It’s inevitable that computing will eventually replace mental health clinicians as diagnosticians and treatment providers in a world where those with mental illnesses and lesser mental health problems are continuously monitored and treated without a human intermediate, even as human beings will likely continue to need human-to-human connection for optimal mental health for many years to come. In this sense, psychotherapy that relies on human-to-human connection may well be the last form of treatment to be completely replaced by computing, although there are attempts already underway to create an empathic, validating, mirroring, guiding and formulating artificial intelligence that mimics human-to-human interaction.
Digital health technologies have numerous avenues by which they can improve upon the current system of mental health care. To understand these various avenues, one has to be adequately familiar with the current system of care. Individuals who are adequately resourced and who are symptomatic may present to a mental health clinician for diagnosis and treatment. Those who are not may not even understand that they are suffering from a mental illness.
Once an individual decides that he has a problem that requires professional help, right from the outset, we are confronted with a problem: the current method of rendering a diagnosis for mental disorders is not optimal for a variety of reasons. For one, psychiatric diagnoses are largely made by querying patients for symptoms (which are inherently subjective), obtaining collateral information from family and friends when necessary, performing a mental status examination, ruling out “medical” diagnoses and, finally, synthesizing all this information to see if it fits a pattern of categorical diagnoses outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The rendering of treatment is initiated after a diagnosis (or diagnoses) has been carefully established. Evidenced-based treatments are those that have been studied by the scientific method and proven to be better than placebo or some other form of intervention, but all the while using the diagnostic system outlined above for subject selection and exclusion. However, there is no guarantee that evidence-based treatments are necessarily the best treatments for individual patients, because, for one, the best treatments may not be adequately studied or studied at all.
Part of the problem with this picture is that the mechanisms of disease for the vast majority of mental illnesses have not been firmly established, although progress has been made in understanding the underlying pathophysiology of several. What is clear, however, is that these illnesses are primarily brain-based disorders, although some may well involve the systemic immune system and hormonal axes that affect other organ systems.
Given that many mental illnesses create suffering by virtue of negatively affecting our cognitions, perceptions, moods/emotions, executive functioning and behaviors and, secondarily, by affecting school/work and interpersonal functioning, the brain seems to be the logical place to start in understanding and teasing apart these illnesses. At some level, mental illnesses can be thought of as disturbances in functioning of various neural circuits that lead to experiences that deviate from some societally-determined normative experience or range of experiences.
As functional imaging technologies evolve, we will gain a better understanding of the different brain regions/neural circuits that are involved in various mental illnesses. At this time, however, there are no biomarkers that can be reliably used to make a diagnosis of a mental disorder, although an EEG-based system has gained FDA approval to confirm the diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD).
So, where do digital health technologies come into play regarding mental disorders, you might ask. From my perspective, the logical answers seem to be:
Delivery of care
Forming community/facilitating connection
At different points in time on this blog, we will look at how various digital mental health technologies are poised to tackle the big problems in the field:
Inadequate access to care (e.g. due to geographic location)
Unequal access to care (e.g. across socioeconomic and racial divides)
Delay in access to care (e.g. due to under-resourced clinics)