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August 21, 2019

Experimental Therapeutics for Digital Mental Health

Author Affiliations
  • 1Center for Behavioral Intervention Technologies, Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
  • 2Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University, Chicago, Illinois
JAMA Psychiatry. 2019;76(12):1223-1224. doi:10.1001/jamapsychiatry.2019.2075

The efficacy of digital mental health (DMH) services is well established. Digital mental health services are comprised of the technology, service protocol, and, ideally, implementation plan to support delivery. Like their traditional in-person treatment counterparts, DMH services have been developed and are being studied to target the behavioral, cognitive, and/or affective mechanisms that impact functioning (eg, decreasing avoidance via a digital anxiety intervention). However, when DMH services move from controlled research settings to deployment in real-world health care settings, engagement is an acute problem.1 Implementation attempts often show low rates of service use and retention among patients (ie, failure for individual-level engagement), and DMH services fail to be integrated successfully within their targeted systems of care (ie, failure for systems-level engagement among clinicians/organizations). For example, a large-scale attempt to implement commercially available and free-to-use digital depression services in primary care failed.2 Several factors impede successful implementation of evidence-based interventions into care, such as organizational, sociopolitical, and economic policies (eg, reimbursement challenges) and failed understanding of mechanisms by which implementation strategies improve outcomes. Another critical factor affecting low engagement is the failure to adequately incorporate end users (eg, patients, clinicians, and care systems) in the design of DMH services.

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    2 Comments for this article
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    Digital mental health does not exist
    Theo Broekman, Psychologist MSc | Bureau Bêta, Nijmegen, The Netherlands
    The word "services" has been forgotten in the title. Digital mental health is a non-existent entity. The reification of a kind of "digital" mental health will divert efforts for good mental health services to irrelevant targets. So we should be careful and precise in using terminology and omit any combination of digital and health.
    CONFLICT OF INTEREST: None Reported
    A Digit[al ] by any other name
    Lee Reichbaum, Ph.D. Clinical Psychology | University of Pittsburgh School of Medicine; Dept of General Medicine; Internal Medicine Residency
    I support digital therapeutics. It would be foolish not to do so. It already offers benefits never before realized, i.e. problem-solving immersion in the virtual reality anxiety. The importance of thoughtful, planful engagement of patients is critical. I've had my patients participate in two beta trials of digital therapeutics. The lessons you point out are if nothing else repetitious of what we've repeatedly learned from patients, but they remain critical components. "Compliance" that leads to healing doesn't occur easily. Regardless of how much shared decision making we employ and evidenced based advice we provide to patients to help them understand themselves, the risks to their lives, and the means to change to improve quality of life---people do what perfits them best.

    My biggest concern can be rooted in the simplest defining of digit [online dictionary source] and its dichotomy:
    1] any of the numerals from 0 to 9, especially when forming part of a number.
    2] a finger (including the thumb) or toe.

    At once we think of DIgit [al] as being a number, oftentimes binary, or the bases for conclusive statistical research. It does not take into account that the digit serves to represent patients, human beings who often, thankfully vs "tear my hair out", are more unpredictable than the digits of our research take into account. Our patients have to be more than the numbers on a dog tag

    The second definition literally points to the important point: digits [finger] are attached to human beings. It is critical to have any therapeutics be capable to accounting for and using what can be learned of the individual that it intends to help. Digital technology is still far away from including the subjective emotive answers a patient might fill out on a "Get to Know Me" form. Digital care still has miles to go before it reads and understands facial expression, can see dirty or well-groomed hands, hear intonations/characterizations expressed in a voice, inhale the aromas of perfume or body odor that pleases, covers-up, or represents parts of the patient's life. I know that computers are well on the way to do so, but...

    I expect digital therapeutics, artificial intelligence [how I hate those words] will eventually be able to succeed in the above solving the above challenges. But to do so will be to amputate the bodily digit. So many of our mental health problems are rooted in social behaviors. Once we extract the human aspect of clinical care from therapeutics, patients will lose the opportunity of real life interaction, collaborative active problem solving, the risk taking of honesty, exposure to a human clinician and real world empathy. The therapeutic microcosm of the Doctor-Patient relationship will be significantly diminished. Therapeutics will be an accident waiting to happen, much like the head-down texter who is driving or the teenager lost in an online game not paying attention to the family at the dinner table.

    I hope that digital therapeutics and face-to-face care will have a healthy marriage, complementing one another rather than causing a triadic divorce of fragmentation among the digitizing machine, patient, and clinician. Some of the finest music in the world is unplugged. Among the most critical of therapeutic goals is for human beings to be unplugged, untethered, free. Reliance upon digital therapeutics can lead to changing whether individualism is a value, whether a socialization has any relevance, and whether we remain free or fall into single-mindedness that can be engineered to follow some other entities dictation.
    CONFLICT OF INTEREST: None Reported
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