Speaking of Psychology: Smartphones are a problem: Can they be a solution? With Thomas Insel, MD

Smartphones allow us to connect with loved ones, keep us informed and entertained and on time for our meetings, but they are also negatively affecting our attention spans, relationships, sleep and mental health. What if smartphones could be used to monitor our mental health and wellbeing? You guessed it. There’s an app for that.

Thomas Insel, MD, a psychiatrist and neuroscientist, is a co-founder and president of Mindstrong Health. Dr. Insel served for many years as director of the National Institute of Mental Health, the component of the National Institutes of Health committed to research on mental disorders. Prior to that position, Dr. Insel was professor of psychiatry at Emory University where he was founding director of the Center for Behavioral Neuroscience in Atlanta. Most recently, he led the mental health team at Verily (formerly Google Life Sciences) in San Francisco, California.

Kaitlin Luna: Hello and welcome to Speaking of Psychology, a podcast produced by the American Psychological Association. I'm your host, Kaitlin Luna. I'm joined by Dr. Thomas Insel, a psychiatrist and neuroscientist who is co-founder and president of Mindstrong Health, a company that is using mobile technology to diagnose and treat behavioral health disorders.

Prior to Mindstrong, Dr. Insel was a longtime director of the National Institute of Mental Health. Welcome, Dr. Insel.

Thomas Insel: Thank You Kaitlin, pleasure to be here.

Kaitlin Luna: Thank you for joining us today.

So, at the 2018 APA convention, you gave a talk with a provocative title called “Smartphones: Our Problem, Can They Be a Solution” and every day we hear about how smartphones are impacting our attention spans, relationships, a number of things -- our health overall. But there really are lifelines. We use them to get wherever we need to go, whatever we need. So, how can they be a solution if they are a problem?

Thomas Insel: Well Kaitlin, the way that you frame that, I think is exactly the way we think about it. They have become a lifeline. They become a way that we navigate the world. It's probably not too strong to say that we live on our phones or we live through our phones -- not making a value judgment here, but that is for better or worse the state of play for most people, especially younger people in the U.S. and increasingly around the world.

In behavioral health broadly, we've spent much of the last five decades trying to understand how to measure how people are doing and the way we usually do that is we say how you are feeling in the hopes that we will get from them, a reply that will help us to assess their level of functioning over the previous day's weeks or months.

For the first time we actually have a way of looking directly at how they're functioning by using the device that is their lifeline -- that is the way in which they're living. We've never been able to do that before and smartphones give us this kind of unprecedented opportunity to get a window directly into how somebody's functioning without having to use a paper and pencil test, without having to get them to guesstimate for us, like with the phq-9 how they've been feeling over the previous two weeks. We can actually look everyday over the previous two weeks and know exactly how they're doing in terms of how they're managing the world around them.

Kaitlin Luna: And can you walk us through the Mindstrong abs, talking about what we'll know from those apps. Can you tell me how they work?

Thomas Insel: What Mindstrong did was actually not to begin around behavioral health. The birth of the company came about because our founder, Paul Begum, was in a different realm altogether. He was in cybersecurity and the question he was posing was in cybersecurity, is there a way to track hackers? Is there a way to identify individuals not by how they are posting a username or where their address is, but by how they type. And he was able to develop that. It's a tool now called behavioral analytics -- very important in the forensic area of cybersecurity and Paul developed this with the hope of being able to create a sort of robust mechanism for identifying individuals.

He called it a digital fingerprint when his company was bought, and he was looking for the next opportunity to use digital fingerprinting, he thought maybe we could use this in healthcare. His background was as a physician. He was in a previous career -- a cardiovascular surgeon and so he took this digital fingerprinting idea and began using it in the company that it's now called Mindstrong for digital phenotyping.

What is that? It's very simple. It's using a measure through an app of how someone interacts with their keyboard. It's the taps, it's the scrolls, it's the clicks. It's all of that and mentoring that across time to create a set of potential biomarkers that have then been developed by taking hundreds, actually now thousands of people and at the same time using gold standard reference tools, whether that is the phq-9 or a Hamilton depression score or whether it's a neurocognitive battery or even now doing the same kind of thing with neuroimaging. Trying to find ways to validate those signals against gold standard measures and begin to say do we have a way currently to use this smartphone device to use these tools to begin to say rather than having you to fill out a form every other day or every week, maybe we could get continuous, objective passive measurement from the way you interact with your phone -- not and what you type, but how you type. That's what Mindstrong is all about.

Kaitlin Luna: And how does that work? How does your swiping behaviors show that you might be experiencing depression or something even more serious?

Thomas Insel: Yeah, it's an interesting question. One would think that those two things would be unrelated. What we're discovering is that in the same way that we say this is your lifeline, this is how you navigate the world, that the way you do that is reflected in changes in mood.

Now if that sounds surprising and maybe it should be, I should point out that there's not a single measure. It's not as if we've simply said oh, you know the delay between hitting the spacebar and a character on the smartphone is the same as whatever you're Hamilton depression score will be -- or it's a predictor of relapse. It's not like that. There are a thousand potential biomarkers. There are hundreds that go together through machine learning to create the panel that we call a digital biomarker and those -- there's not one single event or one single operation on the phone, but that is predictive itself range of those put together.

And interestingly, we can customize this so as you might expect, the signals are a little bit different. If you're 73 instead of 23. If you live in China versus living in the United States. So, part of the work of Mindstrong is identifying those signals in a customized, robust way that provides some clinically actionable signal that we can use for healthcare.

Kaitlin Luna: And for someone who's listening and watching who doesn't know, it doesn't have a background in science, what is a biomarker?

Thomas Insel: Yeah, a biomarker. We know biomarkers mostly through the rest of Medicine. So in diabetes care we used to use glucose -- now we use something called the hemoglobin a1c. In the case of monitoring your hypertension, we look at blood pressure. It's a biomarker for prostate cancer. We have the PSA. We have a whole range of tests in medicine, often blood based tests, that we use as objective, robust measures that tell us how somebody is progressing in the course of their illness or whether they meet the criteria for an illness.

Part of what's really been a handicap for us in the whole realm of mental illness is that we do not have biomarkers at this point that are clinically useful. There's been a tremendous amount of research around this looking for markers in blood and markers in the brain through imaging. We still lack anything that has a clinical validity to it as a biomarker for either diagnosis or for monitoring care.

The hope here is that by using the smartphone we can begin to find those signals that actually will do for depression and PTSD and schizophrenia what the hemoglobin a1c has done for diabetes.

Kaitlin Luna: And so, so if the app has indicated that you might be suffering from depression, what's next? What is the next step? Does Mindstrong tell you what to do?

Thomas Insel: Yeah, yeah that's absolutely the best question Kaitlin because we often call these biomarkers, these digital signals, we call them digital smoke alarms. I mean, basically it's telling you that there's a problem that needs attention. That's important. It's not enough, right? It tells you that you need to do something. So, what do you? And what Mindstrong is involved with now is creating what we often call the efferent loop, not just the accurate loop, but hey, there's a there's a smoke signal here but actually doing something to put out the fire.

What would that be? Well, in our case we have the advantage again of having a platform, which everybody carries around on their pocket and which allows us not only to detect a problem but to deliver solutions. Those solutions could be a form of psychotherapy. It could be a form of education. It could be a form of connecting people to care so that it could be helpful not just for online, but offline care.

There's a whole range of resources that you can deliver through the phone so that people have access to them in real time that allow you to provide what we would call not only measurement-based care but connected care. So, it keeps in touch with people and it connects people to the resources either online or offline that can make a difference once they're developing a problem.

Kaitlin Luna: And so, cybersecurity is a big issue and you talked about people within your organization, your president, co-president, who was a background in that. So, he talked about cybersecurity. What do you say to people who might be worried about ok you're getting in my phone, like what I'm worried about there -- and what do you say to that?

Thomas Insel: Well, it certainly helps to have a founder who's got great expertise in security and knowing how to handle questions around privacy.

There are several issues here. The deep dive and certainly we're in this era where so many of us have been burnt by bad behavior from tech companies. We often now talk about the tech lash, the backlash against tech companies because of the way they have mishandled our personal data or people have been miseducated about what would happen to their data.

So, at our company and most of the companies in this mental health space -- and there are many now, this has become a major focus of figuring out how to do this with public trust. How to do this with tight security, with data protection. There are, of course, new regulations like the GDP are in Europe or the new California consumer privacy law that just passed last month here in California.

We've gone way beyond those to make sure that the data that we collect is not only encrypted, but it's doubly protected. And most of all, it's set up in such a way that if someone is uncomfortable with what's happening with their data, they have full agency, full opportunity to be able to withdrawal us.

So, this is all about building a system that's not only effective in terms of its clinical value, but it’s earns public trust because it provides transparency, it cares about privacy and security and most of all it confers agency to the people whose data you're collecting. Those together, I think can help us.

What we've said is our north star of Mindstrong is the idea that we're empowering patients and families by giving them better data. And I think if we keep that as the north star, as the way that we want to build a product that really helps people by giving them the best data we can give them. I think that actually goes a long way to building public trust.

Kaitlin Luna: And so, can you talk about how apps like this improve healthcare, mental health care and then healthcare overall?

Thomas Insel: You know, it's an interesting point in time. I think we're still early on and what will be I think a very exciting story We may be in chapter 1 or chapter 2 where many apps and many companies have shown the feasibility and showing the power of the signals they can create or the value of the interventions they can deliver through the smartphone.

What we don't know at this point is what the impact of this new technology will be on public health. We haven't yet had the deployment to millions or multi millions of people in need to be able to say hey, this did decrease the suicide. This reduces hospitalization and emergency room visits. This reduces the cost, while improving the quality of care and giving us better outcomes. All of us want that. All of us are on that path, but I'd say here at the beginning of August 2018, we're not there yet.

Kaitlin Luna: And so, I believe you probably just answered my question about its doubletrack. Is this the future of healthcare and if so, what are the limitations? What are the benefits and the limitations?

Thomas Insel: Yeah, so what an interesting time we're in. I think it's fair to say that health care will be changing and in some ways we’re slow to this change and retail and entertainment and banking and so much of our society has already been transformed by this digital and information revolution. It hasn't happened for health care and maybe that's not surprising. Maybe we should have expected that health care would be a little slow to the party.

The fact that Amazon and Berkshire Hathaway and JP Morgan and they'll come together to say, “hey we want to look at health care and we want to try to provide something that gets better outcomes and lower costs and is more acceptable to our employees.”

That's interesting and I think we'll see over the next couple of years that those companies and many others are going to begin to transform the way healthcare gets delivered.

My guess is at the end of the day we're not talking about a completely online system, not only because we need to have surgical centers; we need ICU’s; we need to have hospitals where people can get intensive care. But even for mental health care, it's likely that we will have both online and offline.

And I think the future of mental healthcare is going to be both high-tech and high-touch. How we put those together and how we build both the high-tech and a better high-touch system, it's going to be really interesting. And we’re going to see that over the next four or five years.

Mindstrong is one of many companies pushing on this high-tech side. But we recognize, as well, the tech is only going to go so far and that when you're dealing with people with serious mental illness, you've got to have the high-touch piece, as well.

But we're banking on is that we can use height, we can use the tech to get much better height touch and that I think will be the future of the mental healthcare system in the way that we're going to build it.

Kaitlin Luna: So, I do have one more question. One more, I know it’s supposed to be my last. So, where is Mindstrong at this point? Where are you right now? Is it available for people that, where are you?

Thomas Insel: Right, so Mindstrong is a work in progress. It's a company that's a little over a year old. You're an app old, although it has about four or five years of data behind it, we are building the company through partnerships with mostly at this point healthcare providers and payers.

So, our interest is in creating a new healthcare company for mental health that would use technology. We don't provide a consumer device or a consumer app, though the app is on the Play Store and it's on the App Store, it's not really set up for downloading for individuals to use for themselves.

We want to use this within a healthcare setting and so it's available through the research we're currently doing in the partnerships we currently have with a range of both academics for research and the partners that are payers and providers for actually testing out what this does in healthcare.

Kaitlin Luna: It sounds like there's some exciting times ahead.

Thomas Insel: Super exciting and you know, I think for a lot of members of the APA, in particular for students who were thinking like, what's my future all about, it's important to recognize that this is a moment in time where the sands are shifting in the same way that a decade ago that would have been true for retail, for entertainment, for many aspects of our economy. That's happening now in healthcare and in mental health care. You know, Bill Gates famously said that things will change much less than we expect in the next two years and much more than we expect in the next ten and I think that's true for mental health care and technology, as well.

Kaitlin Luna: Well, thank you so much for joining us today.

Thomas Insel: Thank you, Kaitlin.

Kaitlin Luna: Speaking of Psychology is part of the APA podcast network, which includes other great podcasts like APA Journals Dialogue, about the latest and most exciting psychological research and Progress Notes about the practice of psychology. You can find our podcasts on iTunes, Stitcher and wherever you find your podcasts. You can also visit SpeakingofPsychology.org to view other episodes and resources about the topics we discuss. I'm your host Kaitlin Luna for the American Psychological Association.