This is Dr Jeffrey Lieberman speaking from Columbia University
Today I am going to address what could be considered the new, new thing in mental health care. Now, you may be thinking, “He is going to talk about precision medicine, personalized medicine, or genomic medicine.” Although those are new things that promise to revolutionize how all of medicine in all disciplines is practiced and healthcare is provided, I want to discuss something that is of comparable significance but has not yet reached the same level of visibility and expectation of impact.
This new thing that I believe will transform the way healthcare—particularly mental health care—is provided involves technology. It is apparent that in our society and civilization, so much of what we do and how our lifestyles are shaped is related to technologic progress and innovation. Just look at the Internet; look at electricity; look at computers; look at jet propulsion and air travel. In medicine, we have evolved similarly, depending on technology—for example, with the development of electrophysiologic devices—for diagnosis, such as the ECG, and diagnostic imaging measures or methods such as the MRI and positron emission tomography scans.
Of course, in psychiatry and mental health care, we have not been able to take advantage of some of these technologic innovations as much as our sibling specialties have. But I certainly expect that we will be able to in the future.
The new technologic innovation that is emerging and which does seem likely to impact psychiatry and mental health care in a time that is commensurate with the other specialties of medicine, is the technology that informs how we use Internet-based smartphone mobile app devices. The rudimentary ways in which this has already begun to permeate medicine and mental health care include electronic health records and telemedicine, which is ideally suited to psychiatry in terms of being able to provide consultation at a distance.
But the real tsunami of technology and devices that awaits us involves the use of applications that are smartphone- and mobile device–based. These have begun to proliferate and attract the attention of many companies in the private sector.
The initial idea is to have smartphone-based applications that can perform several functions. One is a monitoring function: having apps that can passively monitor the activities or biologic signals of an individual—whether it is movement, heart rate, respiratory rate, or level of activity—and have an ongoing record that can be catalogued, observed, and interpreted by clinicians. A second function is as a means of communication. Doctors already have begun to employ FaceTime, Skype, and texting to maintain contact with patients remotely in a variety of situations. Another area would be to develop apps that could provide some kind of actual therapeutic assistance, including cognitive-behavioral therapy, motivational interviewing, and supportive types of techniques or protocols when needed. All of these have great potential and can expand the reach of healthcare providers, psychiatrists, and mental health care clinicians, and provide help to a larger proportion of people when they need it.
While there has been a groundswell of interest in this area, and while heavy-hitter companies like Microsoft, Google, and Apple are getting involved in this and are developing approaches that can be rolled out, marketed, and made available, it will be critical to vet them in a way that establishes their real efficacy in contributing to healthcare, in terms of either diagnostic monitoring or therapeutic intervention. That will be necessary for these devices and applications to become eligible for a revenue stream that comes from third-party payers. Insurance companies, Medicare, and Medicaid are not going to pay for anything new unless it is thoroughly vetted and approved by no less than the US Food and Drug Administration (FDA).[T]he real strength and ability to move this area forward in an innovative way and to develop technology that can be used in healthcare must indeed come from the private sector.
That means that this technology must be subject to rigorous testing and acquisition of data that demonstrate value, reliability, and efficacy. While companies are going at it full-force and spending a lot of money developing these techniques, it has been done primarily in the private sector. Some members of academia have begun to put their feet in the water and engage in the development of these applications or devices, or in the assessment of their effectiveness. This has been a very limited engagement, however.
It is clear that, as with pharmaceutical development, the real strength and ability to move this area forward in an innovative way and to develop technology that can be used in healthcare must indeed come from the private sector. Academia simply does not have the resources, and the National Institutes of Health will not fund it. Thus, we will need engagement of both the private sector and the academic medical community to vet these. That has not yet begun to happen. I do not know whether this is because the development process is not yet mature enough and so it has not reached that stage, or whether companies have not fully thought this through, which is hard to imagine.
But that will have to happen before these can be seriously considered to be elements of treatment that become part of any standard of care for a given condition. These approaches will have to be tested; they will have to undergo studies or controlled trial applications to produce data that demonstrate their value, which then will be reviewed by the FDA and ultimately approved.
The FDA is aware of this. They know what’s coming and are prepared to handle it. But it still has not come to fruition. I believe the private sector needs to figure out how it will engage in this process, unless they just want these technologies to be recreational, acquired “off the shelf” or through the Apple store, Amazon, or wherever, and then used on an individual basis by clinicians or patients, without permeating clinical practice or being incorporated into standards of care and becoming reimbursable by the third-party payers.
One leading-edge indicator of how this is going is 23andMe. The 23andMe service, which now has many imitators, is essentially recreational genetics. Anyone can pay to have their genome sequenced and receive a report about what diseases they may be vulnerable to or have a positive genetic background for. This is not something any third party will pay for, however. And it is not something that doctors necessarily will use to make their diagnoses or treatment decisions. At some point, though, this could be used for these purposes. The same is true for the mobile device– and smartphone-based applications, which have great potential, and probably greater potential for psychiatry and mental health care than for perhaps any other discipline.
Stay tuned. We will have to see how the companies continue their efforts to engage in this market. I do believe that it is a very important and valuable undertaking and potentially could be transformative—or as they say now, disruptive. It has not begun to happen, despite what people may say and what you may hear in the news. The rubber will really hit the road only when academia and the private sector engage in serious development of these smartphone and mobile device applications.
