Digital Mental Health Reduces Barriers and is ‘Not Going Anywhere’

(Part 2 of 2)

Steven R Chan, MD, MBA, clinical assistant professor, Stanford University School of Medicine, California, and Gowri Aragam, MD, clinical instructor in psychiatry, Harvard Medical School, Boston, Massachusetts, discuss the barriers and challenges when implementing digital mental health (DMH) into clinical practice and whether telepsychiatry and telehealth will continue to be widely used. Dr Chan and Dr Aragam sat down at the recent 2021 Psych Congress to discuss the current and future landscape of DMH.

In the previous part 1, Dr Chan and Dr Aragam define DMH and explore how telepsychiatry fits into DMH such as increasing access, altering the patient-clinician relationship, and giving way for patient self-care.

Read the transcript:

Meagan Thistle, Psych Congress Network: Hello and welcome back PCN listeners. In the last episode of this 2 part podcast, Dr Steven Chan, clinical assistant professor at Stanford University School of Medicine in California, and Dr Gowri Aragam, clinical instructor of psychiatry at Harvard Medical School in Boston, sat down at the recent 2021 Psych Congress to discuss the current and future landscape of DMH.

They defined DMH and explored how telepsychiatry increases access, alters the patient-clinician relationship, and gives way for patient self-care.

In this concluding episode, listen as Dr Chan and Dr Aragam discuss the barriers and challenges surrounding implementing digital mental health into clinical practice and whether or not they think telepsychiatry and Telehealth will continue to be widely used within the changing landscape.

We hope you enjoy the podcast.

Dr Steven R Chan: The next question that we have has to do with barriers in using digital mental health. What are some challenges in implementing digital mental health into clinical practice? Oh my goodness, there's a whole can of worms here.

Dr Gowri Aragam:  Oh my God, where do we begin, Steve? We can go back and forth, shoot out words.

Dr Chan:  We can take every other word and every other syllable. I'll just say one thing. Support, support, support. Is there support for the clinician? Is there support for the patient? Is there support for ensuring that the hardware and the software all work?

That is the huge challenge when it comes to not just digital mental health but also digital health in general. Think about the pharmacy infrastructure that we have for prescribing your medicine.

You know that the pharmacy infrastructure is there to deliver the medicine or educate about the medicine. We also need to have some sort of infrastructure for these digital medicines as well.

Dr Aragam:  Absolutely. I was referring to this on the panel in the talk, which is that we have support for things like Epic and EHRs. Nowadays, if you don't know how to do something, you either Google it or call IT, and they'll help you walk through it with you.

There was training to be able to even get on board with this kind of thing. There's a lot more people who I knew would never have even thought of using an EMR 10 years ago are now so definitely able to do all kinds of different tasks on it and are wanting more.

Once you help establish mastery, you want to be able to add on to that. What was I going to say? The barriers. Support is a huge, huge one, a fundamental one.

It seems so simple, but it's so fundamental, because in that moment when you're with the patient, or you're in between patients, or you're in the morning and you want to know how to use something, you need to be able to know that you're going to be able to get that reminder and that support.

That's support in the moment, but also support on the larger scale. We talk about pharmacy. I remember when there was a company called GoodRx that came into play. I could just print out a coupon and give it to a patient who couldn't otherwise afford the medication.

That was huge, because there was this larger-scale policy-wide support, and there was support for payment and support for access. Things like that with digital tools as well is going to be important, because whether it's being able to provide access, and access including cost, access including, are we able to match the tool with the patient in need?

What's tough here is people don't always know what digital tool is going to work for what patient. In the same way that we had to learn pharmacological management of depression, you're to understand what medications are going to be useful for a certain patient. When, how, what dose?

There's a new similar learning process when it comes to digital tools, and there is a wide variety. Sometimes, what you use is based upon what is going to be reimbursed or who partners with your hospital or your health system. You're going based off of what's available.

To that end, that's why all these regulatory bodies and being able to not just regulate safety, but also ensure the effectiveness is going to be huge. Being able to empower actual companies building the tools to also have that incentive in mind and align that with the incentive of the care provider is difficult to do, but it's possible.

That's some of the work that I'm doing, which is talking about understanding why that is even important for the sustainability and scalability of what's being built in the long run. I don't know. I'm going off a little bit right now because I'm getting, again, excited about this topic. Does that make sense to you, or does that resonate, what I'm saying?

Dr Chan:  Absolutely. You were thinking about systems. There's a whole system. It's not just, "Here's an app. Go ahead and use it." We've seen that. That doesn't help with engagement. There's attrition, certainly, in people's use of apps. Even things like broadband, do they have a data plan? We've seen this in the mainstream media, how people...

Dr Aragam:  Digital divide.

Dr Chan:  Digital divide. People are hovering near WiFi hotspots in order to log on to school. This is not just a health issue, it's a whole society. If we want to have a lot of these digital tools available for other aspects of industry, we need to have 5G. We need to have broadband penetration throughout all communities, underserved, rural, urban.

We also need to make sure that the technologies work. There's already a divide between Android devices and iOS devices and a lot of the developments being driven for iOS versus Android. Is that an equity issue, too? I think it is.

Dr Aragam:  Absolutely. Health equity is a huge issue is consideration, because what we were talking about earlier is that these tools have the ability to push us forward, increase access, increase equity, and dismantle a lot of systemic injustice even.

They also have the very strong possibility, if we go with the status quo, to perpetuate all of those systemic injustices that the healthcare system currently experiences and partakes in. We definitely cannot tread lightly in the excitement around digital mental health tools. We can't just perpetuate.

We have to be especially mindful as to who we're serving if they're going to be served, who's building these products, who are involved in that building. It's an exciting time to be able to get that user feedback and get a diverse array of user feedback and input, which is not something that we've been accustomed to doing in the healthcare system. [laughs]

Dr Chan:  The next question that we have is about telepsychiatry and telehealth. Do you feel that telepsychiatry and telehealth will continue to be widely used, especially with the new digital mental health platforms?

Dr Aragam:  I can't imagine them not continuing to be widely used. There is this idea of people want flexibility in the same way people want the work-from-home flexibility after COVID, especially.

They're like, "Oh, we can be productive at home. We can also be productive in the office. Wouldn't it be nice to do something where there's an in between, where we get to spend some days at home, some days in the office?"

Having that optionality is huge and is in service of health equity as well, because you can't expect people to show up for their appointments every week, for example, if they don't have the infrastructure in their own life to make that happen.

Whereas now, I see patients, they can be taking care of their kids, they're helping make food, and they're living their life, but also engaged in the actual session. Harder for therapy in that particular way, but you know what I mean. It's nice to give people that option.

Especially, there are so many concerns around that worsening care somehow, but it's, at least in my experience, and in my colleagues' experience, augmented it.

These new digital mental health platforms are only going to make telepsychiatry that much better in the way that we were just discussing, in terms of all the ways you can augment that experience in and of itself, let alone build in tools for people to use in the interim. Short answer is it's not going anywhere.

Dr Chan:  You mentioned how it's valuable for patients, but I think of it also as valuable for clinicians and health systems. For groups and clinicians who want to have the flexibility of working from home or working from wherever they are, they open up a lot of possibilities if this is continued on as an option.

Health systems and certainly provider groups who have difficulty recruiting for their, say, geographic vicinity, maybe there's a high cost of living and there are not enough providers to go around, this is a great way to reach out and find folks who do want to work for you. It's advantageous all around.

Dr Aragam:  Hopefully, it expands more and more and more, would be the goal.

Dr Chan:  The last question that we have, as we move into the post-pandemic world, have you seen an increase in patients going back to in-person sessions, or are patients more receptive to remote sessions?

Dr Aragam:  My answer is a little bit biased in this case, because currently, I'm working at a VA in San Francisco, and so the catchment area is quite broad. I have patients who are like, "Oh, I'm not coming in. I live three hours away. I live 2 hours away."

Even patients who live close by down the street prefer to be seen virtually. Again, in my experience, I've had more people who say, "Hey, can I just stick with how we're doing things? This is actually working for me. It's fitting into my life better."

There are definitely patients I've heard, at least from colleagues, who I don't engage in as much therapy, but people I know who are in therapy, for example, there are certain people who do want to be in person again, in terms of preference.

I wouldn't say it's the majority of people by any means, which is also great, in terms of being able to, when there is demand for that virtual care, hopefully all of the accommodations that were made during COVID continue, in terms of reimbursement. That's getting ahead of myself.

To answer this question, I've only experienced people wanting to continue and then have the optionality, again, of coming in if they need to, for any particular reason.

Dr Chan:  That mirrors my experience, too. We have a lot of patients who are spread out across a wide geographic region. Having them be able to beat traffic in an instant by logging on is very, very helpful for them and staying connected as well.

I don't think that this option is going to go away, but some folks do like the in-person experience and they do like having in-person sessions. The challenge will then be, if you are holding a group session, then how do you make it an equal experience for folks who are in-person and online as well?

That's essentially a hybrid model. If you are still doing in-person, but then, say, the provider's out or you need to have a covering provider come in, do you have enough seats, rooms, telehealth equipment to have another clinician beam in, essentially?

Lots of things to consider, certainly. It's exciting. There are so many possibilities.

Dr Chan:  This was a very exciting conversation for me. We covered so many topics.

Dr. Aragam:  I know. There's too much to cover. We both get excited about it, and there's limited time, and we're in person again, so it's all very exciting. Thank you for having me and for having this discussion with me. I'm always happy to be here.

Dr. Chan:  Absolutely. If you want to learn more or want to reach out to us, you can reach me on Twitter @stevenchanmd, with an A-N-M-D, or you can also find my website, stevenchanmd.com.

Dr. Aragam:  For me, you can find me on Twitter as well @gowriaragam, first name and last name, or you can also find me on LinkedIn.

Dr Steven Chan (@StevenChanMD, www.stevenchanMD.com), is a Psych Congress steering committee member. He is a clinical informaticist and Medical Director for Digital Health, Addiction Consultation & Treatment at Palo Alto VA Health, and is a clinical assistant professor at Stanford University School of Medicine. Dr Chan is co-investigator on clinical research — on UC Davis asynchronous telepsychiatry and UCSF ADviCE Health, a digital health evaluation and outcomes platform.

Dr Gowri Aragam is a psychiatrist at Massachusettes General Hospital and co-founder of Stanford Brainstorm, the first academic laboratory for mental health innovation where she co-developed and directed a university-wide course of mental health product development. Dr Aragam has been a consultant for multiple tech companies, with her work featured in Wired and TechCrunch, and was a 2020 Fast Company Innovation by Design Finalist. Dr Aragam is currently a Scientific Advisor to BetterUp. Dr Aragam was a Chief Resident at Massachusetts General Hospital/McLean Hospital. She received her MD from the University of Massachusetts and AB in Neurobiology from Harvard.