November 28, 2016

The Therapeutic Alliance in the Age of Digital Health

Revere L. Greist and John H. Greist, MD

Healthcare Technology Systems, Madison, Wisconsin

A recent opinion piece in JAMA Psychiatry called for caution in the use of mobile and digital health (mHealth) applications. These are software programs that allow patients and physicians to share information and permit patient assessment and, in some cases, treatment. The authors argue that mHealth applications pose a risk to patient privacy, worry that patients won’t be able to distinguish between good and bad applications, and advocate for the use of mHealth only by patients under the care of a psychiatrist. While this recommendation is a proper consideration of the first principle of medicine “Primum non nocere,” it is probably unworkable given the present reality of widespread use and promising utility of these applications. The opinion piece does, however, raise a question that is doubtless on the minds of many practitioners: What does digital health mean for the therapeutic alliance with patients? Fortunately, the answer is encouraging. When validated and used appropriately, mHealth applications can not only enhance existing doctor-patient relationships by expanding treatment options and extending the reach of clinicians, but also substitute for the therapeutic relationship where none is present or possible.

Digital health applications that are validated through randomized controlled clinical trials published in peer-reviewed journals offer truly standardized measurement-based and evidence-based care with customization rivaling that of expert clinicians. Always available, these programs are most often used outside clinic office hours when clinicians prefer not to be working but when patients find convenient. As program improvements are made, they are immediately available to existing and subsequent users. Cost for mHealth applications can be much lower than care from a clinician. These programs are well suited to address a prominent challenge faced by those suffering from mental illness: access to high-quality care.

Consider cases in which no therapeutic alliance is possible or desired by the patient. Cost, geography, and preferences for treatment often conspire to prevent patients from seeing a primary care physician, much less a psychiatrist. Montana, where our family is fortunate to spend a good deal of time, is a good example. The state ranks 35th in median household income, and ten of the 56 counties are considered to be rural, while 45 are designated “frontier.” No mental health prescribers—physicians, nurse practitioners, or physician assistants—practice in the eastern half of the state. For patients facing these and similar circumstances, digital health can provide treatment where none has been available. For patients who cannot or will not engage in a therapeutic alliance and do not wish to take medications, mHealth can provide access to evidence-based treatment alternatives.

Where a therapeutic alliance already exists or can be formed, mHealth applications can enhance the relationship. For patients seeking a complement or alternative to medication, they or their referring psychiatrists can be hampered by constraints in finding practitioners of evidence-based psychotherapy. Validated digital therapies enable psychiatrists and other clinicians to offer this form of treatment even in the absence of qualified therapists. Moreover, when psychiatrists and other healthcare providers integrate mHealth into their practices, they provide additional support for patients between appointments, during the intervals when the hard work of behavior change actually takes place. Digital health solutions can also give information to healthcare providers that enables them to make modifications to the treatment plan before the next appointment. For willing physicians, mHealth can strengthen the doctor-patient relationship by supporting additional forms of therapy and enhancing the exchange of useful information.

Digital health applications are here to stay, and we as physicians should be encouraged by this development. These applications permit treatment when a therapeutic alliance isn’t possible or wanted by the patient and can improve the relationship when there is one.

Financial disclosures: Mr Greist is a consultant to Healthcare Technology Systems and is a stock shareholder of Waypoint Health Innovations and Healthcare Technology Systems. Dr Greist is an employee of Healthcare Technology Systems; is a consultant for the Center for Mental Health Research and Recovery and independent Data Safety Monitoring Boards for Pfizer; and is a stock shareholder in Waypoint Health Innovations and Healthcare Technology Systems.

Behavioral Change in the Era of Digital Mental Health

John Torous, MD, and Steven Chan, MD

Beth Israel Deaconess Medical Center, Boston, Massachusetts (Dr Torous) and University of California, Davis (Dr Chan)

What can bats in Florida tell us about behavioral change in the era of digital mental health? You might not realize it, but quite a bit.

Let’s jump back to 1929. Malaria was increasingly recognized as an urgent public health issue, spreading in the Key West region of Florida. Knowing that mosquitoes transmit malaria and that bats eat mosquitoes, a real estate developer copied a San Antonio doctor’s plan to stop the disease. The idea was innovative yet simple. A bat hotel of sorts, termed a “hygiostatic bat roost,” was built with the hope that bats would take up residence in this custom roost and control the mosquito population. However, the bats that were moved into their custom-built home flew away, never to return.

Return to the present day: mental health care is increasingly recognized as an urgent, unmet public health need. While we are making progress in reducing mortality from cancers and cardiac disease, the rates of suicide are actually increasing. Mobile health technologies—eg, smartphone apps, wearable sensors, virtual reality headsets—offer the potential to bring new tools to the field, new means to quantify mental health, and new treatments for patients. The growing interest from patients, clinicians, researchers, and policy makers alike reflects the excitement and hope that digital health tools will usher in a new era of improved mental health care. Such optimism seems well-founded. Early experiences with these digital tools in mental health have been encouraging.

But the key word is early. There are still issues we need to work out and much we do not know. We often assume that building an app or collecting data is inherently valuable, but do patients stick with apps and use them after they download them? Or, like bats at the Florida bat tower, do they try an app once and never return? How much do patients benefit from apps in the real world? What are the clinical correlations of app data? Do we want to invest in digital tools without having data demonstrating that they add value? Or, do we just hope they work, like the builders of the bat tower hoped? What is the right dose and duration of technology use? How secure are the data that patients provide, and who controls these data?

The point is not to halt progress on or naysay the potential of digital technology in mental health, but rather to ensure that we remain on track to realize it. Previously, the British National Health Service (NHS) had an app library on its website that offered a selection of apps curated for quality. But, in October 2015, the NHS realized that many of these curated apps were not only not evidence-based but also leaking patients’ private data! The app library was removed from the NHS website, causing a dip in the trust of health apps.

To build technology-based mental health tools that will change the field, we need to build tools that are trustworthy, evidence-based, and patient-inclusive. Real innovation is not achieved by merely claiming that an app or product is innovative but by showing that it actually works to improve the care of patients.

There are many exciting ideas in the digital mental health care area, and some of them surely will transform the field. But, rushing them forward with more fanfare than science behind them will only create modern-day bat towers that will become historic curiosities instead of transformative technologies.

(You can visit the bat tower today, now on the National Register of Historic Places, near Sugarloaf Key outside of Key West, Florida.)

Financial disclosures: Dr Chan is an employee of Dr Torous had no relevant personal financial relationships to report.