Nassir Ghaemi M.D., M.P.H.

Mood Swings

Mental Health "Lite"

How digital technology can help persons with bipolar illness

Posted Jan 10, 2019

Recently I was contacted by Katherine Ponte, a Mental Health Advocate and Entrepreneur and lawyer and Founder of ForLikeMinds – the first online mental health peer support community dedicated to mental illness – thriving with severe bipolar I disorder.  She has some important experience to share about digital technology and mental health. I'm posting an article by her written specifically for this blog.

The growing availability apps and web-based services for mental health is both promising and exciting.  Over 165,000 mobile applications are available for health care, with mental health being the largest category.  For better or worse, barriers to entry of building a mental health app are lower than in other medical specialties.  The growing awareness of mental health issues and demand for more accessible treatment options is positive, but this allows for less than effective apps to find a market. 

Mental health lacks objective biomarkers, so there’s more subjectivity in assessing conditions and outcomes. The number of downloads and star ratings for an app in the app store will indicate consumer popularity and marketing effectiveness, but not necessarily effectiveness in actual health outcomes.  In addition, while venture capitalist (VC) funding supports the development and execution of creative business plans, VC incentives are not necessarily aligned with end consumers. VC's may seek accelerated, scalable adoption and commercialization of consumer-facing business models, even where scientific-support may be lacking.  The VC approach is typically one of placing multiple “bets” on start-ups with a view that a select few will be major outsized wins, significantly exceeding the losses in most investments which are unsuccessful. While a net positive, the increasing consumer and investor interest in more accessible mental health solutions may stimulate the proliferation of highly commercialized technologically-mediated mental health offerings with questionable effectiveness.  Moreover, this commercialization may also trivialize and minimize the challenges of treating real mental health conditions. Often, these approaches belittle the pain and suffering of serious mental illness by suggesting that getting well can be achieved easily and conveniently.

Marketing strategies for apps and web-based delivery of mental health solutions may distort perceptions of mental health and mental health conditions.  To maximize market size, the broader mental health market is defined to include those with mental health conditions.  While mental health may occur on a spectrum, you don’t kind-of-sort-of have a mental health condition, just as in any other disease.  Hence, blurring the line between mental health and a mental health condition can be dangerous, especially with gimmicky approaches.  Mental health is defined as a “state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”  However, as described by the Mayo Clinic: “many people in good mental health are often, from time-to-time, sad, unwell, angry or unhappy, and this is part of a fully lived life for a human being.”  These feelings do not on their own constitute a mental health condition.  A mental health condition refers to one of nearly 300 disorders defined in the Diagnostic and Statistical Manual of Mental Disorders.  They affect mood, thinking, and behavior, and ongoing signs and symptoms cause frequent stress and affect the ability to function.  Mental health conditions require comprehensive professionally-led care, not care by app alone. 

Marketing campaigns that co-opt stigma may very well compromise those with mental health conditions, those who support them, and mental health professionals.  True stigma campaigns—decades long and costing tens of millions—seek to end the discrimination against individuals with mental health conditions.  They were certainly not intended for use in broader commercial marketing campaigns.  By seizing on stigma as a tool to promote a range of offerings, these campaigns water down true mental health stigma campaigns, which both obfuscates and harms the very community they were intended to help.  This is especially true at a time where increasing attention is being called to the mental health community.  Increasing commercial interest that could strongly benefit individuals with mental health conditions might instead flow to products, more broadly positioned as mental health solutions.  By analogy, we may recall what happened in the green movement.  The term greenwashing was coined in the 1980s to identify a company or organization that spent more time and money claiming to be “green” through advertising and marketing than actually implementing business practices that minimize environmental impact.  We could be careful not to engage in “mental health washing”   

Most concerning is the lack of evidentiary support for these apps, but that has not dampened demand.  There are many great apps out there, but there many more that are unhelpful or even detrimental on their own.  Understandably, user-provided reviews and ratings on the iOS-based Apple iTunes, Android-based Google Play, and Android-based Amazon App Store app marketplaces provide few data on quality, safety, or efficacy of smartphone apps.  The FDA, has taken a largely hands-off approach.  Professional communities are acting.  Recognizing that the pull of mental health apps may be too strong to resist, rather than counseling their patients against using them, some professionals are trying to evaluate them.  A recent commentary recommends a framework that psychiatrists should consider when evaluating all “ASPECTS” of an app, namely whether the apps is Actionable, Secure, Professional, Evidence-Based, Customizable and Transparent.  The American Psychological Association has established a Smartphone App Evaluation Task Force.

This lack of evidentiary support reinforces the most troubling risks of mental health apps. When used alone, they may make things worse not better, by delaying effective treatment among other reasons.  This may result from mental health app providers overselling their product to attract users.  Industry wide regulation that could enhance the effectiveness of apps is absent.  Privacy concerns are always present.  The therapy profession may also suffer.  The lower treatment cost offered by apps will increasingly drive price-based, but not necessarily quality-based, competition for services.  This may discourage some from entering therapy.  Therapy is not mass-producible service, nor should it be.  Competition based on unique education, expertise, knowledge, experience, and talent produce better outcomes.

Notwithstanding the above risks, technology-mediated mental health services have great potential and can expand the reach of healthcare providers, psychiatrists, and mental health care clinicians. They help increase access expanding the universe of people who benefit from mental health support.  Technology based services can also be complementary to other traditional approaches.  Technology will continue to drive innovation and progress in our lifestyles, and mental health will be no different.  In mental health, technology may take many exciting forms:  Wearables can allow people, patients and clinicians to track and monitor emotional and physical well-being.  Digital communication tools can link people with 24/7 support, either online or at crisis centers. Technology based models can also deliver actual therapeutic assistance, including cognitive-behavioral therapy, motivational interviewing, and supportive techniques or protocols when needed. 

The most positive impact of technology-based offerings may simply be making individuals feel more comfortable talking about mental health.  Communicating digitally allows people to more easily open up and seek help anonymously, which can be a critical step towards seeking help.  That can be the first step to finding more evidence-based help.  This too is not without risk.  Mental health apps may position their service as a substitute for existing evidence-based options.  Some may use the app as a substitute for in-person care or they may be discouraged from turning to professionals where an app does not work.  The advantages of mental health apps are indisputable, as is their popularity.  This should inform the mental health profession and how they may themselves improve their offerings.  Convenience, anonymity, lower cost, service to more people, interest, 24-hour service, consistency, and support make apps highly appealing.

The possibilities of technologically-mediated mental health are tremendous.  They are giving the public, doctors, and researchers new ways to access and provide help.  One should, however, always proceed with caution, especially in the face of entrepreneurial ambition to come up with up with new solutions for old problems.  New is not always better, especially for the mental health community where the lack of treatment and sometimes worse, poor treatment, can have very serious consequences.  For individuals with mental health conditions, the true promise lies in clearly defined patient-centric evidence-backed approaches, that are meant to complement not substitute existing professional services.  Rather than creating a new treatment approach, ForLikeMinds is a technologically-mediated alternative to evidence-based in person peer support, which we hope may complement, but not substitute traditional care offerings.  We hope that as this model is used the delivery method also proves to be an evidence-based practice.

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