Digital Psychiatry Apps May Create New Burdens, Have Limited Efficacy Data

A smartphone app now in development monitors a person’s voice frequency and detects when mania or depression is creeping in. Another prompts patients to take daily mental health assessments and sends a report to their psychiatrist, including whether they’re feeling suicidal. Yet another encourages people to adopt mindfulness practices as they go about their day.

These are just a few examples of digital psychiatry apps that were discussed at a packed session at APA’s 2018 Annual Meeting in May. Increasingly, patients are picking from among the 10,000 mental health apps now available and downloading them onto smartphones, tablets, or computers. Clinicians, too, are encouraging patients to use them in between sessions and might even be uploading symptom data from patients, according to John Torous, M.D., director of the Division of Digital Psychiatry at Beth Israel Deaconess Medical Center in Boston. He is also a member of APA’s Council of Health Information Technology and chair of the Smartphone App Evaluation Work Group.

With smartphones available for as little as $50 at big-box retailers, virtually everyone can have access to digital psychiatry tools, Torous said. One type of app is a “symptom tracker,” which prompts people to enter their subjective experience of their mental health throughout the day or week. Other apps use sensors or smartphone hardware to capture “passive” data, such as how many hours a user has slept or how much a person has moved and where he or she has traveled using geolocation. Thousands of “interventional” apps, too, promise to coach users to better mental health.

What’s unique about digital psychiatry apps is the ease with which they allow physicians to access data, the volume of data generated, and the length of time that the data are retained, said former APA President Paul Appelbaum, M.D., the Dollard Professor of Psychiatry, Medicine, and Law at Columbia University College of Physicians and Surgeons. “They can also provide new types of information we’ve never had access to before, like where your patients are at every moment in time or what their voice tells you at any point in time,” he said.

Apps may be able to capture other important data that a clinician cannot, in part because people tend to report symptoms at a higher severity to an app than they do a physician, Torous said. In one recent study of which he was a co-author, patients reported suicidal ideation at a much higher rate—and had far worse depression scores via the app—than when they were with the clinician during check-ins. One theory: “It may be easier to tell some things to a cell phone than a person,” Torous said, adding that more research is needed to understand this phenomenon.

In addition, Torous said patients tend to think what they share with an app is protected and held in confidence just as it is with their psychiatrist, but that is rarely the case. “It’s important that patients be fully informed that they’re selling your data to pay for the service,” he said. “Often, the price of a free app is you.”

Appelbaum is urging clinicians to be cautious before adopting or encouraging patients to use digital psychiatry apps. “Whether they are a ‘net’ benefit or a burden on treatment and on the therapeutic relationship is just a big question at this point. And it would be nice to have that question answered before we move ahead too quickly.”

In addition to the lack of outcomes evidence, there are some important legal issues to consider as well, Appelbaum said. For starters, the wealth of data captured by digital psychiatry apps could be subpoenaed during divorce, criminal, or accident litigation.

Applebaum said clinicians who delve into digital tracking of patients are assuming a whole new duty. For example: “Let’s say you have an app that you’ve encouraged your patients to use that allows or encourages them to record their suicidality. … How often are you going to look at that? Every day, once a week, every two weeks? What happens if there is a string of strong suicidal impulses recorded and you don’t look at the app, and then the patient unfortunately attempts or succeeds in killing themselves?”

Clinicians have only two choices for managing what could easily be an overwhelming amount of data produced by digital psychiatry apps: review the data in a session with the patient—taking time away from other important work—or find time outside of sessions to sift through the data, Applebaum said. Microsoft, Google, and other companies are already developing programs to mine data for mental health diagnostic purposes. For example, a study was recently published showing that monitoring women’s Twitter feeds during and immediately after pregnancy could predict which women would develop postpartum depression, he said.

Appelbaum wonders whether widespread adoption of these apps by clinicians might move the profession toward a duty to monitor patients digitally. “The standard of care is what a reasonable physician in a similar situation would do in this case. But as more and more of our colleagues adopt this technology, failure to adopt it might well constitute negligence down the road.”

The use of digital psychiatry data can blur the boundary between what goes on inside the consulting room and what goes on in the rest of the patient’s life, Applebaum said. “In some sense we are with them through their entire days and nights in a way that we never have been able to be there before.” While some patients may feel protected by having their clinician looking over their shoulder, others might feel intruded upon or spooked by it.

Laura Dunn, M.D., a professor of psychiatry and behavioral sciences at the Stanford University Medical Center, pointed out there is far more certainty surrounding the risk-benefit ratio, potential adverse consequences, and informed consent with the use of psychotropic medications than there is with digital psychiatry apps.

“There’s a lot of excitement about this new technology, and there’s a lot of hype. But in the realm of the patient-physician relationship, I still think that we’re invaluable. And we need to keep ourselves and our patients in the center of that relationship,” Dunn said.