Person: Torous, John
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Torous, John
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Publication Creating boundaries to empower digital health technology(Royal College of Psychiatrists, 2018-07) Hsin, Honor; Torous, JohnThe potential of digital health tools such as smartphones and sensors to increase access to and enhance delivery of healthcare is well known. However, a lack of regulation and delineation between those technologies seeking to offer direct clinical diagnostics and treatments and those involving clinical care enhancements or direct-to-consumer resources has led to patient and clinician confusion about the appropriate use and role of digital health. Here, we propose that creating boundaries and better defining the scope of digital health technology will advance the field through matching the right use cases with the right tools. We further propose that ethical clinicians, as stewards of standard of care, are well suited to uphold these boundaries and to safeguard best practices in digital health.Publication A crossroad for validating digital tools in schizophrenia and mental health(Nature Publishing Group UK, 2018) Torous, John; Staples, Patrick; Barnett, Ian; Onnela, Jukka-Pekka; Keshavan, MatcheriPublication Recent advances in understanding schizophrenia(Faculty of 1000 Ltd, 2014) Haller, Chiara; Padmanabhan, Jaya; Lizano, Paulo; Torous, John; Keshavan, MatcheriSchizophrenia is a highly disabling disorder whose causes remain to be better understood, and treatments have to be improved. However, several recent advances have been made in diagnosis, etiopathology, and treatment. Whereas reliability of diagnosis has improved with operational criteria, including Diagnostic and Statistical Manual of Mental Disorders, (DSM) Fifth Edition, validity of the disease boundaries remains unclear because of substantive overlaps with other psychotic disorders. Recent emphasis on dimensional approaches and translational bio-behavioral research domain criteria may eventually help move toward a neuroscience-based definition of schizophrenia. The etiology of schizophrenia is now thought to be multifactorial, with multiple small-effect and fewer large-effect susceptibility genes interacting with several environmental factors. These factors may lead to developmentally mediated alterations in neuroplasticity, manifesting in a cascade of neurotransmitter and circuit dysfunctions and impaired connectivity with an onset around early adolescence. Such etiopathological understanding has motivated a renewed search for novel pharmacological as well as psychotherapeutic targets. Addressing the core features of the illness, such as cognitive deficits and negative symptoms, and developing hypothesis-driven early interventions and preventive strategies are high-priority goals for the field. Schizophrenia is a severe, chronic mental disorder and is among the most disabling disorders in all of medicine. It is estimated by the National Institute of Mental Health (NIMH) that 2.4 million people over the age of 18 in the US suffer from schizophrenia. This illness typically begins in adolescence and derails the formative goals of school, family, and work, leading to considerable suffering and disability and reduced life expectancy by about 20 years. Treatment outcomes are variable, and some people are successfully treated and reintegrated (i.e. go back to work). Despite the effort of many experts in the field, however, schizophrenia remains a chronic relapsing and remitting disorder associated with significant impairments in social and vocational functioning and a shortened lifespan. Comprehensive treatment entails a multi-modal approach, including psychopharmacology, psychosocial interventions, and assistance with housing and financial sustenance. Research to date suggests a network of genetic, neural, behavioral, and environmental factors to be responsible for its development and course. This article aims to summarize and explain recent advancements in research on schizophrenia, to suggest how these recent discoveries may lead to a better understanding and possible further development of effective therapies, and to highlight the paradigm shifts that have taken place in our understanding of the diagnosis, etiopathology, and treatment.Publication Creating a Pilot Educational Psychiatry Website: Opportunities, Barriers, and Next Steps(JMIR Publications Inc., 2015) Torous, John; O'Connor, Ryan; Franzen, Jamie; Snow, Caitlin; Boland, Robert; Kitts, RobertBackground: While medical students and residents may be utilizing websites as online learning resources, medical trainees and educators now have the opportunity to create such educational websites and digital tools on their own. However, the process and theory of building educational websites for medical education have not yet been fully explored. Objective: To understand the opportunities, barriers, and process of creating a novel medical educational website. Methods: We created a pilot psychiatric educational website to better understand the options, opportunities, challenges, and processes involved in the creation of a psychiatric educational website. We sought to integrate visual and interactive Web design elements to underscore the potential of such Web technology. Results: A pilot website (PsychOnCall) was created to demonstrate the potential of Web technology in medical and psychiatric education. Conclusions: Creating an educational website is now technically easier than ever before, and the primary challenge no longer is technology but rather the creation, validation, and maintenance of information for such websites as well as translating text-based didactics into visual and interactive tools. Medical educators can influence the design and implementation of online educational resources through creating their own websites and engaging medical students and residents in the process.Publication Bipolar disorder in the digital age: new tools for the same illness(Springer Berlin Heidelberg, 2016) Torous, John; Summergrad, Paul; Nassir Ghaemi, S.“Nothing is more difficult than to ascertain the length of time that a maniacal patient can exist without sleep.”—Dr. Sutherland (Br J Psychiatry 7(37):1–19, 1861). Dr. Sutherland’s patient was suffering from an acute manic episode, which today is called bipolar illness. 150 years later, we continue to struggle with the same challenges in ascertaining accurate symptoms from patients. In era of new digital tools, the quantified self-movement, and precision medicine, we can ask the question: Can we advance understanding and treatment for bipolar illness beyond asking the same questions as in 1861?Publication Patient Smartphone Ownership and Interest in Mobile Apps to Monitor Symptoms of Mental Health Conditions: A Survey in Four Geographically Distinct Psychiatric Clinics(JMIR Publications Inc., 2014) Torous, John; Chan, Steven Richard; Yee-Marie Tan, Shih; Behrens, Jacob; Mathew, Ian; Conrad, Erich J; Hinton, Ladson; Yellowlees, Peter; Keshavan, MatcheriBackground: Despite growing interest in mobile mental health and utilization of smartphone technology to monitor psychiatric symptoms, there remains a lack of knowledge both regarding patient ownership of smartphones and their interest in using such to monitor their mental health. Objective: To provide data on psychiatric outpatients’ prevalence of smartphone ownership and interest in using their smartphones to run applications to monitor their mental health. Methods: We surveyed 320 psychiatric outpatients from four clinics around the United States in order to capture a geographically and socioeconomically diverse patient population. These comprised a state clinic in Massachusetts (n=108), a county clinic in California (n=56), a hybrid public and private clinic in Louisiana (n=50), and a private/university clinic in Wisconsin (n=106). Results: Smartphone ownership and interest in utilizing such to monitor mental health varied by both clinic type and age with overall ownership of 62.5% (200/320), which is slightly higher than the average United States’ rate of ownership of 58% in January 2014. Overall patient interest in utilizing smartphones to monitor symptoms was 70.6% (226/320). Conclusions: These results suggest that psychiatric outpatients are interested in using their smartphones to monitor their mental health and own the smartphones capable of running mental healthcare related mobile applications.Publication Corrigendum: Barriers, Benefits, and Beliefs of Brain Training Smartphone Apps: An Internet Survey of Younger US Consumers(Frontiers Media S.A., 2016) Torous, John; Staples, Patrick; Fenstermacher, Elizabeth; Dean, Jason; Keshavan, MatcheriPublication Utilizing a Personal Smartphone Custom App to Assess the Patient Health Questionnaire-9 (PHQ-9) Depressive Symptoms in Patients With Major Depressive Disorder(JMIR Publications Inc., 2015) Torous, John; Staples, Patrick; Shanahan, Meghan; Lin, Charlie; Peck, Pamela; Keshavan, Matcheri; Onnela, Jukka-PekkaBackground: Accurate reporting of patient symptoms is critical for diagnosis and therapeutic monitoring in psychiatry. Smartphones offer an accessible, low-cost means to collect patient symptoms in real time and aid in care. Objective: To investigate adherence among psychiatric outpatients diagnosed with major depressive disorder in utilizing their personal smartphones to run a custom app to monitor Patient Health Questionnaire-9 (PHQ-9) depression symptoms, as well as to examine the correlation of these scores to traditionally administered (paper-and-pencil) PHQ-9 scores. Methods: A total of 13 patients with major depressive disorder, referred by their clinicians, received standard outpatient treatment and, in addition, utilized their personal smartphones to run the study app to monitor their symptoms. Subjects downloaded and used the Mindful Moods app on their personal smartphone to complete up to three survey sessions per day, during which a randomized subset of PHQ-9 symptoms of major depressive disorder were assessed on a Likert scale. The study lasted 29 or 30 days without additional follow-up. Outcome measures included adherence, measured by the percentage of completed survey sessions, and estimates of daily PHQ-9 scores collected from the smartphone app, as well as from the traditionally administered PHQ-9. Results: Overall adherence was 77.78% (903/1161) and varied with time of day. PHQ-9 estimates collected from the app strongly correlated (r=.84) with traditionally administered PHQ-9 scores, but app-collected scores were 3.02 (SD 2.25) points higher on average. More subjects reported suicidal ideation using the app than they did on the traditionally administered PHQ-9. Conclusions: Patients with major depressive disorder are able to utilize an app on their personal smartphones to self-assess their symptoms of major depressive disorder with high levels of adherence. These app-collected results correlate with the traditionally administered PHQ-9. Scores recorded from the app may potentially be more sensitive and better able to capture suicidality than the traditional PHQ-9.Publication Empowering the Digital Therapeutic Relationship: Virtual Clinics for Digital Health Interventions(Nature, 2018) Torous, John; Hsin, HonorAs “digital phenotyping” and monitoring technologies begin to unleash the potential of data insights for mental health care, we propose here a complementary concept of the “digital therapeutic relationship” to unleash the power of the patient-provider alliance in clinical care. In millions of clinics today, care decisions are made on a daily basis in the context of a relationship honed through professional training to be respectful, protective, and empowering of patients. Now as clinical care evolves toward online and especially mobile platforms, it is critical to not ignore the digital therapeutic relationship and instead to realize that supporting it will require new and innovative means of care delivery. Here, we propose that technology can be harnessed to facilitate, augment, and expand these relationships directly, and identify virtual clinics as the currently missing but necessary environment to unleash the true potential of digital medicine. Introduction On paper, digital health tools like smartphone apps appear to be the ideal solution to the current mental health crisis. Depression is now the leading cause of disability worldwide, and mental health disorders impact one in four people globally, yet current and projected future access to care and treatment remain inadequate. Today’s limited access to clinical care stands in contrast to the ubiquity of smartphones, heterogeneity in care delivery in contrast to standardized protocols of apps, and snapshot diagnostic assessments in contrast to continuous longitudinal monitoring by phone sensors. Digital phenotyping, the moment-by-moment quantification of individual-level human behavior and physiology in situ using data from smartphones and other personal digital devices1 offers a new window into understanding and addressing the real-world lived experience of illness. Yet the reality of digital health services like apps is different—uptake is low in clinics and engagement remains poor among the public.2,3 Searching for the cause of this striking disparity has proven difficult because it is neither tangible nor a fault in apps, clinicians, or patients. Rather we propose that a failure to address the digital interaction between patients and clinicians—the digital therapeutic relationship—and resulting lack of support for this new relationship limits the true potential of digital care.Publication Electronic behavioral interventions for headache: a systematic review(Springer Milan, 2016) Minen, Mia Tova; Torous, John; Raynowska, Jenelle; Piazza, Allison; Grudzen, Corita; Powers, Scott; Lipton, Richard; Sevick, Mary AnnBackground: There is increasing interest in using electronic behavioral interventions as well as mobile technologies such as smartphones for improving the care of chronic disabling diseases such as migraines. However, less is known about the current clinical evidence for the feasibility and effectiveness of such behavioral interventions. Objective: To review the published literature of behavioral interventions for primary headache disorders delivered by electronic means suitable for use outside of the clinician’s office. Methods: An electronic database search of PubMed, PsycINFO, and Embase was conducted through December 11, 2015. All eligible studies were systematically reviewed to examine the modality in which treatment was delivered (computer, smartphone, watch and other), types of behavioral intervention delivered (cognitive behavioral therapy [CBT], biofeedback, relaxation, other), the headache type being treated, duration of treatment, adherence, and outcomes obtained by the trials to examine the overall feasibility of electronic behavioral interventions for headache. Results: Our search produced 291 results from which 23 eligible articles were identified. Fourteen studies used the internet via the computer, 2 used Personal Digital Assistants, 2 used CD ROM and 5 used other types of devices. None used smartphones or wearable devices. Four were pilot studies (N ≤ 10) which assessed feasibility. For the behavioral intervention, CBT was used in 11 (48 %) of the studies, relaxation was used in 8 (35 %) of the studies, and biofeedback was used in 5 (22 %) of the studies. The majority of studies (14/23, 61 %) used more than one type of behavioral modality. The duration of therapy ranged from 4–8 weeks for CBT with a mean of 5.9 weeks. The duration of other behavioral interventions ranged from 4 days to 60 months. Outcomes measured varied widely across the individual studies. Conclusions: Despite the move toward individualized medicine and mHealth, the current literature shows that most studies using electronic behavioral intervention for the treatment of headache did not use mobile devices. The studies examining mobile devices showed that the behavioral interventions that employed them were acceptable to patients. Data are limited on the dose required, long term efficacy, and issues related to the security and privacy of this health data. This study was registered at the PROSPERO International Prospective Register of Systematic Reviews (CRD42015032284) (Prospero, 2015).