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PRESIDENTIAL ADDRESS Table of Contents  
Ahead of print publication
Integrating technology into 21st century psychiatry


 Consultant Psychiatrist, Manasa Hospital; Private Practice At Manasa Hospital, Kurnool Andhra Pradesh, India

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Date of Web Publication23-Nov-2021
 


How to cite this URL:
Babu BR. Integrating technology into 21st century psychiatry. Arch Ment Health [Epub ahead of print] [cited 2021 Dec 7]. Available from: https://www.amhonline.org/preprintarticle.asp?id=330922





  Technology in Psychiatry Top


(The Presidential Address given on September 26, 2020, at Andhra Pradesh Psychiatric Conference held at Guntur in Andhra Pradesh state).

Warm greetings to all,

I have chosen this topic as my presidential address, as all of you are well aware that because of the prevailing pandemic COVID-19 situation, we should bring drastic changes in our behavioral healthcare services for the benefit of our patients (pts.) and also ourselves. Hence, my talk intends to provide you a pragmatic review of some of the major technologies being used in psychiatric practice, as well as those in the near horizon that are likely to contribute to the next wave of practice transformation.

Two relatively recent rubrics of an interface of technology in psychiatry are:

The first rubric is classifying technologies into (1) base technologies and (2) emergent technologies. Base technologies are those that are already in widespread daily use and have a body of evidence and experience supporting their deployment. These consist of e-mail, the internet, mobile devices, live interactive videoconferencing, and electronic medical record (EMR). Emergent technologies are those that have more limited use, have less accumulated evidence on their value, and have not been widely diffused, and these include virtual reality, virtual worlds, voice and face recognition, and positional tracking.

The second important rubric dating back to 2001 explaining our changing society is digital natives versus digital immigrants concept. Digital natives are defined as the generation born into and came out of age with our modern technologies and are assumed to be more comfortable with technology (more tech-savvy) and more at ease with the pace of technological change. Digital immigrants are people who did not grow up with technology and began being exposed and learning technology in their adult life, more wary of technology, use it less, and take longer to adopt and ingrate it. Based upon these, Wang et al. further proposed the concept of digital fluency, defining it as the ability not only to know how to use technology but also to leverage to produce “things of significance.” The authors go on to proffer a seven-factor model that shapes digital fluency: demographic characteristics, psychological factors, social influence, educational factors, behavioral intention, opportunity, and actual use of technology. These factors can be leveraged in understanding an individual pt. or psychiatrist's past exposure to technology, their digital fluency, and where they land in the digital immigrant and digital native continuum. These factors are part of overall pt. and provider cultural backgrounds that affect clinical processes and the psychiatrist/pt. relationship.

I want to express myself in the following heads:

  1. Historical aspects of technology and information technology (IT)
  2. Promise and scope of telepsychiatry
  3. Self-help and automated tools in mental healthcare
  4. The interface of culture and technology.



  History of Technology and Information Technology Top


It is the history of the invention of tools and techniques and is one of the categories of world history. Technology ranges from as simple as stone tools to complex genetic engineering and IT that has emerged since the 1980s [Figure 1].
Figure 1: Technology in stone age

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The term technology comes from the Greek word techno, meaning art and craft, and word logos, meaning word and speech. It was first used to describe applied arts, but it is now used to describe advancements and changes which affect the environment around us.

New knowledge has enabled people to create new things. Conversely, many scientific endeavors are made possible by technologies that assist humans in traveling to places they could not previously reach and by scientific instruments by which we study nature in more detail than our natural senses allow.

Information technology

  • IT is the acquisition, processing, storage, and dissemination of vocal, pictorial, textual, and numerical information by a microelectronics-based combination of computing and telecommunications
  • IT-enabled services (ITESs): ITESs are defined as outsourcing of processes that can be enabled with IT and covers diverse areas such as finance, human resource (HR), administration, healthcare, and telecommunications. All the services which use IT to enhance the services are termed ITES
  • Some examples of ITES are medical: Medical transcription, EMR, telemedicine, E-journals and E-books, and websites of various societies and E-group

    If we go back to the history of IT, we can say that in about 3000 BC, humans started writing in the era of Sumerians in Mesopotamia, thus initiating the process of storing, retrieving, and manipulating. Later, only in 1958, Harold J. Leavitt and Thomas L. Whisler coined the term “IT” in the Harvard Business Review
  • Four distinct phases of IT development: Premechanical (3000 BC–1450 AD), mechanical (1450–1840), electromechanical (1840–1940), and electronic (1940–present).



  Promise and Scope of Telepsychiatry Top


Despite the high prevalence of mental disorders, specialized mental health services are extremely deficient, leading to the so-called “Mental Health Gap.” Moreover, the services are concentrated in the urban areas, further worsening the rural–urban and tertiary primary care divide. Strengthening and expanding the existing HRs and infrastructure and integrating mental health into primary care appear to be the two major solutions. However, both the strategies are complicated with logistic difficulties and have a long gestation period. In such a context, telepsychiatry or e-mental health, defined as using information and communication technology to provide or support psychiatric services across distances, appears to be a promising solution. The practice of telemedicine, i.e., the practice of medical care using interactive audiovisual and data communications, is active all over the globe in various disciplines of medicine including PSYCHIATRY, except in developing countries where telepsychiatry is still in its infancy stage existing more as an offshoot of telemedicine, rather than an independent service.

Grossly, inadequate accessible mental health services and high prevalence of mental health disorders, thus resulting in mental health gap, are very well evident by the following facts and research findings:

  1. Epidemiological studies in India state that the prevalence rates of psychiatric illnesses range from 9.54 to as high as 370 per 1000 population
  2. Mental disorders come in the first ten significant illnesses contributing to DALY
  3. The number of psychiatrists, psychiatric nurses, psychologists, and social workers are 0.2, 0.05, 0.03, and 0.03 per 10,000 populations
  4. Only 29% of mental health needs are met by the available HRs, with huge urban, rural discrepancies.


This insurmountable mental health gap can be overcome by the ongoing technological developments in India (India is considered an IT giant).

The application of technology for delivering mental health services can be a turning point in the mental healthcare system.

TELEPSYCHIATRY can be dealt with in detail in the following heads:

  1. Modes of communication
  2. Applications of telepsychiatry
  3. Legal and ethical issues
  4. Challenges of telepsychiatry
  5. Future of telepsychiatry in India.


Modes of communication

Use of telephone (for consultation, crisis management, psychotherapy, referral), cell phone text messaging, and two-way closed-circuit television have been integral in telepsychiatry communication and are precursors to the more sophisticated and latest distance technologies.

E-mail, instant messaging, online chat forums, and professional advice via websites and blogs are among the different ways in which the internet has been used.

Online and virtual chat rooms offer a platform where people interact with others, including mental health professionals sharing their experiences.

Technological advancement made videoconferencing an important modality in the field of telepsychiatry as it permits to live, two-way interactive, full-color, simultaneous video, audio, and data communication.

Gross communication technologies are of two varieties: synchronous or interactive and asynchronous or store and forward. Synchronous services are nothing, but the provision of live, two-way interactive transmission between pt. and provider at distant locations. The store-and-forward mode of communication, on the other hand, acquires medical data and then transfers this clinical information via e-mail or web applications for later review by a specialist. As against synchronous forms of communication, asynchronous communication involves nonreal-time or “store-and-forward” interaction and does not require the presence of both parties at the same time.

Applications of telepsychiatry

Several studies concluded that telepsychiatry could be practiced in the following fields of psychiatry successfully:

  1. Assessment and services of various psychiatric illnesses such as depression, panic disorder, posttraumatic stress disorder, bulimia nervosa, and schizophrenia
  2. Psychiatric emergency services can be provided through synchronous and asynchronous modes in the form of consultation–liaison service with the collaborative model where psychiatrists and primary care physicians are involved in video conferencing, telephone, secure messaging (e-mail), and internet
  3. Videoconferencing can also be utilized to deliver psychotherapy such as cognitive behavioral therapy (CBT), supportive therapy, and group therapy for depression and anxiety disorders
  4. Internet-based, highly structured CBT programs include self-guided online lessons and homework assignments through e-mail, telephone, or online forum with a therapist proved successful for major depressive disorder (MDD), social phobia, generalized anxiety disorder, and panic disorder
  5. Crisis intervention programs in instant messaging, e-mails, and chat groups have also been demonstrated in pts. with suicidal ideas
  6. Telepsychiatry has also a place in geriatric people (who have poorer accessibility to specialist healthcare institutes), with psychological problems, but with special technology (HIGH BANDWIDTH TELEPSYCHIATRY) to counter their sensory impairments
  7. Telepsychiatry also provides assessment, consultation, and educational services in child and adolescent psychiatry such as treatment of depression, anorexia, conduct disorder, and attention-deficit hyperactivity disorder (ADHD).


Most of the randomized controlled trial studies conducted to compare various telepsychiatry modes with face-to-face assessment modes found no significant difference regarding the clinical outcome, quality of life, and adherence in these pts.

Challenges and limitations of telepsychiatry

  1. Cost-effectiveness of e-mental health: Telepsychiatry saves time, expenses incurred on travel, and daily wage losses of the clients. However, whether such savings would balance the cost of setting up the requisite infrastructure including the support staff is an important question
  2. Issues of privacy, confidentiality, and ethical and legal implications also need attention.


  1. Legal and ethical matters such as duty of care and role in emergency situations, especially at a site distant from the pt., can be addressed by consultant services rather than therapist services via telepsychiatry, i.e. the consultant does not directly assume responsibility but at the same time provides support to the primary care professionals
  2. In addition, the above arrangement might resolve the “tele” versus face-to-face controversy, the essential components of empathy and human interaction being maintained
  3. In addition, clinicians to take care of privacy and confidentiality issues must make sure that the electronic information is effectively protected against improper disclosure when it is stored, transferred, received, or destroyed. Encrypted software helps safeguard against unauthorized interception and tapering of e-mail messages.


Future of telepsychiatry in India

Chief objectives of our National Mental Health Program are (a) to ensure the availability and accessibility of minimum mental healthcare for all, particularly the most vulnerable and underprivileged sections of the population, and (b) to apply mental health knowledge to general healthcare and in social development. Hence, based upon various research studies done, so far, one can say that telepsychiatry will fulfill such objectives through the training and supervision of primary care physicians. For the achievement of this goal, Sharon and Malhotra suggested that developing software packages with codified medical knowledge as an aid to assessment, diagnosis, and management will be necessary.

Telepsychiatry, thus, can solve the enormous and intertwined problems of under-diagnosing and under-treating persons with mental illness and the lack of trained workforce at a grassroots level.


  Self-Help and Automated Tools in Mental Healthcare Top


  • Asynchronous technologies power self-help and consumer-run education in the treatment of behavioral and mental health. These include interactive media, artificial intelligence (AI)-powered chat-bots, voice assistants, and video games
  • Automated behavioral intervention technologies refer to websites with standardized information that use artificial intelligence for input and feedback, thus including computational recognition of speech, facial expression, vocal intonation, and text.


Merits of above technologies are:

  1. They decrease geospatial, temporal, and financial barriers
  2. They allowed many providers to reach and educate a mainstream public audience
  3. These are the most accessible formats, as the cost for reproducing books is minimal, as are training videos that have jumped from videotapes to video discs to learning platforms.


These various technologies can be detailed as follows:

  • Blogs and news sites: Internet websites will provide education and support for those with serious mental illness (SMI). The higher the education and the lower the age, the more likely users would use the internet. Medical societies and scientific journals, such as Nature, maintain blogs that package content for both consumer audiences and professional audiences
  • Social media: Social media such as Twitter tweets, Facebook posts, and Instagram are now essential for education and advocacy and can be helpful to reduce stigma in both pts. and practitioners and provide support. Many clients with SMI such as schizophrenia, MDD, and bipolar illness use Instagram, Snapchat, etc., to connect with others, to learn about mental illness from others, and to share their own experiences about MI, etc
  • Mobile apps: Mobile apps provide self-help and stand-alone health services, which are akin to self-management with self-help books. They extend standardized interventions based on scientific evidence. Users can use the app as they like, wherever they want, repeating the content to reinforce learning, and can use multiple apps addressing the issues they need. Some popular apps are personalized real-time intervention for motivational enhancement (PRIME) and PRIME–D, addressing persons with schizophrenia and depression, respectively. Ecological momentary apps are self-monitoring apps that enable pts to track their symptoms or quantifying the lived experience of mental illness outside the clinic, e.g. a smartphone app that offered the patient health questionnaire-9 depression screening scale. Meditation and mindfulness apps and various anxiety apps are available on the commercial marketplaces. However, the evidence remains unclear for their quality, efficacy, and validity or utility
  • Chat-bots and voice-assistant apps: These apps recognize speech, convert them into text, and process such text through natural language processing techniques. This processing allows apps to understand what the user wants and the sentiment of the user instead of requiring him to type or click. Such numerous commercial apps use CBT content, goal setting, and behavioral activation strategies to help users. Modern chat-bots and voice agents can recognize dangerous messages such as “I want to commit suicide” and offer a phone number to crisis support hotlines
  • Measurement tools: These apps can function passively to implicitly track physical activity, smartphone app usage, etc., without the user's active involvement or explicit input. These apps can later provide feedback and guidance to the user, such as encouragement to walk more steps or limit social media apps usage
  • Videogames: Also called “serious games,” used for a wide variety of conditions such as DM and nicotine use disorders, which encourage users to achieve goals with multiple forms of media such as visually appealing graphics, sound effects, and music.


Augmented reality (AR) smartphone games overlay information and interactive characters in the user's environment, thus encouraging users to perform physical activity. AR may be used for social eye cue training in autism pts., stimulus exposure for animal phobias, and schizophrenia education and training. VIDEO games are also used to improve cognitive focus and reduce symptoms of ADHD to varying degrees.

To successfully implement these technologies, practitioners and organizations must rigorously evaluate the technology's vendor, design, development, and clinical content. Once the providers are comfortable using the new technology, providers can then prescribe the new app, demonstrate the use of the app with their pt., and provide hands-on exercises and assignments. These assignments can highlight the particular aspects of the app that are appropriate for the pts. needs.

I want to emphasize that all the above tools will not replace traditional care, and the gold standard is to have a mental health professional assess, diagnose, and treat the pt. Even then, these tools can help provide support for pts. who have no access to care or otherwise have limited access due to geographic or time constraints.


  Interface of Culture and Technology Top


As providers and healthcare systems navigate the evolving healthcare landscape, they should take steps to account for the impact of “techture” (culture and technology) on the clinical processes. Individual providers should consider in their initial evaluation process not only the appropriate elements related to cultural issues but also pts.' past experiences and perspectives on technologies.

Providers should also be aware of their own experiences and perspectives on technologies and how these may influence their interactions with pts. including biases and limitations in the technologies they are using.

A psychiatrist should monitor in an ongoing fashion the impact of “techture” on clinical processes, including comfort, rapport, and communication.

“Computers never forget and are excellent at scheduling, reminding, and remembering; but humans are still much much better at data analysis and decision-making.We need to make sure that we use computers.for what they are best at, and what we do not forget or set aside the honed human skills in pattern recognition and data interpretation that are essential to the diagnostic process and that make psychiatrists such sensitive and broadly trained physicians.it is essential to redesign business processes before introducing or developing new software technologies.”[10]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Trivedi HK, Shore JH, Chan S, Li L, Torous J, Gratzer D, et al. Review and Implementation of Self-Help and Automated Tools in Mental Health Care. . Psychiatr Clin North Am 2019;42:597.  Back to cited text no. 1
    
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Ashok Reddy K. Information technology and psychiatry. AP J Psychol Med 2010;11:7-11.  Back to cited text no. 2
    
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Malhotra S, Chakrabarti S, Shah R. A model for digital mental healthcare: Its usefulness and potential for service delivery in low- and middle-income countries. Indian J Psychiatry 2019;61:27-36.  Back to cited text no. 5
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Chakrabarti S, Shah R. Telepsychiatry in the developing world: Whither promised joy? Indian J Soc Psychiatry 2016;32:273-80.  Back to cited text no. 6
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Malhotra S, Chakrabarti S. Development and Implementation of a Model Telepsychiatry Application for Delivering Mental Healthcare in Remote Areas. (Using a Medical Knowledge-Based Decision Support System). Project Report August 2010-June 2014. Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh and Department of Science and Technology, Government of India; 2014.  Back to cited text no. 7
    
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Malhotra S, Chakrabarti S, Shah R, Gupta A, Mehta A, Nithya B, et al. Development of a novel diagnostic system for a telepsychiatric application: A pilot validation study. BMC Res Notes 2014;7:508.  Back to cited text no. 8
    
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Malhotra S, Chakrabarti S, Shah R, Sharma M, Sharma K, Singh H. Diagnostic accuracy and feasibility of a net-based application for diagnosing common psychiatric disorders. Psychiatry Res 2015;230:369-76.  Back to cited text no. 9
    
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Malhotra S, Chakrabarti S, Gupta A, Mehta A, Nithya B, Shah R. Development of a semi-structured diagnostic tool for adult psychiatric disorders for use in primary care: Preliminary results. Indian J Psychiatry 2012;54:S74.  Back to cited text no. 10
    

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Correspondence Address:
Batchu Ramesh Babu,
Door No. 43/121, Manasa Hospital, Road No. 5, NR Pet, Kurnool - 518 004, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amh.amh_117_21



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