November 28, 2016

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.