Evolving Role of Technology In Behavioral Health and Developmental Disabilities March 12, 2014

1. Evolving Role of Technology In Behavioral Health and Developmental Disabilities March 12, 2014 Melissa D. Pinto, Emory University eSMART-MH Where technology and behavioral health research intersect Technology Prepares Americans to address behavioral health needs Real Life Implications Improves well-being of Americans

2. Objectives • Evolving role of technology based interventions in Behavioral Health Technology (BHT) • Benefits and concerns about use of BHT • How BHT impacts the clinical relationship and care • State of science of BHT • eSMART technology

3. Who suffers from “Technophobia”?

4. What is Behavioral Health Technology (BHT)? • Application of interventions through use of technology to address behavioral, cognitive, and affective targets that support physical and mental health

5. Types of BHT • Remote delivery-real-time, time-bound • Videoconference and telephone • Reduced contact • Internet CBT, email-therapy, automated or personal text messages • Online chat

6. How are BHTs Delivered? • Web-based intervention (internet intervention) • Mobile devices (mHealth) • Laboratory • Gaming

7. Importance of BHT Today • Growing need • Workforce development alone cannot fully meet need • Expand capacity and extend reach • Critical shortage of providers, especially child and adolescent

8. Importance of BHT Today • 75% patients identify 1+ structural or psychological barriers to care • Access more difficult for minority groups and individuals in rural areas • Potential for totally new interventions

9. Strengths and Benefits of BHT • Improved Access • Brings service to people (rural) • Overcomes psychological and structural barriers to care • Convenience and private • Reduce costs-preliminary findings

10. Strengths and Benefits of BH Tech • Flexibility • High fidelity and individualized tailoring • Designed for many conditions • Interactivity and consumer engagement • Incorporates multimedia • Consumer empowerment • Improve continuity and integration of care

11. Concerns & Barriers of BHT • Will it replace important and needed services? • Will it divert attention from funding for conventional services? • Will it be costly to develop, implement, and evaluate?

12. Concerns & Barriers of BHT • What will happen to the important therapeutic relationship? How can this happen? • Will people not get the correct level of service or delay seeking appropriate services? • Can it be reimbursed? How will this work?

13. Does BHT Work?Early Findings • Clinical outcomes similar to face-to-face in adults • Therapy outcomes diminished in some BHT studies compared to traditional therapies • Self-guided, self-help just as effective as some traditional approaches

14. Early Findings • Therapeutic relationship robust to distance, asynchrony, and limited contact. • BHT offer both traditional therapies on or new therapies all together? • Mechanism for clinical improvement could be different in BHT? • Hope, self-efficacy, learned resourcefulness, self-determination, empowerment.

15. How does BHT impact therapeutic relationship? • Therapeutic relationship critical for improved outcomes • Changing role of the therapeutic relationship

16. Four Types of BHT Interventions • (1) Therapist administered • Clients sees therapist • Technology augments and adjunctive • (2) Minimal-Contact • Therapist actively involved, lesser degree typical therapy (≤1.5 hrs) • Therapist assists client with application of techniques

17. Four Types of Interventions • (3) Client predominantly independent self-care • Therapist checks-in, teaches how to use tool • (4) Self-administered therapy • Pure self-help • Therapist may do assessment only • Fully automated system no therapist contact

18. State of Science: delivery of BHT (ALSO APPLICABLE TO Developmental Disabilities)

19. Extending Therapist Reach: Psychotherapy via videoconference, telephone, and Instant Message • May be equally effective as face-to-face • Acceptable to patients • Increased access to care

20. Concerns and Needs • Managing emergencies and crises • Risk for privacy • Diminish therapeutic relationship • Limited pool of providers • Evaluate cost-effective model

21. Mobile Technology • Real-world, “in the moment” use • Findings mixed, but some positive for depression, anxiety, bipolar and schizophrenia • Successful adherence of medication • Collect/track data by sensors and infer patient state and location for intervention

22. Concern and Needs • How interventions can be integrated with existing care seamlessly • Transition into the medical record if desired • Dissemination and safety of interventions • Protection of data on mobile devices • Blending social media, sensor, and self-report health

23. Simulated Places and People • Immersive virtual reality and exposure therapy • Anxiety disorders • Avatars • High on empathy and alliance • Deliver health information in nonthreatening manner

24. Concerns and Needs • Cost-effective methods of delivering virtual reality therapy • Avatars beginning

25. Gaming • Video, web, & mobile • Role play and support exploration • Increase therapeutic alliance and motivation • Fun! Serious games for health • Most games for children • May increase cognitive benefits and change neural circuitry

26. Needs and Concerns • Efficacy for games on clinical outcomes in early stages • Reasonable for adults and older adults • Examine how games may work to improve clinical outcomes • Is it content or delivery or both?

27. Developmental Disabilities • Most studies using iPod Touch, Pad are beginning • Little evidence base • 3 popular applications • Proloquo2Go • Pick a Word • Pixtalk • Most studies among young adults

28. Autism Spectrum Disorder • Most research in this area • Use robotics, interactive video, handheld and touch device, internet virtual environment • Interventions address: • Initiate, maintain, and terminate behavior • Recognize faces and emotion • Improve spatial planning, functional activities of daily living, safety skills, vocabulary, and reading skills, and social participation • More rigorous research and evidence needed

29. eSMART-MH

30. http://www.youtube.com/watch?v=zcjYYX_GS38 Demonstration of esmart

31. Co-created with community members • Starts at the experience of the participant • Objective: Improve depressive symptoms by self-management in young adults Overview of eSMART-MH Technology

32. How can e-SMART help? • Simulates interaction with health providers • Practice self-management skills in realistic environment • Increase confidence and self-efficacy • Overcomes stigma and traditional barriers Overview of eSMART-MH Technology

33. How can eSMART Improve Behavioral Health? • Uses Cognitive Behavioral Strategy: SBAR3 • S: Share your story • B: Bring your background • A: Askfor what you want and/or need • R: Review the plan • R: Reflect on whether it is “right for me?” • R: Repeatthe plan

34. How can eSMART Improve Behavioral Health? • Promotes self-management • Mental health education • Empower patients • Validates feelings and thoughts: They Realize They Are Not Alone

35. What are the implementation considerations? • Consistent access to Internet • Transition to a mobile platform • Complete independently

36. eSMART-MH participants show fewer depressive symptoms.

37. Potential Reach • 30 million young adults between the ages of 18-24 • 1 in 4 of them have a diagnosable mental illness • Digitally connected: • Spend 25 hours per week • online • 75% use social media • 95% have a cell phone • 70% have a laptop • 74% have an mp3 player • Usage Spans all SES levels Sources: U.S. Census Bureau, National Alliance on Mental Health, Pew Internet Research, and WSL /Strategic Retail

38. John M. Clochesy, PhD, RN, CS, FAAN, FCCM Professor University of South Florida eSMART-HD National Institute on Minority Health and Health Disparities (RC2 MD004760) Special Acknowledgements

39. Special Acknowledgements L30MH09173 KL2TR00440

40. Questions?

41. Melissa Pinto, PhD, RN Email: mdpinto@emory.edu Phone: 404.727.0126 @md_pinto