Towards digitally-enhanced psychiatry

Dig­i­tal tech­nol­o­gy is already trans­form­ing the world of health­care, open­ing up unprece­dent­ed prospects. From per­son­al­is­ing care to reduc­ing hos­pi­tal over­crowd­ing, the expec­ta­tions are aston­ish­ing. But for this rev­o­lu­tion to live up to its promise, health­care pro­fes­sion­als need to both adopt these tools, while rethink­ing how they are used. The i3-CRG lab­o­ra­to­ry, head­ed by Éti­enne Min­vielle at École Poly­tech­nique (IP Paris), has launched a series of sem­i­nars on the inte­gra­tion of dig­i­tal tech­nol­o­gy in health­care. One of the most eager­ly await­ed top­ics has been men­tal health, an area where tech­no­log­i­cal advances could real­ly change the game. Pro­fes­sors Pierre-Alex­is Geof­froy and Jean-Bap­tiste Mas­son take a look back at the sem­i­nar ses­sion devot­ed to psy­chi­a­try, which was also attend­ed by Guil­laume Couil­lard, Direc­tor Gen­er­al of the Paris Psy­chi­a­try & Neu­ro­sciences GHU, and Raphaël Gail­lard, Pro­fes­sor of Psy­chi­a­try at Uni­ver­sité Paris-Cité.

“Giv­en the eco­nom­ic con­straints on the sys­tem, it is impos­si­ble to imag­ine that every­one will be going to hos­pi­tal in the future,” explains Pro­fes­sor Pierre-Alex­is Geof­froy, a psy­chi­a­trist at GHU Paris. “One per­son told me that her son had devel­oped sleep dis­or­ders quite ear­ly on, and that she had tried to have him mon­i­tored by a child psy­chi­a­trist, to no avail. In the end, six years lat­er, he was diag­nosed with schiz­o­phre­nia. But child psy­chi­a­try will nev­er be able to treat all chil­dren with sleep dis­or­ders or anx­i­ety dis­or­ders. And so these dig­i­tal solu­tions, which are also less expen­sive, will be there to adapt to the lev­el of inten­si­ty of care that needs to be put in place, but also to the lev­el of inter­ven­tion that we can offer.”

“We talk about dig­i­tal health­care as if it were sci­ence fic­tion,” admits Pierre-Alex­is Geof­froy. “But the truth is that dig­i­tal tech­nol­o­gy is already here, and we all use it on a dai­ly basis.” Today, 95% of prac­ti­tion­ers com­plete their patients’ files using dig­i­tal tools. “When we write pre­scrip­tions, for exam­ple, AI can already tell us about pos­si­ble drug inter­ac­tions,” adds the pro­fes­sor. “All of this is based on sci­en­tif­ic lit­er­a­ture, which is updat­ed in real time.” The point, then, is not so much to take stock of the tools already avail­able and in use in the world of psy­chi­a­try. Rather, it’s about look­ing ahead to the pos­si­ble changes that this world will under­go as a result of the tech­no­log­i­cal advances that could be made.

“For a long time, we were try­ing to trans­pose var­i­ous scales and assess­ments that we used in real life into the dig­i­tal world. But that did­n’t work because adapt­ing to new dig­i­tal tools requires us to rethink every­thing,” explains the psy­chi­a­trist. Exist­ing health appli­ca­tions are an exam­ple. Although few­er in num­ber than well­ness apps, only 15% of them fol­low a sci­en­tif­ic approach, mean­ing they are based on a study with proof of effec­tive­ness. “When we look at using this type of solu­tion, we also realise that there is a prob­lem with com­pli­ance,” he con­tin­ues. “Only 30% of peo­ple com­plete their pro­grammes. So, the ques­tion is: how do we devel­op this type of solu­tion properly?”

“In men­tal health, we are for­tu­nate to have very robust mod­els,” points out Pierre-Alex­is Geof­froy. “To devel­op this type of solu­tion in addic­tol­ogy, for exam­ple, we need to adapt mod­els with a known sci­en­tif­ic approach to dig­i­tal tech­nol­o­gy.” For exam­ple, an appli­ca­tion to encour­age peo­ple to give up an addic­tion, such as smok­ing, needs to be devel­oped on the basis of an exist­ing mod­el, such as Pro­chas­ka and Di Clemente’s mod­el of prepa­ra­tion for change. 

“If my solu­tion fol­lows the log­ic of ‘one size fits all’ we will estab­lish a bal­ance of the pros and cons of what stop­ping smok­ing will bring to the patient. How­ev­er, if the patient is already in a relapse phase, this will not speak to him. They will need much more tan­gi­ble pro­pos­als. Pro­chas­ka and Di Clemente’s mod­el is there­fore impor­tant for deter­min­ing what phase the patient is in, and there­fore what type of fol­low-up they will need. If they are at the con­tem­pla­tion stage, they will need moti­va­tion­al inter­views to try and clar­i­fy with them what they want and what they are pre­pared to do. If they are already in the action stage, we need to organ­ise with­draw­al with them. And if they are at the relapse stage, we need to ask them about what they have already done, to deter­mine what has worked well and what has not. This is essen­tial to ensure that patients are com­mit­ted to the solu­tion and that they don’t stop every­thing after 5 min­utes because the appli­ca­tion does­n’t meet their needs.”

Accord­ing to the pro­fes­sor, the pri­ma­ry inter­est of dig­i­tal tech­nol­o­gy lies in pro­vid­ing an addi­tion­al ser­vice to the doc­tor’s prac­tice. Offer­ing patients more reg­u­lar mon­i­tor­ing does not mean mak­ing them inde­pen­dent in their approach, or even ask­ing them to be too involved in this mon­i­tor­ing. “Just under 10 years ago, the Monar­ca I¹ study had an inter­est­ing idea. How­ev­er, today, this solu­tion already seems ‘has-been’,” he argues. “The idea was to self-mon­i­tor patients with bipo­lar dis­or­der, in order to pre­dict when they might relapse. To do this, the 61 patients were asked to record their symp­toms on depres­sion scales.” The authors of this study showed that the more depressed patients were, the less they inter­act­ed with the med­ical team. Con­verse­ly, the more man­ic the patient, the greater the num­ber and dura­tion of calls.

“The results were suf­fi­cient­ly clear for the patien­t’s con­di­tion to be eas­i­ly clas­si­fied,” con­firms Pierre-Alex­is Geof­froy. “This led the authors to con­clude that smart­phone appli­ca­tions were valid for real-time patient mon­i­tor­ing.” How­ev­er, a sec­ond study fol­lowed this one, with far less favourable con­clu­sions. “In this sec­ond study, the authors decid­ed to keep all the patients, even those who had stopped using the pro­posed solu­tion,” explains the pro­fes­sor. “The result was that there was no sig­nif­i­cant effect of self-mon­i­tor­ing, and the authors even observed that not­ing down depres­sive symp­toms every day wors­ened the patien­t’s men­tal state.” 

“This type of mon­i­tor­ing is not intend­ed to replace the doc­tor, but rather to offer an addi­tion­al ser­vice that he or she can pre­scribe.” So, it’s a new tool avail­able to doc­tors to ensure that their treat­ment is effec­tive. Because, in addi­tion to the pos­si­bil­i­ty of remote patient mon­i­tor­ing, dig­i­tal tech­nol­o­gy also offers ther­a­peu­tic solu­tions. “I often use the exam­ple of ther­a­py using aug­ment­ed vir­tu­al real­i­ty. I’m a psy­chother­a­pist and I have a patient with a pho­bia of cock­roach­es. I can work with him on expo­sure to insects by pro­ject­ing insects around his hand using vir­tu­al reality.”

“Accep­tance of this type of tool is a major issue. When we ask stu­dents whether they would pre­fer to be treat­ed using a dig­i­tal solu­tion or by a real per­son, only 9% of them choose the dig­i­tal option,” notes Pierre-Alex­is Geof­froy. “We there­fore need to pro­vide evi­dence of the effec­tive­ness of these meth­ods to unlock these bar­ri­ers. Dig­i­tal tech­nol­o­gy is not yet present in my prac­tice, because dig­i­tal solu­tions for pro­vid­ing real-time patient data are not yet avail­able. I dream of one day, in my prac­tice as a psy­chi­a­trist, in addi­tion to my tra­di­tion­al prac­tice, hav­ing dig­i­tal argu­ments to help me make deci­sions. So, I think that sup­port will be de fac­to greater when such solu­tions, proven to be effec­tive, are available.”

This type of mon­i­tor­ing is not intend­ed to replace the doc­tor, but rather to offer an addi­tion­al ser­vice that he or she can prescribe

Pro­fes­sor Jean-Bap­tiste Mas­son, a researcher at Insti­tut Pas­teur, ques­tions the method­olo­gies used to assess the effec­tive­ness of dig­i­tal tech­nol­o­gy in med­ical con­texts. “At some point, if we want to prove that some­thing is effec­tive, we’ll have to car­ry out sta­tis­ti­cal tests,” he says. “We’ll have to com­pare one group with anoth­er, where­as the human mind is not eas­i­ly put into cat­e­gories. It is true that dig­i­tal tech­nol­o­gy pro­vides an enor­mous quan­ti­ty of data and enlarges the con­trol group. In psy­chi­a­try, the larg­er the group, the more het­ero­ge­neous it will be. Sub-groups will emerge, and com­par­isons will become less spe­cif­ic. So, one dif­fi­cul­ty will be in trans­pos­ing con­vinc­ing results from a small sam­ple of peo­ple to a larg­er sam­ple for which the results will be less reli­able,” he adds. This lim­i­ta­tion is also reflect­ed in the num­ber of para­me­ters that can be mea­sured dig­i­tal­ly: the more para­me­ters and data that are stud­ied, the greater the chance of cor­re­la­tions, due to ran­dom­ness, with­out them being sig­nif­i­cant.” These method­olog­i­cal lim­i­ta­tions are still hold­ing back the val­i­da­tion and adop­tion of these dig­i­tal solu­tions by practitioners.

The mar­riage between dig­i­tal tech­nol­o­gy and men­tal health there­fore opens up fas­ci­nat­ing prospects. But for these solu­tions to win the con­fi­dence of prac­ti­tion­ers and patients, they must be accom­pa­nied by sol­id proof of their effec­tive­ness. And that’s not easy to do. As Pro­fes­sor Geof­froy sums up, “dig­i­tal tech­nol­o­gy is not intend­ed to replace the doc­tor, but it can become a valu­able ally in our prac­tice.” With rig­or­ous clin­i­cal research and grad­ual adop­tion, dig­i­tal tech­nol­o­gy could well rede­fine the approach to psy­chi­atric care, mak­ing treat­ments more acces­si­ble, per­son­alised and effec­tive. How­ev­er, the final hur­dles to the suc­cess­ful devel­op­ment of these solu­tions will have to be overcome.

Pablo Andres