Gen Hosp Psychiatry. 2013;35:332-338. (doi: 10.1016/j.genhosppsych.2013.03.008)
In 2010, the Agency for Healthcare Research and Quality and the National Institute of Mental Health convened a technical expert panel, entitled “Health Information Technology and Mental Health: The Way Forward,” that culminated in a multidisciplinary advisory meeting. Their aim was to review the state of research on health information technology in mental health and to identify research priorities. A subgroup of this panel focused on behavioral intervention technologies, or BITs, which leverage technology to address behavioral, cognitive, and affective targets. The expert panel identified 6 types of BITs (Figure 1).
BITs are a research priority, the panel noted, because of their potential to extend care providers’ reach and bring behavioral treatment to populations who otherwise could not access it.1 They offer the opportunity for real-time monitoring and intervention; the possibility to create well-controlled simulated worlds for delivering therapy, via virtual reality; and a way to boost patient engagement, via gaming applications.
Figure 1. How Are Behavioral Intervention Technologies (BITs) Delivered?
Mobile (mHealth) technologies . Research has indicated positive benefits of mobile BITs for several disorders, such as anxiety2 and schizophrenia3 as well as for increasing medication adherence.3 The panel noted that mobile BITs can passively collect data via sensors, eliminating the need for a patient-initiated login. These data can then be used in one of two ways: (1) Clinical knowledge-based algorithms can use the data to predict the patient’s mental state and determine if intervention is needed, or (2) Machine-learning techniques can match up sensor data with simultaneously gathered patient self-report data to predict when a given mental state will occur, triggering the need for an intervention.
Psychotherapy via videoconferencing, telephone, and instant messaging. These resources address geographic barriers to care by allowing patients who may live in rural areas or lack transportation to receive treatment from a trained therapist. Of course, a therapist’s time is still required for the administration of treatment. Despite concerns that delivery of psychotherapy by these modes eliminates certain visual and voice cues, evidence indicates that therapy conducted via telephone may be nearly as effective as face-to-face therapy.4
Social media. BITs in social media have mostly taken the form of Internet support groups. Panelists noted that there may be potential in this area if Web-based intervention tools can be integrated, but research has not indicated a positive effect of these support groups in their current manifestations.5
Web-based intervention. Web-based interventions can be delivered with little or no requirement for face-to-face therapy and have shown efficacy in a large number of trials for a variety of mental health issues (including depression,6 anxiety,7 substance abuse,8 and insomnia,9 as well as some evidence in bipolar disorder10 and schizophrenia11). Most of these BITs convey didactic information, often using evidence-based treatments as frameworks. They might also include interactive tools such as thought records or distress ratings. e-mail reminders can encourage patients to revisit the website. These interventions have shown greater success when they are supported by a “coach” or therapist.6
Virtual reality. Immersive environments for use in exposure therapy can be created via virtual reality technologies; this strategy may be effective for anxiety12 and other disorders. The panelists pointed out, however, that cost remains a significant barrier to virtual reality-based treatments.
Gaming. Many of the current gaming applications identified by the panelists are directed at children and target such areas as ADHD, autism spectrum disorders, and reduction of aggression.13 Clearly, the strong point of gaming-based therapies lies in their ability to engage patients and increase motivation to continue treatment. The panelists asserted that gaming may also have great potential in adult patient populations and that more work is needed in this area.
A recent commentary by Hsin and colleagues14 offers further useful perspective on the issues discussed by the panelists. The authors call for the establishment of guidelines regarding the role of mobile health in psychiatry. Privacy policies should be clear, and transparency of products (eg, ensuring that patients and psychiatrists are informed of potential risks and benefits) will be critical.
Hsin et al also point to a need for education of psychiatrists regarding the use of mobile health tools in individual patients. They urge psychiatrists to stay abreast of current trends and to seek continuing education as needed.14 Along these lines, the expert panel noted that the incorporation of BITs into existing health care delivery systems will require acceptance and proactive adoption by health care delivery personnel.
Also necessary will be research into how BITs fit into the treatment armamentarium, the integration of BIT data into existing structures (eg, electronic medical records), and economic integration of BITs into the current system. The expert panel pointed out that BITs vary widely in terms of their stages of evolution. Some technologies still require basic development work, while others are ready for evaluation and implementation studies.
The panelists concluded that optimizing the efficacy of BITs will require new research frameworks. Developmental models can be borrowed from engineering, and user-centered design and usability testing will be crucial to ensuring that new products are understandable and usable for patients and providers. The panelists observe astutely that by the time a new BIT is validated using the traditional evaluation processes, its underlying technology could already be obsolete.