The future has been preponed: building a new digitally-enhanced psychiatry in the aftermath of the pandemic

To succeed, planning alone is insufficient. One must improvise as well. – Isaac Asimov

The COVID-19 pandemic has brought about a sea of change in our understanding of how technologies can be leveraged for mental health care. We have already witnessed the scaled adoption of telemedicine for mental health care worldwide, and as a result, both clinicians, as well as patients, have developed proficiency in incorporating digital tools into psychiatric care (Aref-Adib & Hassiotis, 2021). Early evidence suggests that telecare-based models offer several advantages and efficiencies in care provision that are likely to remain foundational to mental health care long after the pandemic itself subsides. This includes improved access, eliminating redundancy, and facilitating more flexible, patient-centric models of care (Merchant et al., 2020). The pandemic has also shown that the use of technology can be protective against known mental health stressors such as loneliness and isolation (Vahia et al., 2020).

It has been suggested (Torous et al., 2020) that this scaled adoption of digital platforms for conducting care visits may also catalyse broader adoption of other digital approaches. The great challenge of modern psychiatry has been to find ways to balance the occasionally contradictory goals of providing more individualised and precision-based care while also being able to reach the millions of people worldwide with limited access to mental health care. Increasingly, lessons learned from the pandemic demonstrate that the thoughtful use of technology may help us achieve this balance, and new familiarity with using communication technologies to access care may speed up the adoption of other tools as well.

This special issue of the International Review of Psychiatry arrives at this exciting and unprecedented moment. The issue features eight publications from around the world that collectively offer a glimpse of how we may bring this possibility of new digitally-enhanced psychiatry into reality. Each paper represents the work of a team with globally recognised expertise in their specific domain. The included publications are from the United States, Norway, and India and address a range of complex questions including whether digital approaches can be incorporated into real-world practice, whether and how information from patients’ digital lives can be included in care, and how the impact of technologies should be measured. The work in this issue also addresses highly specialised topics such as neuropsychology, geriatric mental health, and technology adoption in low and middle-income countries.

Zulueta and Olusola (2020) challenge the paradigm of telepsychiatry care being inferior to in-person care and propose that new developments in remote-sensing and digital phenotyping offer a chance to overcome inherent limitations characteristic of remote health care. They argue that these approaches have the potential to remedy the limitations of in-person outpatient care models. Using these technologies, more relevant and objective clinical data can be collected and used to improve the quality of care received and how it is delivered. However, the use of these remote-sensing and digital phenotyping technologies requires important ethical considerations.

Lhaksampa et al. (2021) discuss how data from patients’ electronic communication may enhance care. They note that smartphones have increasingly been used to maintain social relationships and support networks in the wake of physical distancing guidelines and that supplementing telehealth-based care with collateral information gleaned from a patient’s electronic communications (smartphone applications, texts, email, messaging services, social media, etc.) may provide clinicians with valuable insight into a patient’s mood state and offer them information that may influence their course of treatment. The authors also highlight the need for longitudinal data and attention to ethical considerations.

Singh and Germine (2020) write on the impact of COVID-19 on neuropsychology, which is a cornerstone in the assessment of a range of psychiatric conditions including dementia, learning disorders, and attentional deficit disorders. In balancing the need to modify existing paradigms and providing safe care, many are opting to adopt a Hybrid Neuropsychology model that combines traditional modalities with technology-based ones. They suggest that neuropsychologists are likely to persist with the use of this hybrid model beyond the COVID-19 pandemic as it enables clinicians to have a more modern, equitable, and lasting neuropsychology practice in the digital world and capture real-world functioning in a way that traditional neuropsychology is unable to.

The paper by Rauseo-Ricupero et al. (2021) provides critical proof-of-concept that a highly digitally enhanced care approach is feasible. Using a case series from the Digital Clinic, an outpatient mental health program integrating smartphones into traditional mental healthcare at a tertiary care centre in Boston, they demonstrate the feasibility and benefits of integrating digital technologies to improve the quality of remote mental healthcare. The authors show how smartphone and digital technologies work to diversify methods of clinical engagement, safe and ethical data collection, and to promote person-centered care.

Two of the papers in this issue focus specifically on technology use during the pandemic to address COVID-19 related mental health issues and include new original data. Gedde et al. (2021) report on the use of assistive technologies in a cohort of Norwegian home-dwelling dementia patients and caregivers. The authors found that before the pandemic, assistive technology was available to 71% of this group and only 17% of caregivers showed an interest in adopting novel technologies such as wearables or passive sensors during the pandemic. Their data demonstrate that technology adoption can vary widely across age groups and that the issue of engagement and adoption must be taken into consideration when developing new technologies and applications. In the second paper, Southwick et al. (2021) highlight how technologies, including wearable and digital devices, and digital and social media data, have been valuable public health and epidemiology resources throughout the novel coronavirus-19 pandemic. The authors report original work analysing the Reddit posts made by persons experiencing lasting effects of the disease caused by COVID-19 (COVID Long Haulers). The authors found that these patients used social media to identify key concerns and priorities. The authors were able to identify several themes in the Reddit posts, including frustrations with the medical system and the exchange of medical advice, support, and questions among peers. Analysis of these narrative posts demonstrated the value of digital technology and social media as an important public health tool in today’s digitally-dependent environment.

The final two papers in this special issue focus on robotics and gaming – technology-based approaches that are not yet part of mainstream care but whose potential is rapidly becoming evident. Kulpa et al. (2021) review socially assistive robots and their use in older adults.

Their work indicates that socially assistive robots have proven useful in clinical care, including the care of older adults in a socially-distanced manner - a population particularly vulnerable to the effects of the global COVID-19 pandemic. This review demonstrates that robotic care has left the realm of feasibility studies and is beginning to show a significant impact on psychiatric indications. The authors highlight that for the use of robots to become the standard of care, there will need to be a better application of standardised outcome measures that will help clinicians and researchers understand precisely how robots impact mental health.

Banerjee et al. (2020) present a novel viewpoint on mental health treatment in India, a country with a large population of young people and a great demand for mobile games. The authors note that digital gaming-based interventions utilise the playfulness and domain-targeted designs of games to deliver psychotherapy, biofeedback interventions, cognitive training and rehabilitation, behaviour modification, and social skills training. These gaming interventions have been used in a variety of psychiatric conditions, including mood disorders, neurocognitive disorders, and to promote healthy aging, among others. However, there are concerns around cultural appropriateness and barriers to implementation in a rapidly-globalizing India despite steps to increase access to technology.

Several themes cut across the papers in this issue. A major one is a need for evidence to support the use of technologies. Thus far, digital mental health has been the subject of excitement and anticipation, but its widespread adoption has lagged. This may be because the majority of digital tools are not supported by rigorous research. A second theme is the need for ensuring data privacy and security. Since much of digital health involves clinicians and other stakeholders accessing information from personal devices, protections must be put in place if these technologies are to be a part of care at scale. Complex questions around who owns digital data and who controls its distribution and access must be addressed. Simultaneously, there are no identified standards of care or best practices around digitally enhanced care at this time. Implicit in this issue is the assertion that professional medical organisations, as well as governments, will need to step in and provide a regulatory framework around digital mental health to realise its true potential. Finally, this issue highlights the need for a highly interdisciplinary approach to conduct digital mental health research and to provide digitally enhanced care. Mental health researchers will have to collaborate with engineers, the technology industry as well as data scientists. There will also need to be a new generation of partnerships between academia, the healthcare industry, and the technology industry. As is the case with any paradigm-shifting developments in mental health care, clinicians will have to develop new skills and practice methods that involve understanding and using large volumes of fine-grained digital data.

One can confidently state that the pandemic has brought about this shift towards digitally enhanced psychiatry and that this shift is likely permanent. The work of building a sustainable, secure, patient-centric, digital psychiatry, however, has only just begun.

Acknowledgment

The author acknowledges the assistance of Hailey Cray, BA, in the preparation of this manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).