A Glimpse Into the Future

Justin T. Baker Thinks It’s Time for Psychiatry to Adapt to a Changing Culture and a Younger Cohort of Patients

Moving to a more data-driven practice poses a challenge in a health care system that is moving toward what is thought of as a more cost-effective model of providing the right care in the right place at the right time. One that may no longer focus as heavily on direct contact in a brick-and-mortar environment.

“Humans who are suffering don’t want to be alone all the time,” said Justin T. Baker, MD, PhD, scientific director of the McLean Institute for Technology in Psychiatry and director of Functional Neuroimaging and Bioinformatics for the Schizophrenia and Bipolar Disorder Research Program at McLean Hospital. “So, the idea here is not to just push people into remote monitoring scenarios where they never see another human.”

“We can either choose the glass and metal future, or we can choose the grass and mahogany future,” he continued. “We have to be careful that the future that we generate for our patients is the one we’d want. I chose the grass and mahogany. What I like about McLean is that while it has 200 years of history behind it, the hospital continuously strives to embrace and set the bar for a modern approach to patient care.”

Baker pointed out that McLean was established in 1811 to promote the ethical treatment of individuals with mental illness. “That is something McLean proudly continues to do today, but we also understand that the need for our services is greater than ever, and not everyone can physically come to our campuses for care. That’s where we blend tradition with the future.”

The start of that shift can be seen in MultiSense, an artificial intelligence program developed at Carnegie Mellon University, and the SimSensei virtual interviewer named Ellie. This AI model draws on techniques taught to psychiatry residents by McLean’s Elizabeth Liebson, MD, and relies on methods used by psychiatrists at inpatient programs.

But a virtual interviewer will only be effective if it serves as an extension of—and not as a replacement for—the in-person encounter, Baker stressed.

An interim step is underway in a just-launched study. Using data and information gleaned from both devices and in-person encounters, researchers will track many aspects of daily lives, from work and leisure patterns to interpersonal interactions and what someone is doing at those moments.

“It’s a union of all of our methodologies into one massive study of more than 100 people who let us take a bird’s-eye view of their life over a year or so, during which they’re going to go through all kinds of ups and downs,” said Baker. “We want to sort of be there with them and experience that journey alongside them as much as possible.

“Say that person has a smoking habit. Let’s zoom in to them taking a single drag of a cigarette and zoom out to a year to see every single drag of a cigarette. Where did it happen? When did it happen? Who were they with? How was it influenced by their treatments or stress? Can we use these data to unpack a manic episode and understand at the level of an individual how it emerged from a series of events? We get to see all of these things unfolding in the real world and really understand them for the first time.”

The tracking data will be combined with monthly check-ins where the patient and clinician will review the data along with audio and video recordings. That is in keeping with the fact that care requires basic flesh-and-blood contact beyond technology.

“Why do we need in-person contact? Because without it, the clinician may be missing key information when it matters most,” he said.

While chatbots can serve a useful purpose, particularly with the growing reliance of younger people on text-based interactions, a problem remains.

“What happens when that person gets really sick? Do we have her see a specialist? How do you get that person triaged?”

The move to a more technology-based practice will also require stronger privacy and ethical safeguards. The growth of blockchain technology and a recognition that patients, not health care systems, own the data will help on the privacy front.

“You’ll be able to share [data] with the researcher, with your clinician, in a way that they don’t have otherwise,” Baker said. “When you come in for your visit, there will be an expectation that you’re being recorded, and there’s data entering your chart, and it will get integrated with your medical record.”

Baker acknowledged ethical issues are “uncharted territory.”

“I think we’re in that moment now where we are starting to look for the first time at what it actually means to be human in a really granular way,” says Baker, “and we’re watching people with these sensors and cameras to understand that condition in ways that no one has ever done before. And people start to say that’s creepy. And it kind of is. But people opt in to this level of scrutiny.”

Baker drew upon an unusual comparison to frame how patients and clinicians should view behavioral health in the future.

“What the dental industry was able to do was convince the public that hygiene mattered,” said Baker. “They marketed the toothbrush. They marketed the 6-month checkup from age 2 on. And now we all just do that. Insurance companies pay for it, because they know that actually it’s cheaper than having to pay the oral surgeon.”

Ultimately, he said, the challenge involves merging the Hippocratic Oath and humanist medicine with a radical re-envisioning of what mental illness is.

“We’re not just going to assume that the doctor knows best,” said Baker. “You could never design a system to do what a doctor can do anyway. We’re going to try to be humbler and let patients guide us toward solutions that work for them, even if it’s not always great for the doctor or the system.”