By Kunmi Sobowale
Sobowale envisions a day when technology like Siri for iPhone 4S can be used to address the early signs of depression. Here he discusses the potential for primary care doctors to leverage mobile technology to play a key role in improving mental health care.
In the summer of 2011, I traveled to Hong Kong to investigate the cultural adaptation of primary care-based intervention to prevent depression. Thousands of miles away from home, I heard a familiar discussion among a group of Hong Kong primary care physicians—how to effectively deliver mental health care with limited resources? Though known as a modern financial hub, Hong Kong has only 300 psychiatrists for over 7 million people or roughly 4 psychiatrists per 100,000 people. By comparison, Japan, has 9 psychiatrists per 100,000 people and the U.S has 14 psychiatrists per 100,000 people, according to the Lancet
Despite vast differences in culture, these countries all have a shortage of mental health professionals and stigma associated with seeking mental health care. In fact, according to the Public Library of Science, by 2030, major depressive disorder will carry the highest burden of disease in the United States. In terms of health, this means exacerbated co-morbidities including diabetes and high blood pressure and increased risk of peptic ulcers, heart attacks, and suicide. Economically, it means decreased work productivity and medical expenses of at least $83 billion annually (measured in 2000 dollars), says the American Psychological Association. Because of the shortage of psychiatrists, the brunt of this mental health emergency will fall on the first line of defense in the health care system, primary care physicians.
However, Internet-based technology may help alleviate this burden. The purpose of my visit to Hong Kong was to explore such technology as a solution to lack of access to mental health care. There are a number of online interventions that aim to prevent the onset of depression. Some of the well-known websites are Moodgym
and Beating the Blues
. These interventions, so-called “behavioral vaccines,” aim to prevent the onset of depression throughout life. Imagine a recently retired lawyer experiencing a few symptoms of depression. Instead of waiting for the disease to develop, an astute physician noting these symptoms would assess the problem with evidenced-based practices. An abbreviated screening test, such as the nine-item depression scale of the Patient Health Questionnaire (PHQ-9), in combination with or in lieu of the lengthy Structured Clinical Interview for DSM Disorders (SCID) would be provided for assessment. If the patient is found to be below the threshold of clinical depression but remains at high-risk, the physician could refer the patient to try the online intervention. Afterward, the patient could work through the program in the comfort of his own home at his leisure.
I have been fortunate to be involved in research related to one of these Internet-based interventions. The intervention, Competent Adulthood Transition with Cognitive-behavioral, Humanistic and Interpersonal Training (CATCH-IT), was originally developed by Dr. Benjamin Van Voorhees and collaborators from the University of Chicago, Johns Hopkins University School of Medicine, University of Iowa School of Medicine, Northwestern University Feinberg School of Medicine, and the University of Illinois School of Medicine. The primary-care based intervention seeks to prevent depression in adolescents. According to the American Psychological Association, approximately 20% of all people have their first depressive episode during adolescence, so it is an ideal time to intervene and provide teenagers and young adults with tools to prevent this chronic and recurrent disease. CATCH-IT is based on sound psychotherapies that have demonstrated the best clinical outcomes. Furthermore, two previous trials of the CATCH-IT intervention, the results of which were published in the Journal of Developmental Behavioral Pediatrics
, demonstrate high levels of user engagement with the Internet component and favorable outcomes lowering depressed mood and strengthening some protective factors for depression.
There is much work to be done in order to optimize these interventions to appeal to modern-day youth. However, significant progress is being made. In the near future, these online sites will be more interactive and even personalize care depending on symptom severity and personality type. It is only a matter of time before they start appearing on mobile devices in areas of the world where computers are not a household luxury. As a result, users will be able to access these interventions anytime and anywhere there is Internet access – all while providing privacy for those dealing with stigma or shame related to their illness.
Some physicians may be hesitant to buy into Internet-based technology. Indeed, dropout rates for stand-alone Internet-interventions tend to be high, so some human intervention will always necessary. There is no substitute for a good history to determine if a patient has depressive symptoms. Primary care physicians can play a big role by referring and motivating their patients to use these programs.
So despite the challenges ahead, I remain optimistic that access to mental health care can be improved and that primary care can play a key part in that. One day, I imagine, we will have artificial intelligence-based interactive interfaces similar to Siri on the iPhone 4S that will be specialized for depression. But for such possibilities to become reality we must realize the importance of providing mental health care, particularly in primary care settings, and aim for far beyond the status quo.
Kunmi Sobowale is a rising third-year medical student at the University of Chicago Pritzker School of Medicine. He has spent some time in East Asia studying the interaction of culture and mental illness.