Mental Health in a Digital World

By Dan J. Stein, Naomi A. Fineberg and Samuel R. Chamberlain

Mental Health in a Digital World addresses mental health assessments and interventions using digital technology, including mobile phones, wearable devices and related technologies. Sections discuss mental health data collection and analysis for purposes of assessment and treatment, including the use of electronic medical records and information technologies to improve services and research, the use of digital technologies to enhance communication, psychoeducation, screening for mental disorders, the problematic use of the internet, including internet gambling and gaming, cybersex and cyberchondria, and internet interventions, ranging from online psychotherapy to mobile phone apps and virtual reality adjuncts to psychotherapy.

• Reviews research and applications of digital technology to mental health
• Includes digital technologies for assessment, intervention, communication and education
• Addresses data collection and analysis, service delivery and the therapeutic relationship
• Discusses the E-related disorders that complicate digital intervention

• Language: English
• Publisher: Academic Press
• Release date: Nov 13, 2021
• ISBN: 9780128222027

Book preview

9780128222027_FC

Mental Health in a Digital World

First Edition

Dan J. Stein

University of Cape Town, South Africa

Naomi A. Fineberg

University of Hertfordshire, United Kingdom

Samuel R. Chamberlain

University of Southampton, England

Table of Contents

Cover

Title page

Copyright

Contributors

Preface

1: Introduction

Data collection and analysis

Communication, psychoeducation, and screening

Problematic Internet use

Interventions

Conclusion

Section A: Digital Data Collection and Analysis

2: Information technology and electronic health record to improve behavioral health services

Abstract

Introduction

Setting goals to achieve value and quality in practice and the role of technology

Components and processes of systems used by clinicians

AI and big data

Clinician, team, system, and institutional/organizational competencies

Discussion

Conclusions

References

3: Big data and the goal of personalized health interventions

Abstract

Introduction/Overview

What is big data?

Where does big data come from?

Data storage and preprocessing

Data analysis

Insights from genetics, neuroimaging, and eHealth

Key challenges

Looking to the future

Conclusions

References

4: Collecting data from Internet (and other platform) users for mental health research

Abstract

Introduction/overview

A brief historical overview of the Internet’s use within psychology

Are the use of Internet sampling procedures reliable and valid?

Benefits to utilizing the Internet to answer research questions

Risks/costs of Internet research

How to go about collecting data from Internet users

Tools to construct surveys and tasks online

Conclusion

References

5: Ecological momentary assessment and other digital technologies for capturing daily life in mental health

Abstract

Introduction

Mental health revolution

Precision medicine

The importance of context

Modern care practices

The relevant time window

Ecological validity

Profiled vs iterative personalized medicine

Digital health solutions

Ecological momentary assessment

Added value to cross-sectional methods

Learning from group-level research

Toward a paradigm shift in clinical practice

Reliable assessment of subjective experiences

Individual EMA use in clinical practice

Case example

Leveraging the full potential of technologies

Digital phenotyping

Unobtrusive mental health assessments

Conclusion

References

6: Social media big data analysis for mental health research

Abstract

Mental disorders

Social media data

Social media typology

Data collection from social media users

User verification and annotation

Data collection from social media platforms

Natural language processing (NLP)

Machine learning

Machine learning algorithms

Deep learning

Evaluating ML models

Ethics surrounding profiling social media for mental health

A framework for the use of social media for health intervention

Ethical considerations and practices

Identifying health conditions from social media behavior

References

Section B: Communication, psychoeducation, screening

7: Telepsychiatry and video-to-home (including security issues)

Abstract

Introduction

Effectiveness

Patient satisfaction

Provider satisfaction

Regulatory and safety issues

Licensure portability and reciprocity

Security and privacy of patient information

Patient safety during TMH encounters

Global telemental health

Future directions in global TMH

Conclusion

References

8: Social Media and Clinical Practice

Abstract

Introduction

Background

Clinical Use

Concerns

Discussion

Conclusion

References

9: Websites and the validity of mental health care information

Abstract

Quality assessment methods

Types of mental disorders

Quality of mental disorder information on social media

Longitudinal changes in website quality

Summary

Conclusion

References

10: Digital phenotyping

Abstract

The importance of measurement

The challenge of measurement in mental health

Virtual care and electronic patient self-report

Digital phenotyping of mental health

Challenges faced by digital phenotyping

Promise and future of digital measurement

References

11: The digital therapeutic relationship: Retaining humanity in the digital age

Abstract

Introduction

Human factor science and the design of person-centered e-interventions

Conceptualizing e-interventions within a relationship-centered paradigm

Toward a theoretical conceptualization of relationship-centered e-interventions

Future directions for theory and research

Conclusion

References

Section C: Problematic use of the Internet

12: Gambling disorder, gaming disorder, cybershopping, and other addictive/impulsive disorders online

Abstract

Introduction

Phenomenology, comorbidity, and clinical assessment tools

Psychobiology

Treatment: Pharmacotherapy and psychotherapy

Discussion and concluding remarks

References

Further reading

13: Cyberchondria, cyberhoarding, and other compulsive online disorders

Abstract

Declaration statement

Introduction

Cyberchondria

Cyberhoarding

Other digital forms of OCRDs

Conclusions

References

14: Internet-use disorders: A theoretical framework for their conceptualization and diagnosis

Abstract

Disclosure statements

Introduction

Diagnosis

Etiology

Disordered smartphone use

Conclusion

References

15: Cybersex (including sex robots)

Abstract

Introduction

Epidemiology, definitions, and phenomenology

Diagnostic criteria

Differential diagnoses

Assessment and evaluation

Psychobiology

Pharmacotherapy

Psychotherapy

Conclusion

References

16: Developmental aspects (including cyberbullying)

Abstract

Introduction

Behavioral development

Neurodevelopment

Conclusions

References

Section D: Interventions

17: Internet-based psychotherapies

Abstract

Background

Procedures

A typical treatment case

Research support

Implementation and evidence in clinical settings

Future and ongoing developments

Conclusion

References

18: Apps for mental health

Abstract

Introduction

The potential of MH apps

Functions of MH apps

Key aspects of mobile apps evaluation

Current app evaluation frameworks

Conclusions and future directions

References

Further reading

19: Clinical interventions for technology-based problems

Abstract

Introduction

Social perceptions of problems and interventions

Types of intervention

Primary preventions

Secondary prevention

Tertiary prevention

Prevention and treatment evidence

Government responses

The role of industry and online content providers

Future research directions

Discussion

Conclusions

References

20: Scaling up of mental health services in the digital age: The rise of technology and its application to low- and middle-income countries

Abstract

Introduction

Technology for community outreach, raising awareness, and challenging stigma

Technology for mental health in humanitarian settings

Digital Interventions for youth mental health

Technology for supporting clinical care and building capacity of frontline health workers

Technology for severe mental disorders

Ethical considerations

Mental health during pandemics and the need for digital interventions

Discussion and conclusion

References

21: Addiction, autonomy, and the Internet: Some ethical considerations

Abstract

Introduction

Distinguishing clinical and ethical debates

The ethics of persuasive design

The nature of the harm

Ethical implications

Conclusion

References

Index

Copyright

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Notices

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Contributors

Anzar Abbas     AiCure, New York, NY, United States

Shalini Ahuja     Centre for Implementation Science, Health Services and Population Research Department Institute of Psychiatry, Psychology and Neurosciences King’s College London, London, United Kingdom

Michael Van Ameringen

MacAnxiety Research Centre

Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada

Gerhard Andersson     Department of Behavioural Sciences and Learning, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden

Ole A. Andreassen     NORMENT Centre, Institute of Clinical Medicine, University of Oslo and Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway

Jason Bantjes     Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Stellenbosch, South Africa

Joël Billieux

Institute of Psychology, University of Lausanne (UNIL)

Centre for Excessive Gambling, Addiction Medicine, Lausanne University Hospitals (CHUV), Lausanne, Switzerland

Sydney B. Clark     Department of Psychological Sciences, Kent State University, Kent, OH, United States

Beáta Bőthe     Department of Psychology, Université de Montréal, Montréal, QC, Canada

Matthias Brand

Department of General Psychology: Cognition and Center for Behavioral Addiction Research (CeBAR), University of Duisburg-Essen, Duisburg

Erwin L. Hahn Institute for Magnetic Resonance Imaging, Essen, Germany

Valentina Caricasole     University of Milan, Department of Mental Health, Department of Biomedical and Clinical Sciences Luigi Sacco, Milan, Italy

Lior Carmi     Post Trauma Center, Chaim Sheba Medical Center, Ramat Gan, Israel

Samuel R. Chamberlain

Department of Psychiatry, Faculty of Medicine, University of Southampton

Southern Health NHS Foundation Trust, Southampton, United Kingdom

Samantha L. Connolly

Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System

Department of Psychiatry, Harvard Medical School, Boston, MA, United States

Allison Crawford     Virtual Mental Health, Centre for Addiction and Mental Health Associate Professor, University of Toronto, Toronto, ON, Canada

Vasa Curcin

Department of Informatics

School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom

Giselle Day

Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center

VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States

Philippe Delespaul

Department of Psychiatry and Neuropsychology, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht

Mondriaan Mental Health Trust, Department of Adult Psychiatry, Heerlen, The Netherlands

Paul H. Delfabbro     School of Psychology, The University of Adelaide, Adelaide, Australia

Anthony H. Ecker

Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center

Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine

VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States

Fernando Fernández-Aranda

Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona

Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid

Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain

Luwishennadige M.N. Fernando     Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia

Naomi A. Fineberg

School of Life and Medical Sciences, University of Hertfordshire, Hatfield

Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City; University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom

Christopher A. Flessner     Department of Psychological Sciences, Kent State University, Kent, OH, United States

Oleksandr Frei

NORMENT Centre, Institute of Clinical Medicine, University of Oslo and Division of Mental Health and Addiction

Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway

Johannes Fuss     Institute of Forensic Psychiatry and Sex Research, University Duisburg-Essen, Essen, Germany

Isaac R. Galatzer-Levy

Reality Labs, Facebook

Psychiatry, New York University School of Medicine, New York, NY, United States

Theresa R. Gladstone     Department of Psychological Sciences, Kent State University, Kent, OH, United States

Gabrielle F. Gloston

Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center

Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States

Pattie P. Gonsalves

Sangath, Saket, New Delhi

Sangath, Bardez, Goa, India

School of Psychology, University of Sussex, Brighton, United Kingdom

Jon E. Grant     Department of Psychiatry, University of Chicago, Chicago, IL, United States

Anna Hartford     Brain-Behaviour Unit, Neuroscience Institute, University of Cape Town, Cape Town, South Africa

Donald Hilty     Department of Psychiatry & Behavioral Sciences, Mather, CA, United States

Guy Hindley

NORMENT Centre, Institute of Clinical Medicine, University of Oslo and Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway

Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom

Julianna B. Hogan

Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center

Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine

VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States

Kevin Ing     University of California Irvine School of Medicine, Department of Psychiatry & Human Behavior, Orange, CA, United States

Thomas R. Insel     Humanest Care, Pleasanton, CA, United States

Konstantinos Ioannidis     Department of Psychiatry, University of Cambridge, and Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, United Kingdom

Madeleine L. Jarrett

Child, Youth and Emerging Adult Program, Cundill Centre for Child and Youth Depression, Centre for Addiction and Mental Health

Human Biology Program, Faculty of Arts and Science, University of Toronto, Toronto, ON, Canada

Susana Jiménez-Murcia

Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona

Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid

Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain

Anthony Jorm     Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia

Daniel L. King     College of Education, Psychology, & Social Work, Flinders University, Adelaide, Australia

Taishiro Kishimoto     Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan

Ashley A. Lahoud     Department of Psychological Sciences, Kent State University, Kent, OH, United States

Jan A. Lindsay

Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center

Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine

VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States

Christine Lochner     SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa

John Luo     University of California at Irvine School of Medicine, Director of Emergency and Consultation-Liaison Psychiatry, UCI Medical Center, Health Sciences Clinical Department of Psychiatry & Human Behavior, Orange, CA, United States

Gemma Mestre-Bach     Universidad Internacional de La Rioja, Logroño, La Rioja, Spain

Kai Mueller     Outpatient Clinic for Behavioral Addictions, Department of Psychosomatic Medicine and Psychotherapy at the University Medical Center, Mainz, Germany

John A. Naslund     Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States

Jim van Os

Department of Psychiatry and Neuropsychology, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht

Department of Psychiatry, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands

Department of Psychosis Studies, Institute of Psychiatry, King's College London, King's Health Partners, London, United Kingdom

Beth Patterson

MacAnxiety Research Centre

Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada

Marc N. Potenza

Department of Psychiatry

Department of Neuroscience

Yale Child Study Center, Yale University School of Medicine

Connecticut Mental Health Center, New Haven

Connecticut Council on Problem Gambling, Wethersfield

Wu Tsai Institute, Yale University, New Haven, CT, United States

Nicola Reavley     Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia

Katharina Schultebraucks     Emergency Medicine, Columbia University, New York, NY, United States

Jay H. Shore

Department of Psychiatry and Family Medicine, University of Colorado Anschutz Medical Campus

Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Anschutz Medical Campus, University of Colorado, Aurora, CO, United States

Saher Siddiqui     Harvard College, Harvard University, Cambridge, MA, United States

Philip Slabbert     Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Stellenbosch, South Africa

Olav B. Smeland     NORMENT Centre, Institute of Clinical Medicine, University of Oslo and Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway

Dan J. Stein     SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry & Neuroscience Institute, University of Cape Town, Cape Town, South Africa

John Strauss

Child, Youth and Emerging Adult Program, Cundill Centre for Child and Youth Depression

Shannon Centennial Informatics Lab, Centre for Addiction and Mental Health

Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada

John Torous     Department of Psychiatry and Director, Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States

Miguel A. Vadillo

Department of Psychology, Autonomous University of Madrid, Madrid, Spain

School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom

Alberto Varinelli     University of Milan, Department of Mental Health, Department of Biomedical and Clinical Sciences Luigi Sacco, Milan, Italy

Simone Verhagen

Department of Psychiatry and Neuropsychology, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht

Department of Lifespan Psychology, Faculty of Psychology, Open University, Heerlen, The Netherlands

Matteo Vismara     University of Milan, Department of Mental Health, Department of Biomedical and Clinical Sciences Luigi Sacco, Milan, Italy

Elisa Wegmann     Department of General Psychology: Cognition and Center for Behavioral Addiction Research (CeBAR), University of Duisburg-Essen, Duisburg, Germany

Akkapon Wongkoblap

Department of Informatics, King’s College London, London, United Kingdom

School of Information Technology

DIGITECH, Suranaree University of Technology, Nakhon Ratchasima, Thailand

Jasmine Zhang

MacAnxiety Research Centre

Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada

Preface

Thomas R. Insel, Humanest Care, Pleasanton, CA, United States

Digital mental health is exploding as a discipline for innovation, research, and investment. It is no longer possible to track all of the new companies innovating in mental health, but at least 1000 start-ups have been launched in the past decade, with $1.8B (USD) invested in 2020 alone, nearly a threefold increase over 2019 (https://rockhealth.com/reports/2020-market-insights-report-chasing-a-new-equilibrium/; https://medium.com/what-if-ventures/approaching-1-000-mental-health-startups-in-2020-d344c822f757). By early 2021, PubMed listed over 2500 references for digital mental health, a term that was scarcely reported in the literature a decade ago (https://pubmed.ncbi.nlm.nih.gov/). And for the first time there are venture funds and investment vehicles organized specifically to support innovation in this space (https://www.whatif.vc/).

Why all of this interest in digital mental health? There was no technological breakthrough, like CRISPR, that can explain this new fascination. There was no particular discovery or research finding of effectiveness that would shift mental health to this new discipline. Although during the Covid-19 pandemic the focus of the field was on remote care with a rapid transition to telehealth, there was no clear global change in the prevalence or incidence of mental illness, as there was for the virus, which appeared to be a driver of this intense interest.

One explanation for the explosion of digital mental health is more prosaic. In spite of the progress in neuroscience and genomics, the emergence of new interventions, and the increasing awareness of the importance of mental health for overall health, the field has largely stalled in terms of outcomes. Measures of morbidity and mortality for the major mental illnesses have changed little over the past 4 decades, even while outcomes for many chronic noncommunicable diseases are improving globally. As a result, mental health has become a crisis in many parts of the world.

Our failure to bend the curve for mental health outcomes is not due to lack of means or lack of knowledge. Psychiatry and psychology have developed powerful treatments that compare favorably to treatments in the rest of medicine. Rather the crisis in mental health is a crisis of care. We simply have failed to deliver the medical and psychological treatments that we know are effective. Or we deliver them so late in the course of illness or with so little fidelity that they are no longer effective.

To solve this crisis of care we need to address three critical gaps: engagement, quality, and accountability. That’s where digital mental health comes in. The nearly ubiquitous tools of modernity—smartphones, sensors, and data science—may be able to bend the curve for mental health by solving for the gaps in engagement, quality, and accountability. This volume describes much of the empirical data to support this potential. These are early days in this new world for mental health, a world that includes unavoidable ethical and practical challenges. But given the imperative for better outcomes, we must navigate through these challenges to find a way to better outcomes. That path leads through engagement, quality, and accountability.

Engagement is more than access. Access is ensuring that anyone can find care when they want it. Access may be enough to improve outcomes in many areas of medicine, but in mental health, many of the people who most need care do not want it or, at least, do not want the care we offer in traditional brick and mortar clinics, emergency rooms, and hospitals. Engagement raises the bar. Engagement builds care that people want because it gives them agency, it is built to serve them not the provider, and involves them continuously not just during a crisis. As described in this volume, digital mental health can learn from the social media revolution which has created products that are so engaging we now worry they are addictive. Digital mental health offers a strategy through community, gamification, and in-the-moment access for building care that is engaging and effective.

For those who access care, quality has been a barrier to recovery. In most of the world, mental health care is fragmented, reactive, and crisis-oriented. Medications and psychological treatments are rarely integrated. Also few providers are trained to provide evidence-based psychological treatments with fidelity. Chapters in this volume describe how digital tools can integrate and democratize care, ensuring that the same high-quality treatment can be delivered remotely in Boston and Botswana. While most of the attention has been focused on remote, transparent therapy, the use of remote tools for training is equally important for building quality.

Finally, accountability has been lacking in mental health care. There has been little focus on outcomes because there is little measurement of outcomes. To borrow a business axiom, we do not manage what we do not measure. Digital mental health via wearable sensors and smartphone data can provide passive, continuous, objective measures of how we think, feel, and behave. Just as HbA1c provides feedback in diabetes and blood pressure helps us manage hypertension, digital phenotyping may give us the accountability essential to improve outcomes for people with mental illness.

The critical question for our field is how we improve outcomes. Beyond reducing acute symptoms, how do we ensure that people with anxiety, mood, or psychotic disorders recover to enjoy a full life? How do we prevent suicide and unnecessary suffering? How do we solve the equity gap and the social determinants that have kept us from reducing morbidity and mortality? Digital mental health may not be able to answer all of these questions, but if we can use these new tools to improve engagement, quality, and accountability, we will be making a good and much needed start in the right direction. This volume provides an important introduction to help readers navigate this new world.

1: Introduction

Dan J. Steina; Christine Lochnerb; Samuel R. Chamberlainc; Naomi A. Finebergd    a SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry & Neuroscience Institute, University of Cape Town, Cape Town, South Africa

b SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa

c Department of Psychiatry, Faculty of Medicine, University of Southampton, Southampton, United Kingdom

d School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom

Computer studies were introduced into high schools in some parts of the world in the 1970s, and one of us—Dan—was fortunate to be one of the first in line to enroll. It is extraordinary to think that students worked on a massive mainframe computer, writing each line of code using a card-punching machine, and waiting hours for their programs to run. No one had a personal computer, and no mental health clinician was using a computer at work or at home. While that seems forever ago, it is as well to bear in mind that in many parts of the world, many people still do not have ready access to computers.

By the time Dan completed his psychiatric training in the early 1990s, the personal computer was on many desks, and this was starting to impact many aspects of work life (for example, one could conduct electronic searches on a compact disk), and home life (for example, one could use the computer for word processing). Excited by these developments Dan edited a special issue of a continuing medical education journal devoted to Computers and Psychiatry. It had nothing on the Internet or phone apps, on gaming disorder or cyberchondria, or on computer-delivered psychotherapy.

In high-income countries today, devices with enormous computing power are ubiquitous, constantly relied on at work and at home. They have hugely enriched many aspects of our lives, providing wonderful ways of communicating, and incredible sources of information. For mental health professionals there are many opportunities; the Internet and phone apps provide many sources of information, a way of communication, and new avenues for monitoring mental health and delivering psychotherapy. However, there is an increasing digital divide; in poorly resourced settings where access to online data is less available, or among older age groups unaccustomed to using online technologies, these forms of psychoeducation and psychotherapy are not readily accessible.

At the same time, mental health clinicians are aware that the digital world has had many negative impacts. Email and social media often seem to steal individuals’ attention and time, the Internet gives our patients a great deal of false information about medical matters related to their health, and it provides an avenue for many destructive behaviors such as cyberbullying. The accessibility of online platforms has led to a range of putative new disorders, ranging from online gambling and gaming disorder to cyberchondria and cyberhoarding. Appropriately, there is growing attention to the notion of problematic Internet use, and negative aspects of the digital life comprise a growing public health problem.

It seems timely therefore to review global mental health from a digital perspective. e-Health, or the use of information and communications technology in health services may be particularly useful given the high penetration of mobile phones in the low- and middle-income world. m-Health refers to the use of mobile phones, wearable devices, and related technologies and is a rapidly advancing area. There is an opportunity for clinicians and researchers to consider the intersections between global mental health, e-health, m-health, and problematic Internet use, and to assess their implications for contemporary psychiatric practice and research.

The volume is divided into four sections, each addressing a key aspect of the intersections between global mental health, e-health, m-health, and problematic Internet use. In his introductory preface, Thomas Insel—who on leaving his position as the director of the National Institute of Mental Health, devoted the next phase of his career to digital psychiatry—argues that this field may help bend the curve for mental health by addressing current gaps in engagement of patients, in quality of mental health care, and in accountability of clinicians. In the remainder of this introductory chapter we outline the framework and contents of the volume, and reflect on some of the key issues it raises for global mental health and psychiatry.

Data collection and analysis

Digital technologies have transformed the way in which we collect and analyze data, including medical and psychiatric data. The section has chapters on various aspects of current work on mental health data collection and analysis.

Clinical informatics is a rapidly expanding field. In his chapter on Electronic medical records and information technology to improve mental health services Donald Hilty provides an overview of contemporary work in clinical informatics. The chapter covers developments in information systems, electronic health records, electronic communications with patients and staff, behavioral health indicators, and related digital advances to improve practice and research. By understanding how systems are designed and tailored to collect data, clinicians can use technology to inform decisions and facilitate outcomes. Hilty proposes that expert application of information technology allows health care to be both efficient and patient-centered.

The concept of Big data is increasingly important in psychiatry research, with large datasets now available in a range of areas including neurogenetics and neuroimaging. In their chapter on Big data and the goal of personalized health interventions, Guy Hindley, Olav Smeland, Oleksandr Frei, and Ole Andreassen review the key concepts relevant to work on big data, describe how big data are collected and analyzed, and provide examples of the application of big data to mental health research. The authors emphasize some of the key challenges faced in using big data to develop a more personalized medicine that improves outcomes, and they consider how these challenges may be addressed in future work. Notably, they emphasize the importance of ensuring that mental health data are obtained from around the globe.

The development of the Internet has led to a range of online research on various aspects of mental health. In their chapter on Collecting data from Internet (and other platforms) users for mental health research, Ashley Lahoud, Theresa Gladstone, Sydney Clark, and Christopher Flessner consider the potential advantages and pitfalls of such online research. They provide a brief historical overview of the Internet’s use within the context of mental health research, discuss the validity of using the Internet for such investigations, and outline both benefits and costs of such work. They conclude their chapter by describing different tools for conducting research online, as well as where to access research participants on the Internet.

In their chapter on Ecological momentary assessment and other digital technologies for capturing daily life in mental health, Simone Verhagen, Jim van Os, and Philippe Delespaul emphasize that to advance mental health care, we need innovative strategies that are person-centered, contextually embedded, and able to capture symptom occurrence and nonoccurrence in daily life. They assert that traditional static measures are unable to capture the dynamic variation that is needed to fully understand both vulnerability and resilience. Instead, they argue that m-health digital technologies, such as ecological momentary assessment strategies and passive sensor tracking, provide attractive solutions that may ultimately contribute to more personalized psychiatric approaches.

While digital phenotyping is typically thought of in relation to individual patients, social media analyses provide another level of data that may shed light on a range of phenomena relevant to mental health research and practice. In their chapter on Social media big data analysis for mental health research Akkapon Wongkoblap, Miguel Vadillo, and Vasa Curcin review current work in this area. The chapter discusses the potential value of data from a range of different platforms, and also describes a range of approaches to analyzing the big data that are derived from such platforms. The chapter concludes with a framework for the use of social media platforms in health interventions; this brings together different stakeholders, namely, users, social media platforms, research communities, health organizations, and governments.

Communication, psychoeducation, and screening

Digital technologies have transformed the way in which we communicate and seek information, and have the potential to transform the ways in which we screen for mental disorders. The second section of the volume addresses issues around using digital technologies to enhance communication, psychoeducation, and mental disorder screening.

Telepsychiatry is increasingly employed, and in the aftermath of the Covid-19 pandemic has become standard practice in many regions. In their chapter on Telemental health via videoconferencing, Samantha Connolly, Julianna Hogan, Anthony Ecker, Gabrielle Gloston, Giselle Day, Jay Shore, and Jan Lindsay provide an overview of telemental health, including factors related to effectiveness, safety, and uptake on a global scale. They argue that telemental health can be an effective form of care delivery with high acceptability among patients and providers alike. Telepsychiatry can significantly increase access to care around the world, provided that key factors are in place to ensure successful and sustained uptake.

Social media are not only increasingly central in our social lives, but also increasingly relevant to clinical practice. In their chapter on Social media and clinical practice John Luo and Kevin Ing help clinicians to navigate the waters of social media. The chapter provides useful practical advice about mental health practice in the digital world. As the authors emphasize, understanding the use of social media in medical practice, including both its benefits and risks, is key for improving access to clinicians, education about mental health, and delivery of psychiatric services, while minimizing the risk of boundary violations and privacy breaches.

In a very short space of time, the Internet has become the main source of information for many clinicians and patients. In their chapter on Websites and the quality of mental health information, Nicola Reavley, Luwishennadige Madhawee Fernando, and Anthony Jorm provide evidence from a systematic review that despite the increasing number of websites and social media devoted to mental health, there is overall low quality of online information, with the possible exception of information for mood disorders. They argue that ongoing evaluations of website quality are needed to ensure that individuals with mental disorders are provided with accurate and usable information.

The penetration of mobile cellular phones across the globe has already changed many aspects of daily life (including payment for goods and services), and promises to also change aspects of clinical practice. In their chapter on Identification, prediction, and intervention via remote digital technology: Digital phenotyping and deployment of clinical interventions in psychiatry, Lior Carmi, Anzar Abbas, Katharina Schultebraucks, and Isaac Galatzer-Levy review the use of mobile phones and other digital devices for screening and assessment of mental disorders. They argue that harnessing smart devices for clinical use holds immense promise for characterizing clinical functioning and intervening remotely. At the same time, they note that much work is needed to understand clinical risk based on digital signals and to develop coordinated systems to deploy useful interventions.

A small but important literature has emerged on the digital therapeutic alliance. In their thoughtful chapter The digital therapeutic relationship: Retaining humanity in the digital age, Jason Bantjes and Philip Slabbert note the concern that use of technology for mental health delivery has the potential to dehumanize care and to deny the need for human connectedness. The authors go on to suggest that by using a human factor approach to design person-centered e-interventions, humanity and connectedness can be retained. They also explore how e-interventions can be conceptualized within relationship-centered paradigms, considering, for example, the application of attachment theory to guide research and practice in the development of humanistic e-interventions.

Problematic Internet use

While digital technologies hold a great deal of promise for advancing many areas of physical and mental health, there are important public health concerns about the Internet, ranging from the broad construct of problematic Internet use to specific conditions that are related to digital technologies. This section of the volume includes chapters on a range of such conditions including Internet gambling and gaming, which are now recognized by the World Health Organization as the ICD-11 diagnoses of gambling disorder and gaming disorder, respectively, and cybersex and cyberchondria. It also addresses developmental aspects of problematic Internet use.

Problematic Internet use is an umbrella term that refers to excessive engagement in and lack of control over online activities, associated with distress or impairment. The term encompasses a wide range of excessive online activities, including online buying, online gambling, online gaming, cybersex, online pornography, online streaming, use of social media, cyberchondria and cyberbulling. In their chapter, Jon Grant, Konstantinos Ioannidis, and Samuel Chamberlain focus on online addictive and impulsive conditions, particularly gambling disorder, gaming disorder, and cybershopping. The prevalence and burden of these conditions is increasingly recognized, and there is a pressing need for appropriate diagnosis and treatment.

There has been growing interest in the phenomenological and psychobiological overlaps and contrasts between impulsive and compulsive psychiatric conditions. In their chapter, Matteo Vismara, Valentina Caricasole, Alberto Varinelli, and Naomi Fineberg go on to address online compulsive disorders including cyberchondria and cyberhoarding. The prevalence of and burden associated with obsessive-compulsive and related disorders has only been recently recognized, but there have been important advances in understanding their neurobiology and treatment; these lessons may be useful in addressing online compulsive conditions.

What is the best way of conceptualizing the spectrum of problematic Internet use, ranging from impulsive to compulsive conditions? In their chapter on Internet-use disorders: A theoretical framework for their conceptualization and diagnosis, Elisa Wegmann, Joël Billieux, and Matthias Brand address this question. They also discuss the related questions of how best to differentiate between normal, problematic, and disordered use of digital technologies, and how to conceptualize the heterogeneity of different kinds of problematic Internet use. Such work is able to draw on a range of relevant research on offline impulsive and compulsive conditions, and online conditions may in turn also provide unique and important windows onto the relevant questions.

Online sexual activity has likely been a key driver of Internet traffic as well as of advances in Internet technology. While the boundaries between normal and pathological cybersex are invariably controversial, it has been suggested that there are both compulsive and impulsive forms of excessive cybersex, ranging from online consumption of erotic and pornographic material, to sexual interaction and simulation. In their chapter on Cybersex, Johannes Fuss and Beáta Bőthe cover a broad range of sexual activities using digital technologies, ranging from Internet pornography to sex robots, emphasizing how such technologies have brought about significant changes to how humans experience and express their sexuality.

A developmental perspective is key for understanding the nature and course of psychopathology. In addition, early exposure to digital technologies is increasingly ubiquitous, and may in turn influence a range of developmental processes. In their chapter on Developmental considerations regarding Internet use, Gemma Mestre-Bach, Fernando Fernández-Aranda, Susana Jiménez-Murcia, and Marc Potenza address not only the positive aspects of social networking, but also key negative aspects such as cyberbullying. The developmental perspective of this chapter usefully complements the content of other chapters in this section.

Interventions

The fourth section of the volume addresses Internet and digital interventions for clinical problems. Such interventions range from online psychotherapy to mobile phone apps and virtual reality adjuncts to psychotherapy. The section includes work not only on online interventions for problematic use of the Internet, but also on health policies to mitigate problematic use of the Internet.

In his chapter on Internet-based psychotherapies, Gerhard Andersson emphasizes that the evidence base for Internet-based psychotherapies and other technology-based interventions is increasing rapidly. The chapter provides a comprehensive overview of the field, discussing how Internet treatments can be delivered, as well as different treatment formats, target groups, and clinical implementations. He points out that while some guided Internet-based psychotherapies tend to work as well as face-to-face treatments, they are not yet widely implemented, and he outlines future directions for much-needed research on efficacy and implementation.

Smart phones provide a key opportunity for advancing the field of digital mental health. In their chapter on phone apps, John Strauss, Jasmine Zhang, Madeleine Jarretta, Beth Patterson, and Michael van Ameringen provide a comprehensive review of publications in this area. They provide a framework to evaluate mental health apps, and consider the extent to which evidence-based recommendations about such apps are possible. We expect ongoing innovation and implementation in this area; the field seems in its infancy, and deserves careful nurturance.

To address the growing prevalence and burden of digital technology-based mental health problems, a range of clinical and public health interventions are urgently needed. In their chapter on interventions, Daniel L. King, Joël Billieux, Kai Mueller, and Paul Delfabbrod provide a comprehensive review of this key area of work. The authors not only review online psychotherapies for such conditions, but also emphasize that an optimal approach to digital technology-based mental health problems may entail coordinated efforts of stakeholders ranging across families and peers, schools, health providers, government bodies, and the industries that provide online content. Global mental health practitioners and researchers can expect that one of the key public health battles of this century will be between public health advocates and digital industries; this area deserves a great deal of focused attention.

Digital technologies may be a crucial tool for scaling up mental health services around the world. In their chapter on Scaling-up of mental health services in the digital age: The rise of technology and its application to low- and middle-income countries, Saher Siddiqui, Pattie Pramila Gonsalves, and John Naslund explore five major areas benefitting from these emerging digital technologies: community outreach, challenging stigma, and spreading awareness; youth mental health; mental health in humanitarian settings; clinical care and frontline health workers; and technology for severe mental disorders. Their chapter includes a discussion of broad ethical considerations in low- and middle-income countries, highlighting risks pertaining to misinformation, victimization, and widening health inequities.

In their chapter on The addictive qualities of the Internet: Some ethical considerations, Anna Hartford and Dan Stein expand on the ethical ramifications of advances in digital technologies. They focus in particular on debates regarding persuasive digital technologies—those which aim to maximize use, or even to encourage compulsive engagement—as well as the difficulty in articulating the harms involved in excessive Internet use. The chapter also addresses practical ethical implications, including regulation of design features, concerns about growing socioeconomic inequality in online services, and whether there should be a right to disconnect. Hopefully these issues will receive further attention in the future.

Conclusion

A key theme of this volume is the need to balance the immense potential of digital technologies for advancing global mental health versus the psychiatric burden of problematic Internet use. Addressing the pros and cons of technology has been a key feature of modernity, and the need for a balanced approach in health care in particular, encompassing both scientific rigor and a humane focus, has been an increasingly pressing need as health care itself has become more technological over the past century.

Digital technologies, with their incredibly rapid rate of change, and their overwhelming intrusion into all aspects of life, make this key dilemma of modernity a particularly acute one, and one which is highly relevant to global mental health. We hope that this volume, by covering a range of pertinent areas, ranging from the value of electronic medical records for mental health services, to the human right to disconnect, provides a useful resource for global mental health practitioners, researchers, wider stakeholders, and the public, as they grapple with this dilemma.

We are grateful that so many leading clinicians and researchers from around the world have contributed to this volume, endeavoring to provide comprehensive and balanced overviews of their particular areas of work, and outlining future clinical and research directions. Our hope is that the volume will be useful to a broad audience including both clinicians and consumers, as well as academics and policy makers. While we are aware of how quickly the landscape of digital mental health is changing, we are also impressed by the need for immediate and ongoing attention to this area, in order to ensure that our approaches are balanced and rigorous, and that they contribute positively to global mental health. Finally, we wish to acknowledge that some chapters in this publication are based on work from COST Action 16207 European Network for Problematic Usage of the Internet supported by COST (European Cooperation in Science and Technology) www.cost.eu.

Section A

Digital Data Collection and Analysis

2: Information technology and electronic health record to improve behavioral health services

Donald Hiltya; John A. Naslundb; Shalini Ahujac; John Torousd; Taishiro Kishimotoe; Allison Crawfordf    a Department of Psychiatry & Behavioral Sciences, Mather, CA, United States

b Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States

c Centre for Implementation Science, Health Services and Population Research Department Institute of Psychiatry, Psychology and Neurosciences King’s College London, London, United Kingdom

d Department of Psychiatry and Director, Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States

e Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan

f Virtual Mental Health, Centre for Addiction and Mental Health Associate Professor, University of Toronto, Toronto, ON, Canada

Abstract

We continue to increase our exchange of information through health technologies, used to access, disseminate, and analyze information. Clinical informatics is a rapidly expanding area and facilitates patient-centered care as defined by quality, affordability, and timely health care. This chapter covers developments in information systems, electronic health records, electronic communications with patients and staff (e.g., alerts, texts), behavioral health indicators and related digital advances to improve practice and research. The reader can learn how to set goals toward quality outcomes and be efficient while remaining patient-centered using technology, and adapt to technological components and processes used by systems. By grasping how systems are designed and tailored to collect data, clinicians can use technology to inform decisions and facilitate outcomes. Setting priorities involves input from all care participants, as well as technological competencies for the clinician and institutional/organizational. Patient, clinician, and institutional competencies for skills, attitudes, and behaviors can align clinical care, training, and research missions and stimulate quality improvement.

Keywords

Mobile technologies (android, app, asynchronous, device, e-, e-behavioral, e-consult, e-mental, health, mhealth, mhealth, mobile, phone, sensors, smartphone, social media, tablet, text, wearables); Informatics (artificial intelligence, Clinical Decision-Support, Clinical Decision-Support System, Electronic Health Record, Information Systems, information Technology, kiosk, machine learning, patient portal); Synchronous telepsychiatry, telebehavioral or telemental health (Internet, online, store-and-forward, video, web-based); Behavioral health, psychiatry, and psychology (behavioral, clinician, care, diagnosis, health, medicine, mental, patient, services, psychiatry, psychology, treatment); Therapeutic relationship (alliance, boundaries, communication, engagement, empathy, intimacy, satisfaction, therapy, trust); Competency (behavior, cognition, curricular, didactic, education, learner, methods, pedagogy, skill, teaching, training)

Acknowledgments

The authors acknowledge support by American Telemedicine Association and the Telemental Health Interest Group; Department of Psychiatry and Behavioral Sciences, University of California, Davis School of Medicine; European Psychiatric Association; Veteran Affairs Northern California Health Care System and Mental Health Service; and World Health Organization and Psychiatric Association.

Conflicts of interest

None.

Introduction

We continue to increase our exchange of information through health technologies, particularly clinical informatics, used to access, disseminate, and analyze information, and to facilitate patient-centered care (PCC), defined as high-quality, affordable, and timely health care by the Institute of Medicine (IOM) (Hilty, Torous, Parish, et al., 2020; Institute of Medicine, 2001). Health-care systems and governmental agencies across the world are emphasizing quality, evidence-based care, and are trying to set individual and population outcomes that can be evaluated by behavioral health (BH) data/indicators (Proctor, Silmere, Raghavan, et al., 2010). This requires services that are acceptable to patients, with measurable outcomes, and scalable approaches. For feasible and sustainable services, and effectiveness, implementation science and translational approaches are suggested, with input from all stakeholders in health-care settings (Gargon, Gorst, & Williamson, 2019; World Health Organization, 2017a). Technology is a key part of the World Health Organization (WHO) global health strategy, with the expectation of scalable BH interventions, particularly for people in communities affected by adversity (Crawford & Serhal, 2020; World Health Organization, 2020). In our immediate context, care is needed during the COVID pandemic, so that the innovation curve does not reinforce the social gradient of health and worsen health-care inequities (Luo, Hilty, Worley, et al., 2006).

The Health Information Technology for Economic and Clinical Health (HITECH) Act brought a wave of electronic health records (EHRs), and with this, meaningful use of criteria standards in the United States. The EHR or computer-based patient record (CPR) is credited with improving clinical practice through ease of access and retrieval of information (e.g., clinical guidelines), decision support systems with reminders and alerts and data collection for outcome measurement. CPR notes are more completely documented and have more appropriate clinical decisions compared to handwritten notes (Shanafelt, Dyrbye, West, et al., 2016). Evolution in health care has brought improvements, but it has also created inefficiencies and new challenges, with EHRs linked to high rates of burnout among health professionals (Hilty, Unutzer, Ko, et al., 2019). This may be happening because the impact of technology and related change have not been fully assessed, at least in behavioral health (BH)/psychiatry (Luxton, 2016; Shanafelt et al., 2016).

System management [e.g., health information systems (IS), telemedicine, Information technology (IT)], facilities and clinics (e.g., labs, home health) and delivery structures (e.g., integrated networks) play a key role in health care. IT falls into the categories of clinical information systems, administrative information, and clinical decision support (CDS). CDS is supported by advances in artificial intelligence (AI) to assist patients and clinicians with decision-making in time and across home, in life, in health care and across populations (The National Academy of Sciences, Engineering, and Medicine. Health and Medicine Division, 2020) (Fig. 2.1). Advances in sensing technologies and affective computing have enabled machines to longitudinally analyze data for patterns in time and help users detect, assess, and respond to emotional states. The use of machine learning (ML) and pattern recognition promises to improve public and population health surveillance.

Fig. 2.1

Fig. 2.1 Person-centered health, lifestyle, clinical care, and population health integration via technology.

Many assume that good clinicians will adapt in-person care to video, telephone, mobile health, and other technologies, and intermix these options with ease in combination (Hilty, Torous, et al., 2020). But clinician or learner-centered approaches that parallel patient-centered ones are needed to ensure quality care so technologies can complement EHR, CDS, and IS processes. Furthermore, organizational/institutional competencies have been suggested for synchronous and asynchronous technology implementation (Hilty, Torous, et al., 2020; Luxton, 2016), as a way to align work by training directors, faculty, department administrators, and health system leaders. Clinicians/faculty need to embrace technology as part of health-care reform (Mostaghimi, Olszewski, Bell, et al., 2017; World Health Organization, 2020), so students in health disciplines and other team members can professionally deliver care via technology (Crawford, Sunderji, López, et al., 2016; Hilty, Crawford, Teshima, et al., 2015) and create a positive e-culture for clinics and health systems (Hilty, Torous, et al., 2020). Competencies have been published for video (2015, 2018) (Hilty, Chan, Torous, et al., 2019b; Hilty, Maheu, Drude, et al., 2018), social media (2018) (Hilty, Chan, Torous, et al., 2019a; Hilty, Zalpuri, Stubbe, et al., 2018), mobile health (2019, 2020) (Hilty, Armstrong, Luxton, et al., 2020; Zalpuri, Liu, Stubbe, et al., 2018), wearable sensors (2020) (Aung, Matthews, & Choudhury, 2017), and other asynchronous technologies (2020) (Hilty, Torous, et al., 2020).

This chapter introduces topics primarily from Section A, as well as Sections 2–4 of the book. Section 1 focuses on issues around data collection and analysis, EHRs and information technologies, which improve services and research. It also provides an overview on big data and personalized health interventions, use of the Internet to collect data, and research on the Internet (e.g., social media), as well as new developments in ecological momentary assessment (EMA), digital phenotyping, and social media and tracking (MISST) (Chapters 2–6). Section B addresses issues around e-health to enhance communication, psychoeducation, and screening for mental disorders. It addresses telepsychiatry or telebehavioral health, new options for patient care via mobile health, the role of social media in practice and how to help patients use the Internet—developments that impact the digital therapeutic relationship (Chapters 7–9,11). Section C addresses problematic Internet use, with chapters on topics including Internet gambling and gaming, cybersex, cyberbullying, and cyberchondria, as well as developmental aspects of problematic Internet use (Chapters 12–16). Section 4 addresses Internet interventions, ranging from online psychotherapy to mobile phone apps and to virtual reality adjuncts to psychotherapy; online interventions for problematic use of the Internet, health policy to mitigate problematic use of the Internet and ethical considerations are also included (Chapters 18–21).

Specifically, this chapter will help the reader:

(1)learn how to set goals toward quality outcomes and be efficient and patient-centered using technology,

(2)adapt to technological components and processes used by clinicians and systems,

(3)consider how systems are designed and tailored to collect data, inform decisions, and evaluate outcomes, and

(4)set priorities in line with clinician, team, system, and institutional/organizational technological competencies for care.

Setting goals to achieve value and quality in practice and the role of technology

Innovation with technology is only as good as the evidence base that supports it, and the evidence-based approaches used by clinicians to provide care, as well as the process/quality improvement and evaluation of outcomes by a health-care system. Technology serves to efficiently collect data to show that quality care was provided, but to date, most of the technology deployed to assess quality has focused on process metrics (e.g., productivity, errors, cost) and many forces besides payment (e.g., population health, economic cost analyses, the linkage between health and other social progress) are propelling the shift to outcome metrics across the world.

Advances in the collection and analysis of big data hold promise to advance BH practice and research. Much of this work aims toward achieving personalized BH interventions, which started in high-income countries and are taking root around the globe (see Chapter 3) (Aung et al., 2017; Naslund, Aschbrenner, Araya, et al., 2017). At a minimum, the treatment of mental illness relies on subjective measurement for diagnosis, treatment/intervention and long-term monitoring. At a maximum, a variety of sensors and wearables offer new options for patient care, clinician decision-making, and population health—via mobile phones and other smart devices. This technology more precisely assesses and captures human behavior through continuous monitoring and can enable personalized digital interventions aligned with clinical outcomes. These options can reduce geographical cost and temporal barriers, with privacy and professionalism risks that are reasonable (Ahuja, Hanlon, Chisholm, et al., 2019; Torous & Roberts, 2017).

Health-care clinics and hospitals can help by identifying BH domains or targets to assess (Hilty, Torous, et al., 2020). Standard quality reporting metrics in the United States come from the Center for Medicare and Medicaid Services (CMS) and National Quality Forum (i.e., G-PRO), as well as the International Consortium for Health Outcomes Measurement (ICHOM), which outlines international standards of health outcome assessment in BH care (Obbarius, van Maasakkers, Baer, et al., 2017). The Mental Health Atlas of 2017 shows discrepancies in availability of data on BH, with almost a quarter of all countries in the African region reporting no regular collection of BH data in the last 2 years (World Health Organization, 2017b). To improve monitoring and transparency, in 2014 the Organization of Economic Corporation and Development recommended a list of BH indicators, including those measuring: readmissions; case management and mortality with severe mental disorders; anticholinergic and antidepressant drugs with elderly patients; continuity of care and timeliness of ambulatory follow-up after hospitalization; use of antidepressant medication and visits during the acute phase of treatment; and racial and ethnic disparities and BH follow up rates (Organisation of Economic Corporation and Development, 2014).

In low- and middle-income countries (LIMCs), the lack of BH data from primary care limits the scale-up of community mental health programmes (Ajuah, Shidhaye, Semrau, et al., 2018; Cohen, Eaton, Radtke, et al., 2011). This information gap is responded to by the formulation of contextualized BH indicators, for example, a minimum set of frequently endorsed indicators were codesigned using a Delphi study across five LMICs. These indicators measure mental health coverage and performance covering domains such as needs, utilization, quality, and financial risk protection (Ajuah et al., 2018). While evaluating the use of these new indicators in LMICs, interviewees perceived that new and simpler BH forms led to a better collection of data, monitoring, and documentation (Ajuah et al., 2018; Proctor et al., 2010). Iterative development with input helps with prioritization, customization, and coordination for health and governmental systems (Hilty, Torous, et al., 2020).

Important clinical and administrative outcomes include no-show rates, percentage of treatments completed over time, and proportion of first-time patients presenting for follow-up visits within recommended time frames. Stable, simple and standard measures can directly shape quality evaluation and clinical decision-making—with input by patients on selection and alignment with regulatory and payor metrics and can avoid complexity and burdening care participants. The forms and results should appear in clinician notes to inform decision-making—meaning EHR compatibility is key. The level of knowledge, competence, confidence, and motivation of health workers affects the likelihood of implementation and sustainability (Proctor et al., 2010).

Use of technology for clinical care requires a careful assessment of the type, its feasibility and its fit with a purpose/goal (e.g., need to learn, treatment plan). BH-related, technology-based services exist on a continuum (Table 2.1): Internet information—self-help/support groups and psychoeducation classes—self-assessment and care (e.g., depression)—informal online consultation with a clinician—formal online evaluation with a questionnaire, completion of an app-based mood questionnaire or asynchronous but structured clinical interview—to continuous monitoring fed to clinicians for decisions—video consultation or management—and combinations of the above technologies or with in-person services (i.e., hybrid care) (Hilty, Chan, Torous, et al., 2015; Hilty, Torous, et al., 2020).

Table 2.1