a cell phone• 70% have a laptop• 74% have an mp3 player• Usage Spans all SES levels

Potential Reach

Sources: U.S. Census Bureau, National Alliance on Mental Health, Pew Internet Research, and WSL /Strategic Retail

Special Acknowledgements

John M. Clochesy, PhD, RN, CS, FAAN, FCCM Professor

University of South Florida

eSMART-HD National Institute on Minority Health

and Health Disparities (RC2 MD004760)

Special Acknowledgements

L30MH09173KL2TR00440

Questions?

Melissa Pinto, PhD, RNEmail: mdpinto@emory.edu

Phone: 404.727.0126

@md_pinto