Media and the role of digital psychiatry in mental health

Abstract

The mass media is largely regarded as an integral cogwheel in health service delivery, with a decisive influence on public attitudes. Numerous studies identify connections between media use and negative outcomes such as increased depression, suicide, anxiety, substance use, aggressive behaviour, obesity and eating disorders. Digital tools in psychiatry may promote change and improve health service delivery, augment clinical relationships and influence the dynamic relationship between mass media depictions of mental illness and the public´s understanding. Unlike most journalists, who must rely on second-hand accounts, mental health professionals can weigh in directly with their advice, opinions, and expertise on social media, based on direct accounts from patients.

Keywords:

• Media
• mental illness
• negative portrayal
• positive portrayal
• tool for change

Introduction

Definition

Media has been defined as any storage and transmission channel or tool used to store and deliver information or data. Mass media is synonymous to media, which may refer to one single medium used to communicate any data for any purpose [1].

Forms of Media

The term media commonly refers to the mediums of books, radio, magazines, newspapers, cinema, television, billboards and computer complexes. Each medium is a symbolic model of a big industry, which is further interlinked with other related industries. The various studies cited in this chapter focus on one or another of these media, and others examine a combination of media. India being the largest democracy and with fairly unrestricted media is likely to be a case in point about how media influences the perception of mental illnesses

Media and its influence in the society

Over the past few decades, considerable amount of research has been conducted to examine the effect of the mass media on the belief systems of the public [2]. These studies have concluded that the media’s power to influence public perception, the frequency in which it is used, and the degree to which people are exposed to media representations combine to make the mass media one of the most significant influences in developed societies [3].

What people see and hear in the media impacts their daily lives. It encourages them to buy something they saw in a commercial, informs them of the latest ‘craze’ and also tells them how they ‘should act.’ This becomes alarming because the power of the media is easy accessible. The power that the media holds has evolved over time, with people trusting the message delivered, without really critically evaluating the information received [4]. But there have been differences in the levels of scepticism about media, with some being more accepting than the other. This article though, may be biased to first world countries, and change in mindsets of individuals residing in third world countries like India need to be further explored [5]. Hottentot and colleagues [6] in a study reported the various sources of media from which people gather information regarding mental illness or any information regarding psychiatry. These are TV and news 70%, Newspapers 58%, News magazines 34%, TV talk shows 31%, Radio news 26%, Internet 25%, Non-fiction books 25%, Talk shows on radio 18% [6] (Table 1). The limitation here, though, is that the influence of social media has grown tremendously in the interval between this study and current times, and this needs to be considered in future investigations.

Table 1. Popular sources of information about mental illness [2].

TV news and magazine shows	70%
Newspapers	58%
TV news	51%
News magazines	34%
TV talk shows	31%
Radio news	26%
Other magazines	26%
Internet	25%
Non-fiction books	25%
Talk shows on radio	18%
Women’s magazines	18%

Various studies have concluded that the different forms of media are the most significant source of information about mental illness for the common man [7–9]. Conception and ideas of mental illnesses for both positive and negative experiences in the common man are distorted and synthesized by media influences. A very compelling observation by Philo in 1996 [10] was that media could supersede people's own personal experiences in relation to how they view mental illness. The initial low interest of media guilds about mental health have changed significantly over time, with Rhydderch et al finding a substantial increase in articles covering mental health, including a reduction in stigmatization and portrayal of mental health as dangerous, but a concomitant increase in articles depicting psychiatrically ill persons as incapable [11]. These then advocate for sensitization as a way of persuading media for more effective involvement in mental health initiatives.

Long-term anti-stigma campaigns that encompass human-rights-based, normalization, and educational approaches are needed. Media involvement is crucial for success, but for the media to be used effectively, its motivations and limitations must first be implicit and transparent. Many other studies have found a definite connection between negative media portrayals of mental illness and the public’s negative attitudes towards people with mental health issues. Cutcliffe and Hannigan [12] further state that rarely does a week go by without a reference to mental illness in the mass media [7,12,13].

Considerable research has concluded that the media are the public’s most significant source of information about mental illness and television being one of the most powerful milieu for framing public consciousness [14].

Negative images and stereotypes in entertainment media

Media has certainly highlighted key social movements and has promoted fundraising for several worthwhile causes; but it has also served as a platform for less beneficial and sometimes troubling occurrences at both individual and societal levels. According to Diefenbach’s [8] content analysis of television programming, depictions of people with inferred psychiatric conditions or stated psychiatric diagnoses were highly correlated with the portrayal of violent crime. 72.1% of the adult characters who were portrayed as mentally ill in prime-time television dramas injured or killed others. Characters with a mental illness were nearly 10 times more violent than the general population of other television characters, and 10 to 20 times more violent during a two-week programming sample than real individuals with psychiatric diagnoses were over one entire year in the U.S. population [15].

In both Bollywood and Hollywood movies, the depictions of psychiatric treatment, especially electroconvulsive therapy (ECT), were often inaccurate, distorted and over dramatized. ECT was shown to be administered by force to punish, to repress identity and to induce insanity [16]. The clinical evidence of safety and usefulness of ECT, which is one of the most effective forms of psychiatric treatment in severe mental illness, had been largely overlooked. ECT treatment has been depicted to cause mental disturbance and amnesia without clinical improvement in movies like Raja, Damini, Khamoshi, Jewel Thief, Rath aur Din, etc [17,18]. Extreme forms of treatment like lobotomy like in the Hollywood movie One flew over the cuckoo’s nest and forced medication have been depicted in movies without a clear indication and rationale, suggesting a rather barbaric side to psychiatric treatment [19].

Yet in reality, people suffering from a mental illness who do not have a concurrent substance abuse disorder are no more likely to commit a violent crime than anyone else [20]. In fact, one study found that 95–97% of violent episodes in the United States are committed by people with no mental illness [21]. Another study found that media representations of mental illness are so powerful that they can override people’s own personal experiences in relation to how they view mental illness [22]. The truth is that people with mental disorders do recover and make significant contributions to our communities and studies show that optimism about outcome from severe mental disorders like schizophrenia is justified [23]. Most people with mental disorders are our relatives, neighbours, friends and peers who are caring and law-abiding citizens [24].

Media as a risk factor in mental illness

The true relationship between the use of media and mental health is a relatively new and a complex area of study given the constantly changing technological landscape. While some studies point to the positive aspects and outcomes of our interactions online, a growing base of research seems to reinforce the opposite view.

Media and suicide

Glamorised depictions of suicidal behaviour in the media can have a negative influence and could possibly facilitate suicidal acts by people exposed to such stimuli. The impact of the media on suicidal behaviour seems to be most likely when a method of suicide is specified, especially when presented with over inclusive details, when the story is reported or rendered overdramatically and strikingly – for example with photographs of the deceased or large headlines. The process by which one suicide becomes a coercive model for another suicide is termed the Werther effect [25]. In India, Chowdhury et al. [26] looked into a judicial hanging in West Bengal to study how news projections generated copying of hanging behaviour. They reported 18 cases of copycat suicides, 17 other replica acts with 5 deaths. This imitative behaviour with copycat suicides and attempts has been observed even in children and adolescents. Many factors have been postulated as risk factors for such cloned suicidal behaviours. It has been seen that imitative suicides are more common within 2 weeks of the first event, with greater media coverage, repeated coverage and high-impact stories, when the person described in the story and the reader/viewer are similar in some way especially core features such as age, sex and nationality, when the person described in the story is a celebrity and is held in high regard by the reader/viewer, with the most vulnerable being young people, people suffering from depression and substance use disorder [27]. A critical facet of the media’s presentation of suicide is that it usually oversimplifies the causes, attributing the act to solitary factors such as broken relationships, financial disasters or failure in examinations [28].

Stack and colleagues reviewing 55 studies determined that: (1) studies measuring the presence of either an entertainment or political celebrity were 5.27 times more likely to find a copycat effect, (2) studies focusing on stories that stressed negative definitions of suicide were 99% less likely to report a copycat effect, (3) research based on television stories (which receive less coverage than print stories) were 79% less likely to find a copycat effect, and (4) studies focusing on female suicide were 4.89 times more likely to report a copycat effect [29].

On a positive note farmer suicide is an issue that has been highlighted by the media in recent times, constructively raising awareness about the stress and plight of the farmers and sensitizing the authorities [30].

WHO guidelines on reporting a suicide are as follows:

1. Statistics should be interpreted carefully and correctly

2. iAuthentic and reliable sources should be used

3. Impromptu comments should be handled carefully in spite of time pressures

4. Generalizations based on small figures require particular attention, and expressions such as ‘suicide epidemic’ or ‘the place with the highest suicide rate in the world’ should be avoided

5. Reporting suicidal behaviour as an understandable response to social or cultural changes or degradation should be resisted.

Media and substance use

Media can play a key role in the initiation and accentuation of substance use. Social media is a common medium of exposure to two decisive factors associated with alcohol use: peer alcohol behaviour [31,32] and alcohol advertising [33]. Social learning theory postulates that individuals learn both by enactive experience and by observation [34–36]. Especially, early alcohol initiation is governed at least in part by observation of alcohol use both by friends and by social network characteristics [36]. In today’s technological world, this observation can occur both online and offline.

The Media Practice Model suggests that media users explore information or display content based on experiences or behaviours they are considering, which may lead to reinforcement or advancement of these ideas. Thus, an adolescent who is considering initiating alcohol consumption may choose to watch a movie depicting drinking at a party, which in turn may influence him or her to attend such a party in the future. It has been shown that exposure to alcohol commercials is associated with positive beliefs about alcohol consumption [37]. Displayed alcohol references have been linked to alcohol behaviours offline, because older adolescents whose Facebook posts suggested problem drinking behaviours are more likely to score as ‘at risk’ on a problem-drinking screen [38].

Research has revealed that advertising may be responsible for up to 30% of adolescent tobacco and alcohol use [39,40]. Exposure to tobacco marketing and advertising increases the smoking initiation rates in teenagers more than twofold [41]. Advertisements and promotion of cigarettes have been increasing in developing countries like India due to a sharp decline in sales in Western countries, and pose a major concern [42]. Although such cross-sectional studies do not prove causation and if only association, it is of interest that in a 1990 study, 56% of students in grades 5 to 12 said that alcohol advertising encourages them to drink. Findings showed that girls who had watched more hours of TV advertisements at ages 13 and 15 drank more wine and spirits at age 18 than those who had watched fewer hours of TV [43]. One study suggested independent associations between marijuana and alcohol use, and media exposure. In particular, music exposure is associated with marijuana use while movie exposure is related to alcohol use [44]. These findings suggest a clear cause–effect relationship between media influence and substance use but may be an oversimplification of the problem, as multiple other biological, psychological and social factors may be in play in different contexts.

Media research also shows that illicit drugs were commonly shown in a large proportion of movies as well as through the television [45,46]. Characters are often shown smoking as a part of daily life. Covert sponsoring of mega sport events like international cricket matches and bravery awards surreptitiously aim to promote tobacco products. These may attract the vulnerable adolescents toward smoking as a desirable ‘grown up’ activity [47]. A study from India suggests that those children who are exposed to cigarette brand names through television are more likely to smoke, while those exposed to anti-tobacco messages are less likely to smoke [48].

Media literacy can teach youth to understand, analyse, and evaluate mass media messages, enabling them to actively process the information rather than passively remaining targets of mass media. India wrestled with a lot of polarized debates and controversy for the ban on on-screen smoking in films and television programs. Initially, ban was imposed from January 1, 2006 and then on January 23, 2009, the Delhi High Court lifted the smoking ban in films and TV [49]. There is a dire need for evidence based guidelines for such issues.

Media and eating disorders

Exposure of women to alluring thin images in the media has been speculated to lead to body image discontent, poor self-esteem, an intense urge for thinness and a drive for dieting which may result in eating disorders [50–52]. Media can have a causal effect; act as a trigger or a confounder for those who are otherwise predisposed. It is possible that only those individuals having pre-existing anxiety, depression, low self-esteem or a genetic liability are susceptible to cultural demand and go on to develop symptoms of eating disorders post exposure. Looking at factors that may lead some women to be more vulnerable to the messages and images portrayed in the media the review by Groesz et al. [53] indicated that females who have already internalized the thin beauty ideal and already have high levels of body dissatisfaction are most vulnerable. A meta-analytic review further indicated that adolescent girls with initial deficits in social support are also more vulnerable to the effects of the media messages [54].

In the context of mass media, regional differences exist in body image dissatisfactions. Until the advent of televised media on the Fiji islands, eating disorders had not been recorded [55,56]. In Iran, ban on Western media after the fall of the Shah averted being exposed to the thin body beauty, leading to a higher body esteem of Iranian female students [57]. Both India and China reported cases of eating disorders after 1990 with increased and more consistent exposure to the Western media [58]. Shroff and colleagues in Mumbai in 2004 [59] examined the relationships among the variables of body mass index, interpersonal teasing, media internalization, body dissatisfaction, and drive for thinness in 96 and 93 adult females. Their findings reflect previous work with U.S, and Swedish samples, suggesting that there are similar potential risk factors, cross-culturally, that may explain the development of eating and shape-related problems. Muscular dysmorphia, a type of ‘reverse anorexia’ in males with a fixation on muscle bulk, has surfaced as a male counterpart of anorexia nervosa seemingly sustained by media portrayal of lean and muscular men [60]. Women’s magazines remain a significant source of such exposure. One prospective study examining the thin ideal-endorsing media use in young adolescent girls found that decreases in magazine reading over 16 months was associated with decrease in disordered eating symptoms [50].

The age of exposure also seems to be an important determinant. A meta-analysis of 25 studies involving female subjects, examined the effect of exposure to media images of the slender body ideal. Body image was significantly more negative after viewing thin media images than after viewing images of average size models, plus size models or inanimate objects especially in women younger than 19 years of age [53]. Field et al found that both boys and girls aged 9 to 14 years who were making an effort to look like the figures in the media, were more likely than their peers to develop weight concerns and become regular dieters [59].

Media and depression

The rise and acceptance of social media has been particularly marked around the globe. Although it may act as a means of making friends and gathering social support, it may lead to stress in some individuals [61]. Because social media websites are among the most commonly accessed websites with a large quantum of users [62]. Multiple studies have linked social media use with declines in subjective mood, sense of well-being, and life satisfaction [63,64]. Passive consumption of social media content, as opposed to active communication has been linked with decrease in bonding and increase in loneliness [65]. One hypothesis is that exposure to highly idealized representations of peers on social media evokes feelings of envy and the erroneous belief that others lead happier lives. Subsequently, these envious feelings may gradually lead to a sense of self-inferiority and depression [27]. In a longitudinal study of adolescents by Frison and Eggermont in 2016 [66], the association between negative online comparisons and decreased life satisfaction was reciprocal. Thus, depressed adolescents with less life satisfaction can be more vulnerable to negative online social comparisons even as these comparisons are unlikely to be based on reality.

Cyberbullying is an emerging public health concern that has been associated with several negative consequences. Victims report increased levels of depression and suicidal ideation, as well as elevated levels of emotional distress, externalized hostility, and delinquency compared to non-victimized peers [67]. While much media attention has focused on its targets, research has shown that perpetration of cyberbullying is also associated with negative health effects. For example, adolescent girls who cyberbully others have been found to have increased rates of depression and anxiety compared with uninvolved peers [68].

Media exposure at night can disturb sleep, which is integral for normal cognitive and emotional development [69]. In addition, messages transmitted through the media could lead to fear, anxiety and aggression [70]. Whether media multitasking is used by persons who are depressed and anxious as a means of distraction needs to be further evaluated [62,71].

Media and social anxiety disorder

Two different hypotheses have been proposed in order to interconnect media use and social anxiety. The first hypothesis proposed is the social compensation hypothesis, according to which individuals use online social networking sites in order to compensate for deficits in social skills or discomfort in face-to-face situations. The second theory is called the social enhancement hypothesis. According to which, socially skilled individuals use online social networking sites to find additional opportunities to interact with others. There is mixed evidence regarding the two hypotheses, as both have received support [72,73].

Media and sexual behaviour

The influence of media on sexual behaviour was first documented in a sex education newsletter in 1981 and since then several overviews have examined adolescents’ use of media and its possible effect on their sexual behaviour [74–76]. Concerns have been raised about the influence of media depictions on sexual attitudes, sexual behaviours and the normalizing expectations of adolescents at a critical developmental stage [77–79].

Media exposure to pornography may lead to experience of conflict and sexual dissatisfaction [80]. Media exposure to sexual themes could have a negative effect on the attitudes towards women and may harbinger to a greater disposition to indulge in coercive encounters and experimentation [81,82].

There is an increasing trend of messaging of sexual contents through mobiles among school going adolescents. Survey results indicate that TV programs watched by adolescents contain high levels of sexual content and include little information about sexual risks [83]. A study found that nearly 75% of 15- to 17-year-olds believe that sexual content on television influences the behaviour of their peers ‘somewhat’ or ‘a lot’ Adolescents who selectively viewed more sexual content on television were more likely to have sexual intercourse in the preceding year [84]. Ashby, et al. with the use of longitudinal data examined the relationships between amount of television viewing and parental regulation of content on sexual initiation and observed that watching TV 2 or more hours per day and lack of parental regulation of television programming were each associated with increased risk of initiating sexual intercourse within a year [85]. Peterson, et al. concluded that co-viewing television and discussing television with parents were linked with decreased sexual initiation in certain adolescents [86]. It is true that individuals already exposed to and engaging in such behaviour may have a higher chance of watching or reading similar content on media. But it is equally true that media can influence new people coming across the content as well as validate behaviours of the ones who are already engaging in them.

Sending or receiving sexually explicit content – texts, pictures or videos is referred to as sexting. Some people hold positive attitudes of sexting, due to the thrill and excitement of it; it may also be a normal practice in the current technologically advanced environment for many romantic relationships. It may also be used as a way to seek acceptance and to fit in a peer group and may lead to sharing compromising images of themselves, without due consideration about how widely these images can be disseminated. The downside though, is the ease with which this content can be misused, as it can be used for bullying, cybercrimes such as creating pornography, the consequences of which are profound, such as anxiety, depression and even suicide of the victim who is involved [87].

Media and aggression

Exposure to violence via media has been positively associated with subsequent aggressive behaviour, ideas, and with higher rates of aggression in later life [88,89]. During childhood children encode social scripts in memory to guide behaviour though observation of family, peers, community, and different media. Further on, observed behaviours are often imitated long after they were observed [90]. During this period, children’s social cognitive schemas about their environment are also elaborated. For instance, protracted observation of violence has been shown to bias children’s world schemas toward attributing hostility to others’ actions [91,92]. Conversely, there is a significant negative impact on helping behaviour. Ray, et al. reported that children having exposure to violence through media had poorer school performance and a deleterious impact on their psychosocial adjustment [93]. One other study from India revealed how vivid display of violence through media during the 9/11 terrorist attack caused significant stress in adolescents [94].

Few studies suggest that television violence does not directly influence children's behaviour or make them excessively prone to violence but genetic and environmental factors apparently interact to increase the risk of the development of aggression among violence-prone personalities [95]. Media may just act as an impetus, in the sense that when an individual with high-violence proneness exhibits aggression, he or she may model it on what was encountered through media. However, since aggression is multifactorial in origin, no single factor including media influence can be attributed as a dominant influence [96].

Desensitization

Repeated exposures to emotionally activating media or video games can lead to habituation of certain natural emotional reactions. This process is called ‘desensitization.’ Increased heart rate, perspiration, and self-reports of discomfort often follow exposure to blood and gore. However, with repeated exposures, this negative emotional response habituates, and the child becomes ‘desensitized.’ The child can then think about and plan proactive aggressive acts without experiencing negative affect [97].

Discussion

Media as a tool for change

Media is a tool that can be potently used to increase knowledge, create favourable attitudes and change overt behaviour. We need to find ways to optimize the role of media in our society, taking advantage of their positive attributes and minimizing their negative ones, to use the media to help people avoid behaviours that reduce their wellbeing and increase behaviours that promote it. If the media can worsen stigma in the field of mental illness, it is reasonable to assume that media can also potentially be used to reduce stigma as well [98]. Documentary films can be used to educate the general public about mental health and disease. Viewing a documentary about schizophrenia have led schizophrenia to be perceived as less dangerous [99]. Reading an article containing corrective information has led to a greater acceptance of persons with mental illness and less fear about mental illnesses [100].

Developing a new unified, integrative identity and working on the positive public image of psychiatry and its public relations are of great importance for the future of our profession. The media can have a substantial imprint on the demand and supply of mental health treatment as well as on the position of psychiatry in the society. One of the most compelling image builders is how psychiatrists present their profession with patients and their families, and other medical doctors, and the public. It is very interesting to note that the father of public relations was a nephew of Sigmund Freud, Edward L Bernays. Suggestions have been made about how psychiatrists and mental health professionals should interact with the media while discussing about psychiatric illnesses. A sensitive use of language and terminology that preserves the dignity of those with mental illnesses, and at the same time avoiding miscommunication, is beneficial. Interaction with media should be taken as an opportunity to debunk myths and give a lucid account of the psychiatric illnesses in question. It is imperative to abstain from speculation and to provide clear instructions about how to avail services when in need.

Education of the media and using fake news screens can help control the problem to some extent, but possibly would not impact much on individuals working through social media accounts. Actions such as suspending the account for a brief period of time if there are lapses in the rules against propagating fake news, and reinstation on retraction of the particular content could be attempted, but this requires significant resources and further planning, as it has to be done without impinging on the personal right to freedom of speech. This can make it difficult to report the ‘citizen reporter’ and therefore make it difficult to block fake news and misinformation that makes the rounds on social media.

Digital psychiatry in clinical practice

Telepsychiatry first was recorded in 1957 is time saving and cost saving. Advancing technology has led to its widespread use to help mentally ill patients’. With the help of telephones, crisis help lines and suicide prevention centres are set up. Emergency psychiatric services are provided through telephones or mobiles. Email has been increasingly accepted as a mode of communication with the therapist. Tape recording of psychotherapy sessions is helpful for initiation of a session. They are easy to store and retrieve. It can be passed on to another therapist if needed. Videotaped group therapy and other psychotherapy sessions help patients see themselves as other saw them. Through television and TV shows as well as movies proper portrayal of mental illness can increase its awareness. Radio can reach the unreached and unmet. Talk shows and radio programmes related to psychiatry can also increase awareness regarding mental illness. Through Internet self-help groups and support groups can be connected. Internet is an important source of International Electrotechnical Commission activities. The internet provides information about mental health problems such as suicide, anxiety, depression. Increasing knowledge can improve help seeking behaviour. There is evidence that mobile phones can lead to a number of positive health effects like quicker diagnosis and management, better stress management, improving adherence and compliance to medication [101].

The availability of digital media and Internet makes it extremely easy to share, download and engage in playing video games, to the extent that this behaviour can go to the extent that the person has impaired control over gaming, with playing taking precedence over daily activities and may result in the development of gaming disorder. On the other hand, games are being used for positive results too, with gamification- the use of game design elements in non-game contexts, and can be used in the management of several medical and psychiatric conditions in a creative and effective manner, such as depression, anxiety, schizophrenia, post-traumatic stress disorder and eating disorders. It is also being used in medical education, and lends itself suitably to the digitalisation of medical education, when used effectively [102]. The juxtaposition between addictive potential of gaming and its advantages in being of use in treatment and education needs further investigation.

Media can have significant positive impacts on sexual health-related attitudes, beliefs and behaviours. Mass media can provide knowledge about healthy sex, contraception, family planning, sexually transmitted diseases and treatment of sexual disorders. Viewing advertisements about human immunodeficiency virus (HIV) have led to a reduction in the reported number of sexual partners by both men and women and increased condom usage [103]. Several international studies have found that women who view more family planning messages on television, radio and print media are more likely to use contraceptives than those who see fewer messages [104].

Resistance to change is a serious obstacle to effective utilization of new knowledge, but media can help to overcome resistance. Although media training is common among business professionals, it is relative rare within academic psychiatry. This is a missing opportunity, especially in view of growing public dependence upon mass media for both factual information and perspective [105]. Learning how to use mass media effectively to educate the public about issues like quality of life, community health, mental health vs. mental disorders and its treatment, and the workings of the delivery system for mental health care (when, how and where to seek help) is quintessential for the advancement of public health psychiatry.

A much more active involvement of mental health professionals in creation of media related to mental health is the need of the hour, with a successful attempt involving active liaison of individuals from the media houses and health industry. Unless the media is conscientious about what it streams out, it is difficult to regulate what kind of content reaches the public. Although psychiatrists do make educational videos, write newspaper articles and blogs, participate in seminars, panel discussions directed towards education of the non-medical population, these rarely get dispensed through the mainstream channels which are utilised by most of the general population.

Internet based technology has the wherewithal to revolutionize digital psychiatry. For instance internet CBT, has the potential to treat patients who currently are unable to access care, to prevent disease, and to provide early intervention and quality treatment—it can be the gateway to psychiatric care. With these new modalities, clinicians are better able to provide quality care to all patients with mental health and other problems. We need to understand emerging telemedicine trends that will lead the way to better health and greater opportunity for our patients to access help. Smartphones in patient care can be used as adjunctive interventions for to collect and monitor information and sensing big data to predict relapse in bipolar and schizophrenic disorders. Torus J [106], in demonstrating a patient-driven innovation for mobile mental health technology at Harvard medical school, helped a patient who wanted to be able to quantify the effects of this new medication use a smart tally counter, a digital device that, with the push of a button, wirelessly transmitted the current count to an online portal. This digital tally counter was convenient to use as it offered easy access to automatically time-stamped data which could be analysed later. The patient noted that there was a correlation between higher doses of medication and fewer symptoms and it was possible not just to track and quantify his own mental health experience, but also that such data could be useful for assessing the effectiveness of treatment. The fact that the tally counter tracked the time of each button press allowed him to gain insight into times of the day that were more triggering and to recognize weekly fluctuations in symptoms [106]. Clinical technology is progressing in tandem with structural changes in the mental health care delivery system. One of the biggest moves from a systems perspective has been in leveraging digital tools to create and improve care coordination. Virtual clinics that can support the digital therapeutic relationship also offer an unexplored avenue to potentially realize the value of new technologies like smartphone apps for mental health disorders. Instead of forcing traditional clinics to adopt apps and alternate technologies in a setting that is not well suited to foster a digital therapeutic relationship, these new clinics could potentially be established for exactly that purpose. Since the clinicians and workflow of this virtual clinic would be constructed around digital care and patients self-selecting for this type of care, an opportunity exists for the true potential of digital psychiatry to be realized [102]. This represents a shift in thinking of apps as tools that can themselves revolutionize care to envisioning them as resources to facilitate and augment clinical relationships.

Conclusion

There is an intricate dynamic relationship between mass media depictions of mental illness and the public’s understanding. The link appears bi-dimensional in the sense that negative images in the media cultivate negative attitudes, and the resultant media coverage feeds off an already negative public perception. Accurate information must therefore be circulated to the public, and here, not only the mainstream media, but blogs, forums and social media platforms would do well to adhere to desirable standards of exercising restraint and caution before broadcasting or uploading inaccurate matter onto public domains. Psychiatrists have a potentially a pivotal role to play in educating the public about the current state of the psychiatry. Unlike most journalists, who have to rely on second-hand accounts or expert opinion, psychiatrists can weigh in directly with their advice, opinions, and expertise on social media, based on direct accounts from patients based on doctor-patient relationships. But this is unusual, as most psychiatrists would prefer to not contribute to such discussions, in view of potential breach of clinical and institutional guidelines, and also medical litigation. The onus therefore, at least for now, falls on the media itself, and it is fundamental to highlight stories of successful recovery, stories of resilience and hope, which if presented properly, can both educate and entertain the audiences.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Suhas Chandran

Suhas Chandran, MD, is a Senior Resident from the Department of Psychiatry at St. John's Medical College Hospital. His research interests include child and adolescent psychiatry, suicide and role of digital technology in mental health.

Supriya Mathur

Supriya Mathur is a Junior Resident from the Department of Psychiatry at J.S.S Medical College and Hospital, Mysore. Her research interests include substance use disorders, internet addiction and geriatric mental health.

Kishor Manohar Rao

Kishor Manohar Rao, MD, is an Associate Professor from the Department of Psychiatry at J.S.S Medical College and Hospital, Mysore. His research interests include suicide, use of psychotherapy in clinical practice and use of internet based technology in mental health.