Just some housekeeping stuff, we know this is the end of the conference, the energy levels are low, please feel free to interrupt if you have any questions, if you want to make any relevant comment, we want to make it informal and interactive as much as it's possible. So my name is Saba Afzal, I am the Residency Program Director at Hackensack Meridian Health in New Jersey, Ocean University Medical Center. I am joined by three psychiatry residents from the two residency programs that we have at Ocean University Medical Center and Jersey Shore University Medical Center. Dr. Amir Al-Samadisi, he's a PGY2 psychiatry resident at Ocean University Medical Center. Dr. Harsh Patel is also a PGY2 resident at Ocean University Medical Center and then we have Dr. Malik from Jersey Shore University Medical Center. And today our topic is new tech, new psychiatrist and new treatments. And the reason we chose this topic because I know APA asked us the same question, why are we choosing this topic, because we do feel there's a lot of work that's being done in the digital psychiatry but the research has not been really translated into the clinical work because of the apprehensions. Oh, I'm sorry, how about now, better? Okay, I think we got used to that mic. So, and the heels, they don't help. So, the topic here is new tech, new treatment and the new psychiatrist. We chose this topic because we have been looking into all the work that's been done in the digital psychiatry but it has not really been translated into the clinical work. There are a lot of apprehensions, there's a lot of fear and uncertainty that we are hoping to address today. We at Hackensack Meridian Health, we were also able to successfully launch our own section of digital psychiatry. We were the first one in the state of New Jersey to do so and ever since we have been trying to motivate and collaborate with others to just come up with the innovative solutions to, you know, address all the challenges that we are facing right now, especially with access to care. So, we are really hoping today that we will, you know, cover all these apprehensions, the challenges, limitations and the advantages that it might bring. So, very briefly, objectives today, first we will talk about relevance of recent technological advances to mental health research and care. It's very important nowadays, you know, the access to care, especially mental health is a global health issue. There's a lot that was done in recent years but there's still a need for the innovative solution. So, we are hoping that we can look into digital psychiatry to find some solutions. We will also look at the current evidence for the use of these new technological approaches across different mental health contexts. We do get asked a lot about where's the evidence? Are there any evidence-based interventions that are being translated into the digital platform? Which app do I trust? Which app I don't trust? I don't know. There are 500 apps out there. So, FDA has approved some of them but APA has also made this helpful resource for the psychiatrist where they can go onto their page to check the app effectiveness. So, this is also something that we will be sharing with you, all the resources, all the evidence-based interventions that we have come across. Some barriers, challenges, limitations, there are a lot of them. We all understand there's a lot of uncertainty. This is really rapidly changing landscape. There's a lot of development in the recent years. So, we will touch upon that as well. We are hoping to motivate you guys to learn more and possibly utilize technology in your practice. So, more to come on that. And then finally, we will be talking about the new directions for innovation in this field. So, without further ado, I will turn it over to Dr. Malik to take it from here. Thank you so much, Dr. Afzal, for setting up the stage. Mental health and COVID's impact. So, I just want to take us a little further back, COVID-19. In 2019, I remember that day very clearly. I was a third-year medical student finishing up my OBGYN rotation. And it was a Friday and we got an email to not show up next week. And, you know, I was thinking maybe it's a week, it'll be one week, I'll go back, study a little bit, take the shelf, and then move on. One week turned into one month, one month turned into a year. And that was a year of changes, a year of changes in the hospital, a year of changes for medical students, residents. And what I really felt during that one year of just staying inside, not interacting with family, friends, staying on a screen, watching Netflix maybe, it wasn't enough. I felt socially isolated. And I can't imagine for the rest of the country how that felt. People with increased psychosocial stress or people in different atmosphere environments, I can't even imagine what they went through. So, simply put, COVID had negative impacts and positive impacts on the country. Negative including increasing challenges for people with preexisting mental conditions and positive impacts, which included us trying to meet some of those needs as we continue to combat that. Now, just to paint the picture numerically, CDC reports that one in five adults carry some sort of mental health illness in 2021. That's one in five. That's almost 20% of the country. Now, if we just carry that over a little bit to understand, it takes about 11 years to take the onset of the diagnosis and treat it. That's almost a decade before we tend to the symptoms, and that's a long time. And it makes a lot of sense in the same vein that polysubstance use disorders, alcohol use disorder, went up during this time. Social isolation kind of increased that a little bit. And in the same vein, we've had increased crisis volume as well. This is just a graph, a bar graph to kind of elucidate that a little bit. If we look at the symptoms of anxiety disorder, symptoms of depression, and then comorbid symptoms as well, you can see since 2019, they have quadrupled in all of the domains. And this kind of pictures it out really well. So how far have we come along? I talked a little bit about the positives. We can look at the numbers of psychiatrists and applicants particularly. In 2014, about 10 years ago, we had about 600 applicants. In just about 10 years, that more than doubled. So we are increasing in terms of workforce and personnel, but it doesn't just stop there. The number of medications have also increased. We've had advances in our pharmacology as well. And not just in the number, but in the quality of the medications we use as well. We've had novel treatment mechanisms that are coming out. Just to point out a few examples, in 2019, we approved Zolvresso for postpartum depression. It's a novel neurosteroid for postpartum depression. And not just there, Espirvato as well, which is an NMDA modulator. We're moving further away from the classical antidepressants and the mechanisms, and also coming far along while COVID has been changing the landscape of psychiatry. Perfect. Thank you so much, Dr. Malik. So as you heard, COVID has changed the landscape of psychiatry, which kind of gets into the meat of this PowerPoint, technology and mental health. Before we kind of delve into it, I want to ask everyone here today, when I say technology and mental health, what comes to your mind? What pops up? Telepsychiatry. What else? Smartphones. Yeah. Everyone is on their smartphone. Apps. Exactly. One more time. Brain mapping. Yeah. EHR. These are all wonderful examples of all the ways technology is used in mental health. What often is also said is social media. So I want to delve into that just a little bit. So we're going to have Dr. Patel explain social media and how it's often perceived. Thank you so much, Dr. El-Samadisi. So how often do we associate social media, especially with our patients and the plethora of negative consequences? Right. I know myself when I'm seeing patients in the clinic and in the ED and teens, I'm always asking, how do you use your time? What kind of apps are you using? Who are you talking to on these apps? Right. And then we're talking about all of the ways they're interacting with their peers. And more often than not, they're reporting some sort of anxiety or depression associated with these apps. They're having issues with their self-image because they're constantly fighting or having some sort of an issue with their friends or peers. And in my assessment, I'm always interested in understanding what about bullying, right? That's a huge issue in the nation. And how is that affecting them? And more often than not, they have reported cyberbullying. In the US, about 60% of teens have reported some sort of cyberbullying. That's a huge number. And that is peer to peer interaction, right? That's something that they're doing with each other. What about YouTube and the content they're exposed to? There was a study done at Brown where they looked at 400 youth who were admitted to the inpatient psychiatric unit for suicidal ideations. And roughly 15% of them reported that they had viewed some sort of content online that promoted suicide. That is a huge number. And now when we see these patients in our hospitals and our clinics, how do we talk to them? How do we talk to the parents of these patients? We always have the agenda that, hey, maybe limit the use, right? Or maybe just take away completely. We don't really know. We're still coming up with those answers. And the American Academy of Pediatrics specifically have mentioned so many things on their website, including the negative effects of social media, including weight, sleep, self-image, the things we had discussed earlier, and also the unsafe content. Who remembers the Tide Pod Challenge? What a bizarre way to entertain ourselves, right? Right. So before we begin further, I do want to look at the neurobiology of how social media affects our brain. We're going to take a look at a quick video by Dr. Andrew Huberman. He's a neuroscientist at Stanford on his take on what social media does to the brain. Just how triggering are our phones when it comes to dopamine? OK, great question. We often hear that, you know, that social media is getting dopamine hit after dopamine hit. When we first get on social media after a while, for the first time or after a long period of time, the amount of dopamine that's released, we think, is quite substantial. It's novel. Remember, dopamine is about novelty, surprise, and the sense that we are on some exciting track. That's what dopamine is really about. It puts us into states of readiness, anticipation, looking, seeking, et cetera, almost always for things outside the confines of our skin. Just to contrast it maybe for a bit more of a future discussion, serotonin does the opposite. When there's a lot of serotonin in our brain and body, typically it makes us feel satisfied, sated, more quiescent, comfortable with what we have in our own immediate sphere and within us, right? The comfort of a good meal, the food you have. Dopamine is about go, go, go. If you look at somebody who's high on cocaine or methamphetamine, it's all about pursuit because that's a very dopaminergic drug. You look at somebody who's taking a drug, and I'm not suggesting people do this, but that really ramps up serotonin. Let's say a selective serotonin reuptake inhibitor, Prozac, Zoloft, et cetera. The side effects of those drugs, if the dosages are too high, lack of appetite, lack of libido, kind of meh about life, you know, then so they'll adjust the dose down. That's because those are serotonergic drugs. So in general, when we are in pursuit of things, dopamine is quite high. So now you have to remind me your question because I've set up the dopamine serotonin parallel. Cell phones, yes. Forgive me. So the thing about cell phones is when you first get on there and you haven't met, let's say you're no Wi-Fi on the flight or something and you land, it can actually be quite stimulating. You get a lot of dopamine. Oh, there's this. Oh, there's that. But very quickly, when you're scrolling on social media, you're no longer getting the novelty, but you're continuing to do it. You almost don't know why you're doing it. At that point, it shifts over to something that's a bit more like an obsessive, compulsive behavior where we can define an obsessive compulsive behavior where the obsession leads to a compulsion. So the obsession is a thought. The compulsion is a behavior. But the acting out of the compulsion merely serves to increase the obsession. Right. This is very different than being obsessed with food or obsessed with cleanliness. There's no payoff. Right. Exactly. There's no anxiety relief by carrying out the compulsion with OCD behaviors like scrolling social media. The dopamine quickly wanes. And then you find that you're just sort of and we've all been there. You're scrolling. Why am I doing this? This isn't that interesting. That is this isn't that interesting. Now, the algorithms for social media are very clever. And I don't want to demonize it. I, you know, provide a lot of a lot of my life has been, you know, on social media now. But in the algorithms that they've incorporated function on the the most powerful way to keep people doing a behavior or an animal, for that matter, is intermittent random reward or random intermittent reward that you don't know when you're going to hit the jackpot. So you're scrolling, you're going and then you see something. Typically, it's very high. What you know, in nerd speak, we'd say signal to noise. So if you're reading some interesting things, this came out in the news, this came out and then it's all of a sudden a riot or a person that is base jumping off a building. Or, you know, for people that are scrolling, looking at bodies or something like that, live bodies, hopefully people aren't looking at dead bodies. But look, if something's very tragic, then that has this gravitational pull. And then what happens is you start getting the system working for that next dopamine hit that you don't know when it's going to come. It's just like gambling. So I look at social media as initially being very dopaminergic, driving rewards, surprise and excitement, but very quickly transitioning to something more like OCD and the kinds of behaviors where it looks if you if we were to look at ourselves through the lens of an experiment, like we would an animal experiment, we think that animal is sick. If you saw an animal digging in the corner, looking, looking, looking, looking for a bone, the dog is looking, looking, looking, looking, looking, looking, looking, looking. You'd think that's really sad. That's us. What's happening, people? If you enjoy. So that was a brief overview on his take and sort of the neurochemistry that takes place when we're using apps and we're not just using one app. We have multiple apps where kids are getting notifications while they're studying, while they're in school, after school, before sleep, after sleep. And it really affects the brain. And over time, it can really be a necessary tool not only to study for a lot of the kids, right, they use that to communicate and be connected like we've seen, but it can also have a negative impact. And I think as psychiatrists, the more we understand this, the better we can communicate these ideas with our parents, with our kids and the teens that we see in the clinic. And technology does not just end here. Exactly. So as Dr. Patel kind of highlighted, as often social media is seen as a negative experience. It's seen as something we should tell kids to stop using. Before I go on to the next slide, I want to ask you guys these two questions. The first one is, is social media all negative? Can anyone here think of any positive uses of social media? Can you tell us one? You can speak in the microphone if you'd like. Oh, in through WhatsApp, I'm able to keep up with a lot of family members and also through Zoom with a lot of medical school classmates. So definitely makes one kind of social interactions much more possible now, and more frequent. That was beautiful. That is a perfect segue to the next slide, which will we I agree with, sir. It is on another thing is when you are talking globally, we declare that the depression, let's talk. There are lots of people cannot tell. They can express through this social media. That is a huge impact on the mental health, I think. You guys here have worded it better than I would have myself. So that is what we call positive technology. We split it into three parts. The first is social media. As you both said, it is a way to stay connected. There was a study done by the Pew Research Center that looked at a nationally representative sample. What they found is that 80% of people using social media had primarily positive and connecting experiences, especially during COVID's landscape when you really couldn't go out and see your family and go see your friends. You had to use social media as a way to create that intimacy that you might not have had otherwise. Using Zoom, using FaceTime, you were able to connect with your friends. But positive technology doesn't just end there. Next, we have video games. I feel like everyone here at some point in their life have played some video games and have found some relief. And that's the idea. There was a meta-analysis conducted by Mr. Russell Pine from the University of New Zealand. He looked at 13 of the largest studies that looked at what he called casual video gaming, which is basically playing for 30 minutes. Most people play a lot more, but that was what he looked at. And what they found is that most of the participants who use casual video games actually reported a reduction of anxiety and depressive symptom. How does that make sense? Often when we see our patients, we talk about stress relief. We talk about ways to cope. We say, like, go to the gym, exercise, working out, good nutrition. But video games can also be a way to cope. It can be a way to step back from your current life, your current stressors, and kind of be engrossed in something else. Last is technology as treatment. The most basic example is something like TMS, neuromodulation, where the actual technology is what's helping you. Even telehealth, which someone mentioned before, is an example of positive technology. Over one third of patients now seeing their mental health providers use it via telehealth. I know even me as a resident in our private clinic, so many of our patients are seen online. But the question that always we have is, is telehealth as good as in-person? And often we say, like, in-person you can see more. But there was actually a really good study that looked at in-person therapy versus telemedicine therapy. They were looking at smoking cessation, and they found it was almost pretty much exactly the same. 50% cessation with online versus in-person therapy. There was one stark difference, though. People who used telemedicine therapy were 80% more compliant, which makes sense, right? You don't have to come into the office. You can do it from home. Some people, even between jobs, they'll call you in the car, they'll park, and they're actually able to get the help that they need. And that's why positive technology's something we really need to be on the lookout for. The next part of the PowerPoint is we're gonna split it into technology as treatments. Dr. Patel is gonna talk about artificial intelligence and screening and treatment tools. Dr. Malik is gonna talk about wearables and the physical technology. And then I'm gonna wrap it up with creative technology. New, unique things are on the forefront of discovery. Let's dive right into artificial intelligence. Now, this part is more of the software of screening and treatment for mental illnesses. And artificial intelligence is this huge word, and to simplify, it's computational algorithms. These are codes written by software developers and coders. And the premise is that you take data and then you analyze it, and you use that to stratify mental illness. A study was done, and they looked at how that it was able to identify it at 70% accuracy. That's a very good number. And in artificial intelligence, we have two big umbrella terms, right? We have machine learning. So when we're thinking about that, we're thinking, okay, maybe these are algorithms that learn themselves, and then they produce more results within it. And then we have natural language processing. And specifically, NLPs are taking data, specifically textual data, analyzing it, predicting the emotional states of people, and then detecting mental illness. Where does the data come from? A lot of our data, as you can see in the graph on the right, 81% of it comes from different social media sites. Somebody had pointed out that as humans, we share a lot of our feelings, nowadays, especially with social media posts. So we'll make a Facebook post, Instagram, we'll share images, we'll share our sort of life journey that's happening, and that's all being recorded. And NLPs can take this textual data, analyze it, have different indicators, and then predict the mental illness. And how has this been done in practice? We're gonna take a look at two big studies. They were done using Twitter data and Facebook data. And this was in particular for postpartum depression. Now, they looked at 376 mothers who were active on Twitter, and with prenatal data, this was before birth, they were able to accurately predict at 71% for postpartum depression. And when they added two to three more weeks of postnatal data to this, they were able to increase it to 80 to 83%. Now, the Edinburgh scale that we do in the hospital is about 80 to 85% sensitivity and specificity. That's a very comparable number. Are you saying that Twitter data is as good as the Edinburgh postpartum depression scale? The data speaks for itself. And so that's looking at data before and after, right? And somebody had mentioned that we express ourselves through social media. The Facebook study did something similar, but in a different lens. They looked at individuals who were less interactive. And when they looked at the data, they said, mothers who had postpartum depression were 30% less interactive on Facebook. Well, that's an amazing sort of viewpoint that we can take away, because we're not seeing the patients in the visit. This data is being collected even before they come to the clinic. And most often, we can even track them and continue to follow them post-visit in the clinic. Now, that was screening, and that was using the data from social media. But we also have applications that are running on cell phones that can do much more than that. Companion MX, it's a company by Cogito. It's an app, it's a mobile app. And specifically what they did was they looked at the tone of the voice. They looked at the quality of the voice. They looked at the speaking rate of patients. They would have patients sort of check in weekly. They would also have them sort of do some exercises on that app and collect cell phone metadata. So privacy was maintained. We're not going to look at text. We're just gonna look at the number of phone calls made, the amount of messages being sent out. And when they looked at all of this, they were able to successfully predict depression and PTSD symptoms in these patients. And this is simply by them analyzing the tone of the voice. And this was done while the patient was at home in their comfortable zone. And it doesn't just stop here. There's more. As we looked at screening and detecting, we also have treatment options for depression. This artificial intelligence bot by VISA, it's a conversational agent. So we're sort of talking about this and the premise behind this was that patients can talk to somebody on the phone and sort of have a conversation when they're having a tough time. And users that used VISA more, they were able to reduce their PHQ scores by six points. That's comparable with users that used it a little less. It was 3.5, four points. That's amazing, I think, that they're able to not only have more convenient options, but also maybe they're more comfortable sharing a few things and sort of getting some sort of counseling. And a lot of them also were finding this experience helpful and encouraging. Almost 67% of them. So that was software. With an AI. It's a conversational bot. So it basically converses with you based on what you're writing and what your messages are across. And it's using NLPs as well to sort of understand, okay, is he feeling or she feeling a little bit more upset, more anxious, and sort of tracking that. So this is very promising, but I think one biggest challenge we are facing with this one is data regulation. Who's keeping the track of the data? So this is something that we still don't have answer to. We have researched a lot. There's little industry regulation there with these apps. This is something that we keep looking into. I think this is one area we need more research. And then we are hopefully able to answer more questions. But right now, they're promising results, but little data on the safety regulations and industry regulations. Perfect. So thank you so much, Dr. Patel, for going over some software technology that has been used for diagnosing, screening, and treatment. So one thing I want to point out is there's an equal amount of promise in physical and hardware technology in psychiatry. We've usually been using medication and therapy for a long amount of time, but now we have procedures using physics and using electrical stimulation and magnetic stimulation to kind of focus on some mood centers that can help depression and anxiety. One of them we're probably all familiar with is RTMS. It came out in 1985. It's larger in practice in the 2000s. The one other thing we may not be as aware of, I didn't know about this until I made this PowerPoint, was a cranioelectrical stimulation approach, particularly using gadgets like Fisher-Wallace and Alpha Stimulator. So jumping right in, what is cranioelectrical stimulation? Think of it like a mini ECT, but you have a wearable tech that applies a small amount of current right above your earlobes, and it's a tiny enough stimulation that activates parasympathetic fibers to calm you down and subsequently lowering the amount of anxiety and increasing the amount of sleep. To go over some of the research and data on cranioelectrical stimulation, there have been five large randomized control trials on cranioelectrical stimulation. One of them by the Barclay Group particularly looked at 115 participants with anxiety disorder and had them use an Alpha Stimulator for about six weeks, and they found that there was a 32% reduction in anxiety symptoms. And it doesn't stop at anxiety. There was a total amount of sleep increase just after three electrical stimulations with the Alpha Stimulator. And we all know how important sleep is. It's super intertwined with mood. So if there was an increase in sleep, there's a possibility that it helped with some of the mood symptoms as well. Now just to talk a little bit more about this gadget, Fisher-Wallace, it's been around for quite a bit of time actually. I didn't know it was around since 2009. And since 2009, there have been about 80,000 gadgets sold and 14,000 prescribers have given this particular gadget in their clinics as an adjunct to some of the mood symptoms. Now the next one is a little bit more new on the market, the Alpha Stimulator. The benefits that it carries are, it's approved by some of the insurances. Fisher-Wallace, you normally have to pay out of pocket. The Alpha Stimulator is approved by some of the insurances and it has a broader scope. It also is used for pain and more increasingly used for sleep and mood as well. Now our favorite, our alternative to some of the ECT stuff and it has been growing in the past 10 years, is RTMS. The Transmagnetic Stimulation. Using the power of magnets to stimulate an electrical stimulation just in the right areas to excite the cortex and decrease the mood symptoms. Has been growing and it has been good for some of the people that weren't as responsive to ECT. Just to give you guys an idea of when it started, when did it grow, in 2013 it was first approved for major depressive disorder and you can see just in five years, it was also approved for OCD as well. And then just following that in two years, it was cleared for smoking cessation and then it didn't stop there. It was also used for anxiety and comorbid depression as well. You can see it was a quick rise in the past 10 years. Now, how many of you guys have heard of HeartMath? Good, good number. Well, thankfully you don't have to do the math, you don't have to do addition, division, subtraction. The technology does it for you. You can use a handheld device, you can use a desktop. Essentially what it does is it uses the principles of biofeedback to kind of regulate the skin temperature, muscle tension, heart rate, blood pressure and kind of combines it onto the digital aspect of things. You can see how regulated your heart is, how much harmony is it in at the moment with the rest of your organs. And we call this coherence, being able to have that interplay of parasympathetics and sympathetics and to use that along with the meditation techniques, the yoga, to be able to achieve that intuition, maintain that composure and overall reduce fatigue. This directly plays a role into your mood. I remember the first time I used HeartMath, I think I was in the red zone for a little bit, meaning that I was out of sync. It took some time to be able to meditate and get to that green zone. So it does take time, but it does have long-lasting effects. One more time. So we have been using it, I'm gonna go to your mind. So we have been using it at our new integrative psychiatry clinic that we have at our institution. So it's a small, small device. It is connected to a software data on the laptop. So you see all the data on the laptop where it will show you the blood pressure and the heart rate and your pulse ox, it going up and down. So the goal is basically you tie it to the patient's wrist and then you look at the data, it will show you that they are in the sympathetic zone in terms of activity. So their heart rate has increased, blood pressure is up, then you ask them to do some meditation, deep breathing, and then there is objective evidence on the screen that heart rate is going down, the oxygen saturation is getting better, the blood pressure is going down. So really converting a person from sympathetic to parasympathetic state. It comes with a software, it's a small device, size of this phone. I think that there was a successful launch last year at our integrative psychiatry clinic. We have bought at least 10 of those now. And they're very popular among our patient. It's like 200 something. But insurance covers, depends on your insurance and depends on why you were referred to the integrative clinic. Yes, absolutely. It's pretty much self-regulatory and you do get all the directions when you plug it in. It will tell you do this, do that. So it's really good for people with especially the anxiety and panic disorder. But then it helps with other OCD and other things as well just to calm their minds down and just make them being more mindful of their surroundings. So this is a great question, not yet, but we just recently submitted the proposal to look at the data from the heart math and really look at the effectiveness for the in-person versus telehealth. This is the proposal, this is the hypothesis that we have developed, but we have not started recruiting patients for this research project. It depends. It depends on, you know, what I was told, because I'm the medical director of the outpatient center where we have integrative psychiatry clinic, so it really depends on the reason of the council to the integrative psychiatry, so the way you word it. Anxiety, which was resistant to the treatment with other medication, but responded really well to, you know, biofeedback and other means, and they do. We had success. Thank you. Thank you so much. So as Dr. Afzal said, it's very promising, and it's only $200, I think a little bit less if you wanna use your phone, and 25 years of research into this biofeedback and the technology aspect of it as well. So moving right along, we're gonna get into the creative and the more miscellaneous side of technology, and Dr. El-Smith. So I'm gonna talk a little bit about new kinds of technology and how they've been used. One of my favorite things is video games, so obviously we're gonna start with that. Little history lesson. In 2013, there was a study done in Nature that looked at a game called NeuroRacer. It was basically Mario Kart without green shells. It was kind of a boring racing game. But what they did find is that people who played the game actually had improved attention afterwards. If you gave them attention tasks following playing the game for a little bit, they showed that they were doing pretty well. So a company called Akili decided to take a look at this with children and ADHD. They made a game called EndeavorRX, which is basically Mario Kart, but a lot more complicated. Has a lot more intricacies, and you need to really pay attention. And this is how they got their FDA approval. There was five studies. They looked at 600 children. All they had to do was play 25 minutes a day, five days a week for four weeks. After that, if you tested them, over a third of them showed no attention deficit on at least one measure of attention on any scale. And then if you talk to the parents, over 50% of them have noted a significant decrease in their child's, sorry, well, decrease in their day-to-day missed attention. So basically, the parents were able to see their children doing better. They were able to see them staying more on task, paying attention, and it was just through a video game. The reason this is really important is because often, when we're talking about ADHD treatment, we're quick to jump to stimulants. We're quick to jump to medications. If we wanna be a little conservative, as we call it, we say, well, start Stratera, a non-stimulant option. But there are even non-medication options. These are something you can start with, you can use to augment, and they can be very helpful. I know I didn't even know about this game until I started doing this PowerPoint, and it's something I really wanna use. I'm gonna show you a little trailer of how they describe their game. Excuse me? It's called Endeavor RX. Yeah, so here, I'll show you a little clip, and that would be a perfect segue. Imagine a medicine made up of pixels and play. Created with cognitive science and proven in clinical studies. A video game that invites your child to discover new worlds. You did it! Build their universe. Capture mystic creatures. Boost past challenges. And unlock new characters. Oh, yeah! All to create positive change. Introducing Endeavor RX. The first prescription ADHD therapy. Look at us, rocking it again! Delivered through a video game experience. Designed to work alongside your treatment plan. Hey, hey, whoa! You were all wrong, and I was a hoot! Awesome! And proven to improve attention. Amir, can I add one thing here? Go for it. The first time ever I saw that video game was on my way to San Francisco, when I was in the plane. Flight got delayed, and I was sitting next to this girl who started playing this video game, and it was such a bizarre coincidence. I actually texted these guys, that, okay, so this is what you guys were talking about. So she was getting very antsy that flight is delayed, and she's getting very anxious, and I'm thinking about coping skills and other things that people of my generation would think. Then she pulled out this video game and just started playing it, and then she said, do you mind that noise? I just calmed down when I played that. So I did see that. I know it sounds really bizarre. We were on the way to the conference to talk about this, but it was just a very, really surreal experience to see that in action and how it helped her. So I think as psychiatrists it's just very important for us to know what it is and what are the options available, because these are the kids who are asking these questions all the time. The next thing I wanna talk about is virtual reality exposure therapy. If any of you were in the exhibit hall the last couple of days, there was a lot of virtual reality, so we're gonna talk about it a little bit. Basically, this is using virtual reality via device, often something like the Oculus if you've ever tried, and the two main things it's been found to really help with is specific phobias and PTSD. There was a large study that looked, I think, at about 1,000 people, and they looked at all kinds of specific phobias. Half of them were treated with virtual reality, the other half were treated with normal therapy in vivo. And they found that virtual reality was actually better than in vivo in almost everything outside arachnophobia and agoraphobia. It makes a little sense, because if there was a spider on a giant screen in front of you, you might be a little terrified. But why was it so helpful in terms of most of the specific phobias? And because it allows incremental progression. So let's say you have a fear of flying. You can start someone with maybe walking upstairs in virtual reality. So they're one floor above the ground, two floors. And then as they get a little more comfortable, you can maybe put them in a plane. As they get more comfortable, you can even make the plane have turbulence. What this allows you to do is really go incrementally, and they're doing it in the comfort of their own home or in the comfort of your practice, which allows them to ease the anxiety and really get over it. The same thing for PTSD. The way we commonly treat it now is with narrative exposure therapy. Someone comes in, we ask them about their traumatic experience. Their memory's a little fuzzy. They go home, we ask them to write about it, come back, repeat. And the more they say it and the more they get detail-oriented, they're able to remember the experience without reliving the experience, which really helps with the trauma. Virtual reality works the same way. In the first session, it could maybe be kind of like two-dimensional. It's not really gruesome. It's not really detail-oriented. So it allows them to have low stress, low anxiety as they kind of go through the game. And every step forward, it gets more detailed. This has found to be really helpful. Looking at them three months, six months, even some studies I was looking at today have shown that decrease of PTSD symptoms even a year after treatment with this. The next kind of creative technology I wanna talk about is applications used to augment current treatment. Almost all of these work via positive feedback loop. The first one is something called Reset-O. This is basically paired with buprenorphine or suboxone treatment. And it allows you to kind of communicate with your app. If you're craving, you can click that you're craving and they'll give you positive affirmations. They'll give you things you can do. They'll give you resources. In the study that they used, 80% remained in treatment versus 68% who didn't use the app. Why is this app so unique? It's developed by a company called Pair Pharmaceuticals. And if anyone's up to date, during the last two months, they're actually talking about taking it off the market or not using it. And that's what makes this very unique. When we're talking about technology, there is a burden and there is a detriment when you don't use it, is that these apps can develop better. We can discover new apps and then we can't use them to better help our patients. That's why it's something that we need to have in the forefront of our mind. The next one is something called nightwear. I was saying that there is a problem where you don't use this technology, which is that obviously the companies aren't gonna make money so they can't develop them. They can't put them out there. More people can't use them, right? So if we're able to use these applications and use these programs and see if they're effective, one, the programs will get better. Two, they might actually help our patients in ways we don't know. And that's what we really value. The next one is nightwear. They were actually here and we got to speak to them, which was kind of a surreal experience. It's basically mainly for veterans who have nightmares, whether it's from PTSD or any primary nightmare disorder. It's kind of like an Apple Watch that measures your sleep rhythm. You wear it for a couple of weeks. And then when it recognizes you have a nightmare, it kind of vibrates a little bit. Not enough to wake you up, but enough to kind of break the nightmare. They've used it in numerous veterans and they have pretty good results. And it's something that can be helpful for even patients that don't have PTSD but other nightmare disorders. Yes, exactly. As you said, right now it's only approved for active duty and they're working on getting it approved for other things. Thank you so much. Last but not least is something called Pivot Plus CO. This is basically something to aid in smoking cessation. One of the biggest problems in general we have with smoking cessation is people don't necessarily feel better right when they start quitting. They usually feel worse, right? They're like, oh my God, I've been craving, I really want another cigarette. So this gives you that positive feedback. What they found is people that smoke consistently actually exhale more carbon monoxide. So this is a carbon monoxide monitor. So let's say on your first week you're trying it, you're smoking a pack a day, you breathe out and you see that you have exhaled 2,000 units of carbon monoxide. Then as you cut down, let's say to three fourth of a pack or half a pack and you exhale, you see that your number dropped to like 500 units, which is really helpful because it gives you that affirmation that you kind of need during that time. You need to know that there's a difference even if you don't feel it. This gives you the visual difference. Now, as we talked about, we've used all this new technology that's been very helpful. But the next thing we want to delve into is what stops us from using this new technology? Thank you so much, Dr. El-Samadisi. We've seen so many new technologies, right? Apps, wearables, software. But what is actually stopping us from using new technology, right? One of the, and I'm happy to have it. What do you guys think? Thank you. Thank you so much. Using the microphone will be really helpful. Well, my perception is that we are generally scared of change. I think as a race, as physicians, as psychiatrists, we are generally skeptics. And I think that's my impression of one of the biggest reasons why. I mean, I've always tried to adopt technology when I generally have an idea that it's not gonna typically hurt the patient. And I mean, you just mentioned about ResetO. I have been using ResetO for about three and a half years. One of the earlier adopters in the whole country. I had about more than 200 patients who actively used the program. Benefited from it. So it was personally a set. I still have about 20 patients who are active on the program. But you pointed out something really important. Unless we adopt some of these technologies, we won't have them. And I'm facing, I'm living that right now. I'm trying to find out what can we do to kind of enhance. Again, I don't necessarily see these as standalone applications. But they're like the perfect adjuncts. I mean, I can tell you from my experience as an addiction psychiatrist, like contingency management is the best tool that we have for certain addictions such as stimulant use disorders. And there's no lack of evidence base. There's like hundreds and hundreds of papers pointing out that methamphetamine use disorders or cocaine use disorders. That's the best thing we have. But how can we deliver that? Show me how many programs are actually delivering contingency management. Almost non-existent. Right, absolutely. And so these technologies were helping me to kind of deliver something so valuable. And I think that's why I really appreciate you guys like trying to start this discussion and help in using different ways we can enhance our care. Because it's 2023, guys. So the reason why we're not changing is generally people are skeptics. And I think that's really sad. But I hope we can make a difference. Thank you. Thank you so much. That was beautiful. Thank you for sharing your experience. I would just like to add one comment here. You know, you mentioned about change. That reminded me, you know, the technology pioneer, Bill Gates. He said something like, we always overestimate the change that will come in next two years. And then we underestimate the change that will come in 10 years. So this is really the way I see it, the whole picture. Please. So on a similar note with change, I feel like with any new medicine or any new technology out there, you know, it's kind of like you're always where you want to wait. You want other doctors to try it on their patients because you're like, you know what? I want to see their side effects before I actually prescribe it to my own patient. And I tell my patients sometimes, like this drug is out, but it's only been six months. I don't want to try it on you even though it's FDA approved. I'm going to wait a year to see what other doctors say. So that's one. Number two, but knowing more really helps. So sometimes when you actually attend a drug webinar, actually attend a talk and you see the numbers and you see the data and what all has gone behind it, that also makes a difference than just knowing something is out there. So then you feel more confident in saying, okay, I feel confident that this would work. And then I guess my last point would be just accessibility. So some things are easier to prescribe if medicines approve them, insurance would cover it, it's great. But like for technology, if it's not approved, would my patient actually be able to purchase it? And so actually with the Stim, I tried it on myself. I said, before I actually, I might just purchase it, use it on my patients before I say, okay, you can try it in my office. I don't want you to spend all this money if it's really not something you're comfortable with or if I'm not comfortable using it. So I think that access is that when I have it and it can patients afford it. Wow, beautiful. Wonderful, thank you. Oh yeah, what I'm gonna say is largely goes along with the comments you made. There's also a factor of inertia. And people, if people show you how to use something, it's a mixture of overcoming inertia and some big anxiety. And so that's the reason the workshops like this are quite important. And actually, we should also, instead of simply the product in the exhibit, actually, that demonstrating is very good. But if APA sponsors a workshop wherein we have vetted some apps, and then we, without getting any money from anybody, if we show these are the options that you guys are doing, right, to some extent. No financial disclosure. Exactly, yeah, no. Workshop next year. That's very important, yeah. But also in terms of the inertia, to give you an example, in, I think, around 2002 or something, I passed an action paper in the AAPA Assembly that the AAPA should promote telehealth as a way of advancing access to care, because all the psychologists were, you know, demanding prescription privileges, and one of the arguments they used was access to care. And, you know, so, and unfortunately, it took COVID. Suddenly, psychiatrists, everybody now wants to do mainly telehealth, you know, like, but that was a phenomenal attitude change. So people have to overcome these anxieties and inertia and do it. Thank you. Beautiful. Thank you so much. Hi, thanks so much for the presentation. You know, I'm a bit of a skeptic, actually. I work for an insurance company, and we take a look at the data that the digital therapeutics present us with quite carefully. And they're, frankly, not always as compelling as we might like them to be. So in the case, in the instance of Endeavor RX, for example, they use the ADHD-RS, the rating scale, fairly minimal changes, actually, on it, particularly among those who were not also taking a stimulant medication. So adjunctively, a little bit of benefit. The other issue, and this may be a factor I don't know for a lot of people who are prescribing, is that the medications, or the digital therapeutics can be quite expensive. So I think that's a barrier, that's obviously, the pricing's obviously a business decision, but that's worth taking into account. And I think everyone in this room needs to be aware that many of these digital therapeutic devices have sort of shell organizations set up, and it's not just psychiatry, it's also dermatology and other things where some medications may have more of a cosmetic benefit where you log in, you answer a question, you get your prescription. So just for folks to have a healthy degree of skepticism and to really look at the data as opposed to simply the marketing. Yes, absolutely. That's extremely important, that's the reason the committee to bet and make some. Yes. Absolutely, that's why we mentioned the industry regulation part, that we don't have it right now. But I will tell you, I mean, if you work in the hospital system, our hospital system is desperately looking at the measures where they can have objective measures for quality and whatnot. So they really like that we start incorporating these things, I'm not going into all the detail, but from the funding standpoint, that every time we need a software or whatnot, if it's tied to the quality metrics, hospital is willing to pay for that. That's how we were able to develop our own digital psychiatry section. But all great points, we totally agree that there is a need for the industry regulation there. Yeah, this is a start. I mean, it's a beginning. So, and I noticed that none of you up there have any gray hair that I can see. So first, I want to commend you all, the youth in psychiatry for sort of bringing this to the fore for the rest of us who have maybe practiced a little bit longer because we are gun shy about these things. And I would just like to give you guys a round of applause for a wonderful presentation. It's just so exciting to see our youth come on like this. In terms of limits and starting these types of technologies in our practice, liability, liability, liability. Yeah. Perfect. I have a couple of thoughts. For me, I work in a prior practice and a county clinic. So I do it from both ends. Number one is just the data security is, I work with OMD, I work with other ones, and I've asked the companies about their processes and I'm kind of baiting them a little bit. And they generally give me inconclusive or wrong answers about it. And it's such a high yield, and I take it really seriously. The second, in the county system, it's just frankly a lot more work. It's a ton more work, and the system isn't prepared to actually document or incorporate this into the workflow. And that ends up more work. Those were all wonderful points, and they really segment us to our next part, which is talking about what does stop us from adopting new technologies. And one of the few things, and I think all of you have mentioned most of these points, and right along that, as we get older, get a little older, adapting to new technology gets a little cumbersome. The learning curve becomes a little steep, and it can become more time-consuming. I know for myself, when I was trying to adopt to the new Epic workflow, it was so cumbersome. I had to go to the training sessions that were eight hours long, and then when you're with the patient, things don't go the right way. You're not sending the medications the right way. I think same thing with technology as well. The new software, it can be challenging at times to adopt, but with, I think, enough practice and just that sheer motivation, we can overcome such changes. Exactly. The next few parts, you guys all gave the practical skills. I'm just gonna give the theories behind it, because I think that's always really helpful. I'm gonna talk about cognitive biases and how that leads us to resistance to change. The first one is the availability heuristic. What that means is basically it's a mental shortcut where you rely on immediate information, and that's how you make your decisions. So kind of like you said, is when the first thing that comes to mind is medication, or we don't know about this information or about these resources, we kind of discount it. We don't even need to search about it. We just say, what's next? The next one is the confirmation bias. This is the tendency to search for, interpret, and favor information that supports your own ideals. So the basic example I always give is who here has a favorite SSRI? Everyone should be raising their hand. I can tell you all my attendings, if I ever sometimes mention Lexapro, they'd be like, I like Zoloft, it always works better. And the reason is you give that medication, you see it works, it supports your belief. So I'm just gonna keep using the medication. And then if there's any data that maybe doesn't support it, I can either acknowledge it, or it's a lot easier to discount it, which goes into the last and my favorite cognitive bias, which is cognitive dissonance. It's the idea that when you hold two opposing beliefs, you usually choose the one that kind of is easier to cope with and has less anxiety. The example I gave is when you're thinking about treating ADHD, you're like stimulants are first line, why start a non-stimulant? Why try Endeavor? Why even consider it? Because it's easy, right? It's easy once the ball starts rolling to just kind of push everything away into what you know, what you've been used to, what you've been taught. New information is kind of scary. So I just wanna say the favorite part of this presentation has been how ahead of the curve this crowd has been thinking. This slide particularly was coming later, but you guys made some really valid points, making it really easy for me. So just moving right along, the layers get deeper. There are barriers to change that you guys talked about before. One, capability. Two, opportunity. Three, motivation. First, capability. We have all been in inpatient units, rotations, that we work with attendings, and like Dr. El-Smadisi was saying before, everyone has their medication preference. You might be on a unit that uses Haldol for agitation over Zyprexa, and their rationale is I've used it more, I have more experience with it. And these stringent practices carry over, and you tend to get very comfortable with that one medication. So in order to kind of combat that a little bit, we should increase the awareness, as some of you guys mentioned before, and the education, getting comfortable using that kind of stuff. Second, opportunity. So just the other day, I was finding out from Dr. El-Smadisi that Billify has a two-month shot. And then the following day, Dr. Patel was like, there's a result that you approved for Alzheimer's dementia agitation. I'm like, I didn't hear about all this stuff. Where are you guys getting this information from? And they were kind enough, thankfully, to let me know the subscriptions that they were signed up for. And I was like, wow, I'm getting all this news up to date. And I felt good about that. So the solution I'm trying to present here is collaborate with your peers and colleagues. They might be using something different. They might like something better. You might like it as well. Talk to them. And then the last one, probably the most important one, you guys mentioned it, is the motivation to change, having that growth mindset, being comfortable with that uncomfortableness, right? The growth is at that edge of discomfort. And we have to be able to realize that in order to move forward. Now, we said a lot of information today. There's a lot mentioned, and there's a few takeaways that we want you guys to take away, which include the following. So the first one, that psychiatric data is not limited to our interview. Right, we have looked at how we can leverage AI, how we can leverage all these apps to really gather data, even before the patients present to our clinic. Guys, remember the number Dr. Malik had said, 11 years gap between symptom starting and treatment. Maybe we can bridge that gap. Right, and second, treatment does not consist of only medication and therapy. I think we've talked a lot about technology today, and so many adjuncts, and that partnership with technology is essential moving forward. And third, which is the first step in overcoming cognitive biases, is being aware of the issue. Insight is key. Everyone has these unconscious beliefs that makes their decision, but just by recognizing that and being at the forefront of it, we can make strides forward. And I want you all to stay tuned. You're all here today for collaborative care, and there is so much more research. Psychiatry right now is on the precipice of so many discoveries, and we kind of have to be up to date. There's research on psychedelics such as psilocybin, and that has been showing pretty effective data. There's augmented reality. There's so many things that we can do and so many more ways that we can develop. We just need to be kind of opening our eyes and paying attention. Now I would just add that the biggest challenge remains that we have evidence-based intervention translated into the digital platform. So we are really looking forward to the future and the new innovations in the field. I appreciate everyone's comments and questions during the presentation. Is there any other question you guys want to bring up? Yeah, I have a patient who's probably 60-ish. He's a full-tenured professor of a major science at a major university. And he has ADHD. He's on 450 of Welbutrin. I don't remember the dosages, I don't know. He came with me with that. But he actually is autistic. And we've been doing telehealth. He's been a patient for a long, long time, 10, 15 years or more. And basically, I'm kind of like his only family. But he's also a gamester. So he spends much of his life playing games when he's not dealing with academic things. How could I use any of this to, it would be egocentronic for him to be able to use something like that. I don't know what I could do, how to pick anything that would be useful because I don't know these games. What would you suggest? The goal would be to be able to get him to be more social, not so social to other gamers, which he sometimes does, to be able to get him out more, to go to more dates or social things or religious things, just getting him out in the world. I think it really depends on his capability and the level of functioning. Because there are some- He's a very high level of functioning. He's just very OCD and ADD. And a little bit, not exactly antisocial, but he's actually, underneath it all, I think he's autistic. He's just not good at social skills, makes him uncomfortable. Because we can really divide the apps into two categories. I'm sorry. So there are skill management apps that if you're looking for the particular skill that we really want them to improve their social skills. So there are specific apps that work on the skill management. But then there are also self-regulatory apps where they can connect you with a mental health counselor. And that's just really like an online therapy. Dr. Patel, you wanted to add anything? Yeah, I think one way that I was thinking, especially for your patient, that uncomfortable feeling that you were mentioning, I think we've had a few patients at the integrative clinic who have told us that even thinking about going to a social activity makes them anxious. And one of the things we had done was we had put the heart math. We saw them. We told them, okay, think about the situation. We saw how incoherent they were. And then we practiced breathing. And that actually sort of, over time, helped them understand that it is okay to feel uncomfortable. And then you take that uncomfortable feeling, you breathe through it. And I think you might want to try heart math. That could be a cool sort of adjunctive treatment that may be beneficial for him. It would be a fun thing to do because he would enjoy the technology. I think he would. And he would see the graph go up and down and he would really, really work with that. And I just kind of want to add to that. Just, you can use all these tools as well, but I would say keep your eye open for more video games like this. And if you can figure out what kind of gamester he is, we can probably have more options as resources increase. We can not just use Endeavor, but maybe perhaps a different genre of video games, maybe role-playing, that can promote some social growth as well. So stay tuned. There's a lot coming out. And the last thing I was going to say is, I'm, again, a strong proponent of incremental. So if you want him, let's say, to get out of the real world and socialize, you can take a step back if he's talking to his friends that are gamers. Like, if you're using virtual reality, you can literally be in a room with everyone who's using this Oculus. So then he can literally feel like he's in a room talking to them and see how he feels. If he enjoys that, maybe let's take them to virtual reality where they're outside. Then from there, let them actually go outside. Like, you can slowly go up. He'll enjoy the gaming side of it. He'll enjoy talking to his friends on the game. And then that might lead him to be like, okay, let's all hang out for lunch, maybe. Or let's all hang out and play video games together, then go to lunch. Thank you. I will add it's time-consuming. So if you have resources to just make, you know, a little section of digital psychiatry or a half day of integrative psychiatry clinic where you have one dedicated person who can go over these apps or the virtual reality or the video games, and that person has dedicated time to do so, that is really helpful for us. Say that all again. I didn't quite understand. So, you know, these things, you know, explaining all the video games and, you know, some people, they are not really aware of what's out there that can be time-consuming for the busy practitioners. So if you, I don't know if you work in the hospital system or you have a private practice, but if you can dedicate half day to either digital psychiatry or integrative medicine or psychiatry and have a dedicated person to have, you know, just keep track of all the data that is out there is to go over with the patients. That really speed things up for us. That's what we do. Like if there's a reluctance, we have one person just dedicated for this. So it's a way of getting expertise. So the social worker, she keeps track of everything and then she opens up the catalog and, you know, you can do this and you can do that. How would we access that? I'm in, now I'm in telehealth private practice. So I really have little contact with other physicians except socially. So we are happy to share our email address. I can share the resources that we are using. I'm not saying they're the best in the country, but we are trying to keep, you know, up to date. Well, neither am I. Perfect. We'll make it work. We'll make it work. Yeah, we'll give you the information afterwards. We'll give this. Okay, I'll ask. Thank you. Thank you. Well, thank you for the talk. It was really comprehensive and a very good overview. So I really enjoyed it. I wanted to ask if you have any recommendations for apps other than like apps for meditation that we know of for tracking mood for like mood disorder and anxiety disorder patients that I, you know, because there's so many out there some of them gather suicidal ideations, which I would rather patients not, I mean, you know, because they probably might feel like somebody would respond if they were to have, but just for patients to see how many times they feel manic or anxiety or depression and bring back that data on follow-up visits for me to look at. So there are a few apps. I don't have them readily to mind, but if you give me your email, I can give you information. Because I even know there's apps, like for example, my sister recently gave birth and for like her breastfeeding app, one of the questions they ask in the end is like mood. Like, how are you feeling right now? So there are apps solely for mental health diagnoses. And that, I think that's a beautiful point, like them bringing it in. Then you can see like every Friday, this person was feeling super depressed. Maybe it's because of the weekend and then you can target there. So we could definitely give you a list of some resources. Yeah. Hi, thank you. This is really interesting. I had a comment and a question. My comment was about the AI success. I just don't believe it, because I feel like maybe I'm too old, but I feel like what people most benefit from is not what I say. It's not anything other than the fact that there's another human present with them. So I wanted to bookmark that and get your comments on that. And then I had a question. Yeah, so nothing beats human interaction. I think these are all the solutions to just make sure that we have access to care. There's a lot going on with the scope of practices, lack of access to mental health. So really we are looking into digital psychiatry as just the innovative measures to increase access to care and really bridging the gap, where there's a lot of fragmentation in psychiatry. They have inpatient hospitalization, but they cannot find outpatient appointment. They only need therapy appointment, but there is no therapist in the area. So this is really to bridge those gaps. Totally understand. And I think this is a very valid point that nothing beats the human interaction. And that reminded me one of the other stories that we had at our hospital. The radiologist showed up for some medical emergency somewhere in the hallway and said something like, I can take the history, but then you have to do the clinical correlation. And I was like, well, I'm a psychiatrist, we'll try. So it's the same thing. Like we can get all the information, get all the data from them, from these apps. They can help us to get the information on the patient, not just in the snapshot moment of time, but in the long run. But at the end of the day, you need a person to really interpret this data and just making sure that you are translating into something more real and meaningful. I guess I was interpreting the AI as therapy, but you're saying it was more for intake purposes. There are two parts to it. Specifically, the first part that we discussed was more of screening and sort of gathering data like Dr. Abzal mentioned. And the second part that one company specifically was doing was having a CBT model on an app. So it's a conversational agent where you can type out in your own privacy, say, I'm not feeling so well today, et cetera, et cetera. And it will have a conversation with you. And that's what these algorithms can do. It can talk to you, they can pick up on different indicators. And that's one avenue. But I think right now, the more focus is on gathering the data and really just making sure that we have seen the patient, not just in our clinic for that 30, 40 minute visit, but two weeks out, four weeks out. Okay, then I misunderstood. Thank you. My other question was, you work in an integrative psychiatry clinic. I'm sorry, doctor, I don't know your last name. All of us. All of you. Oh, okay. Wonderful. So we have, it's just one of the clinics. We work in different settings. Yeah, so my question was for like, I work with diplomats and their families, and I just see a lot of generalized misery slash anxiety. And I'm just wondering what technology, doing the work you do, you'd recommend. Thanks. This is a very good question, but a very broad question. I think it really depends on the end of the day with the patient presenting with something specific, but integrative psychiatry and medicine is not just limited to all these interventions that we have been talking about. We have biofeedback, we have CBT for insomnia, we have aromatherapy there, we have ancillary staff doing acupuncture and different things like that. So it's more like a holistic approach for the patients who are already being seen by the psychiatrist in our outpatient center, but they just need an adjunct. So that's how we refer them to the integrative psychiatry clinic. And I will tell you, we had a couple of celebrities from New York as well, and they really enjoyed the biofeedback and the heart match. So it's just sometimes it's something extra and more reassuring for them. They're doing something more than average patient is doing out there. I wanna thank you very much for putting together this symposium. It's extremely useful, I think, to be exposed to this sort of thing. I would love to get your thoughts about sort of the special challenge of bringing this type of technology to mainstream medicine, things like third-party reimbursement and that. I was involved with kind of early treatments for seasonal depression and various kinds of light therapy. And there's a paradigm in medicine that nobody can argue against called evidence-based medicine. But the way it's really implied is often the only studies that really count are the ones that cost so many million dollars that only big pharma can afford it. This is usually not available for all these kind of techniques. And so I think, in a sense, there should be a different standard because the benefit-risk ratio is very different when you've got a drug versus something like heart math where there's very little chance of bad side effects. But yet, when these analyses are done, a lot of the studies just get pushed aside. And so I'm just curious your thoughts, how to move the field when there's a lot of forces pushing back. So I have the numbers in front of me. I feel like that we have been talking about this evidence-based intervention, a lot of research that needs to be done. So NIMH, they granted, between fiscal year 2015 to 2019, 404 grants totaling $445 million for technology-enhanced mental health intervention just to conduct the research studies. I think this is really the first step towards this direction. If we have a lot of data, a lot of practitioners, a lot of physicians, they would like to see the evidence-based data before they go and start using this app. I think that is really important that we do more research in that area. I remember one of the comments that I heard from one of the physicians that I was told in residency never be the first one to start the medicine and never be the last one to start the medicine. I feel the same way about these apps. But then I said the same thing that you have mentioned, that benefit versus risk, what can happen with the hard math? It's not same thing like using the medicine. So more research. That's my opinion on that. Right. And NIMH is sponsoring that. And I just wanna add to that, more research and then increased awareness. If it works for your clinic, if you're using hard math, let your colleagues know and let them try it too. And hopefully it'll have some sort of domino effect where more and more people are using it. And if we can kind of spread that message a little bit, increase that motivation, then perhaps we could have more of these technologies as adjuncts. Not mainstay treatment maybe, but just to try it as an adjunct. And always for the cost, something you can always do that sometimes we try to do is like kind of email the person who makes it. Like, hey, can we get a free trial or free sample? And most people are pretty open because they want you to use their software or hardware. You might run into some issues obviously, but it might help. At least that's the first step toward it. Because you can't just ignore it because it could be helpful, especially if it's not harmful. I'm sorry, I just wanna let the crowd in the back. I think they were waiting for a while. Hi, I'm a PGY2 resident. So definitely, these things are coming up. We're still learning the traditional techniques and traditional methods. But I am a little skeptical, especially when I'm dealing with adolescent and children. It seems like a lot of these apps are tested in a very controlled setting. And I'd imagine context switching is a really important thing that most people would be aware of, but would not be testing in practice. I'll give you an example as to what I mean. You can have the best ADHD map, but if that icon's next to Instagram, in real life, it's very unlikely, unless they're extremely type A personalities who are like going back to it and saying, so I feel like there needs to be a little more transparency. And honestly, there needs to be more of a regulation, which is not, well, similar to how pharma study shouldn't be studied by the company who's doing it. There should be more studies done by independent parties to look at these real life applications. Yeah, and the other thing is, I think, though, this is just a comment. I don't think that's the direction things are gonna go to, because at the end of the day, it seems like a lot of these interventions are kind of the salesman kind of pitch. So, you know, these guys offer medicine and therapy, but we offer medicine therapy and apps, or, and hydrotherapy. So it's just a me too kind of movement. So I don't know what your thoughts are on that, and if there's been any movement in changing that. So I think what you described is a really common problem. It's like, you don't know if something's gonna help, you feel like it's a salesman pitch, so you decide to not use it. And we are taking steps forward in understanding and filtering a little better. So for example, I think last year, APA dropped, I'm looking at it right now, it's the comprehensive app evaluation model. So they have five different ways they evaluate different apps. And it's something, it gives you a little more information, right? Obviously, nothing is gonna beat good data, but often you don't get the data because these apps need more people to use it to obtain the data. So you're in this weird, vicious cycle. So someone has to break it. So that's why it's always, you have to take a look at data yourself, take a look at these methods, like for example, the APA have to see if the data is a little helpful and try it out. If it doesn't harm you and doesn't cost a lot of money and you could, it might be helpful. And that's gonna be the best thing for us as psychiatrists and more importantly for patients. Like let's say the app is next to the Instagram app, but you made that app with such a good user interface and people like it, they might click on it first. They will go to Instagram, but even if they click on it for a few minutes a day, it might lead somewhere. Yeah, thank you for your talk. I think it's very, definitely, it's great to learn about the novel treatments. I would say, I mean, I think I'm more mid-career and I have three young children and I'm a child and adolescent as well as adult psychiatrist. And I think I try to spend more of my time discouraging screen time and encouraging my children and adolescents to unplug from technology and encouraging that for my own children or trying to, right, as much as possible. So I think that's what I think of as a potential side effect of all of these treatments, right? But many of these, I would say, is that even Endeavor Rx, you're thinking of a child spending 25 minutes a day, five days a week, not, you know, on a screen, right? Not mobile. They're not interacting with other children. They're not interacting with nature. They're not, right? They're not building those human social connections. So there is that drawback, right? Not to mention, you know, climate change, the environmental cost of all of these technologies as well. You know, maybe because I'm Californian and Bay Area and I worry about that a little bit more perhaps. But yeah, I just wanted to kind of point out those aspects as well to consider. And just to comment on that, I think that's the hardest thing to navigate, especially with children. It's you want them to do these things like go outside, but at the same time, you can't completely shield them away from like technology and social media because that's such a big part of today's world. Like I didn't have a phone until I was like 16, but my little cousin has a phone and she's like six because that's what they kind of need to talk to their friends or they say they need to talk to their friends. So figuring out that balance is hard as a parent and a psychiatrist. And it's never fair to discount completely anything and just be like, okay, so let's say you are playing video games for an hour, make this video game half an hour and then go outside, ride your bike or however you want to do it. I have lots of questions about boundaries between the different mental health professionals. The and how this will affect all of that. So if the, these FDA games or programs are they require physicians to get prescriptions for them? Or can anybody buy them? Yeah, so for some of the things like Endeavor and I think AlphaStim, you need a prescription for it. Some other things like for example, the Fisher Wallace, the cranial electrostimulation, anyone can actually buy that online. It's very expensive though, it's like $6,000. It's $6,000, so it depends on what the program is and what exactly. And even hard math, it's available online and it's 295, $300, so. But then the clinic buys it. So they buy these technologies and they lend it. That's how it usually works with these apps. But I'll tell you for Endeavor and the other one, we need a prescription, but for many things we don't. So then psychologists, social workers, clinical social workers. They can recommend. They can recommend. It'll be interesting to see how it pans out. No, I agree with you, but I feel like that's a whole other debate for the scope of practices. That's gonna be the next talk we have. Thank you. Well, thank you for your comments. Thank you so much. So I didn't have a question, but I just wanted to make a comment. I think I look at this as not something that would replace the human touch, but just to supplement to say, because we cannot see patients every day. We cannot see them every week or even every month, but there's something in between that patients can use to maybe even search for emergence of symptoms or as a form of treatment. And then the other thing is just, it's important to meet the patient where they're at, because I used to be where I'd say, okay, no, I only believe in med management, only in this. But this year I am doing an integrative psychiatry fellowship and I am, so I won't do it. So if somebody is tech savvy here, I have the video game for you. If somebody believes in Eastern medicine here, I have Ashwagandha for you. If you just want standard with the most research, you have Prozac too. So just, it's important to be equipped with everything possible so that you don't say, hey, I cannot treat you. You're depressed, I'll do whatever I know that's available, any form of research. And I'll give you the data. Like if you do Ashwagandha, there's that much evidence. If you do Prozac, there's that much. And if you do tech, it's new edge, but who knows, it may be the best. Exactly, a lot of this is just to augment treatment and it gives you more information as a psychiatrist, which is what we really want and need. Right, so the longer I stay in practice, the more skeptical I become about the so-called evidence-based medicine. And my rationale behind that is, evidence-based medicine is based on studies which exclude patients I actually see. Because comorbidity is the norm when you're actually in practice, but you don't see them in the studies. So my point is, yes, I'm not saying evidence-based medicine is not important. I'm not advocating for complete rogue practice behavior. But at the same time, we need to be mindful that we can be the best evidence by use of different modalities and techniques while they're done within the parameters of safe practice. I think my point is, you made that very clear. Unless we start using these and figuring out our own evidence, because there'll always be pressures from all ends. Yes, there's gonna be the industry pressure, which will keep telling us that these things are the best thing since sliced bread. And we'll have to have some benevolent skepticism with that. While at the same time, we'll have to be careful when we hear the other side. It's like, oh, I'll wait a decade before I adopt any of these things. Because these things might not be around for a decade unless we adopt them. So that's why I wanted to make that point. Thank you. All great points. I must say that I remember when TMS came. So initially there was a lot of resistance and reluctance. So not evidence-based, but in my clinical judgment. I like that. Thank you so much. Thank you all so much for being here. Yes.

digital psychiatry

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Dr. Saba Afzal

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