Can Digital Technologies help manage Depression?
I have never suffered from depression but witnessed it with a close friend. I’m not talking about the sadness that comes from heartbreaks or fighting with a loved one. The depression I saw was the one that comes without a precipitating event. My reactions as a friend were usual and regrettable – why are you depressed, your life is so good; you have so much more than other people, how can you be depressed; why don’t you go out more often, meet friends, socialize; you cannot go on like this. Finally, we decided to seek professional help (it was really me pushing for the visit; I needed to do something) for my friend and visited a psychiatrist. We narrated the history to a disinterested looking senior physician who prescribed anti-depressants and we returned home with the medicines. 6 weeks later, our life changed as we witnessed the magic of pharmaceuticals. My friend’s mood improved and life became a lot better. I found myself thinking – damn, if it was that easy, I wish I had gone to the doctor earlier. Since then, we’ve had no follow-up care from the doctor. How is my friend doing now – I think much better but honestly, I’m afraid to ask.
My friend’s journey was probably easier than that for many of the 350 million people that suffer from depression globally. I was fortunate that we sought treatment and that my friend (otherwise a stoic person), who had no other obvious symptoms other than occasional sadness, responded to the treatment. If you do not relate to the story here, you probably haven’t looked hard enough in your circles to find the friend or family member that at some point must have been through a similar experience.
As the world grows older, richer and more informed, the number of people being diagnosed with depression is expected to increase even further. Besides the impact on health and lifestyle, at its worst, depression can lead to suicide. Over a million people are lost to suicide every year – for each of those deaths, there are about 20 that attempt to end their life. Even scarier is the high rate of depression reported in our doctors. A study in JAMA found as many as 30 % doctors suffer from depression. An Indian study found over 50% of medical undergraduates to have suffered from depression.
Clearly, there’s a lot more that can and must be done. In India, where one in 10 people suffer from depression and there are over 250,000 suicides every year (over 30% of the global annual suicide rate), there are only 3500 trained psychiatrists. For a quarter of India’s population, the USA has close to 50,000 psychiatrists, and that’s a significant shortage. Though the supply problem is compounded in India, the reality is that we just don’t have the trained workers to meet the needs of the fast growing depressed population in most countries around the world. There is a need to use digital innovations to find non-linear ways to help educate, diagnose and provide care to many patients with depression. A number of digital interventions launched over the last few years are helping manage patients of depression. I found some of these in online research (Disclosure: No association with any of the listed interventions).
Examples of digital tools
Intellicare is a suite of 12 interactive mini-apps that combat depression and was launched by Northwestern Medicine. The intervention is funded by the National Institute of Mental Health and functions like a shopping site by recommending a simple mobile app to help in mental distress based on past preferences and feedback from a larger crowd of users.
The MoodHacker app takes a self-management approach to depression management. Users can track their mood on the app along with other factors like food and activity, to educate themselves about what things correlate to different moods. The app responds to the data with analysis and videos about depression. A randomized control trial of the app in 300 adults showed users performed better on behavioral activation, depression knowledge and management of negative thoughts.
Research has been saying for a while that exercise and going outside can improve people’s mood. Motivating someone to do those things has been hard. Gaming apps like Pokémon Go have helped in both these aspects and while nobody is claiming they are a treatment for depression (not yet, anyway), they do provide learnings into how gaming could help in managing depressed patients.
A number of other digital health interventions like Lantern and TalkSpace that use web and mobile app based platforms offer cognitive behavior therapy for depression and other mental health conditions.
In rural India, where suicide rates may be higher that the rest of the country, a scarcity of healthcare workers is leading to innovative digital solutions. The SMART program deployed in villages of Andhra Pradesh, empowers healthcare workers with mobile phones and tablets to conduct standardized tests in target populations. The test results are reviewed by remotely placed experts who then can direct the health workers to specific interventions. Challenges abound in scaling such solutions, but they do provide a template to use digital technologies for increasing diagnosis and intervention options beyond those currently available.
Challenges with Digital interventions
The availability of digital technologies offers a great opportunity to address the issue of access, affordability and outcomes for patients of depression. This is evident from the profusion of mental health apps in the last few years. However, the promise of these interventions must be tempered with results they have produced thus far. A UK based study found that over 85% of the National Health Services accredited mental health apps do not show any evidence of outcomes. The same study found that that while there were more than 1,500 apps available in 2013 that claimed to help deal with depression, only 32 academic articles had been published on the subject. Dr John Torous, the Editor-in Chief of the JMIR Mental Health has cautioned that a lot of mental health apps are based on “flimsy science”. “If you type in 'depression', its hard to know if the apps that you get back are high quality, if they work, if they're even safe to use.” Dr Torous, who chairs the American Psychiatric Association's Smartphone App Evaluation Task Force says “Right now it almost feels like the Wild West of health care.”
Depression remains widely under-diagnosed and plagued with a severe shortage of trained health experts. This situation is not getting better and from available trends, the demand-supply gap will continue to widen. It’s easy to see how digital technologies can and must play a bigger role in improving diagnosis, treatment and ongoing care for patients of depression. A recent review recognized the opportunity that smartphones provide in expanding treatment options, especially due to their ubiquity and the privacy they offer to users. The paper also urged the need for randomized clinical trials to validate many of these apps as well as the principles on which they are established. Digital technology proponents have been urged to follow the sixteen recommendations laid in this paper to demonstrate the impact of these interventions on patient outcomes. This paper and the scrutiny around depression apps are great for driving impactful interventions. They provide a map for digital innovators to demonstrate that their solutions indeed accomplish what they set to do.
The Future
I remain cautious and optimistic about the role of digital tools in managing depression. The puritan and the scientist in me believe these tools must be held to the same standards as other interventions. They must not be deployed till we have shown they work and do no harm (we do the same for pharmaceuticals). Else, anyone with an app could claim to manage depression. How’s that different from quackery?
The realist in me knows waiting for trained resources and validated digital health tools to meet patient needs is a lost cause. We’ll never get there in time to save the people that need to be able to access care today. So if smart digital health entrepreneurs can lower the barrier for depressed patients to access care and be able to talk more openly about their condition, that’s a hell of a lot more than we are getting right now.
The healthcare entrepreneur in me knows that we have to bridge these two positions and do so quickly. Helping entrepreneurs demonstrate the value of these tools so they can help reach millions of depressed patients is an urgent priority. That is the only way you’ll know your friend with depression (the one that you don’t know about) will get the care he or she deserves.
First published in the Tincture on 15 Sep 2016.