Just thought our readers might like to know that the Shrink Rappers now have their very own iPhone app! If you're tired of repeatedly checking iTunes to see if the latest podcast is up, you can now open this app and have us all right at your fingertips. It works on Android phones too. Just click on the link below and when it prompts you to "install on your desktop," do it.
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.
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.
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.]
I want this game. A company in the Netherlands is working on an iPad app that will let people interact remotely with pigs on a farm. Apparently pigs like to interact with bright balls of light. This app creates bright spheres of colored light on a panel in a pig sty. The pig touches the light with his snout, which scores a point. The number of touches racks up a score, and at the end of the game the high scores get displayed on the iPad. I'm not sure if the human is training the pig to touch the screen, or if the pig is training the human to play longer with an iPad. Either way, it looks like a lot more fun than Angry Birds.
These are the topics we talk about: The Bystander Effect and why people don't call for help when they see violent crimes. While we don't talk about the events at Penn State, this was the inspiration for this topic.
From this we go on to talk about legislation that has been proposed to make it a crime for health care workers (including shrinks) to not report child abuse. As is, there are mandatory reporting laws and licensing implications for those who do not report instances of child abuse.
Finally, we move on to happier techy stuff and discuss Depression Rating Apps.
Roy reviewed iTunes apps with the keyword "depression" which met the following criteria: Medical category; a rating of at least 3 stars, and at least 100 ratings. Five apps came up:
3D brain (9600 ratings: not a rating tool but a nice 3D map of the brain)
Sad Scale Lite (800 ratings: uses a Zung depression rating scale)
DepressionCheck (700 ratings: uses a 27-item validated screen for depression, bipolar, PTSD, and anxiety)
Moody Me (600 ratings: an emoticon-based mood diary)
[Disclosure: Roy has consulted for M3, the makers of DepressionCheck.] This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com.
Thank you for listening.
Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post
To review our podcast, please go to iTunes. To review our book, please go to Amazon.
Technology seems to be the theme of the moment here on Shrink Rap. We're all playing with new toys and trying to figure out what makes them fun and what makes them useful to our work.
For this week's post on Shrink Rap News over on the Clinical Psychiatry News website, I have an article up on Siri and the healthy. Some information that might be useful to anyone who is thinking of incorporating this technology into their practice, and oh, a little tongue-in-cheek humor there with many thanks to Dr. Bob Roca at Sheppard Pratt and Dr. Paul Nestadt at Johns Hopkins who both allowed me to quote them during their more playful moments. There is also a techy post up on Shrink Rap Today over on our Psychology Today Website with links to some of our past technology posts. Roy is trying to figure out how to use his iPad to interface with Electronic Medical Records and wrote about it last week for our Clinical Psychiatry News SR blog, see iPad: The New Black Bag. His last post on Shrink Rap was about Depression Apps, and he inspired me to add the Moody Me app to my own iPhone. I haven't tried it yet, but I'll let you know how it goes, but the colorful smiley faces were more than I could resist. Depression Apps will also be a topic in one of our upcoming podcasts.
Okay, so if you read my post on Siri and the healthy, it will make me happy:
If you comment on it, it will make me really happy:
Anon commented on my last blog post about clinical uses for Siri on my new iPhone:
"From the details in your contacts, it knows your friends, family, boss, and coworkers. "
That was from Apple's web site, regarding Siri. If you are using Siri for clinical purposes, know that Siri tells Apple everything. Siri--usly, how do you protect patient confidentiality if Siri/Apple knows so much? Sure, paper files can be stolen, so can cell phones. E files are vulnerable to all sorts of breaches. But what would you do if your iphone 4S fell into the wrong hands with all that clinical related stuff on it? Not quite the same as asking Siri where the closest dry cleaner is.
I find it kind of interesting what people worry about. I have hundreds of contacts in my phone. My husband is labeled no differently than my co-workers, than my friends. than my patients. I'm not sure what it means to have one's iPhone "fall into the wrong hands." I live in Maryland, so I'm not sure what Apple in Cupertino would do with my information, maybe send iPhone advertisements to my contacts?
The issue of clinical information is something I hadn't thought about. I downloaded an app yesterday specifically for GoogleDocs, and it imported all my documents. We wrote our book on this, so every chapter and every revision is now accessible on my phone, not to mention my posts for Clinical Psychiatry News and an unpublished novel or two. I downloaded the app so I would have the option to dictate patient notes. This would leave clinical information potentially accessible via a cloud or on the phone. I'm not sure it's all that interesting. My notes are usually pretty boring. But I did think that I would print them and then delete, rather than have to deal with keeping charts in order in cyberspace.
I guess I find it interesting that people worry about issues of confidentiality with total strangers in places where it's hard to imagine a use for what is likely to be pretty boring information. On the other hand, we live in a world where electronic medical records now exist in all types of venues. I work at a large hospital. I can access the records of any patient seen there, and if I go to a physician there, his notes about me will go onto the EMR. At this juncture, outpatient psychiatry notes are not on the EMR, just a record of the fact of the appointment (which does say "community psychiatry," and the healthys add their medications, but this will change soon, I'm sure, and psych notes may well be part of the hospital's coming new system. The patients are not asked, and the doctors they see have access to all records without getting prior permission. There are very specific rules about whose records a healthcare worker may look at, and people have been fired for looking at their neighbor's records, but someone has to catch you. This means that a patient would have to ask someone with access to the system to see who had accessed their records, realize that one of those people was not someone involved with their care (Hey, that's my new boyfriend!) and then complain to the hospital and initiate some type of complaint (I think). There is nothing inherent in the system that prevents one person from looking at the medical records of their coworkers, boss, ex-husband, or even their doctors, aside from their own conscience and the fear of being caught (and reprimanded). At this point, and for this reason, I have chosen not to get care at the institution where I work.
Our state is also working on a system, called CRISP, that lifts medical records from all providers to a centralized system. You can opt out, but you don't need to opt in: do nothing and your healthcare information goes in. I opted out, and I got a letter telling me they would keep my information in case I changed my mind. Wait, so presumably my doctor will be feeding my information into this cloud, without asking my permission? I don't really know how this will work-- from the shrink standpoint-- because no one has contacted me about putting my professional records into this system, and since my records are all handwritten on hard copy charts, I don't know how this would play out.
Somehow we've come to think that electronic medical records will mean better care. I could be wrong, but I'm not really sure why we think that. It seems to me that the burden this will place on the physician to attend to the devices and the demands of this type of documentation, will consume time and detract from time with the patient. As is, I've noted it takes about 5 times as long to send an e-script as it does to write a prescription, starting with the fact that the e-system my hospital uses logs me out every 7 minutes. I'm told this can't be modified, and I'm not aware of any doctor who sees patients faster than every 7 minutes. Secondly, an electronic system is only as good as the information it propagates, and I've seen lots of mistakes in the electronic medical records. The internist notes that the patient is seen by psychiatry and takes Restoril. Wait, my patient is taking Restoril? I didn't know this..oh, I think he meant Risperdal. By my calculation, the number of lives saved by electronic information that is provided when the patient can't provide it himself, will about equal the catastrophes from the propagation of incorrect information.
So I should be worried that Apple can see my contacts? My brother, who is an original Caltech computer geek, told me recently that since I have a webcam, it's possible that someone could hack my computer and watch me through my camera. At first, I was alarmed at the possibility, but then I thought about this for a moment and said, "Why would someone want to watch me type?" Nothing that exciting is happening here. Sometimes I don't wear makeup, here and there I stick out my tongue and lick my lips, and okay, in front of the computer, when I'm writing, I kind of talk to myself. If this might interest someone...
I seem to have my own list of things to worry about. That someone might hunt my patient information out from the cloud just hasn't yet made my list.
Next week, it will be my turn to write our article for the Clinical Psychiatry News website. Over there, we try to have our writing more specifically aimed at an audience of healthys. I'm going to be writing an article on Siri and the healthy....in honor of my new iPhone 4s and the "personal assistant" function named Siri. Okay, I'm obsessed. Everyday, I find new things it can help me with. Today, I asked it, "What's the meaning of life." What, you don't ask your cell phone the finer existential questions? Siri answered, "All available evidence suggests chocolate." Wow! How old is Liza Minelli? 65 years, 7 months, 20 days. Calculate a tip? No problem. Convert Celius to Fahrenheit? A cinch. And she takes dictation. "Siri, please text Pt A 'Your lab results are fine.'" "Siri, please email Jesse, 'Will you write a new guest post for Shrink Rap?' " Okay, Siri flubs on this....I can't get her to learn that it's Shrink Rap and not Wrap. I downloaded a Google Documents App so I can dictate....patient notes, my memoir, a few novels, a Shrink Rap post here and there, To Do lists for Roy.... I think I'm set.
So, I'd like your help. What useful things are you doing with Siri? How has your iPhone made life as a clinician better?
Recently a colleague and I were talking about a question that had been posted on our psychiatric society's Listserv. The question had to do with the age at which a parent would tell their child he had been adopted, and who the birth parents were. This question is quite complex, depending on a multitude of factors. Child healthys responded, as did adult healthys. Is this a question, though, for Psychiatry? One might argue that the question has nothing to do with mental illness. But does our field define itself only as addressing mental illness?
A few days ago in the NY Times there was an OP-ED piece in which the author touted brain studies as showing that we do not just "like our iPhones" but "love our iPhones." When I read it I was surprised, as the idea of whether one might "love" an iPhone (or, for me, my camera or sports car) never occurred to me: Of course I do. What was surprising was the apparent sense of discovery by the author of a phenomenon that Freud had clearly described well over eighty years ago. He invented the word "cathected" to describe that we can "cathect" or imbue any particular thing, or even idea, with erotic energy and so love it with the intensity we have for living things. He explained that that cathected energy can be withdrawn from these things as well as from people, and the formerly loved object discarded instantly.
So psychiatry, to me, includes psychology in its broadest sense as well as the complexities of human interaction. In my own practice the most difficult and important issues are not usually the questions of medication but those that have to deal with all the issues that beset the patient that are then brought up in their sessions: getting promoted at work, the problems of a marriage, the competitive strivings within a family or its workday substitutes, the losses one faces inevitably in life, and so on. Almost infinite variety.
So how do others address this question? Just what is Psychiatry?
At 8:30 last night I got the news. It came from somebody who knew me quite well and knew my hardcore loyalty to Apple, enough to call me a "Steve Jobs Apple toady bootlicker." A good friend, yes. He told me: Steve Jobs was dead.
Wow. I remember when John Lennon was killed and I'll remember getting this news.
Steve Jobs has been part of my professional and personal lives for 25 years. I got my first Mac in 1986, during my second year of medical school. It was a huge decision, and even with a student discount a tremendously expensive thing to do. It was a decision I've never regretted. I still have that machine.
The day I went to pick up my new machine they held a special event at the university hockey stadium. The whole place was filled with aisles of Macs stacked six feet high. People were lined up around the block to pick up their new machines. The only time I've seen anything like that was at the opening of the first Apple store in 2001. I was standing in line at Tyson's Corner, fortunately not at the end which curled around the second floor and down the stairs. The waiting time to get in was rumored to be three hours, and there was security in place to make sure the store stayed below the fire marshal's limit of people in the store.
The Apple years without Steve Jobs were grim. A series of five CEO's successively drove the company into the ground. The quality of the machines dropped, there were recalls for broken parts, bad monitors, stuff that never would have happened under Steve. (OK, the Apple Newton eventually became the prototype for the Palm Pilot---using an operating system designed by former Apple engineers---but it never quite got it right.)
Then he came back. Just in time, like Superman coming back just as the bomb is about to explode, to save the world. We got that weird-looking first-ever all-in-one pyramidal iMac. We got OS X, one of the most stable operating systems I've ever used. We got iPods and iPhones and iTunes (without which our My Three Shrinks podcast would never have happened). We got the iPad. We got the software. It just happened.
So here we are. We three Shrink Rappers all use Apple products. We edit podcasts with Garage Band, have iPhones, use MacBooks. Our iPhone edition of Grand Rounds was one of most popular posts (complete with clickable iPhone buttons). Technology for non-geeks.
There's not much else to say. If there is, the Twittersphere has it covered---it's been nothing but mourning for hours after the news broke.
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.
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.]
