"Healthcare 2014, 2, 220-233; doi:10.3390/healthcare2020220OPEN ACCESShealthcareISSN 2227-9032www.mdpi.com/journal/healthcareReviewMobile Tele-Mental Health: Increasing Applications and aMove to Hybrid Models of Care1, 2 1 1 Steven Richard Chan *, John Torous , Ladson Hintonand Peter Yellowlees 1Department of Psychiatry, University of California, Davis, 2230 Stockton Blvd., Sacramento, CA 95817, USA; E-Mails: [email protected] (L.H.);[email protected] (P.Y.)2Harvard Longwood Psychiatry Residency Training Program, Boston, MA 02215, USA; E-Mail: [email protected]* Author to whom correspondence should be addressed; E-Mail: [email protected]; Tel.: +1-916-734-3574; Fax: +1-916-734-0849.Received: 7 February 2014; in revised form: 22 March 2014 / Accepted: 17 April 2014 / Published: 6 May 2014Abstract: Mobile telemental health is defined as the use of mobile phones and otherwireless devices as applied to psychiatric and mental health practice. Applications of suchinclude treatment monitoring and adherence, health promotion, ecological momentaryassessment, and decision support systems. Advantages of mobile telemental health areunderscored by its interactivity, just-in-time interventions, and low resource requirementsand portability. Challenges in realizing this potential of mobile telemental health includethe low penetration rates of health applications on mobile devices in part due to healthliteracy, the delay in current published research in evaluating newer technologies, andoutdated research methodologies. Despite such challenges, one immediate opportunity formobile telemental health is utilizing mobile devices as videoconferencing mediums forpsychotherapy and psychosocial interventions enhanced by novel sensor based monitoringand behavior-prediction algorithms. This paper provides an overview of mobile telementalhealth and its current trends, as well as future opportunities as applied to patient care inboth academic research and commercial ventures.Keywords: telemedicine; telepsychiatry; telemental health; smartphone; mobile; technology;videoconferencing; ecological momentary assessment; mental disorders; psychiatryHealthcare 2014, 2 2211. IntroductionTelemedicine—a term often interchanged with telehealth—encompasses “videoconferencing, theInternet, store-and-forward imaging, streaming media, and terrestrial and wireless communications” [1].Telemedicine is especially useful for patients who cannot access specialists in their community, patientsfrom differing cultural and linguistic backgrounds, patients of lower socioeconomic status, patientswho prefer to receive care at home instead of in hospitals, institutionalized populations such as prisonersor the elderly, and patients who need special interpreting skills that are not available locally [2].Patients also use telemedicine as an adjunct to their treatment, participate in online self-help or supportgroups, and keep in touch with their healthcare providers while traveling.Providing mental healthcare through real-time videoconferencing comprises the bulk of research in telemental health technologies as this modality is most similar to traditional face-to-face mentalhealthcare practices [3]. Studies have shown that telemental health is effective and increases access tocare. Videoconferencing, in particular, is as effective as in-person care “for most parameters such asfeasibility, outcomes, age, and satisfaction with a single assessment and consultation or follow-up use” [4].However, telemental healthcare also encompasses other modalities, such as “online therapy,eHealth, mobile technology, and health information technology” [3]. The use of mobile technologies,in particular, is rapidly evolving within the field of tele-mental health. Mobile health, or mHealth, isconducted on “mobile phones, patient monitoring devices, personal digital assistants (PDAs), and otherwireless devices” [5].This article provides an overview of mobile telemental health as it is being used for patient care. For the purposes of this paper, we will focus on smartphone devices. We will exclude personal digitalassistant (PDA) devices that do not include a network connection, and cellular phones and earlysmartphones that do not include modern smartphone capabilities including advanced processingpower, graphics, ability to run mobile applications, and interactive capabilities such as touchscreens.2. Potential Advantages of Smartphones in TelehealthSmartphones are well suited for health information dissemination and are increasingly being used asdevices for health service delivery. As of 2013, 61 percent of United States mobile phone subscribersowned smartphones [6] with higher-end capabilities such as larger displays, GPS and accelerometersensors, and higher processing power than low-end cell phones. These typically run on the iOS orAndroid platforms [7]. Worldwide, there are more than 3.2 billion unique mobile users, with anincreasing number of wireless connectivity subscriptions [8].According to the Pew Research Center 2012 report, over 31 percent of cell phone users have usedtheir devices to look up health information with cell phone owners who are Latino or AfricanAmerican more likely to gather health information through their smartphones. And caregivers—whoare critical to a psychiatric patient’s network—are also more likely to look up health information. Thispresents an opportunity for mental health applications targeting caregivers and minorities.Mobile devices—in the context of healthcare—can be used for treatment monitoring and adherence,appointment reminders, community mobilization, health promotion, health surveys and surveillance,patient monitoring, decision support systems, and patient recordkeeping, as well as for the deliveryHealthcare 2014, 2 222of direct patient services via audio or video systems [5]. Software applications for providing ormonitoring mental healthcare on smart phones are being created around the world [9,10]. An advantageof mobile phones is their ability to provide just-in-time interventions using “push” processes withoutrequiring effort on the part of the patient [11]. Because of these devices’ portability and low powerrequirements, they are ideal for low- to middle-income countries that have less established communicationsand electrical infrastructure, and can allow impoverished individuals and communities relativelyinexpensive access to the Internet. Mobile devices thus have an advantage with their lower cost versusthat of traditional videoconferencing infrastructure. A recent paper summarizing all telemental healthcost studies since 1998 mentions fixed costs for traditional real-time telepsychiatry infrastructure cango up to the tens of thousands of U.S. dollars [4].Patients with certain conditions may also do better with mobile devices instead of desktop computers.Younger generations of patients are accustomed to not only using mobile devices but keeping themwith them nearly all of the day [12]. Previous work has shown that telepsychiatry may be better usedfor particular patients—paranoid patients, young children, and people with severe social anxiety andautism—than using face-to-face in-person services [13]. Researchers and clinicians can potentiallyextend these advantages of telepsychiatry to take advantage of the ubiquitous nature of mobile devicesand provide a more intimate, realistic and quantifiable assessment of patients’ lives.3. Challenges to Adopting Mobile Devices in Telehealth3.1. Health Applications Have Low Penetration RatesAlthough smartphone use has pervaded mainstream culture, health applications are less pervasive.In the United States, Pew has reported that while one in five smartphone owners had a healthapplication installed on their phone, less than 1 percent of health application users had an application totrack mood or sleep, and only 2 percent used an application for medication tracking, alerts, andmanagement [14]. The low healthcare penetration rates for application usage mirror historically slowrates of technology adoption within the healthcare industry and signify the need for considerable workon change management with both providers and patients to increase the rate of penetration.Other factors that exacerbate penetration rates include unequal access to mobile devices. Differentage groups, for instance, have lower rates of adoption of mobile devices [3]. Although smartphones,and cellular data plans are relatively cheap, low socioeconomic status still prevents some patients frombeing able to afford them. The use of technology itself is dependent on the patient’s technologicalaptitude and understanding how to effectively use digital information, and thus, e-health literacy isparamount, and this still affects a proportion of the population who are older than those “digitalnatives” who have lived their whole lives with the Internet [15].3.2. Current Published Research Tends to Evaluate Older TechnologiesFrom a research perspective, most clinical trials to date involving mobile telemedicine focusedprimarily on text messaging as a method of remote communication, assessment, and intervention. Textmessaging for appointment reminding, for instance, has been shown to have modest benefits with nodifference being found between text messaging reminders compared with other reminders via postHealthcare 2014, 2 223or phone call [16] There are fewer published clinical trials devoted to evaluating smartphoneapplications, despite more than a decade of the smartphone’s existence. A lack of robust scientificresearch base may preclude adoption of these applications as insurance organizations require thoroughassessment of technologies before determining they are eligible for coverage. The Centers forMedicare and Medicaid Services (CMS), for instance, adopts a Medicare National Coverage Processthat includes technology assessments conducted by staff reviewing evidence through systematicreviews of medical and scientific articles and study criteria “to assess its validity ... clinical relevance ... and weight (magnitude of effect)” [17].The recent incorporation of front-facing cameras in smartphones and tablet computers has enabled video calls using freely available consumer software for mobile phones, such as Microsoft’sSkype, Google Hangouts and Apple’s FaceTime. Despite the widespread availability of such software,and the fact that the iPhone has had such hardware since June 2010 with the iPhone 4, to date, onlytwo published studies have tested synchronous smartphone videoconferencing for telemedicine, withsomewhat mixed results.Mayo Clinic researchers described a telestroke service using built-in FaceTime videoconferencingsoftware on Apple iPhone 4 systems on a secure internal WiFi network compliant with the UnitedStates Health Insurance Portability and Accountability Act (HIPAA) [18]. This study found thatremote neurologists could perform National Institutes of Health Stroke Scale (NIHSS) assessments onthe iPhone 4 with good correlations to bedside vascular neurologists’ scores. Researchers at theNational Center for Telehealth and Technology successfully demonstrated FaceTime as a usable toolin conducting interviews from the United States to military installations in Asia; however, networkconnection problems caused video quality to degrade [19].A number of studies have been undertaken on mobile applications, especially when used formonitoring, and these will be reviewed later.3.3. Current Mobile Health Studies Need Improved, Newer Research MethodologiesMobile health clinical trials, in general, have been said to suffer from lack of standardization, lackof sound methodology, and lack of data interoperability and systems integration [20]. Most pilotprojects have been described as employing a “scatter-shot approach” that creates the “equivalent ofblack boxes,” requiring patients to use multiple applications or methods to manage their health.Researchers at the mHealth Summit 2013 conference in Maryland emphasized the need for differentresearch methods and approaches [21–23]. Research trials should employ more efficient, adaptiveintervention study techniques such as the Sequential Multiple Assignment Randomized Trial (SMART),a type of randomized trial best used for technology interventions that use multiple components [24].This would allow, for instance, researchers to study the efficacy of individual components and thesequence of such components, such as offering SMS text messages with supportive messaging, SMS text messages with directive messaging, smartphone notification alerts, or telephone calls, or a combination thereof. One researcher cited the need to look at habit and timing in mobile healthinterventions, versus traditional evaluation of cognition via surveys, questionnaires and other traditionalpsychological evaluation methods [25]. Others noted that researchers need to work with other disciplinesto transcend the barriers of data interoperability and standardization—such as how particular Healthcare 2014, 2 224interventions are defined, how data is processed, and how to normalize data from wildly differentwearable sensors.Despite these challenges, there is optimism for smartphones’ role in healthcare. Other factorsdriving this optimism include the current unsustainable healthcare expenditures in the U.S. along with a need for personalized, more precise assessments and interventions [8]. A number of commercialventures such as American Well have commenced physician visits via iOS and Android devices toconsumers for video consults [26] despite criticism over potential problems with coordinated care andinadequate diagnosis of diseases like strep throat [27]. Many challenges continue to face mobile health:technical issues, cost, clinical appropriateness and validity, and ethical issues. These challenges arealso relevant to tele-mental health.4. Taking Advantage of Mobile Devices for Mental HealthThe advantages of mobile telemental health are similar to those applied to mobile telemedicine ingeneral: smartphones’ portability allows them to be used independently of a particular location; theyare inexpensive versus traditional desktop and laptop computer-based solutions; and they can be usedfor immediate context-aware interventions [28].Interestingly the majority of patients with mental illness own mobile devices. Of 1592 individualswith serious mental illness in metropolitan Chicago surveyed in 2013, 72 percent owned a mobile device,including not just smartphones, but also “mobile phones ... and devices that enable text-messaging for people with hearing impairment.” Common uses included phone calls, text messaging, and Internetuse [29]. A recent survey we conducted at a university-affiliated outpatient psychiatry clinicdemonstrated that 70 percent of 100 patients surveyed owned a smartphone, and over 50 percent of thoseowning a smartphone were willing to download a mobile application to monitor their mental health [30].In fact, respondents expressed more interest in using a mobile application than text messaging.There are an enormous number of applications with more than 3000 mobile device applications,including mood trackers and CBT applications in both Apple’s App Store for iOS devices and GooglePlay for Android device [31]. Table 1 presents the number of available applications, derived from abasic search on Google Play using the AppBrain website and the iTunes App store website as of 14 January 2014. The Android and Apple operating systems were selected as since 2013, over 90 percent of smartphones sold in the United States are Android- or iOS-based [32].Table 1. Statistics of applications on the Google Play platform via AppBrain, and Apple’sApp Store.Google Play iOS App StoreSearch termsJanuary 2014 January 2014depression 1615 586anxiety 1269 775schizophrenia 67 20bipolar 151 90psychiatry 168 149alcoholism 1911 146 "