Applying mobile technologies to mental health service delivery in South Asia

Asian Journal of Psychiatry 5 (2012) 225–230

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Applying mobile technologies to mental health service delivery in South Asia Neil Krishan Aggarwal * Columbia University Department of Psychiatry, New York State Psychiatric Institute, 1051 Riverside Drive, Suite 1703, Unit 11, New York, NY 10025, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 12 October 2011 Received in revised form 7 December 2011 Accepted 18 December 2011

Mobile phones have increasingly assumed an important role in the treatment of mental disorders in high-income countries. This paper considers such possibilities in the South Asian context. First, a brief review of mobile phone use in mental disorders is provided. Next, data on the market penetration and dissemination of mobile phones in South Asia is presented. Finally, common barriers to treatment for mental disorders in South Asia are evaluated against solutions that could be derived from mobile technologies. Though not without their risks, mobile phones have the potential to increase engagement, treatment, and retention of South Asian patients with mental disorders in unprecedented ways. ß 2012 Elsevier B.V. All rights reserved.

Keywords: Mobile phones eHealth Cultural psychiatry Patient engagement Public health Treatment barriers

1. Introduction This paper considers prospects for the therapeutic use of mobile technologies among patients with mental disorders in South Asia. In the past five years, mobile phones have stimulated an independent line of research in high-income countries with significant functional versatility for many conditions. The type and content of mobile technology has differed throughout studies. In perhaps the most obvious function, providers have called patients on mobile phones to promote medication adherence in patients with HIV and mental illness (Puccio et al., 2006), to deliver psychotherapy in patients with schizophrenia (Depp et al., 2010) and to encourage smoking cessation (Vidrine et al., 2006). In this respect, the innovative nature of mobile phones rests in their ability to contact patients away from their residences. On the other hand, text messaging (also known as Short Messaging Service, i.e. SMS) is a technological capability unique to mobile phones. Personalized text messaging has engaged youth with mental illness around appointment logistics, mood evaluations, medication changes, clinician referrals, and expressions of support (Furber et al., 2011). Text messaging has been especially effective in conveying private appointment reminders for those concerned about the stigma of psychiatric illness (Ma¨kela¨ et al., 2010). Repeated daily text messaging has been used to improve recall in patients with traumatic brain injury (Culley and Evans, 2010) and monitor pathological behaviors in patients with bulimia nervosa also receiving weekly cognitive-behavioral therapy

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(Shapiro et al., 2010). Personalized text messages have promoted substance cessation in randomized controlled trials of community samples (Free et al., 2009; Rodgers et al., 2005), though studies suggest that content could also be successfully automated (Lukasiewicz et al., 2007; Whittaker et al., 2008). In a sophisticated program for patients with schizophrenia, text message algorithms have assessed symptoms and subsequently delivered automated cognitive and behavioral interventions based on prior patient input (Depp et al., 2010). In the most complex interventions, elaborate programs have been created for mobile phones. Programs to assess mood through traditional questionnaires several times daily have shown promise in patients with depression and anxiety (Burns et al., 2011; Reid et al., 2009). In patients with psychosis, the results of such questionnaires have also been emailed to psychiatrists for acute evaluation if scores exceed threshold (Spaniel et al., 2008; Depp et al., 2010). In one study, a complex combination of emails, text messages, interactive voice response, and mood questionnaires has supported patients with smoking cessation by capitalizing on the multi-functionality of mobile phones (Brendryen et al., 2008). Mobile technologies have also begun to attract attention in lowand middle-income countries. Mobile phone consultations for general medical conditions were found to be acceptable and feasible in rural India for a variety of skin, respiratory, mental health and sexual problems (Bali and Singh, 2007). Youth in South Africa also appear receptive to mobile phone engagement for research (van Heerden et al., 2010). The depth of mobile phone saturation and its easy functionality among people worldwide have even led to research agendas planned around its integration (Collins et al., 2011). Mobile phones could therefore complement

N.K. Aggarwal / Asian Journal of Psychiatry 5 (2012) 225–230

226 Table 1 Mental Health Resource Statistics for South Asia. Populationa

Health budgetb

Psychiatric bedsc

Psychiatristsd

Psychiatric nursesd

Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka

24.93 149.66 2.32 1081.00 0.33 25.72 157.32 19.22

5.20 3.50 3.90 5.10 6.70 0.05 0.04 3.60

0.06 0.07 0 0.25 0 0.08 0.24 1.80

0.04 0.05 0.3 0.2 0.36 0.12 0.2 0.2

0.07 0.06 0.16 0.05 0 0.08 0.08 1.80

South Asia Europee Worlde

1460.49 830.36 6697.00

3.51 14.30 14.50

0.24 8.00 1.69

0.18 9.8 1.20

0.08 24.8 2.00

Psychologistsd

Social workersd

0.09 0.002 0 0.03 1.2 0.08 0.2 0.02

0 0.001 0 0.03 0 0.04 0.4 0.07

0.05 3.1 0.60

0.07 1.5 0.40

Data source: World Health Organization (2005). a b c d e

Population figures in millions. Health budget as percentage of gross domestic product. Beds per 10,000 population. All health professional figures as per 100,000 population. Regional figures include mean number of health professionals for Europe and the world.

telepsychiatry programs in India (Thara et al., 2008) and Nepal (Anonymous, 1998) that aim to deliver mental health services for a large population without adequate providers. This interest in mobile technologies points to new opportunities for patient engagement and treatment of mental disorders. Below, two issues are discussed in depth: the abundance of mobile phones in South Asian countries compared to the dearth of mental health services and the acceptance of mobile technologies as a medium of communication that can resolve barriers to treatment. Each development hints that mobile technologies may be incorporated within mental health service delivery through culturally appropriate methods. 2. Mobile phone networks and mental health infrastructure It has long been recognized that South Asian countries lack public mental health infrastructure. At the level of education, psychiatry is not often taught as a separate subject in South Asian countries, with the exception of Sri Lanka, and postgraduate training opportunities are fewer than in other specialties (Trivedi and Dhyani, 2007). The relative few who train in psychiatry migrate to high-income countries, exacerbating the delivery gap (Jenkins et al., 2010) and resulting in loss of human capital. At the level of service delivery, poor health facilities, health knowledge, and health awareness programs have been observed in Bangladesh (Hosain et al., 2007; Islam et al., 2003), India (Khandelwal et al., 2004), and Pakistan (Yousaf, 1997; Gilani et al., 2005; Naqvi, 2005) in varying degrees. War has only compounded these problems in Afghanistan (Cardozo et al., 2004; Scholte et al., 2004; Miller et al., 2008; Panter-Brick et al., 2011), Nepal (Regmi et al., 2004) and Sri Lanka (Nagai et al., 2007). At the level of government commitment, mental health budgets, officials, policy, and comprehensive legislation are insufficient in many of the 153 low- and middleincome countries (Jacob et al., 2007) (Table 1). The urgent need for medical providers has led to innovative propositions. It has been suggested that psychiatrists should relinquish certain interventions to non-specialist health workers and focus instead on optimizing such programs, building clinical capacity, and conducting research (Patel, 2009, 2010). The clinical training of psychiatrists equips them with the ability to provide supervision to non-specialist workers and the scientific base to distinguish among interventions requiring generalist or specialist attention. This proposal corresponds to calls for psychiatrists to focus on systems-level, public health interventions that target common problems such as suicide rather than strictly concentrat-

ing on individual risk factors (Jacob, 2010). Decentralization of mental health services with integration into primary care and community activities could also expand the reach of services (Saraceno et al., 2007). Against this backdrop, the proliferation of mobile phone use throughout South Asia provides an informative counterpoint to the paucity of mental health providers. Current data for all South Asian countries are not available, but statistics of mobile phone use indicate rising growth (Table 2). These figures suggest that the number of mobile phone subscribers is approaching the total population for many South Asian countries. In the Maldives, mobile subscriptions have actually exceeded the total population. Several points should be kept in mind: there may be intra-country differences based on rural/urban mobile density (i.e. the digital divide) and regional development. Also, a single user may subscribe to multiple service providers based on data plan. However, the economies of scale hint that mental health delivery could be transformed by harnessing mobile technologies rather than limiting services strictly to mental health providers. Mobile phone technologies also present an opportunity for intraregional collaborations. South Asian countries share similar cultures, family structures, treatment models, and common barriers to treatment such as stigma (Chaudhry, 2010). Given Table 2 Cell phone statistics for South Asia.

Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka a

Mobile subscribersa

Total populationa,c

% Population

17b 79d 0.39e 850f 0.52g 7h 108i 17j

34.4 148.7 0.66 1170 0.31 29.9 173.5 20.8

49.4 53.1 59.1 72.6 167 23.4 62.2 81.7

All table population figures in millions. Ministry of Communications and Information Technology of the Islamic Republic of Afghanistan (2011). c World Bank (2011). d Bangladesh Telecommunication Regulatory Commission (2011). e Pem (2011). f Telecom Regulatory Authority of India (2011). g SAARC (2011). h Shrestha (2011). i Pakistan Telecommunication Authority (2011). j Telecommunications Regulatory Commission of Sri Lanka (2010). b

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these commonalities, culturally appropriate psychotherapies, technology for health delivery, and local classification systems could be evolved for improved service provision (Trivedi et al., 2007). Borders in South Asia reflect colonial policies that separated communities living together for centuries – indeed, ethnic groups such as Pashtuns, Balochis, Punjabis, Sindhis, Kashmiris, Marwaris, Rajputs, Tibetans, and Tamils belong to more than one country. Intraregional collaboration can capitalize on common linguistic, religious, and ethnic bonds. Research findings from one population common to two countries could be disseminated to promote evidence-based practices. For example, mobile platform interfaces developed in one language and region could be implemented in a similar population of a different country to test suitability and need for modification. Exchange of information technologies can further refine mobile platforms and stimulate a market for health innovation. Intraregional bodies such as the South Asian Association for Regional Cooperation and the World Psychiatric Association could promote scientific exchanges and knowledge transfer. Intraregional collaboration may therefore foster an indigenous evidence base in contrast to the importation of findings from different socio-cultural and geographical groups. Furthermore, mobile technologies may help to restore social infrastructure for the general health and mental health of a population in disaster settings. Recent floods in Pakistan as well as annual monsoons and floods in India and Bangladesh point to the possibilities of cooperation. The 2005 tsunami compelled South Asian psychiatrists to explicitly envision mental health within national disaster-preparedness policy (Chandra et al., 2006; Choudhury et al., 2006; Dorji, 2006; Ibrahim and Hameed, 2006). Mobile phones in such settings could be utilized in several ways. First, telecommunications companies could be integrated within disaster management with text alerts on the imminence of a catastrophe. Second, mobile phone subscribers could be asked to respond to text message prompts on survival status. Basic screening for mood and anxiety disorders could also occur through keypad entry interfaces. Finally, updates on nearest locations of emergency and medical provisions could be coordinated with global positioning systems. The readiness of these complex interventions may be years away, but they point to future directions for research and industry applications. 3. Mobile phones as a culturally appropriate means of mental health engagement A potentially obvious but key point about mobile phones is their cultural relevance in South Asia. With the international spread of biotechnologies, medical anthropologists (Good, 1995; Lock, 2007) have called for studies of their impact on local cultures. Although such studies are not yet available about the medical use of mobile phones in South Asia, mobile phones may help to resolve persistent barriers in mental health care. Common mental disorders have been defined as depressive and anxiety disorders that cause morbidity and disability in primary care (Patel and Kleinman, 2003). Prospective mobile technology use in these conditions is a helpful thought exercise given shared regional challenges in patient engagement.  Stigma: Many people with depression feel stigmatized through the medicalization of their illness and prefer community interventions to health care settings (Rahman, 2007; Wasan et al., 2009). People with depression are frequently ostracized from families and communities (Farooqi, 2006; Kermode et al., 2009a; Shankar et al., 2006). Studies conducted in high-income countries suggest that mobile phones may reduce stigma through personalized phone calls to patients and text messages for appointment and treatment adherence. Culturally appropri-

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ate health literacy applications can also be envisioned through automated text messaging. While this may not entirely eliminate stigma, it could improve the initiation of care.  Lack of interpersonal support: Many people with depression view their illness as caused by psychosocial stressors such as interpersonal problems with family or friends and failure to meet role obligations (Kermode et al., 2009b; Naeem et al., 2004; Pereira et al., 2007; Shankar et al., 2006; Weiss et al., 1995). Interpersonal support from people within the community is often preferred over visits to physicians, especially psychiatrists (Kermode et al., 2009b). Mobile phones may be able to provide supportive care. For example, patients could call community and lay health workers analogous to help lines in Western countries. People can also use mobile phones to access peer support through conference calls. Peer-supported interventions already hold promise in obesity reduction programs in high-income countries (Fukuoka et al., 2011). Interviews and focus groups could determine how people define peers in the community and whether they would prefer conversations on mobile phones as supportive interventions.  Barriers to access: A number of factors influence patient decisions to seek mental health care. These may include the devaluation of psychotherapy as a legitimate intervention within a medical setting (Wasan et al., 2009) and lack of mobility to seek treatment, especially with women in patriarchal households (Farooqi, 2006). Mobile phones can increase access by bringing interventions to the patient rather than requiring the patient to go to the intervention. Patients can use phones to complete questionnaires on mood, anxiety, and substance disorders through text messaging or special program. Results suggesting an acute need for care can reach providers through phone, text, or email messages. Hospitals can also dispatch community health workers with phones to relay information on treatment adherence, appointment reminders, and physician queries through text messaging (Mahmud et al., 2010). This intervention has lowered patient transportation costs, optimized hospital personnel time, and increased hospital clinical capacities. This conceptual outline of common obstacles to patient engagement is not meant to imply that mobile phones are a panacea. In fact, health programs may face partial success or even total demise if social and cultural differences between providers and recipients are not bridged (Hahn and Inhorn, 2009). The health beliefs of a particular culture must be ascertained to supplement health campaigns too often steeped uncritically in biomedical models (Napolitano and Jones, 2006). Mobile phones may mark a widely feasible, acceptable, useful, and appropriate form of general communication throughout South Asia, but studies are needed to determine whether they can serve as a medium for engaging patients with health information and interventions. 4. Potential pitfalls in the mobile platform interventions for mental health The advantages of mobile phone interventions must be weighed against several disadvantages. This can be conceptualized in two domains: (1) factors inherent within the patient–physician relationship and (2) factors related to the telecommunications industry. Each domain is assessed below. The use of mobile phones as an instrument within the patient– physician relationship raises familiar bioethical questions. Privacy remains a major issue, especially if patients are discussing sensitive information within the earshot of others. Similarly, text messages and other transmitted data can fall into the hands of others unless deleted (McGee, 2011). A related topic concerns the privacy of minors who may seek counseling without parental consent (McGee, 2011). While cellular information can be

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encrypted to preserve confidentiality, there is no way to guarantee the authenticity of the caller and safeguard against prank calls (Sneiderman and Ackerman, 2004). Protections may need to be standardized and instituted, such as reminders to delete confidential information, caller identification so that patients can feel assured of contact with true clinicians, and age restrictions – or allowances based on local laws – regarding access to mobile phone health applications. At a broader level, factors related to the telecommunications industry include the reliability and sustainability of connections. The Taliban have threatened mobile phone providers with draconian forms of punishment if they do not observe an embargo on night services, wary of informants relaying intelligence to American and Afghan government forces (Rubin, 2011). Sudden interruptions of telecommunications networks could traumatize those in the midst of seeking services and would prevent new users from engaging technology. Similarly, India has witnessed corruption charges regarding the sale of second-generation telecommunications broadband networks (Timmons, 2010). While penalties have yet to be announced, interruption in mobile services would affect subscribers and, consequently, the ability to engage patients through technology.

5. Discussion This paper has introduced the concept of applying mobile technologies to mental health service delivery in South Asia. Mobile phone interventions are increasingly gaining ground in high-income countries and preliminary studies indicate that South Asian countries could also benefit from this technology. The vast numbers of mobile phone subscribers demonstrate the usability of this technology and mobile phones could serve as an intervening stratum of engagement between patients and clinicians. This technology may offer a culturally appropriate way to reduce stigma, lack of interpersonal support, and barriers to access. A sustained research agenda in this field would require investigation along several avenues. First, while South Asians may freely interact with their cell phones, would they want to receive and transmit mental health information through this technology? This is an open question and, quite possibly, the most crucial to answer before developing research programs. The high market penetration of mobile phones throughout South Asia does not necessarily imply that patients would want to use them for health purposes. Interdisciplinary research from cultural psychiatry, medical anthropology, and the fledgling field of science and technology studies (STS) could contribute answers in this direction. For example, the explanatory models approach from cultural psychiatry could clarify help-seeking attitudes and potential idioms of distress for mobile phone content development. This would be helpful in elucidating pathways to care and customizing content for stigma reduction, health literacy, and treatment adherence. Ethnographic observations and semistructured interviews from medical anthropology could produce thick descriptions of how cell phones are used within the daily lives of potential subjects. Post-intervention anthropological studies could also assess environmental factors in a program’s success or failure. Qualitative research from STS could discover culturally appropriate and inappropriate ways of employing mobile phones for mental health purposes and how such interventions transform society. The increasing dependence on mobile technologies may lead to a reconfiguration of services, causing us to rethink how systems of mental health care are constructed. Mental health professionals may therefore find new research skills and collaboration with social scientists to their benefit in furthering this field.

Second, how would such an intervention be designed, disseminated, and deemed successful? Again, mental health providers may need to engage with non-traditional conceptual bases and stakeholders to answer these questions. People with mental illness could be enlisted throughout research design as current producers and prospective consumers of content to improve the success of an intervention. It has become increasingly appreciated that successful interventions require the investment and approval of communities who are the intended recipients of research (Wells et al., 2004; Smikowski et al., 2009). Community participation can increase internal research capacity and ownership over research (Smith and Romero, 2010) while providing essential cultural knowledge (Stacciarini et al., 2011). Semistructured interviews and focus groups could clarify the roles of mobile phones in patient lives as well as their preferred method of engagement: direct voice, text message, or mobile application. This is not a trivial consideration given that highly technical applications may require advanced phones unaffordable for many South Asians. At the same time, text messaging may be considered too impersonal. Limitations in literacy may require simpler interventions through keypad entry or voice recognition. Thus, the way(s) patients prefer to utilize mobile phones remains an open question. Once content questions are answered, mental health professionals would then need to think about design. Here, researchers could partner with software engineers and specialists in biomedical informatics to create, test, and refine appropriate interfaces. Definable metrics should be established through surveys, interviews, and focus groups for feasibility, acceptability, appropriateness, uptake, and cost-effectiveness at an early stage; implementation fidelity and penetration at mid-stage; and sustainability at a late stage of the intervention (Proctor et al., 2009, 2011). This could appraise the public health impact of the intervention (Glasgow et al., 1999), too often lacking for eHealth research (Glasgow, 2007), and point to general directions for scale up. Finally, who would bear the responsibility of providing such an intervention? At the government level, cooperation between ministries of health and telecommunications could advance development. Ideally, this would take place domestically as well as internationally. Ministries of commerce and revenue could also provide tax incentives for companies that demonstrate tangible health improvements through mobile applications. At the social level, the government could incentivize telecommunications companies to freely offer health programs as a means of corporate responsibility. At the same time, non-profit and private organizations may be able to promote design and dissemination. At the medical level, clinicians would need to agree that this technology could serve their purposes rather than burden them. While there are numerous impediments to immediate deployment, the time may be ripe for studies that make the case for mobile technology health use in South Asia. Conflicts of interest None. Role of funding source None. References Anonymous, 1998. Nepal sets up telepsychiatry program. Telemed. Virtual Real. 3 (4), 46. Bali, S., Singh, A.J., 2007. Mobile phone consultation for community health care in rural north India. J. Telemed. Telecare 13 (8), 421–424.

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