The Future of Psychiatry: Telehealth, Chatbots, and Artificial Intelligence

The Medical Futurist
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Could a chatbot, an online community, or a telepsychiatry solution offer meaningful help for people who are fighting mental health issues?

Could virtual reality, artificial intelligence, or genetics appear as elements of assistance in the toolkit of medical professionals in the fields dealing with the human psyche? While we agree that medical fields requiring the most empathy and human touch will most probably not be swept away by new innovations, we looked thoroughly at how technology will appear in the future of psychiatry. Perhaps even help heal the cursed prince from Beauty and the Beast?

The human touch is indispensable in fields dealing with the psyche

When we started a project to map out the universe of mental health apps, we decided to also test Woebot, a little algorithmic assistant aiming to improve mood. It promises to meaningfully connect with you, to show bits and pieces of empathy while giving you a chance to talk about your troubles and have some counseling in return. Just as a human therapist would.

At first, it was weird to imitate a conversation with a chatbot, personalized as a robot figure, as it was very palpable that the user is chatting with a programmed answering machine. Based on the team’s experiences, sometimes it was amusing, it even had some uplifting words of wisdom to offer, but our editor once said that one day when she thought to herself how sad it would have been if she had only talked to Woebot that day. She could have thought that she’s so lonely and miserable that her sole companion is a chatbot. That day, it clearly failed. Utterly. It could not make her believe that it’s a viable alternative to a human. But the question is: should it make her believe that?

The human touch is a key part of practicing medicine, and regarding the field of clinical psychology, clinical social work, marriage and family therapy, psychotherapy, psychiatry, or psychiatric nursing, human connection, understanding, and empathy build such a basic foundation that it is very hard to imagine how technology could play a meaningful role in it. Regardless, a plethora of smartphone apps, virtual reality and telemedical solutions, experiments for creating artificial intelligence platforms and robots for therapeutic purposes through trying to “teach them” how to mimic empathy are underway, so we decided to look around how technology will appear in the future of psychiatry.

Mental health apps to support therapy

As there’s an app for everything nowadays, an ever-growing pool of health apps have appeared lately to support therapy. The keyword here is ‘support’: these solutions explicitly say that they exist to guide patients on their journey towards mental health and to guide clinicians towards being able to help their patients better. As an example for the latter, the American Psychiatric Association created an online tool to navigate psychiatrists through the bourgeoning mental health app world.

These tools range on a wide scale from harmless anger-soothing, meditation apps through mood trackers to PTSD, stress or anxiety management instruments. These tools offer a temporary solution for people suffering from mental health troubles when a therapist is not immediately available. Beyond the already mentioned Woebot, Pacifica also aims to boost users’ mood through cognitive behavioral therapy. Replika aims to become an “A.I. friend” whom the user can tell everything about their life, while the PTSD coach provides tools and information about how to cope with PTSD-induced stress in daily life. SAM is a friendly app that offers a range of self-help methods for people who are serious about learning to manage their anxiety, and IntelliCare offers a suite of apps that work together to target common causes of depression and anxiety, like sleep problems, social isolation, lack of activity, and obsessive thinking. Even people with suicidal thoughts might get some help through apps: the MY3 helps the user define their network and reach out to others when feeling suicidal.

future of psychiatry

Online communities with peer support

The MY3 app links us to the most powerful helper of people suffering from mental health troubles: community. Words of comfort, uncompromised attention, and empathy coming from members of a trusted group could work wonders. Especially when the community knows what they are talking about. Thus, online communities with peers going through the same problems could also offer tremendous help – especially in times when an offline alternative is not available.

For example, 18percent is a free online mental health community based on Slack, where one can receive peer-to-peer support instantly and constantly. The community offers free, 24/7 support in a moderated environment, with many channels that cover various mental health issues ranging from addiction through depression, mood disorder to OCD. 18percent is an official partner of the US Crisis Text Line and the National Eating Disorders Association. Other similar applications, such as Big White Wall, Elefriends, or the ADAA online support group also provide online spaces where people suffering from various mental health troubles can come together and talk about their problems, with or without support from trained therapists.

Mental health apps’ and online peer communities’ greatest advantage is that they offer immediate help in the middle of the night or during other periods when a psychiatrist or psychologist isn’t within reach. Zach Schleien, Co-Founder of 18percent told The Medical Futurist that “children may use bots since they may be afraid to tell their parents that they are dealing with mental health issues. People who do not have the means to pay for therapy may turn to bots as a low-cost option. Individuals who are traveling or are unable to sleep late at night may speak with a bot since the “human” therapist will likely be unavailable”.

Telemedicine connects patients and therapists

Another way of technology connecting those in need is telemedicine. As it offers a platform for the therapist to pay attention and empathize with another person in a profoundly human manner, it helps link patients with caregivers in the field. Telemedical solutions could work here even better than in the case of other specialties, as contrary to other fields, the patient doesn’t need a physical exam, but a meaningful conversation. Moreover, it could also mean a solution for the still prevailing stigma of “going to a therapist”.

Patients can already schedule sessions with human coaches through smartphone apps, such as Ginger, for example. Launched in 2015, Cloud 9 hopes to make mental healthcare more accessible through its platform offering intervention and prevention support by connecting patients or those in crisis with mental healthcare professionals. Talkspace connects users with over 200 licensed therapists through messaging. The service is not meant to replace real, face-to-face sessions, and the therapists are trained to tell the users if they need more or different counselling.

Children’s Hospital & Medical Center in Omaha, which services Nebraska, Iowa, Kansas, Missouri, and South Dakota in the United States, provides another great example of the impact telemedicine psychiatry has on patients and providers. Children’s Omaha serves over 250,000 children, the vast majority of whom living in rural areas with limited or nonexistent access to psychiatric care. Using telepsychiatry, the health system has been able to reduce follow-up no show rates by 50 percent, eliminate the psychiatrist’s 26-hour weekly windshield time, and have one psychiatrist provide care to over 600 patients in the program’s first year.

Virtual reality against phobias

Virtual reality offers another brand-new way to treat mental health problems, such as anxieties, fears, and phobias. The immersive environment re-creates the fearful situation for patients – but it also offers them a safe place to get over their paranoia: they are under the control of physicians, and they can get out of the simulation any time.

The Spanish and American behavioral health technology company, Psious, offers unique VR treatments for psychological conditions such as fear of flying, needles, various animals, public speaking, general anxiety, or agoraphobia. Virtually Better, the pioneering VR company founded in 1996, offers among others an exposure therapy for people suffering from anxiety disorders, specific phobias, or post-traumatic stress syndrome. A research team at the University of Southern California developed a project called Bravemind, another VR exposure therapy for soldiers to gradually immerse them into a virtual environment similar to the one where they got traumatized to help them process their feelings associated with their trauma.

Virtual reality can also appear in the form of apps outside of the office of the therapist, which leads to better self- management and an overall more efficient therapy. For example, Arachnophobia offers self-guided exposure therapy for people having an irrational fear of spiders. You are exposed to an increasing number of spiders in a room, and if that were not enough of a stressor, you are not allowed to move your hands or arms during the session. On the other hand, Richie’s Plank Experience places you on a plank, 80 stories above ground, to tackle the fear of heights. Even people who are afraid of public speaking can face the dreaded situation with Limelight, which gives users the option of appearing in a business meeting, small classroom, or in a large hall as they give a speech.

Pharmacogenomics for the most appropriate antidepressants

A specific strand in personalized medicine aims to revolutionize how we think about medication, which might also impact psychiatry and prescription medicine, e.g. antidepressants or antipsychotics. Pharmacogenomics deals precisely with this issue area. It is defined as the study of variability in drug response due to the genetic code. It argues that despite general sentiments, medications do not have the same effect on people. There are already some who expressly recommend genetic testing before any prescription of e.g. Warfarin, a type of anti-blood clotting drug takes place.

Psychiatrists are aware that inherited genetic variations (such as in cytochrome enzymes) can influence the body’s response to drugs. For example, people who are poor cytochrome P450 2D6 (CYP2D6) metabolizers will typically have substantial increases in various medications, thus pharmacogenetic testing of CYP2D6 can help determine if the initial and target dosage of certain antipsychotics should be lowered (e.g. halved). Also, pharmacogenetics testing can provide an explanation for why some people experience certain adverse effects while taking tricyclic antidepressants (e.g. anticholinergic effects), and this information can be used to guide management decisions.

We are expecting that genetic screening in clinical practice will soon become routine and will enable psychiatrists to customize drug treatment to achieve better efficacy and tolerability for each patient. This will help us adapt therapies to address genetic variations within our ethnically diverse society.

pharmacogenomics

Artificial intelligence could flag signs of depression and suicidal thoughts

And finally, artificial intelligence can even give a helping hand when it comes to the early detection of depression. For example, in the future, patients might go to the hospital with a broken arm and leave the facility with a cast and a note with a compulsory psychiatry session due to flagged suicide risk. That’s what some scientists aim for with their A.I. system developed to catch depressive behavior early on and help reduce the emergence of severe mental illnesses. The machine learning algorithm created at Vanderbilt University Medical Center in Nashville uses hospital admissions data, including age, gender, zip code, medication, and diagnostic history, to predict the likelihood of any given individual taking their own life. In trials using data gathered from more than 5,000 patients who had been admitted to the hospital for either self-harm or suicide attempts, the algorithm was 84 percent accurate at predicting whether someone would attempt suicide the following week, and 80 percent accurate at predicting whether someone would attempt suicide within the following two years.

In another experiment, researchers proved that a smartphone coupled with an algorithm monitoring user behavior over a period of time could come up with a similar diagnosis. According to preliminary studies, changes in typing speed, voice tone, word choice and how often kids stay home could signal trouble. There might be as many as 1,000 smartphone-based ‘biomarkers’ for depression, said Dr. Thomas Insel, former head of the National Institute of Mental Health and now a leader in the smartphone psychiatry movement. At the moment, researchers are testing experimental apps that use artificial intelligence to try to predict depression episodes or potential self-harm.

Facebook also allows to do something similar on its platforms. For years, the company has allowed users to report suicidal content, but the social network ramped up these efforts after several people live-streamed their suicides on Facebook Live in early 2017. About a year ago, Facebook added A.I.-based technology that automatically flags posts with expressions of suicidal thoughts for the company’s human reviewers to analyze. Thus, the company now leverages both algorithms and user reports to flag possible suicide threats.

How does the future of mental health management via technologies look?

Reading through the technologies, you wonder how the process of diagnosing and treating mental health troubles might look in 10-20 years. So let’s take the Beast from Beauty and the Beast, who was pretty depressed, being cursed and trapped as an ugly monster. His smartphone could have recorded the violent outbursts, the moments of insomnia, and late-night looking up of internet sites about self-harm. At first, the digital tool would have made some suggestions how to improve sleep and manage anger. Later on, when his social media posts had grown more negative, and the algorithm had observed fewer conversations and connections with friends, the smartphone app would have booked him to see a psychologist and a psychiatrist.

The therapist could have observed all the data that the algorithm and the phone had logged, and based on his pharmacogenomics information, the doctor could have suggested therapy and antidepressants. If he hadn’t been open to leaving the castle, as he didn’t want people to see him as a beast, he could have scheduled the sessions via telemedical platforms. Moreover, the smartphone app could have guided him through the most difficult periods, and it would have made him less scary for Belle when they first met. The curse could have been resolved much-much earlier.

On the other hand, psychiatry, clinical psychology, and all the other medical fields dealing with mental health issues will always remain a very personal profession. For the time being, an intimate doctor-patient relationship cannot be built through chatbots, smartphones, or telemedical screens in these fields, although these solutions could alleviate the immediate need for a therapist. One of the main reasons is the question of privacy – when a technology acts as a transmission medium able to record the scene, the participants have to be assured that the shared, very intimate pieces of information will be respected and kept safe and secure without unauthorized access to it. On the other hand, there is a lack of physicians worldwide, so they might need to learn how to use technologies more and more alongside with the skill how to offer words of wisdom and empathy through screens, and how to offer peace of mind regarding data security.

The Future of Psychiatry: Telehealth, Chatbots, and Artificial Intelligence