Post on 18-Dec-2021
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Beyond Magical Thinking
Tom Insel, MDCo-founder and President, Mindstrong Health
Chair, Steinberg InstituteSept 20, 2019
Centennial Conference
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Equity in Alphabet, Apple, Compass Pathways, Mindstrong Health, Sage Therapeutics, Karuna Therapeutics
Board Service: Alto Neurosciences, NeuraWell, Compass Pathways, Mindstrong Health
Non-profit Board Service: Autism Science Foundation, International Neuroethics Society, Steinberg Institute
Disclosures
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Case & Deaton, Brookings, 2017Norman Rockwell, Stockbridge, 1894 -1978
Diseases of DespairSuicideDrug overdoseAlcoholic liver disease
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What is the crisis in mental health?
No reduction in morbidity or mortality
Percent change in mortality
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Why do we have this crisis in care?
60% not receiving careLack of Engagement
Lack of Quality Fragmented, episodic, reactive
Lack of Measurement
We don’t manage what we don’t measure
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UnderservedReceive Minimally
Acceptable Care
SOURCES: NSDUH (2013); Kessler, Chiu, Demler, & Walters (2005); Wang, Lane, Olfson, Pincus, Wells, Kessler (2005); Merikangas , He, Burstein, Swendsen, Avenevoli, Case, Georgiades, Heaton, Swanson,
Olfson (2011), SSA Publication 13-11827 (2014)
~44 million people in the U.S. with any disorder; ~10 million “serious”
NoBenefit
SomeBenefit
FullBenefit
ReceiveServices
The 40-40-30 Rule
Lack of Engagement
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0 50000 100000 150000 200000 250000
Social workers
Psychologists
Psychiatrists
Number of Practitioners in US
0 10 20 30 40 50 60 70
Social workers
Psychologists
Psychiatrists
Percent of Programs Lacking Training in Any EBT
Figure 4.1 (A) The number of practitioners for social work, psychology, and psychiatry in the US. In (B) the percentage of programs for these practitioners lacking training in psychotherapies considered evidence-based treatments (EBT). Data adapted from Weissman et al, Arch Gen Psych 2006)
Quality – The Mental Health Workforce
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0
10
20
30
40
50
60
70
80
90
100
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Percent Meeting Quality StandardMental Health vs Cardiovascular
2005 - 2016
MH-Private MH-Medicaid MH-Medicare
CV-Private CV-Medicaid CV-Medicare
Figure 4-1 Mental health vs cardiovascular quality scores 2005 – 2016. Data show percentage of population meeting quality standard for a mental health measure (outpatient follow-up within 7 days of hospital discharge) compared to a cardiovascular measure (persistence of beta-blocker treatment for 6 months after hospitalization for a heart attack) in patients with private insurance, Medicaid, or Medicare. Improvements across time are evident in cardiovascular care but not psychiatric care.
Quality – HEDIS Measures
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WHAT WE DO TODAY
• Subjective
• Episodic
• Clinic-based
• High Burden
MEASURING MOOD, COGNITION, AND BEHAVIOR
WHAT WE NEED
• Objective
• Continuous
• Ecological
• Passive
Lack of Measurement
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If you don’t get feedback, your confidence grows much faster than your accuracy.
Philip Tetlock, Superforecasting
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GenomicsNeuroscience
Technology +Information
Science
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Will Digital Tools Disrupt Healthcare?
Services - Digital Age
Consumer-focused
Virtual
On demand
Transparent
Information rich
Proactive
Provider-focused
Brick and mortar
Delayed
Opaque
Information poor
Reactive
Healthcare - 2019
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The Changing Ecosystem of Health Research
Start-ups:$22B invested in Health Tech since 2011> 1,000 new companies(Rock Health, 2018)
Tech Giants with health/biomedical initiatives:Alibaba, Alphabet, Amazon, Apple, Facebook, Fitbit, GE, IBM, Intel, Microsoft
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SENSORSActivity
LocationSociality
VOICE/SPEECHProsody
SentimentCoherence
HCI - KEYBOARDReaction Time
AttentionMemory
Executive Function
DIGITAL PHENOTYPINGA New Kind of Biomarker
Digital phenotype can also include“digital exhaust” (social media posts,search terms, AI personal assistantsetc.)
Feature ExtractionPattern RecognitionMachine Learning
Digital Phenotype =Cognition, Mood, Behavior
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detecting deteriorationto prevent crisis
I'm doing a lot better. I was experiencing a lot of auditory hallucinations. They made it difficult to sleep which made things progressively worse.
I checked myself into the hospital. They adjusted my medications, gave group
therapy, and monitored me. I believe I slept for 12 hours each night 3 days in a row.
What a relief! The hallucinations finally subsided.
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WHAT WE DO TODAY
• Subjective
• Episodic
• Clinic-based
• High Burden
MEASURING MOOD, COGNITION, AND BEHAVIOUR
WHAT WE NEED
Objective
Continuous
Ecological
Passive
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Mobile Interventions
CBT, DBT, IPT; Coaching; Peer
Support; Crisis InterventionThe Digital
Health Landscape
Learning Engine
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Digital Phenotyping AI Nurse Connected Care Manager Dashboard
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Lack of Engagement
Lack of Quality
Lack of Measurement
Anonymous, person-centered online care
Coordinated, connected care with quality metrics
The Digital Future for Psychiatry?
Digital smoke alarms for early detection of recovery and
relapse
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Magical Thinking: The belief that a simple cause will explain a complex result or that a simple solution will fix a complex problem.
Causes: Sexual conflict (1920 – 1970), Serotonin deficiency (1970 – 2000), Trauma (2000 – ?)
Solutions: Interpretations (1950 – 1970), Medications (1970 – ?), Technology (2015 -?)
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The Four P’s : A Medical Approach to Bending the Curve
Predictive – identify risk profile
Preemptive – move upstream
Personalized – individualize interventions
Participatory – shared decision making
Beyond Magical Thinking
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Beyond Magical Thinking
The mental health crisis can be defined as medical…
The solutions are complex combinations of medical (neuromodulatory), cognitive (skills), social (connections), commitment (purposes), and spiritual (compassion) interventions.
But
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Service User
Medication/ Primary Care
Cognitive & Behavioral Therapies
Supported Employment & Education
Family Education
and Support
Case Management
Coordinated Specialty Care for FEP
Shared decision makingPersonalized medical care
Skill buildingSocial inclusion
Academic/work support
Focusing on recovery:
Technology for scale
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Service User
Primary Care
Supportive Housing
Supported Employment
Criminal Justice
Diversion
Case Management/ACT teams
Whole Person Care for SPMI
Medical careSUD TreatmentSocial inclusion
Housing & WorkNo wrong door
Closing the longevity gap:
Technology for scale
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Family
Primary Care
Psycho-education
Peer SupportSchool Mental Health
Early Childhood Supports
Moving Upstream
Nurse visitationMental fitness
Emotional regulationMindfulness
Education
Building resilience:
Technology for scale
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Case & Deaton, Brookings, 2017Norman Rockwell, Stockbridge, 1894 -1978
Diseases of DespairSuicideDrug overdoseAlcoholic liver disease
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Camelot for Mental Healthcare
PredictivePreemptive
PersonalizedParticipatory
CognitionCompassionConnection
Commitment+
Integration with SUD, Primary Care
Reimbursement that Recruits and Retains Providers
Engagement of schools, families, communities
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Conclusion• Our mental health crisis is a crisis of care.
• We know what to do to resolve this crisis but we are failing to act. [WE ARE THE PROBLEM.]
• The cause is a set of medical brain disorders but the solutions will require a comprehensive set of interventions.[COGNITION, CONNECTION, COMPASSION, COMMITMENT]
• WE CAN FIX THIS.[BUT NOT THROUGH MAGICAL THINKING]
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Transforming Brain Healthtom@mindstronghealth.com
tom@steinberginstitute.org
Thank You!