The transition out of an inpatient psychiatric setting is never easy—for the patient or the clinician. And the challenge escalates after the day program ends and the patient returns home.
Now, clinicians at McLean Hospital’s Behavioral Health Partial Hospital Program (BHP), a day program that integrates psychotherapy and pharmacotherapy (medications), believe they have a way to improve on that transition. A smartphone app.
“Our patients struggle mightily,” said Thröstur Björgvinsson, PhD, ABPP, director of the program that annually serves approximately 850 patients. “Most are diagnosed with mood and anxiety disorders and participate in up to five group sessions daily over an average of eight days. About half are in transition from an inpatient level of care. The rest need extra help while outpatients. But we have to re-hospitalize just under 10% of our patients.”
Those group sessions teach cognitive behavior therapy skills, such as how to initiate and engage in activities that are known to have a powerful effect on depression. They also teach dialectical behavior therapy skills, such as mindfulness.
As with many medical conditions, the first 30 days after discharge are usually most critical, because “whatever episode or life episode precipitated their hospitalization is still going on,” added Courtney Beard, PhD, the program’s assistant director of clinical research. “Usually it is an interpersonal or psychosocial episode like divorce or dropping out of school.”
Clinicians have long used written assessments to gauge a patient’s progress over the first two weeks post-discharge, but “when you give someone a questionnaire and ask how their day was, it’s totally biased by how they’re feeling in that moment,” she added.
That is where ecological momentary assessments (EMAs) come in. Five times a day, a patient’s smartphone is pinged, and they are asked to answer a short series of multiple choice questions or checklists.
The day’s first questionnaire is a traditional daily symptom measurement, followed by four random checks between 10am and 8pm where questions focus on topics ranging from who they are with and whether that person is a family member, friend, acquaintance, or stranger to what stresses they may be facing and how they may be using the learned coping skills.
A manuscript currently in process on this first-of-its kind study in the post-acute period will report that 90% of the 114 participants in a two-week EMA saw their depression symptoms remain relatively low and stable. The other 10% experienced an increase of symptoms in the first week before a drop in the second week.
The most common external stressors were interpersonal, followed by daily living, “other” or work-related stress, housing or financial issues, and school-related stress. The most common internal stressor was mental health related, followed by physical health.
The ability to use a tool available in virtually every pocket or purse offers great promise for future personalized treatment.
“The phone can be with you when your therapist cannot. It’s very important to deliver these in-the-moment interventions rather than coming to the therapist’s office once a week, said Beard. “The promise and potential of smartphones to be able to extend our treatment outside of the BHP is amazing.”
This research and other BHP smartphone studies at McLean are made possible through contributions from foundations and individual donors.