Computer Aids to Mental Health Care

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Computer Aids to Mental Health Care
Chao-Cheng Lin M.D. 2000-12-14 Decision Systems
Group, Brigham and Womens Hospital Harvard-MIT
Division of Health Sciencs Technology
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Introduction

• A review paper from Marks J, Can J Psychiatry,
  44, Aug 1999 548-55.
• Mental health care is among the many areas
  gaining from surging advances in information
  technology.

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Part I Assessment, Diagnosis, and Outcome rating
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Advantage

• Entering pen-and-paper data into a computer and
  checking them are time-consuming and costly and
  delays analysis and feedback of the results.
• Computer-aided interviewing reduce the problem-
  save time and effort
•  Give the clinician standardized information
  about a patients psychopathology and diagnosis
•  Computerized ratings of severity expedite the
  tracking of patients progress

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Disadvantage

• Lesser flexibility
• For small number of interviewees, the effort to
  set up the program and extract the data may
  exceed the gains

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Suicide risk, diagnosis, and rating systems

• Suicide risk computer interview for suicide-risk
  prediction(1973) still rarely used in clinics

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Diagnosis

• NIMH study(Erdman HP) 1992 117 in- and
  outpatients, the subjects interacted with a
  desktop computer alone were compared with those
  interviewer used the computer as a guide for
  Diagnostic Interview Schedule (DIS). The
  diagnoses were similar to those with face-to-face
  interviews. Subjects felt less embarrassed with
  the computer than with a clinician but said they
  could describe their feelings better to a human.

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Diagnosis

• Lewis G 1994 for self-assessment of neurotic
  disorders in primary care in 92 patients with
  similar results
• Maurer K 1996 Most diagnoses corresponded among
  three groups PRIME-MD(Primary Care Evaluation
  of Mental Disorders) , IVR-PRIME-MD (Interactive
  voice-response), and SCID (Structured Clinical
  Interview for Diagnostic and Statistical Manual
  of Mental Disorders) in 200 patients

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Rating systems

• Personal computer (PC) Desk- and Laptop
• Phobias
• Obsessive-Compulsive disorder
• Depression and anxiety
• Alcohol and other substance abuse

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Phobias

• Carr AC 1983 43 phobia patients and 10 control
  subjects, over one-half preferred using the
  computer to seeing a clinician.
• Katzelnick DJ 1995 Liebowitz social anxiety
  scale
• Kobak KA 1998 Brief Social Phobia Scale and Fear
  Questionnaire, 1/3 pt preferred the computer and
  1/3 the clinician

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Obsessive-Compulsive disorder

• Rosenfeld R 1992 computer self-rated and
  clinician-rated pen-and-paper Yale-Brown
  Obsessive-Compulsive Scale (Y-BOCS) in 31 OCD pt
  and 16 other anxiety disorder no preference

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Depression and anxiety

• Kobak KA 1993 Hamilton Anxiety Rating Scale
  (HARS), 0.92 correlation in 214 psychiatric
  outpatients and 78 community control subjects.
  Most patients preferred the clinician interview.
• Kobak KA 1990 Hamilton Depression Rating Scale
  (HDRS), 0.96 correlation in 72 depressed
  outpatients and 25 control subjects.

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Depression and anxiety

• Kobak KA 1994 on HDRS and HARS in 173
  outpatients with a affective or anxiety disorder
  76 nonpsychiatric control subjects, patients
  preferred clinician interview but felt less
  embarrassed with the computer, while control
  subjects had no preference

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Alcohol and other substance abuse

• Lucas RW 1977 Duffy JC 1984 More alcohol
  consumption was admitted by men in computer than
  human interviews.
• Kobak KA 1997 A twice-higher rate of alcohol
  abuse was found with IVR-PRIME-MD than with
  clinician interviews in US

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IVR(Interactive voice-response)

• An IVR system links a telephone to a computer.
  Subjects call the computer by touch-tone
  telephone and drive the interview by pressing
  keys on their telephone keypad. They may have a
  printed guide on hand during their call.

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OCD

• Baer L 1993 in 18 OCD pt using Y-BOCS and
  Clinical Global Impression (CGI), three groups
  (by pt via IVR, by pt using pen and paper, and
  by a research assistant using pen and paper after
  interviewing the pt by phone) correlated very
  highly.

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Depression

• 1995 Baer L, IVR screening of 1812 people for
  National Depression Screening Day in US

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Broader outcom-monitoring

• Weiss KM 1993 A computer system helped staff
  assess and track the progress of inpatients with
  schizophrenia or major depression.
• Marks IM 1998 Clinical Outcome and Resource
  Measure (CORM) used by 150 clinicians with 2000
  patients in UK, Australia and New Zealand,
  showing pt progress note and cost of obtaining
  the progress, analysis of outcome by age, gender,
  source of referral, diagnositic group, and
  severity.

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Discussion of part I

• Pt often find it easier to disclose sensitive
  information to a computer system, despite knowing
  that humans will see their answers, particularly
  regarding alcohol and drugs, sexual behavior, HIV
  risk factors, diet and suicidal ideas.

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Discussion of part I

• Such systems have been slow to spread and have
  been used more in research trials than in routine
  care.
• Incentives are crucial. Eg. In New Zealand,
  higher reimbursement rates for each CORM outcome
  chart per pt were paid to clinicians.

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Part II Self-treatment

• Pt are motivated to start using computerized
  self-treatment systems under brief supervision
  and pt subsequently can ask people for help if
  they get stuck.
• Systems that are 100 independent of human help
  will emerge for sufferers who are particularly
  self-reliant or who dont want the stigma,
  bother, or expense of seeing a clinician.
• Self-treatment systems vary hugely in how much of
  the entire therapeutic process they can handle
  without therapist input (5 to 95).

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Self-treatment

• Pt are motivated to start using computerized
  self-treatment systems under brief supervision
  and pt subsequently can ask people for help if
  they get stuck.
• Systems that are 100 independent of human help
  will emerge for sufferers who are particularly
  self-reliant or who dont want the stigma,
  bother, or expense of seeing a clinician.
• Self-treatment systems vary hugely in how much of
  the entire therapeutic process they can handle
  without therapist input (5 to 95).

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Self-treatment by computer

• Emotional problems
• Anxiety disorders
• Depression
• Smoking, alcohol use, and psychosis
• Self-treatment by palmtop computer
• Self-treatmnet by IVR
• Self-treatment by virtual reality

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Emotional problems

• Dolezal-Wood S 1998 Of 278 pt who used
  Therapeutic Learning Program (TLP), 78 were
  satisfied with it and felt less distressed, and
  95 felt more able to handle their problem. In an
  Randomized control trial (RCT) of TLP versus
  standard Cognitive-Behavior Therapy (CBT) in 109
  outpatients, both groups were improved at
  posttreatment and 6-month follow-up, but TLP
  saved 40 of therapist time.

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Anxiety disorders

• Ghosh A 1984 1988 84 outpatients with
  agoraphobia, panic or social or specific phobia
  were randomized to self-exposure instructed by 1)
  the psychiatrist, 2) a self-help book, or 3) a
  computer system based on that book. All 3 groups
  had improved similarly and markedly on phobias,
  work, and social adjustment at the end of
  treatment and 6-month follow-up.

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Depression

• Selmi PM 1990 A PC system delivered CBT for
  nonsuicidal depression over 6 sessions. 36
  volunteers with nonsuicidal depression were
  randomized to 1 of 3 groups 6 sessions of CBT
  guided by the computer system, 6 sessions of CBT
  by face-to-face interview with a therapist, or a
  waiting-list control group. Both CBT groups had
  improved more than did control subjects.

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Psychosis

• Burda PC 1994 A cognitive-rehabilitation
  system was tested in inpatients with chronic
  schizophrenia or schizoaffective disorder. Pt
  were randomized to 24 sessions of 30 min each on
  the computer over 8 wks or to no treatment. At
  posttreatment, computer-using subjects had fewer
  cognitive complaints and better memory.

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Self-treatment by palmtop computer
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Anxiety disorder

• Gruber K 1999 compared groups receiving 1)
  12 therapist-CBT session, 2) 8 therapist-CBT
  sessions plus the hand-held system or 3) 12
  weeks on a waiting list followed by 8-therapist
  CBT sessions with no computer. At posttreatment,
  social phobia ahd improved more in each CBT
  condition than on the waiting list.

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Obesity

• Agras WS 1990 Women were randomized to 1 of 3
  obesity treatments 1) an introductory gourp
  session about how to use the palmtop computer
  system, a manual, an obesity program, and a
  calorie book, or 2) the same as group1 plus 4
  group-CBP sessions with a therapist, or 3) 10
  group-CBT sessions with a therapist. All 3 groups
  lost about 5 lbs by week 12 and continued similar
  weight loss to 1-year follow-up.
  Cost-effectiveness was greater for the
  computer-treatment group.

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Self-treatmnet by IVR

• An IVR system links a touch-tone telephone to
  a computer. One can drive the IVR interview by
  pressing keys on the telephone keypad to access
  digitized speech segments, which were prerecorded
  in natural voice. IVR is useful for people who
  cannot access desktop or portable computers and
  who cannot see a clinician

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OCD

• Nakagawa 1999 BT STEPS, 9-step IVR system with a
  manual help OCD pt plan and do their own ERP
  from start to end with almost no clinician
  contact beyond a brief interview
• Greist J 1999 200 pt, improvement with BT STEPS
  was better than with relaxation-control treatment
  and almost as great as with clinician-guided ERP.
  

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Depression

• Osgood-Hynes D 1998 COPE, an IVR system with
  a manual for nonsuicidal depression. An
  uncontrolled trial in 41 pt in Boston, Madison,
  and London for 12 wk. Pt improved significantly
  in mood and disability. Gains were greater with
  more IVR calls.

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Smoking

• Schneider SJ 1995 A IVR system for smoking
  cessation by behavior therapy taught preparation,
  quitting, and maintenance. Of 571 smokers in US,
  35 quit smoking while using the system, and 14
  were abstinent 6 months later.

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Self-treatment by virtual reality(VR)

• Subjects don a helmet with sensors so that head
  and hand movements seem to move objects in an
  environment seen within the helmet
• Rothbaum BO 1995 10 students with height phobia
  had 7 VR sessions improved, unlike 10 waiting
  list control subjects

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Advantages

• For patient
• Pt can have more therapy time than their
  clinicians can usually give them
• ease of time-sheduling at home
• Easier access
• earlier access to care- early treatment
• confidentialty can be greater and stigma avoided

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Advantages

• For patient
• Consistency of treatment instructions is greater
• Self-treatment can enhance a sense of control
  over ones own destiny
• Contents can be more easily updated
• Motivation can be enhanced
• Voices giving instructions in a computer system
  could be varied according to patient preference
  by gender, age, accent, or language.

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Advantages

• For Clinicians
• free clinicians to devote more time to analyse
  symptoms and make better informed decisions and
  help more patients than before Self-treatment can
  enhance a sense of control over ones own destiny
  
• Clinicians can more easily access up-to-date
  information by computer

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Advantages

• For research practitioners
• allow better control of treatment components to
  better determine which ingredients are effective
• greatly speed collection, retrieval and analysis
  of data from large patient cohorts

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Disadvantage

1. Some users are technophobic
2. Computer systems are unable to detect and deal
   with complications that they were not or cannot
   be programmed for
3. Vital yet unknown therapeutic ingredients may be
   absent from a computerized system

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Disadvantage

1. Computer systems apply rules unvaryingly.
2. If security of a computer system fails, hackers
   could screen and access a greater number of
   confidential records than could thieves in a
   paper system
3. Clinician numbers could shrink

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Disadvantage

1. Help from a clinician or technician is still
   needed
2. Universities fail to give staff and students much
   academic credit for creating software versus
   publishing an RCT of that system.

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Discussion

• Despite the wealth of encouraging research, few
  computer aids are used in regular mental health
  care in nonresearch settings.
• RCTs still have to show that computer
  self-treatment system do better than self-help
  books and audio or videotapes

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Other than this paper

• Internet aids to mental health care
• An interactive example of Online self-detection
  of major depression
• An introduction of PsychPark web site

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Thank you !