What if a schizophrenic patient could have the equivalent of a therapist in a pocket, watching for symptoms of a relapse? That’s the promise of a smartphone-based system now being tested at a hospital in Glen Oaks, N.Y. The app, called CrossCheck, uses a suite of sensors to create a profile of a patient’s healthy behavioral and social patterns and can then raise an alert when the patient deviates from the norm.
For a schizophrenic patient, a relapse is both damaging and demoralizing, says Dror Ben-Zeev, an assistant professor of psychiatry at Dartmouth College and the study’s principal investigator. The patient can end up in jail or in the hospital, which disrupts therapies and normal routines.
The CrossCheck study will include 150 schizophrenic patients who have been discharged from Zucker Hillside Hospital, in Glen Oaks, within the past year. Half of those patients will receive smartphones with the app, while the other half, the control group, will receive the standard clinical services that the hospital provides after a patient is discharged. To see if the app leads to better outcomes, “we’ll be looking at the time lag between when they’re recruited and their first relapse, and also at the number of relapses they have over a year,” Ben-Zeev explains.
Mobile health apps have the potential to change the management of chronic illnesses in general and may be particularly valuable for mental illnesses, says John Kane, chairman of psychiatry at the hospital. Kane says his patients come to the clinic about once a month, and in between those visits he has no way of knowing if they’re sliding back into psychosis. “When they’re having the relapse, they might not have the insight to call us and say, ‘I think I’m becoming ill again,’ ” Kane says. “This technology lets us observe the patient’s condition in real time.”
CrossCheck ties together a number of data sets to create patient profiles. It uses GPS to create a map of patients’ typical locations, and accelerometer data to determine when patients are walking, running, or sedentary. It uses the microphone to detect conversations that occur either over the phone or in person, and it records the duration and frequency of conversations (it doesn’t record or analyze content). Finally, to discern sleep patterns, CrossCheck looks for times when the phone is stationary and not in use, and when light and sound sensors determine that the environment is dark and quiet. All this behavioral monitoring occurs in the background as patients go about their lives.
The patient’s only active participation is filling out a brief questionnaire once a week, which asks about mood and symptoms. “When they indicate that things are going poorly, that they’re feeling bad or not getting enough sleep, we mark that as a near-relapse event,” explains Ben-Zeev. CrossCheck looks for behavioral markers associated with that event to create each patient’s unique “relapse signature.” Then, the next time CrossCheck detects that signature in the patient data, it sends out alerts: The patient is encouraged to get in touch with a doctor, and the study investigators at the hospital are notified that the patient may need help.
All this monitoring may seem intrusive and possibly alarming to patients who already have paranoid tendencies. “Part of the challenge with any kind of monitoring is making sure the patients understand why we’re doing this,” says Kane. He says the study will include an education component, in which investigators will present CrossCheck as a partnership between doctor and patient. “We’re trying to work with them and help prevent them from going back into the hospital,” he says.
Ben-Zeev has also developed an app called Focus, which gives schizophrenic patients a much more active role in managing the illness. That app’s home screen lists categories such as “medication,” “voices,” and “social,” and users can tap on which ever category they want help with. After they answer brief assessment questions, they receive either positive reinforcement or some friendly advice. For example, the social assessment might lead to the feedback “You can’t control other people’s behavior, only how you respond to it.” That system is currently being tested in a multistate study that will conclude in 2016.
At Northwestern University’s Center for Behavioral Intervention Technologies, assistant professor Stephen Schueller says he has evaluated a wide variety of apps intended to help patients cope with a mental illness. He’s enthusiastic about apps like CrossCheck, which send smartphone data to health care providers. “When these things are embedded in the existing care relationship, then they hold a lot of potential,” he says. In contrast, he says, those apps that are designed to let patients actively manage their own conditions aren’t effective, because they’re not downloaded often or used consistently. “ ‘If you build it, they will come’ is not true at all,” says Schueller.