REEACT cCBT Trial

January 25th, 2016 by

Comment on: “Computerized cognitive behavior therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomized controlled trial”, Gilbody S et al, British Medical Journal BMJ 2015;351:h5627

This is an important study that sought to evaluate cCBT for the treatment of depression in primary care settings. The study was conducted in the United Kingdom, where cCBT has been promoted and reimbursed by the National Health Service since 2006. Depression is a common illness and most patients are treated by primary care physicians rather than specialists. Antidepressants are frequently offered to patients, but access to psychotherapy and other forms of treatment for depression is often quite limited.

Previous studies of cCBT tend to support the efficacy of this intervention, however these studies have been criticized for having small sample sizes, highly selected participants (in that they may be from academic settings and screened for complicating factors that are common in the “real world”), and for lack of bias (in that they are often supported by companies with a commercial interest in the outcome).

The REEACT study was a “real world” study conducted at large primary care practices in various parts of the United Kingdom.  Patients with depression were randomized to receive: usual care from primary care physicians, usual care supplemented by a commercial cCBT (Beating the Blues) or usual care supplemented by a “free to use” cCBT (MoodGYM). Incidentally, both Beating the Blues and MoodGYM have been reviewed favorably by PsyberGuide. Follow-up data were collected at 4, 12 and 24 months after randomization. Patients assigned to cCBT received weekly support phone calls from trained technicians.

After entering the study, follow-up data were obtained for 76% at 4 months, 70% at 12 months, and 67% at 24 months. Thus, almost one quarter of the subjects had dropped out by 4 months. At four months, 50% of people using Beating the Blues, 49% of people using MoodGYM and 44% receiving usual care were still depressed. Therefore, the authors concluded that there was no demonstrable benefit for any of the three treatment arms. There also did not appear to be differences at 12 and 24 months. Most interestingly, the median number of sessions completed for Beating the Blues was 2, and for MoodGYM was 1. Only 18% of patients completed all 8 sessions of Beating the Blues and only 16% completed all 6 sessions of MoodGYM.

The authors conclude that cCBT programs appear to be effective when they are led by developers but do not appear to be effective in an independent study in a standard primary care setting. They believe that the main reasons for the negative study were low adherence and engagement rather than lack of efficacy.

This study raises several questions for me:

  1. Can depression be treated reliably in primary care settings? I think “high contact” specialty care will be necessary for most patients with significant depression.
  2. Can we develop computer programs that are engaging enough to overcome the inertia and lack of motivation that are part of depressive illnesses?
  3. If “high contact” care is needed for patients with major depression, can therapies delivered on-line (such as tele-psychiatry or on-line social networks of support) solve our access to care issues and be more effective than cCBT?

Wellocracy – Tracking for Health

January 11th, 2016 by

As researchers and developers increasingly tout the potential benefits of health-related apps and wearables, the large number of options available to consumers can make the job of choosing between them nearly impossible. While PsyberGuide surveys the field of products that address mental health concerns, a group of scientists at Brigham and Women’s Hospital and Massachusetts General Hospital have created Wellocracy, a consumer-oriented website reviewing tracking apps and devices that focus on physical health and wellness.

When it comes to apps and wearables, “tracking” relates to the collection and analysis of data about daily health-related activities such as exercise or diet. The idea is that this information can be used to give feedback to the user or to medical providers and researchers in order to improve physical health at both individual and community levels. Wellocracy focuses on nine categories of products that provide this service:

  • Wearable Devices
  • Running Apps
  • Pedometer Apps
  • Sleep Apps and Devices
  • Mood Apps
  • Food and Calorie Apps
  • Heart Health Apps and Devices
  • Connected Scales
  • Healthy Habit Apps

An excellent feature of Wellocracy is that products in each category are compared side-by-side to make it easy to determine which fits best into the user’s lifestyle. To help with this decision-making process, the site includes a useful questionnaire of potential health/wellness goals and problem areas in order to generate individually-tailored suggestions. In addition, Wellocracy provides basic information about tracking and how making it a regular part of a daily schedule can lead to a better life.

Wellocracy holds a lot of promise in the growing field of tracking apps and wearables. As scientists at renowned research hospitals, the group behind Wellocracy is in a unique position to study the current crop of products and offer reliable data about which can be most helpful. We at PsyberGuide think that anyone who is interested in tracking for health should make a visit to Wellocracy the starting point in their search.

Why making good apps is hard: Part 1

October 27th, 2015 by

At PsyberGuide, our goal is to evaluate apps from all perspectives. It is critical that an app has a sound science-based approach toward improving mental health, but it is also critical that an app is not frustrating to use – it is fast, responsive, doesn’t crash, and avoids all of the other common frustrations for users.

Over the next few weeks, we’ll write about some of the difficulties facing app manufacturers in trying to make and maintain apps that perform well. The first difficulty we are going to look at is the constant need for updating an app.

There are several reasons why apps need to be updated:

  • Adding new features
    Products need to frequently add new features, to keep up with competitors and to keep the interest of users
  • Expanding capacities
    Such as adding support for other languages, or extending the app for new smartwatches
  • Responding to updates in the platform
    IOS, Android, and Windows platforms are frequently updated. Apps need to perform well in the updated environment and take advantage of the new features of that environment. They also need to still work well on older versions of the platforms, since many users do not update to the current versions of the platform.
  • Fixing bugs
    Bugs inevitably occur in the products, especially given the quick timeframe in which new versions of the app are produced

Let’s look at two very popular apps – Lumosity and Headspace. Both of these products are considered mature apps – they have been around for several years and are feature-rich and well-tested. And yet this doesn’t mean that they don’t have to keep continuously updating. Recent updates include:

Lumosity: 18 new IOS versions in 2015
Headspace: 8 new IOS versions in 2015

This is just for the Apple IOS platform and just for 2015. Most apps are also frequently updating an Android version and a web version of the product, multiplying the amount of work.

The need for constant updates means that apps have to have access to significant funding.   Some of the apps on PsyberGuide have institutional financing, and many other apps rely on equity funding and growing a large user base. Lumosity and Headspace both use the popular model of offering a limited version of the product for free, and then charging subscription fees for more content. It is likely that they have a large enough user base that they can afford to keep constantly updating their apps in the future. Many other apps may have more difficulty finding the money for updates.

Brain Futures conference

October 23rd, 2015 by

BrainFutures 2015: Exploring New Frontiers to Improve Brain Health & Optimize the Mind’s Potential is an upcoming conference that will cover many of the new developments in brain technologies and neuroscience. There is also a BrainFutures Expo with hands-on access to new technologies.

Hosted by the Mental Health Association of Maryland, the conference is  November 4-5, 2015 in Annapolis, Maryland.  Information and registration for the conference.

Dr. Michael Knable of PsyberGuide is one of the speakers at the conference.  In a recent program on Maryland’s NPR affiliate station previewing the conference, Dr. Knable talks about reviewing mental health software and the issues around the customer benefits and patient safety.  Henry Harbin and Jay Lombard, two of the other speakers at the conference, are also interviewed.  Audio of the presentation is here.

 

The state of bi-polar apps

August 27th, 2015 by

I recently came across a very interesting paper that I think points out the timely need for PsyberGuide and its mission to objectively review apps for mental illness. The paper is entitled: “Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality,” published in the Journal of Medical Internet Research.

The study was conducted by Jennifer Nicholas and her colleagues in Sydney Australia. They attempted to identify all English apps for bipolar disorder and to check on various aspects of their content. They found 517 apps, 82 of which met their very simple criteria for further review. Of these apps, only 22% had a stated privacy policy, only 36% of the apps that claimed to provide psychoeducation contained the accepted “core principles” of this technique, and only 15% of apps that claimed to provide psychoeducation followed best practice guidelines. None of the apps had been evaluated in a research study and only 31% cited a source for the information they contained. In addition, neither the comprehensiveness of the psychoeducation content, nor the adherence to best practice guidelines, was correlated to user ratings. Finally, many of the symptom monitoring apps failed to measure critical data elements such as medication adherence or sleep patterns.

This article points how easily it might be for users to buy an app that differs widely from accepted standards of care, and which therefore, could potentially lead to harm.

Electronic Case Management Techniques

August 4th, 2015 by

A lot has been written in recent years about “access to care” problems for people with mental illnesses. For example, we know that a large sector of the United States lacks professionals who can treat mental disorders  and according to a recent report by Merritt Hawkins, psychiatry as a medical specialty has one of the highest numbers of vacant positions. Not only is access to care difficult for patients who live in rural or underserved urban areas, but communication between the various provider organizations (hospitals, residential programs, partial hospitalization programs, and outpatient clinics) that serve patients with mental illness tends to be poorly coordinated, which further complicates patients’ search for long-term stability. For these reasons, we at PsyberGuide are very interested to learn if digital technologies can close these access to care and communication gaps. To that end, we have been following several companies that are working in the “electronic case management” area.

Wellframe

Wellframe is a private, venture-backed company based in Boston whose purported customers are health insurance plans, provider organizations and pharmaceutical companies. They have developed the “Intelligent Care Management Platform” that uses a smart-phone app health checklist combined with HIPAA compliant Clinical Dashboard to track patient progress in many different health conditions, including psychiatry. They claim that their system allows care managers to meaningfully interact with more patients and reduce the number of costly phone and in-person sessions. They also claim that the system leads to better treatment adherence and consumer self-management. The company has sponsored one pilot studying looking at the use of their platform to improve the physical health of psychiatric patients (http://www.ncbi.nlm.nih.gov/pubmed/25636496). They have also recently concluded agreements with large behavioral health organizations to study their platform in young adults with mental illnesses in Boston, and in a population of veterans in Chicago.

 Mindoula

Mindoula  is a private company based in Maryland. They claim to provide around the clock connectivity between case managers (“Mindoulas”) and psychiatric patients using traditional methods (phone or in-person meetings) or a HIPAA-compliant digital platform that includes a smart phone app. The website is directed at consumers themselves, but the company claims that they can also serve individual and group medical practices, therapists, residential programs, hospitals, college counseling services and geriatric care groups. It is not clear from their website whether they have concluded contracts with larger organizations or are focused mainly on individual patients at this point.

ThriveStreams

ThriveStreams  is a venture backed company based in Brooklyn, NY. They have developed ThriveTracker, which is a smartphone app designed to improve the management of mood disorders by tracking mood ratings, sleep patterns and therapy sessions. Recently, the company has also developed ThriveSync, a platform similar to the two mentioned above, that combines a provider dashboard with a smart phone app to allow for active monitoring of patients with mood disorders, and hopefully for the development of more individualized and timely interventions. It is not clear from their website that any major contracts have yet been awarded.

We are quite sure that there will be many more such companies and technologies hitting the market soon and we will be tracking them closely. If you are a provider or a consumer and have had any experience with these systems we would be happy to have your input and comments.

 

The Promise of Technology: Efficient Systems, Better Care, and Improved Outcomes

June 12th, 2015 by

I participated in this panel at the Kennedy Forum National Conference on June 9 in Boston. I gave an overview of PsyberGuide and our efforts to provide unbiased information on the usefulness and quality of digital applications for mental health. I described our most recent summary of the PsyberGuide internal rating system, the availability of expert reviews, and the difficulties we have had in collecting consumer input directly on our site. I received very positive feedback from many in the audience about the usefulness of our data.

Other members of the panel included: Lisa Marsch, Ph.D. is the Director of the Center for Technology and Behavioral Health at Dartmouth College. This center has received funding from NIDA and other sources to better incorporate digital technologies into clinical practice. Anne Altman is the General Manager of US Federal Government and Industries for IBM Corporation. Anne spoke about the efforts of her company to improve data analytic capabilities for government agencies that provide or evaluate healthcare. Bill Crouse, M.D. is Senior Director, Worldwide Health for Microsoft Corporation. Bill is an internist who is responsible for implementing technologic solutions in the healthcare industry. Stephen Kennedy Smith is Co-Founder and Executive Vice President of Pear Therapeutics, a company that is trying to develop and market linked prescriptions of pharmaceuticals with digital applications that may enhance efficacy.

The discussion was lively and thought provoking and I continue to be very impressed with the overall efforts of the Kennedy Forum to improve mental health care in this country.

App Curation and Prescription Services for Providers

May 12th, 2015 by

While PsyberGuide is intended to be a service that gives information about apps and software marketed directly to consumers, there is a growing trend in the industry to develop “curation services” for providers or health care systems. In these systems, apps are evaluated or rated and providers that sign up for the service can e-prescibe products to their patients. Two of these services are:

AppScript

AppScript was developed by IMS Health, which is a very large (15,000 employees), publicly traded, healthcare consulting company based in Danbury Connecticut. AppScript claims to have evaluated more than 40,000 health care apps with a proprietary evaluation procedure. AppScript allows providers to register for their platform, and after reviewing products, prescribe them to patients by e-mail. The site contains apps for a variety of medical conditions. There is a specific category for Depression, which contains 8 rated apps, and a category called Mental Health and Behavioral Disorders, which contains 12 rated apps. Of the 8 apps for Depression, 6 have also been evaluated on PsyberGuide, and there appears to be general agreement between the two sites’ ratings. The remaining 2 apps in the Depression section are rating scales based on the Geriatric Depression Scale and the Beck Depression Inventory, and these are therefore are not self-directed treatment apps. Of the 12 apps in the Mental Health and Behavioral Disorders Category, only 1 of the products has also been evaluated on PsyberGuide. The AppScript site gives a detailed description of the apps including information on the manufacturer and cost. There does not yet appear to be significant data published on the site from patient and peer ratings. I found the site clever, attractive and easy to use and no fee was required for me to sign up.

SocialWellth

SocialWellth is a private company based in Las Vegas, Nevada. One of SocialWellth’s main investors is Cigna Corporation, the large health insurance company. In December 2014, SocialWellth acquired Happtique, which was started by the Greater New York Hospital Association, and which provided the basis for their healthcare app evaluation platform called mWellth. Apps are screened for functionality, consumer appeal and usability. Apps are then further evaluated for privacy and security issues, such as malware and encryption problems. Finally, an in-depth certification review is performed which includes assessments of research foundation, usability, and self-management capability. About 500 apps have been evaluated in this way. When providers use mWellth, they are able to log in, select a patient from an electronic database, and add a prescription for an app. The patient then receives an SMS message with a link to the app, and after using it, further data regarding patient use of the app are shared with the prescriber. As of this writing, I was not able to determine how to set up an account with SocialWellth, to examine the number of apps that might be relevant for mental illness, or if there was a fee associated with the service.

Take off: The End of ESCoNS 2015

May 8th, 2015 by

As ESCoNS 2015 winds down, it is time to step back and assess what I will be taking home with me. With a serious h/t to Zack Lynch, Adam Gazzaley, Sophia Vinogradov, and Mor Nahum, I want to thank everyone who worked together to make ESCoNS 2015 happen. This was a great conference, and I am looking forward to the next one. My experience was leaps and bounds above what I expected, hopefully some new collaborations are in the works, and some great ideas were shared.

I am walking away with a new appreciation for the readiness of the neurogaming industry for standards and guidelines that will serve consumers and regulators. There was a real eagerness to provide confidence to potential consumers and grow the field through responsible action and high-quality products. This can only be good news for those who think they have a problem and would like to try an eMental Health program: developers’ willingness to submit to third-party certification means that consumers can expect excellence and transparency.

It was gratifying to learn that the mission of PsyberGuide is already such an integral piece of the industry’s overall vision, and many were excited that we are already working to bring eMental Health down to a level that is accessible to everyone, and where consumers are empowered to become informed and make the best possible choices for their needs. Check back with us frequently as we continue to expand our database, develop collaborative partnerships, and push the field to new heights.

Consumer Issues Take the Floor at ESCoNS

May 8th, 2015 by

We had a fantastic panel this morning, focusing on the very important issues of Data Security and Industry Efficacy Standards. By all reports it was a resounding success and all of us on the panel fielded some great questions and received very positive feedback. I was thrilled to see the interest that the industry has in consumer issues, particularly in the general commitment to making safe and effective products that consumer can rely upon.

The idea of industry-wide standards for efficacy became the highlight of the panel, and PsyberGuide’s position bridging both industry and consumer groups got both the panel’s and the audience’s attention. Here is my take: while the field is eager for general standards and guidelines, there are a lot of issues regarding usability, dissemination, top-down regulation that need to be ironed-out. For example, while a variety of developers are working with the FDA to establish the validity of their claims, there was consensus that a specialized third-party certification may be necessary to evaluate products that don’t necessarily claim to cure specific diseases. This was only one of the complex issues that we discussed this morning, and I look forward to bringing PsyberGuide further into this conversation as it develops.