Application of Smartphone Technology in the Management and Treatment of Mental Illnesses

Abstract: Background: Mental illness continues to be a significant Public Health problem and the innovative use of technology to improve the treatment of mental illnesses holds great public health relevance. Over the past decade telecommunications technology has been used to increase access to and improve the quality of mental health care. There is current evidence that the use of landline and cellular telephones, computer-assisted therapy, and videoconferencing can be effective in improving treatment outcomes. Smartphones, as the newest development in communications technology, offer a new opportunity to improve mental health care through their versatile nature to perform a variety of functions. Methods: A critical literature review was performed to examine the potential of smartphones to increase access to mental health care, reduce barriers to care, and improve patient treatment outcomes. The review was performed by searching several electronic databases using a combination of keywords related to smartphones and mental health interventions using mobile devices. Literature concerning the use of cell phones, handheld computers, and smartphones to improve access to mental health care and improve treatment outcomes was identified.Results: The majority of studies identified were feasibility and pilot studies on patients with a variety of diagnosed mental illnesses using cell phones and PDAs. Authors report that most study participants, with some exceptions, were capable of using a mobile device and found them acceptable to use. Few studies extensively measured treatment outcomes and instead reported preliminary results and presented case illustrations. Studies which used smartphones successfully used them collect data on patients and deliver multimedia interventions. Discussion: The current literature offers encouraging evidence for the use of smartphones to improve mental health care but also reflects the lack of research conducted using smartphones. Studies which examine care provider use of smartphones to improve care is encouraging but has limited generalizability to mental health care. The feasibility of patient use of smartphones is also encouraging, but questions remain about feasibility in some sub-populations, particularly schizophrenia patients. Pilot testing of mobile devices and applications can greatly increase the feasibility of using smartphones in mental health care. Patients who are unfamiliar with smartphones will likely need initial training and support in their use. Conclusion: The literature identified several ways in which smartphones can increase access to care, reduce barriers, and improve treatment outcomes. Study results were encouraging but scientifically weak. Future studies are needed replicating results of studies using cell phones and PDAs on smartphones. Larger and higher quality studies are needed to examine the feasibility, efficacy, and cost-effectiveness of smartphones to deliver multiple component interventions that improve access to mental health care and improve treatment outcomes

Detach: design tool for smartphone application composition

Tese de mestrado em Engenharia Informática, apresentada à Universidade de Lisboa, através da Faculdade de Ciências, 2013A Terapia Comportamental Cognitiva (TCC) é uma forma de tratamento que se foca nas relações entre pensamentos, emoções e comportamentos. A TCC pode assim mudar a forma como pensamos (cognição) e como reagimos (comportamento), de maneira a que nos possamos sentir melhor. Para ter sucesso, esta intervenção psicológica usa processos sistemáticos, que são normalmente compostos pelo preenchimento de formulários em papel, com um determinado objectivo específico. Este objectivo poderá ser o tratamento de várias condições: humor, ansiedade, personalidade, obesidade, fobias, depressões, controle de dor, etc. Actualmente, esta área da terapia é normalmente dividida em dois tipos de sessões distintas com os pacientes. Se por um lado existe a sessão no consultório com o terapeuta, por outro, é muitas vezes pedido ao paciente que complete algumas tarefas no exterior, sem a presença do mesmo. Estas tarefas pretendem que este pratique as diversas situações analisadas com o terapeuta. Para isso são usados questionários e formulários em papel que permitem que o paciente registe os seus pensamentos e experiências. No entanto, a incapacidade de adaptação dos mesmos ao paciente e às diversas situações em que são na verdade utilizados resulta na falta de motivação, paciência e sentimento de acompanhamento pessoal para o paciente. Além disso, o tipo de suporte em que estes questionários e formulários assentam acabam por fazer com que o paciente muitas das vezes se esqueça deles em casa ou tenha vergonha de os transportar e preencher em público. Assim, este trabalho vem propor, através das várias tecnologias presentes nos smartphones de hoje em dia, um melhoramento à vertente no exterior do processo terapêutico, que muitas vezes é desprezada pelo paciente ao fim de pouco tempo pondo em causa o sucesso do tratamento. Com isto, pretende-se que o paciente se sinta acompanhado, a todo o momento, por um terapeuta, através de uma aplicação presente no seu próprio smartphone. Idealmente esta aplicação seria criada especificamente para a pessoa em questão e conseguiria adaptar-se às várias situações em que iria ser usada, ajudando eficazmente o paciente. A criação destas aplicações requer conhecimentos técnicos que não estão presentes em todas as pessoas. Se por um lado os especialistas da área de programação são capazes de tal criação, por outro são os especialistas da área da saúde, e neste caso em específico os terapeutas, que são capazes da sua idealização, consoante as necessidades dos seus pacientes. Surge então a necessidade da criação de aplicações móveis, adaptáveis ao contexto do utilizador, por pessoas que não sejam especialistas na área da programação. Assim, este projecto assenta sob três entidades distintas: a) Utilizadores não programadores, que utilizarão uma ferramenta de criação de aplicações móveis; b) Utilizadores das aplicações móveis, que utilizaram as aplicações criadas pelos anteriores; c) Utilizadores programadores, que irão desenvolver novas componentes para a ferramenta de autoria. Nas fases iniciais do desenvolvimento tentámos perceber através de sessões de desenho participativo, como é que os utilizadores não programadores interagiam com um conjunto de elementos presentes num protótipo de baixa fidelidade. Usando algum material de desenho como post-its, folhas de papel, lápis e borracha, propusemos aos participantes que representassem uma determinada aplicação passível de ser utilizada num dispositivo móvel. Os resultados que obtivemos mostraram que a presença destas mesmas representações que foram fornecidas aos participantes permitiram que os mesmos criassem aplicações muito mais complexas e potentes. Adicionalmente estas sessões permitiram também que percebêssemos que a generalidade dos participantes preferiu organizar os elementos da aplicação sobre uma área de trabalho “infinita” e não apenas limitada a uma sequência linear. O método preferencial de relação entre estes mesmos elementos foi a utilização de setas que indicavam quando seria executada a transição entre eles. Com os resultados anteriores construímos o primeiro protótipo funcional de DETACH (DEsign Tool for smarphone Application Composition - Ferramenta de Desenho para a Composição de Aplicações para Smartphones). De acordo com os resultados obtidos nas sessões anteriores com utilizadores, este protótipo continha uma área com alguns ecrãs padrão passíveis de serem usados num ambiente de trabalho “infinito”. Com este protótipo pedimos a alguns utilizadores não programadores que tentassem criar uma aplicação móvel adequada à sua área do conhecimento. Com este primeiro protótipo verificámos que nenhum dos participantes foi capaz de completar todos os passos com sucesso. O aspecto mais problemático que verificámos foi na maneira como os mesmos ligavam os vários ecrãs da aplicação. O facto de o protótipo disponibilizar num dado ecrã a possibilidade de criar dois tipos de ligações, uma que considerasse o mesmo como destino e outra como origem, acabou por confundir os participantes. Apesar de tudo verificámos que a maior parte intencionava usar ambos as ligações considerando o ecrã selecionado como origem. Tais resultados levaram-nos à criação de um novo protótipo com as preferências verificadas pelos utilizadores. Após apresentarmos este último a um novo grupo de utilizadores, para a criação da mesma aplicação, verificámos que mais de metade deles concluiu a mesma com sucesso e em cerca de metade do tempo verificado no protótipo anterior. Tais resultados indicavam que claramente ainda havia espaço para melhoramentos ao protótipo. A visibilidade de algumas das funcionalidades, que ainda não estava clara para alguns dos utilizadores, foi um dos factores negativos apontados. A utilização destes dois protótipos iniciais de DETACH permitiu-nos perceber alguns padrões usados pelos nossos participantes aquando da ligação entre ecrãs, a funcionalidade verificada mais crítica. Enquanto a maior parte dos utilizadores preferiu criar ligações considerando o ecrã selecionado como origem, verificamos também a utilização de outros padrões que se assemelhavam aos usados em ferramentas complexas de programação. Para o produto final decidimos seguir assim a abordagem mais utilizada pelos utilizadores, melhorando o último protótipo. Através dos requisitos reunidos nestas sessões com utilizadores, no trabalho relacionado e em algumas reuniões que tivemos com terapeutas, definimos algumas métricas que a ferramenta DETACH seguiria. De maneira a ser de fácil utilização por qualquer utilizador, proporcionando também o seu alcance através de qualquer plataforma, desktop ou móvel (em tablets por exemplo), seria criada uma ferramenta web. Esta recorreria a um servidor para guardar os projectos criados, para que os mesmos pudessem ser carregados remotamente para os dispositivos móveis destino. De maneira a criar uma ferramenta robusta que possa ser melhorada no futuro com novos tipos de ecrãs ou variáveis de contexto utilizáveis, era necessário também desenvolver a mesma de uma maneira altamente modular para ser então continuada por programadores profissionais. A versão final da ferramenta DETACH nasceu de todo o conjunto de requisitos que verificámos anteriormente. Através de melhoramentos à última versão do protótipo de alta-fidelidade usado chegámos a uma ferramenta que pode até ser usada para além da área da terapia, como para a área de jogos ou do ensino. Para uma correcta avaliação da ferramenta, recorremos a utilizadores distintos daqueles que tinham testado os protótipos iniciais de alta-fidelidade. Os resultados mostraram que todos os participantes conseguiram criar, testar e atribuir a aplicação proposta aos utilizadores destino. Para além da avaliação realizada com os utilizadores finais da ferramenta, pedimos também a alguns programadores para tentarem estender a mesma adicionando um novo ecrã. Os resultados mostraram que também todos os programadores conseguiram realizar a tarefa com sucesso numa média de cerca de 35 minutos. O processo de desenvolvimento deste projecto contribuiu com a publicação de três artigos para conferências na área da saúde e da interacção.This thesis focuses on the Cognitive Behavioral Therapy (CBT) area. This type of therapy is normally subdivided in two kinds of sessions: the ones where the therapist and the patient are both inside an office, and the ones where the patient is outside the therapist office and has to follow some homework tasks, alone. These tasks intend patients to practice the situations analyzed in the sessions with therapists and are normally supported with simple paper forms. The inexistent ability for these homework tasks to adapt themselves to the patient or different use contexts compromises the success of the treatment. It is hence important to find a way where the patient, while outside the office, doesn’t feel that difference, because he carries a virtual therapist inside his smartphone. The usage of modern mobile phones can address the previous problem. Existing solutions encompass replacing traditional treatment methods with a mobile application that is provided to the patients. However, the application content is the same for every patient, regarding the age or treatment focus. Therapists lack the knowledge to create their own mobile applications and information technologies professionals lack the ability to personalize their contents properly. This work aims at circumventing this situation with the introduction of DETACH (DEsign Tool for smartphone Application Composition), a system that comprises: a) a flexible enough platform that allow developers to easily add new components and enables non-programmer users to create powerful mobile applications; b) a framework that runs previously created mobile applications. Particularly important was the user-centered development process of this system. We conducted a series of participatory design and thinking aloud trials with non-programmer users aiming to understand how they conceptualized programming. The results of interacting with low and high fidelity prototypes provided us with a set of interaction patterns and behaviors which we capitalized on in order to design the final DETACH product. Afterwards DETACH was submitted to some tool evaluation tests, by asking non-programmer users to create a mobile application and developers to create a new component for the authoring tool. The results proved the tool success as every participant was able to complete the requested tasks

The Scientific Foundation for Personal Genomics: Recommendations from a National Institutes of Health–Centers for Disease Control and Prevention Multidisciplinary Workshop

The increasing availability of personal genomic tests has led to discussions about the validity and utility of such tests and the balance of benefits and harms. A multidisciplinary workshop was convened by the National Institutes of Health and the Centers for Disease Control and Prevention to review the scientific foundation for using personal genomics in risk assessment and disease prevention and to develop recommendations for targeted research. The clinical validity and utility of personal genomics is a moving target with rapidly developing discoveries but little translation research to close the gap between discoveries and health impact. Workshop participants made recommendations in five domains: (1) developing and applying scientific standards for assessing personal genomic tests; (2) developing and applying a multidisciplinary research agenda, including observational studies and clinical trials to fill knowledge gaps in clinical validity and utility; (3) enhancing credible knowledge synthesis and information dissemination to clinicians and consumers; (4) linking scientific findings to evidence-based recommendations for use of personal genomics; and (5) assessing how the concept of personal utility can affect health benefits, costs, and risks by developing appropriate metrics for evaluation. To fulfill the promise of personal genomics, a rigorous multidisciplinary research agenda is needed

Mobile video annotations: a case study on supporting rehabilitation exercises

Annotations enable us to highlight key points or add information to content presented, for instance, on paper or digital media. Even though smartphones and tablets facilitate video capturing, currently only few applications allow limited video annotations using the mobile device itself. Given that video annotations can assist many tasks that depend or can be enhanced by video capturing, in previous work we have contributed with a tool for allowing multimodal video annotation using mobile devices. Upon experimenting with the tool, we identified that reviewing rehabilitation exercise videos can be especially enhanced with video annotations. Professionals in the field of physiotherapy and occupational therapy can add relevant annotations for their patients to improve performance of their exercises. After an evaluation with a specialist in occupational therapy, we identified new requirements associated with the monitoring of patients. We then identified the opportunity to develop a monitoring system with the collaboration of two rehabilitation specialists. Since these two specialists work with mirror therapy, we defined requirements that are relevant for this type of therapy. The system was developed to support the monitoring of exercises combined with video recording and annotation capabilities. The system aims to support rehabilitation therapy by distance: therapists can monitor patients as they record videos that are sent for evaluation. We identified requirements that may be applied in many scenarios, however mirror therapy demanded many specific requirements related to the recording of videos.Coordination for the Improvement of Higher Education Personnel (CAPES)São Paulo Research Foundation (FAPESP, grant #2011/17040-0)National Council for Scientific and Technological Development (CNPq

Augmented Reality

Augmented Reality (AR) is a natural development from virtual reality (VR), which was developed several decades earlier. AR complements VR in many ways. Due to the advantages of the user being able to see both the real and virtual objects simultaneously, AR is far more intuitive, but it's not completely detached from human factors and other restrictions. AR doesn't consume as much time and effort in the applications because it's not required to construct the entire virtual scene and the environment. In this book, several new and emerging application areas of AR are presented and divided into three sections. The first section contains applications in outdoor and mobile AR, such as construction, restoration, security and surveillance. The second section deals with AR in medical, biological, and human bodies. The third and final section contains a number of new and useful applications in daily living and learning

mHealth: A Utilization Review by Feature Classification for Sustained Use

mHealth is a fast growing segment for healthcare. However, there has been little research into the specific elements of mHealth that can drive continued use for optimization of the potential benefits. The purpose of this case study was to use the Delone and McLean Information System Model as a framework for classification of mHealth functionality and then to review the utilization of those categories over a six month period of time. A sample of 137 pediatric diabetics was reviewed. The activation rate was high at 94.9% indicating an interest in using mHealth. There was higher utilization of system features in the group of users with 60.3% of total uses being related to a system feature. There also were specific use patterns between gender with male patients consisting of 66.2% of the overall uses. Future applications should focus on system features and customization by gender to support sustained use

The Development and Evaluation of an Ecological Momentary Intervention for Social Anxiety

Social anxiety is a common mental health problem. Many people do not seek help due to barriers to accessing services. Novel methods have been explored that enhance existing assessments and treatments to be more accessible to people outside a clinic. Ecological Momentary Assessments (EMA) are real-time approaches that allow a person to self-assess their anxiety while they engage in daily activities. Ecological Momentary Interventions (EMI) are approaches that extend EMA to deliver psychological treatment to people in their natural environment. EMIs can be used as an adjunct to existing therapies, or as a standalone intervention. The current thesis examines the development and evaluation of EMIs for social anxiety through four related studies. The first study is a meta-review of observational and evaluation studies using EMA to assess or target various mental disorders. The study found 14 reviews that examined general psychopathology, mood disorders, borderline personality disorder, smoking addiction, and psychosis. The study concluded that there is a need for higher quality reviews on anxiety and stress and more reviews of studies that evaluate EMI effects. The second study is a systematic review of EMIs for stress and anxiety, which includes a meta-analysis on the EMI effects on generalised anxiety. This study suggests that EMIs may be effective but indicates a research gap in EMIs for social anxiety. The third study is a case study on the design and development of an EMI for social anxiety. This study demonstrated the use of three software development approaches and discussed the implications of those approaches on the iterative design process, the development of software components, and the challenges of engagement and communication with stakeholders, documentation and time management. The fourth study presents the protocol for a Randomised Controlled Trial (RCT) for the evaluation of an EMI for social anxiety. The RCT protocol was a two-arm study design that examined the EMI effects against a waitlist control group. The final study presents the RCT outcomes in an adult sample (n = 55) testing the effectiveness of the EMI for reducing social anxiety symptoms. This study found the EMI was not associated with significant improvements in social anxiety relative to the control. Nor the EMI was associated with a significant improvement in anxiety sensitivity, psychological distress, generalised anxiety and depression, or help-seeking. While the participants who used the mobile app reported being satisfied, the study suffered from significant drop out with 83% of the participants not completing the study. Overall, the current thesis found that EMIs are promising, but more research is needed to address the challenges in developing an EMI for social anxiety that incorporates an iterative and reflexive development process. Furthermore, the RCT on the resulting EMI faced challenges with recruitment and retention, suggesting that alternative methods may be required for increasing the engagement of individuals in self-guided EMIs. Nevertheless, with further technological and methodological developments, EMIs may offer an opportunity to deliver personalised therapy for people experiencing anxiety