WhatsMyM3?

NBC-4 News Clip from Doreen Gentzler (May 16, 2012)

What’s your mental health number?

This is the question that the Bipolar Collaborative is asking, using its WhatsMyM3 screening tool [PubMed]. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.

~from Clinical Psychiatry News

Today's USA Today newspaper ran a story titled, "Screening for mental illness? Yes, there's an app for that," by Michelle Healy.


WhatsMyM3 is a validated, 3-minute tool that screens for symptoms of depression, bipolar disorder, PTSD, and anxiety, and can be used to monitor changes in symptom severity over time.

One of the developers, Michael Byer, approached me about a year ago for my opinions on development and use of the screening tool. Disclosure: After reviewing the research and seeing how useful it is, I have become more involved in the organization, becoming an adviser to the group that was started nearly ten years ago by past NIMH chief, Robert Post MD. (listen to podcast #63)

It differs from other mental health screening tools, such as the PHQ-9 and the MDQ, in that these are all unidimensional -- they only measure one domain of symptoms. The M3 is multidimensional, measuring four areas of symptoms. Furthermore, when compared to results from the standardized interview tool, the Mini International Neuropsychiatric Interview (the MINI measures for 15 different mental illness diagnoses), WhatsMyM3 provides a total mental health score that is 83% sensitive in finding true positives and 76% specific in finding true negatives. In addition to the total score, there are four subscores, one each for depression, bipolar, PTSD, and anxiety.

Put another way, the negative predictive value of the total score is 89%, meaning that if you score under the threshold, there is an 89% chance that you do not have any mental health diagnosis by the MINI. As with most screening tests, you want the negative predictive value to be high so that you don't have to subject the "negatives" to more specific testing. The positive predictive value, or PPV, is generally lower for screening tests. It is 65% for WhatsMyM3, meaning that if you score positive (total score >= 33 and positive for functional impairment), the odds of you having a diagnosis is almost two-thirds. A clinical evaluation can then help to determine if you do have a diagnosis. (Note: this tool cannot give you a diagnosis; it can only describe your relative risk of having, or not, a diagnosis.)

What people have found to be most helpful is using WhatsMyM3 to monitor their symptoms over time once they do have a diagnosis. This can be done for free on the website, or for $2.99 using the iPad or iPhone apps, or the Android app. For mental health clinicians, they can download the free M3Clinician iPad app and then screen their own patients. For about a dollar per screen, they can register their patients who want to track their symptoms over time and share their scores with the clinician. Primary care providers also purchase screens, and can even obtain insurance reimbursement by billing for an annual health risk assessment. The patient reports can be viewed by logging into m3clinician.com.

A sample report for a fake patient can be viewed here.

I think this sort of tool, or app, is exactly the sort of mHealth thing that empowers consumers to better manage and become engaged in their health care needs. This is happening in other areas, like diabetes, heart disease, and obesity. Mental health is also making great strides in mHealth.

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I should also point out here that the folks at M3 Information were the only ones to take us up on our offer of a free "advertisement" on Shrink Rap in return for donating at least $200 to our NAMIWalk for Mental Health Month (we don't typically accept display ads). A logo ad will be running soon on Shrink Rap soon for two weeks in recognition of their charitable donations. It will look like this and link to the iPhone and Droid apps. [We received no money ourselves from M3 nor from NAMI. We've never accepted any money from Pharma companies, nor does M3.]

Mental Health, Military Style-- Guest Blogger Dr. Jesse Hellman

Today, we're talking about mental health and the military.  But first, I just learned, via Facebook, that today is International Polar Bear Day.  If you have one, hug him tight.  Make sure he's been fed first.


Over on his own blog, Pete Earley, has a post up about a veteran who was about to kill himself with a homemade gun.  He called a Suicide Hotline, the police were sent and the patient was charged with possessing a homemade gun.  It's a good post, worth the read, and Earley brings up issues about mental health emergencies and the legal system that aren't limited to veterans. 


Yesterday, the New York Times had an article about military discharges for a diagnosis of "personality disorder."  The diagnosis is presumed to be a pre-existing one, so once a soldier is diagnosed with a personality disorder, he can be discharged without the usual military benefits.  I know that our guest blogger Dr. Jesse Hellman  has an interest in the topic.  He spent two years as a military healthy, and has attended hearings on the topic, so I asked him to do a quick guest post for us:


Jesse writes:
  The article tells of a 50 year old woman psychologist who enlisted, was sent to Afghanistan, and was involved in a number of incidents, eventually being accused of sexual harassment for remarks she had made. She was sent for psychiatric evaluation and was given the diagnosis of personality order on discharge. There are severe consequences of this diagnosis, which can include loss of future benefits, medical expenses, and more. Was the diagnosis properly considered? Did her commanding officer ask that she be given that diagnosis in order to reduce the huge medical expenses produced by the military?

This is not the first time I had heard of this problem. In the fall, I attended in Washington a meeting of the House Committee for Veteran Affairs. Joshua Kors, a writer who had several pieces in The Nation which addressed this very problem, was testifying along with a soldier who had been discharged as having a personality disorder. The Department of Defense sent several people to testify that there was no abuse of the diagnosis.

One of Mr. Kors's strongest points was the sheer number of personality disorder diagnoses that were being made. It looked like these were occurring at two bases in the United States that processed discharged soldiers: Could it possibly be that this number of applicants slipped through the initial screening process?

My own impressions were mixed. It seemed inconceivable to me that any military commander would directly order physicians to misdiagnose in order to reduce costs to another entity. Vastly too great a risk to him, and to what advantage? On the other hand, the diagnosis as described in the DSM is more severe than the problem warrants: it is possible that many soldiers enlisted thinking the military was for them but then, through various routes, found that life in Afghanistan, under fire, with all the dangers and rigors, was too much. Their attitudes disintegrated. They wanted out. They were poor soldiers who disrupted morale.

To those who understand how to use bureaucracy to effect one's ends, direct orders are not needed. If it takes one hour to examine a soldier and find a given diagnosis, but alternate diagnoses require much more paperwork, repeat examinations, record reviews, etc, and the caseload of the examiner is sufficiently great, is it not predictable that the particular diagnosis that minimizes work will increase in comparison to the alternatives?

So what do you think? There are many issues here worthy of discussion.

I Still Don't Need To Talk

Three years ago in a post called I Don't Need to Talk I blogged about the evidence for and against critical incident stress debriefing (CISD) for preventing PTSD. Back then I suggested that CISD should not be mandatory for people who experience trauma for two reasons: most people don't develop PTSD after trauma and get better on their own even without therapy, and there was increasing evidence to suggest that CISD may make some people worse.

Today a story came across my Twitter feed (thanks USMCShrink!) about the medical response to the Japanese tsunami. Apparently psychological debriefing was strongly discouraged by Japanese mental health authorities for the reasons I just mentioned.

I think this is the leading indicator that attitudes are changing toward the role of psychiatry in disaster response preparedness.  It also may mean that we might have to change how we approach the mental health care of veterans. I've talked to a lot of vets who were required to go through post-deployment debriefing. Did it help? Did it hurt? Are we doing the right thing? While treatment should be offered to people who really do develop disorders, in this case preventive intervention may not be so preventive.

Guest Blogger Dr. David Hellerstein on Trauma and Resilience, Ten Years after 9/11

All New Yorkers have vivid memories of the events of 9/11/2011; and for New York-based health care workers our memories are generally mixed with feelings of frustration and helplessness. We recall how we emptied out hospital beds that day, how we were prepared in emergency rooms and clinics, and how we waited hour after hour—in expectation of a flood of patients that never came.  And we recall how in the ensuing days, weeks, and months, survivors finally entered our offices, clinics and hospitals, seared by memories and nightmares and visions they could not erase.

Patients working on Wall Street, living in Battery Park City or in lower Manhattan, those who were evacuated by boats from apartments located close by the base of the towers, people who happened to be shopping or walking in Lower Manhattan that Tuesday morning, firemen who rushed to the site of the rubble, parents who were scheduled for meetings at Windows on the World restaurant, but had to drop their kids off at school first, people who heard the first impact, and—remembering the prior attack on the WTC—immediately  left the buildings and headed North, people whose apartments were destroyed or cars were crushed or jobs were eliminated…or people who waited in the suburbs for a spouse to return on the MetroNorth commuter train, and finally concluded they would never return.  They all came, looking for help.

We remember equally vividly how many months and years it took for recovery to begin. We worked intensely to enhance the process of recovery, whether through medical treatments or psychotherapy.  All of us, patients and doctors alike, were haunted by the memories of those who never emerged from the rubble, and by the randomness of survival.  And yet we patients and doctors had a unique cameraderie as well—a feeling that we were all in this together, united against a common, though perhaps unseen, enemy.  Surely this helped with recovery, along with the expectation that life would eventually return to normal. 

For neuroscience researchers, the events of 9/11 were a sort of natural experiment, similar to the events of war.  Over the past decade, there has been significant progress in understanding the brain’s responses to trauma and what causes PTSD, and as well as understanding what may help people to recover from such cataclysmic events. It has become abundantly clear that the brain’s fear systems, commonly associated with the center called the amygdala, have incredibly tenacious memories for trauma that are extremely difficult to dislodge.

New research has brought illumination and hope to these issues.  NYU researcher Elizabeth Phelps is doing research on the neurological processes involved in the consolidation of traumatic memories, which indicates that there may be a window of time during which the deposition of such memories can be interrupted. Will this eventually provide a way to prevent PTSD, either by new types of psychotherapy or by the development of new medications that can block the deposition of such memories?

On a broader level, the events of 9/11/2001 have underlined the importance of resilience.  Some survivors of 9/11 quickly returned to their usual level of functioning, yet many others, a decade later, are still haunted by those events.  Resilience, or the ability to survive or even thrive under stress, is being studied as a neuroscience-based process. Researchers such as Avram Caspi have determined that there are genes related to resilience. Other researchers have described behavioral characteristics that are related to higher levels of resilience, such as Charles Nemeroff and Dennis Charney in their book The Peace of Mind Prescription.  (Resilience is one of the 6 key New Neuropsychiatry principles described in my book Heal Your Brain and in my blog at Psychologytoday.com).

Just to mention one key element of resilience: appraisal.  Appraisal means the way in which we interpret events.  If an event is interpreted as a threat, it evokes fear responses, including activation of the amgdala, and a series of physical responses including release of cortisol and stress hormones. Yet if an event is interpreted as a challenge, it evokes a different series of responses, including interest, calm, relaxation, and adaptive coping. And as Nemeroff and Charney note, “The hormones released by an appraisal of challenge include growth factors, insulin, and other compounds that promote cell repair, trigger relaxation responses, and stimulate efficient energy use.”

The components of resilience include:

·      Physical resilience, physical ‘toughening’ and ‘tempering’

·      Psychological resilience “situations are viewed as challenges, not threats”:

·      Activating social networks, including confiding relationships

·      Adequate external supports

·      Challenging one’s self

·      Looking for meaning through involvement

·      Learning

Now, a decade after 9/11/2001, it is possible to have almost a strange nostalgia for that moment, since we live in a world with increasingly huge problems but without clear solutions, in which day-to-day stresses seem to be continually increasing, with worsening financial and political instability, and increased polarization between incompatible world-views.  In attempting to cope with all of these ongoing and much less clearly defined stressors, the question is, what can help?

In my view, resilience is key.

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