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Digital Mental Health - UC Berkeley - without hidden - reduced

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Digital Mental Health - UC Berkeley - without hidden - reduced

  1. 1. @StevenChanMD @UCDavisHealth #DigitalMentalHealth#DigitalMentalHealth #DIGITALMENTALHEALTH @StevenChanMD • @UCDavisHealth THANKS TO JOHN TOROUS, DON HILTY, PETER YELLOWLEES, ARSHYA VAHABZADEH, SHIH- YEE MARIE TAN, APA/SAMHSA MINORITY FELLOWSHIP PROGRAM, UC DAVIS PSYCHIATRY
  2. 2. @StevenChanMD @UCDavisHealth #DigitalMentalHealth SLIDES OnTwitter, where available. DISCLOSURES None. #DigitalMentalHealth
  3. 3. @StevenChanMD @UCDavisHealth #DigitalMentalHealth Patient Provider / Doctor / Nurse Live interpreter Collateral Caregivers Family
  4. 4. @StevenChanMD @UCDavisHealth #DigitalMentalHealth IMAGE: : http://www.dentaleconomics.com/content/dam/diq/online-articles/2014/06/vitalsigns.jpg
  5. 5. @StevenChanMD @UCDavisHealth #DigitalMentalHealth time happy neutral sad Feeling down No pleasure Suicidal plans & intent unipolar depression
  6. 6. @StevenChanMD @UCDavisHealth #DigitalMentalHealth happy neutral sad time bipolar hypomania bipolar mania overexcitement euphoria delusions overactivity bipolar depression
  7. 7. @StevenChanMD @UCDavisHealth #DigitalMentalHealth time medicines talk therapy calm environment case management & support happy neutral sad
  8. 8. @StevenChanMD @UCDavisHealth #DigitalMentalHealth 1 IN 5 U.S. adults suffer from a mental health condition in a given year. https://www.nami.org/Learn-More/Mental-Health-By-the- Numbers
  9. 9. @StevenChanMD @UCDavisHealth #DigitalMentalHealth OBJECTIVES 1 APPS YOU CAN USE 2 EVALUATING TECHNOLOGY 3 BIG PICTURE TRENDS 4 HOW MIGHT WE
  10. 10. @StevenChanMD @UCDavisHealth #DigitalMentalHealth@StevenChanMD CURRENT USES As a communications medium. As an extension of face-to-face clinic. As intervention + new monitoring techniques.
  11. 11. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CURRENT USES: AS A COMMUNICATIONS MEDIUM https://play.google.com/store/apps/details?id=com.doctorondemand.android.patient&hl=en
  12. 12. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CURRENT USES: AS A COMMUNICATIONS MEDIUM
  13. 13. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CURRENT USES: AS A COMMUNICATIONS MEDIUM •  Doctors on Demand •  HealthLinkNow •  American Well •  1docway •  Talkspace •  MDLive Breakthrough
  14. 14. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CURRENT USES: AS A THERAPY AND INTERVENTION •  Self-monitoring activities & moods •  Encouraging therapy homework •  Case management for relapse
  15. 15. @StevenChanMD @UCDavisHealth #DigitalMentalHealth T2 APPS (NATIONAL CENTER FOR TELEHEALTH & TECHNOLOGY) ON GOOGLE PLAY
  16. 16. @StevenChanMD @UCDavisHealth #DigitalMentalHealth VA APP STORE — MOBILEHEALTH.VA.GOV 11 total mental health apps
  17. 17. @StevenChanMD @UCDavisHealth #DigitalMentalHealth VA — PTSD COACH
  18. 18. @StevenChanMD @UCDavisHealth #DigitalMentalHealth VA — MINDFULNESS COACH
  19. 19. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HEADSPACE MEDITATION https://itunes.apple.com/us/app/headspace.com-meditation-mindfulness/id493145008?mt=8
  20. 20. @StevenChanMD @UCDavisHealth #DigitalMentalHealth MY3
  21. 21. @StevenChanMD @UCDavisHealth #DigitalMentalHealth SAM http://www.imedicalapps.com/2015/07/anxiety-app-review/
  22. 22. @StevenChanMD @UCDavisHealth #DigitalMentalHealth INTELLICARE https://intellicare.cbits.northwestern.edu—http://clinicaltrials.gov/show/NCT02176226
  23. 23. @StevenChanMD @UCDavisHealth #DigitalMentalHealth INTELLICARE https://intellicare.cbits.northwestern.edu—http://clinicaltrials.gov/show/NCT02176226
  24. 24. @StevenChanMD @UCDavisHealth #DigitalMentalHealth INTELLICARE https://intellicare.cbits.northwestern.edu—http://clinicaltrials.gov/show/NCT02176226
  25. 25. @StevenChanMD @UCDavisHealth #DigitalMentalHealth MOODTREK http://mood-trek.com/moodtrek-for-consumers/
  26. 26. @StevenChanMD @UCDavisHealth #DigitalMentalHealth MOODTOOLS http://www.imedicalapps.com/2015/08/moodtools-no-frills-comprehensive-psychoeducation-psychotherapy-depression-app/
  27. 27. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CURRENT USES: INTERVENTION + MONITORING TECHNIQUES •  Self-monitoring activities & moods •  Encouraging therapy homework •  Case management for relapse •  Immediate intervention at relapse •  Intelligent assessments •  Passive monitoring •  Make it more fun & engaging
  28. 28. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CURRENT USES: INTERVENTION + MONITORING TECHNIQUES PatrickL.DulinPhD,VivianM.GonzalezPhD&KendraCampbellPhD(2014)ResultsofaPilotTestofaSelf-AdministeredSmartphone-Based TreatmentSystemforAlcoholUseDisorders:UsabilityandEarlyOutcomes,SubstanceAbuse,35:2,168-175,DOI:10.1080/08897077.2013.821437
  29. 29. @StevenChanMD @UCDavisHealth #DigitalMentalHealth MEDISAFE http://mood-trek.com/moodtrek-for-consumers/
  30. 30. @StevenChanMD @UCDavisHealth #DigitalMentalHealth GOOGLE SEARCH GoogleSearchapp
  31. 31. @StevenChanMD @UCDavisHealth #DigitalMentalHealth@StevenChanMD CURRENT USES As a communications medium. As an extension of face-to-face clinic. As intervention + new monitoring techniques.
  32. 32. @StevenChanMD @UCDavisHealth #DigitalMentalHealth OBJECTIVES 1 APPS YOU CAN USE 2 EVALUATING TECHNOLOGY 3 BIG PICTURE TRENDS 4 HOW MIGHT WE
  33. 33. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CHALLENGES OF MOBILE HEALTH: RESEARCH METHODOLOGIES ARE OUTDATED •  Way too many apps, pilots •  Lack of standardization •  Lack of sound methodology •  Lack of data interoperability & systems integration Tomlinsonetal.,2013
  34. 34. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CHALLENGES OF MOBILE HEALTH: RESEARCH METHODOLOGIES ARE OUTDATED “Theemergingfieldofmobilehealth“.StevenR.Steinhubl,*EvanD.Muse,EricJ.Topol. ScienceTranslationalMedicine.15April2015
  35. 35. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CHALLENGES OF MOBILE HEALTH: RESEARCH USES OLDER TECHNOLOGIES 3-6 y 6-7 y ½-2y
  36. 36. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CHALLENGES OF MOBILE HEALTH: RESEARCH USES OLDER TECHNOLOGIES up to 15 years
  37. 37. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CHALLENGES OF MOBILE HEALTH: RESEARCH USES OLDER TECHNOLOGIES 15 years ago
  38. 38. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
  39. 39. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CHALLENGES OF MOBILE HEALTH: NIH MHEALTH TRAINING INSTITUTE NIHmHealthTrainingInstitute.Seeobssr.od.nih.gov
  40. 40. @StevenChanMD @UCDavisHealth #DigitalMentalHealth MHIMSS EVALUATION METHODS http://www.mhimss.org/sites/default/files/resource-media/pdf/HIMSSguidetoappusabilityv1mHIMSS.pdf Selecting a Mobile App: Evaluating the Usability of Medical Applications mHIMSS App Usability Work Group July 2012 Table 2 – Usability Principle Attribute ChecklistUsability Principle Mobile Design Tenet Example attributes of a “usable” app Let data scream Only information, visual elements and functionalitynecessary to core tasks and decisions are included.Important information stands out, and function options are easy to understand. The focus is the data.The app has a clear, clean, uncluttered screen design.Speak my sign What interface? Screen metaphors are familiar to everyday life, orcommonly expected computer experiences for theclinician. Workflows match the clinical practice needs.The app is intuitive and easy to learn; minimal, if any, training is required. Iconography and symbols speak “naturally.” Grid it Graphic design and layout have the same look and feel, consistent placement of screen elements (e.g., gutters, columns, margins and captions).Terminology and data entry fields are used consistently. Understanding how one screen works helps youunderstand how other screens work Date your users Simplicity Naturalness Consistency
  41. 41. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CHALLENGES OF MOBILE HEALTH: EVALUATING APPS http://www.wellocracy.com—PartnersHealthcare
  42. 42. @StevenChanMD @UCDavisHealth #DigitalMentalHealth CHALLENGES OF MOBILE HEALTH: EVALUATING APPS http://www.adaa.org/finding-help/mobile-apps
  43. 43. @StevenChanMD @UCDavisHealth #DigitalMentalHealth PresentedatAmericanPsychiatricAssociationAnnualMeeting2015
  44. 44. @StevenChanMD @UCDavisHealth #DigitalMentalHealth DATA & PRIVACY OVERVIEW BY GLENN ET AL. “Predictive modeling, referred to by the advertising community as behavioral targeting, is used to bring specific advertisements to online users based on their perceived interests… Target predicted that a customer was pregnant due to purchasing patterns…” CurrPsychiatryRep(2014)16:494DOI10.1007/s11920-014-0494-4
  45. 45. @StevenChanMD @UCDavisHealth #DigitalMentalHealth DATA & PRIVACY OVERVIEW BY GLENN ET AL. “This incident also highlighted that personal health information can be created by combining seemingly innocuous data, and that a predictive model outside of HIPAA protection can cause harm whether or not it is accurate.” — Tasha Glenn, Scott Monteith CurrPsychiatryRep(2014)16:494DOI10.1007/s11920-014-0494-4
  46. 46. @StevenChanMD @UCDavisHealth #DigitalMentalHealth NATIONAL HEALTH SERVICE — APP STORE RISKS Huckvaleetal.BMCMedicine(2015)13:214DOI10.1186/s12916-015-0444-y x79
  47. 47. @StevenChanMD @UCDavisHealth #DigitalMentalHealth NATIONAL HEALTH SERVICE — APP STORE RISKS Of 27 apps [using online API’s], 16 (59 %, n = 16/27) allowed unencrypted access. Two apps had critical vulnerabilities which permitted access to user information, including information belonging to other users, without authorization. Huckvaleetal.BMCMedicine(2015)13:214DOI10.1186/s12916-015-0444-y
  48. 48. @StevenChanMD @UCDavisHealth #DigitalMentalHealth NATIONAL HEALTH SERVICE — APP STORE RISKS Half of apps (50 %, n = 35/70) included strong identifiers in transmitted information. Two- thirds of these (66 %, n = 23/35, 29 % of all apps) sent identifying information without encryption, including email addresses (n = 5), account login details (n = 5), full name (n=2) or date of birth (n=2). Huckvaleetal.BMCMedicine(2015)13:214DOI10.1186/s12916-015-0444-y
  49. 49. @StevenChanMD @UCDavisHealth #DigitalMentalHealth NATIONAL HEALTH SERVICE — APP STORE RISKS [Of the apps with privacy policies,] for a small number (4 %, n = 2/49) information handling was completely consistent with commitments made by the policy. However, while no apps transmitted information where a specific commitment had been made not to, four-fifths either collected (82 %, n = 42/49) or transmitted (78 %, n = 38/49) one or more data items not addressed by a policy. Huckvaleetal.BMCMedicine(2015)13:214DOI10.1186/s12916-015-0444-y
  50. 50. @StevenChanMD @UCDavisHealth #DigitalMentalHealth THREE KEYS TO INCORPORATING APPS 1  Use reputable institutions & verified developers. 2  Try an app yourself first. If an average person can use it — prescribe it. 3  Informed consent on security, privacy, and lack of testing is key.
  51. 51. @StevenChanMD @UCDavisHealth #DigitalMentalHealth OBJECTIVES 1 APPS YOU CAN USE 2 EVALUATING TECHNOLOGY 3 BIG PICTURE TRENDS 4 HOW MIGHT WE
  52. 52. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE: INPATIENT OUTPATIENT HOME http://www.tedeytan.com/wp-content/uploads/2011/06/Kaiser-Permanente-Innovation-Journey-11.jpg
  53. 53. @StevenChanMD @UCDavisHealth #DigitalMentalHealth WHY SHOULD WE CARE? PATIENTS WILL MANAGE THEIR OWN HEALTH. “People with psychotic disorders were able and willing to use e–mental health services. Results suggest that e–mental health services are at least as effective as usual care or nontechnological approaches.” LianvanderKrieke,M.Sc.,M.A.LexWunderink,M.D.,Ph.D.AndoC. Emerencia,M.Sc.PeterdeJonge,Ph.D.SjoerdSytema,Ph.D.E– MentalHealthSelf-ManagementforPsychoticDisorders:Stateofthe ArtandFuturePerspectives.”PsychiatricServices65:33–49,2014; doi:10.1176/appi.ps.201300050
  54. 54. @StevenChanMD @UCDavisHealth #DigitalMentalHealth PEOPLE CAN’T AFFORD MENTAL HEALTH “According to SAMHSA’s 2014 National Survey on Drug Use and Health (NSDUH), 43.6 million people had a mental illness in the past year. But fewer than half received treatment. That’s one in five Americans over the age of 18.” — Paolo del Vecchio, M.S.W., Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration http://blog.samhsa.gov/2015/10/05/accelerating-access-to-mental-health-treatment/
  55. 55. @StevenChanMD @UCDavisHealth #DigitalMentalHealth WHY SHOULD WE CARE? PATIENTS WILL MANAGE THEIR OWN HEALTH. ArtbyReginaHolliday,StanfordMedicineX2014
  56. 56. @StevenChanMD @UCDavisHealth #DigitalMentalHealth WHY SHOULD WE CARE? PATIENTS WILL MANAGE THEIR OWN HEALTH. http://participatorymedicine.org
  57. 57. @StevenChanMD @UCDavisHealth #DigitalMentalHealth WHY SHOULD WE CARE? PATIENTS WILL MANAGE THEIR OWN HEALTH. JeanaHFrost,PhD; MichaelPMassagli,PhD.”SocialUsesofPersonalHealthInformationWithinPatientsLikeMe,anOnlinePatient Community:WhatCanHappenWhenPatientsHaveAccesstoOneAnother’sData”http://www.jmir.org/2008/3/e15/.
  58. 58. @StevenChanMD @UCDavisHealth #DigitalMentalHealth WHY SHOULD WE CARE? OUTPATIENT SURVEY Harvard LSU New Orleans UC Davis Sacramento Cty U Wisconsin, Madison
  59. 59. @StevenChanMD @UCDavisHealth #DigitalMentalHealth WHY SHOULD WE CARE? OUTPATIENT SURVEY Harvard LSU New Orleans UC Davis Sacramento Cty U Wisconsin, Madison State n=106 Private n=108 County n=56 County n=50 36.2 y 39.6 y 44.7 y 43.9 y MEAN AGE
  60. 60. @StevenChanMD @UCDavisHealth #DigitalMentalHealth WHY SHOULD WE CARE? OUTPATIENT SURVEY Pendingpublication.JohnTorous,MD;StevenChan,MDMBA;MarieTan,MD;JakeBehrens,MD;IanMathew,BS;LadsonHinton,MD;Peter Yellowlees,MDMBBS;MatcheriKeshavan,MD.
  61. 61. @StevenChanMD @UCDavisHealth #DigitalMentalHealth OUTPATIENT SURVEY STATISTICS Pendingpublication.JohnTorous,MD;StevenChan,MDMBA;MarieTan,MD;JakeBehrens,MD;IanMathew,BS;LadsonHinton,MD;Peter Yellowlees,MDMBBS;MatcheriKeshavan,MD. 33 25 6 37 53 17 13 17 62 9 17 13 72 16 5 8 0 25 50 75 100 State C ounty 1 C ounty 2 Private ClinicType Percentage OwnershipandWillingness HasSmartphoneandWil NoSmartphonebutWillin HasSmartphonebutUnw NoSmartphoneandUnw Has smartphone + Willing No smartphone + Willing Has smartphone + Unwilling No smartphone + Unwilling state county 1 county 2 private
  62. 62. @StevenChanMD @UCDavisHealth #DigitalMentalHealth 73 16 5 5 59 16 9 15 29 25 11 35 33 18 6 42 0 25 50 75 100 U nder30 31 − 45 46 − 60 O ver60 AgeGroups Percentage OwnershipandWillingness HasSmartphoneandWi NoSmartphonebutWillin HasSmartphonebutUnw NoSmartphoneandUnw OUTPATIENT SURVEY STATISTICS Pendingpublication.JohnTorous,MD;StevenChan,MDMBA;MarieTan,MD;JakeBehrens,MD;IanMathew,BS;LadsonHinton,MD;Peter Yellowlees,MDMBBS;MatcheriKeshavan,MD. Has smartphone + Willing No smartphone + Willing Has smartphone + Unwilling No smartphone + Unwilling <30 yo 31-45 yo 46-60 yo >60 yo
  63. 63. @StevenChanMD @UCDavisHealth #DigitalMentalHealth OUTPATIENT SURVEY DISCUSSION •  58% ownership of smartphones mirrors national U.S. 58% ownership •  71.4% psychiatric outpatients are favorable to the idea of using smartphones for MH •  Age matters: Younger use >> older •  Socioeconomic status matters: Private insurance >> public patients Pendingpublication.JohnTorous,MD;StevenChan,MDMBA;MarieTan,MD;JakeBehrens,MD;IanMathew,BS;LadsonHinton,MD;Peter Yellowlees,MDMBBS;MatcheriKeshavan,MD.
  64. 64. @StevenChanMD @UCDavisHealth #DigitalMentalHealth OUTPATIENT SURVEY LIMITATIONS •  Use of app hypothetical; not verified practice •  Selection bias what about non-volunteers? •  No individual diagnoses •  No control for differences in smartphone ownership rates in each community Pendingpublication.JohnTorous,MD;StevenChan,MDMBA;MarieTan,MD;JakeBehrens,MD;IanMathew,BS;LadsonHinton,MD;Peter Yellowlees,MDMBBS;MatcheriKeshavan,MD.
  65. 65. @StevenChanMD @UCDavisHealth #DigitalMentalHealth DIGITAL HEALTH OVERVIEW 104 M in the U.S. own smartphones Mobile healthcare & medical app downloads reach 44 M in 2012, rising to 142 M in 2016 McKinsey projects opportunities in global mHealth to be $60 B 19% of smartphone users have health apps http://rockhealth.com/healthcare-and-digital-health-facts/
  66. 66. @StevenChanMD @UCDavisHealth #DigitalMentalHealth DIGITAL HEALTH FUNDING YEAR-TO-YEAR
  67. 67. @StevenChanMD @UCDavisHealth #DigitalMentalHealth Technology will change the way we practice mental health. SPEECH ANALYSIS EYE & FACE RECO SMART CLOTHING INGESTIBLES Tasha Glenn, Scott Monteith.” New Measures of Mental State and Behavior Based on Data Collected From Sensors, Smartphones, and the Internet” Curr Psychiatry Rep (2014) 16:523 DOI 10.1007/s11920-014-0523-3 WEARABLE DEVICES
  68. 68. @StevenChanMD @UCDavisHealth #DigitalMentalHealth ADVANTAGES OF MOBILE HEALTH: MOBILE •  Just-in-time context-aware interventions •  Portable location-independence •  Low-power low- to middle-income countries with less-established infrastructure •  Lower cost than traditional desktop computers Hiltyetal.2013,Harrisonetal.2011,Klasnja&Pratt,2012;WHOGlobalObservatoryforeHealthandWHO,2011
  69. 69. @StevenChanMD @UCDavisHealth #DigitalMentalHealth ADVANTAGES OF MOBILE HEALTH: OPPORTUNITIES FOR OBJECTIVE INFORMATION.
  70. 70. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION. location accelerometer net usage text analysis voice pattern light & imaging mania depression anxiety stress suicidality wandering
  71. 71. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION. TashaGlenn,ScottMonteith.”NewMeasuresofMentalStateandBehaviorBasedonDataCollectedFromSensors,Smartphones,andthe Internet”CurrPsychiatryRep(2014)16:523DOI10.1007/s11920-014-0523-3 smartphones eye trackers smart clothing ingestibles wearables
  72. 72. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION. TashaGlenn,ScottMonteith.”NewMeasuresofMentalStateandBehaviorBasedonDataCollectedFromSensors,Smartphones,andthe Internet”CurrPsychiatryRep(2014)16:523DOI10.1007/s11920-014-0523-3
  73. 73. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: INTERVENTION + MONITORING TECHNIQUES AiCure.com-http://files.abstractsonline.com/CTRL/6d/a/1ab/bbf/190/4b6/1a2/5d9/579/e23/0d4/41/g632_4.jpg
  74. 74. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: INTERVENTION + MONITORING TECHNIQUES Proteusbio-sensor—variantofimagefromhttp://www.turkiyegazetesi.com.tr/dunya/70817.aspx
  75. 75. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: INTERVENTION + MONITORING TECHNIQUES TheColbertReport
  76. 76. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE: GERIJOY
  77. 77. @StevenChanMD @UCDavisHealth #DigitalMentalHealth GERIJOY
  78. 78. @StevenChanMD @UCDavisHealth #DigitalMentalHealth GEPPETTO AVATARS http://www.xconomy.com/wisconsin/2014/05/15/geppetto-avatars-aims-to-read-your-emotions-keep-you-healthy/?single_page=true
  79. 79. @StevenChanMD @UCDavisHealth #DigitalMentalHealth SPECIFIC PHOBIAS SOCIAL ANXIETY D/O ALCOHOL USE D/O PTSD RELAXATION Psious Affordable virtual reality can enhance psychotherapy.
  80. 80. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: VIRTUAL REALITY $40-$350 per unit OculusRift
  81. 81. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: VIRTUAL REALITY $40-$350 per unit OculusRift
  82. 82. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: VIRTUAL REALITY Springer
  83. 83. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: GEORGIA TECH — GOOGLE GLASS
  84. 84. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: GOOGLE GLASS Sension.http://www.wired.com/2013/08/catalin-voss/, http://www.medicaldaily.com/google-glass-vs-autism-how-face-tracking-and-emotion-response-are-putting-18-year-old-catalin-voss
  85. 85. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: GOOGLE GLASS + BRAIN POWER FOR AUTISM
  86. 86. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: GOOGLE GLASS + BRAIN POWER FOR AUTISM
  87. 87. @StevenChanMD @UCDavisHealth #DigitalMentalHealth https://developer.ibm.com/watson/blog/2015/03/23/ibm-watson-personality-insights-science-behind-service/ Machine learning & big data to drive population health and individual health.
  88. 88. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION. DrorBen-Zeev,2013,atmHealthSummit,OxonHill,MD
  89. 89. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: OPPORTUNITIES FOR OBJECTIVE INFORMATION.
  90. 90. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE: INSTAGRAM & SUICIDE Presented3May2014atAmericanPsychiatricAssociation2014meeting “Social media may be a tool to identify those at risk for suicide and self-harm, to improve mental health stigma, and to provide valuable mental health resources.” – Arshya Vahabzadeh MD, Holly Peek MD MPH TEMPLATE DESIGN © 2008 www.PosterPr esentat ions.co m 1 AIMS AND OBJECTIVES METHODS Quantitative and Qualitative Analysis Discussion A Content Analysis and Policy Discussion of Posts Tagged #Suicide on Instagram Arshya Vahabzadeh M.D.1 Holly Peek M.D. MPH2 1Massachusetts General Hospital and Harvard Medical School, Boston, USA 2Tulane University School of Medicine, New Orleans, USA INTRODUCTION References 1. http://www.pewinternet.org/2012/07/11/teens-2012-truth-trends-and-myths- about-teen-online-behavior/ 2. http://www.cnet.com/news/why-teens-are-tiring-of-facebook/ 3. Kross E, Verduyn P, Demiralp E, Park J, Lee DS, Lin N Shablack H, Jonides J, Ybarra O. Facebook use predicts declines in subjective well being of young adults. PLoS One. 2013 8(8):e69841. 4. Krasnova H, Wenninger H, WidjajaT, Buxmann P. Envy on Facebook: A Hidden Threat to Users’ Life Satisfaction? 11th International Conference on Wirtschaftsinformatik, Leipzig, Germany, Feb 27-March 1 2013. 5. Moreno MA, Christakis DA, Egan KG, Jelenchick LA, Cox E, Young H, Villard H, Becker T. A pilot evaluation of associations between displayed depression references on Facebook and self-reported depression using a clinical scale. J Behav Health Serv Res Jul 2012; 39(3): 295-304. 6. Abrutyn S, Mueller AS. Are suicidal behaviors contagious in adolescence? Using longitudinal data to examine suicide suggestion. American Sociological Review, published online 14 February 2014. 7. Gould M, Jamieson P, Romer D. Media Contagion and Suicide Among the Young. American Behavioral Scientist. May 2003; 46(9): 1269-1284. 8. Livingston JD, Cianfrone M, Korf-Uzan K, Coniglio C. Another time point, a different story: one year effects of a social media intervention on the attitudes of young people to mental health issues. Soc Psychiatry Psychiatr Epidemiol. Published online January 9 2014. Social media is popular among teens, with 80% of those aged 12-17 using social media (1). The posting of photos and videos is one of the most frequent activities on social media in this age group (1). Instagram, a picture-based social media platform with over 100 millions users, is the top photo sharing outlet, with 1 in 10 teens visiting the site each month (2). Despite its popularity, there is growing concern that some users of social media experience negative mental health effects (3, 4). Social media sites have also been shown to elicit high levels of self-disclosure which include references to health risk behaviors such as depressive symptoms or suicidality (5). Alarmingly, media stories have highlighted instances where suicides were referenced on social media sites before being carried out, drawing attention to the urgent need to examine these references. The influence of suicidal content posted on social media is concerning, particularly for adolescents as they frequently imitate behaviors of their peers, a phenomenon known as “social modeling.” Media research demonstrates that the young are particularly vulnerable to portrayals of suicide in mass media (6,7). Because of the increased rates of self-disclosure, which include serious imagery or allusions to depression and suicide, and the vulnerability of adolescents to the suicidal content in the media, Instagram states that it has a policy of removing content that promotes suicidal or self-harming acts. Given the concerns for suicide and self-harm risk for adolescent users of social media, we performed an exploratory study that analyzed if Instagram's policy is effective in removing suicidal or self-harm content, and also to describe the content that is labelled by users with the hashtag identifier “#suicide". A search on Instagram was created using the search term "#suicide" and a content analysis was performed on the first 60 resulting images. These images were quantitatively analyzed by two reviewers. Content was categorized by the presence of pictures or quotes and then further subcategorized. Subcategories included content perceived by both reviewers as being depressive, suicidal, self-injurious, eating disordered, reflective, neutral, humorous, or positive. The categories were not mutually exclusive. The images containing suicidal and self- harm content were further analyzed for other qualitative themes. Quantitative analysis revealed 42% of the images contained pictures and 58% contained quotes. Distribution of the themes were as follows: 50% depressive; 15% suicidal; 12% self- injurious; 5% positive; 3% eating disordered; 16% neutral; 3% humorous; 13% reflective. Key Findings: 89% of suicidal themed images were either idolizing, romanticizing, or promoting methodology or locations of suicide according to the reviewer analysis - factors which are linked to an increased risk of suicide. Qualitative analysis for the suicidal theme revealed the following: • No images for suicide help resources • All of those posting were female • Four images visually demonstrated actual methods of suicide, two with hanging and two with pill overdose • Three images demonstrated text only, including a suicide note and other expressions of a desire to die • One image of a self-portrait with a suicidal caption • One image with a humorous overtone Qualitative analysis for the self-injurious theme revealed the following: • No images for self-injury help resources • All of those posting were female • All images depicted a variation on the theme of cutting • Four images showed bleeding cuts, including active cutting • One image was instructive on the method of cutting • One image described the cuts as "beautiful“ • One image with an encouraging overtone of healing with self- injury Our findings show that Instagram’s policy of identifying “any account found encouraging or urging users to embrace anorexia, bulimia, or other eating disorders; or to cut, harm themselves, or commit suicide” resulting in a “disabled account without warning” as ineffective. Searching “#suicide” reveals a majority of images that romanticize and idealize suicidal, self harm or depressive themes including graphic images that are either instructional or suicidal acts in progress. Alarmingly, only 5% of the images send a positive message discouraging suicidal or self-harm behaviors. Furthermore, absolutely no informational or crisis intervention resources are provided within the content of the search. When searching “#suicide” on Instagram, a disclaimer does appear advising that the searched images may contain graphic content and gives an option to “learn more” by redirecting to an outside website for suicide prevention or to alternatively “show posts.” The option to be redirected to a website is a nominal effort in promoting suicide prevention in that suicide prevention information can be easily bypassed by viewing the graphic posts where no suicide prevention resources are available. We suggest the addition of suicide prevention information and resources within the search content rather than an optional redirection to an outside website. Evidence has shown that youth are increasingly seeking health information online and through social media. Social media campaigns can potentially be a successful tool in learning about mental health symptoms, reducing stigma and increasing awareness of mental health services (8). Given the growing popularity of social media among youth, we must engage with social media networks and the wider public to ensure that these issues do not go unnoticed and attempts are made to remedy them. 0 10 20 30 40 50 Depressive Suicidal Self Injurious Eating Disorder Substance Use Neutral Reflective Humor Content of #Suicide in % of tagged Instagram Images (n=60) 0 1 2 3 4 5 6 7 8 9 Poster was female A method of suicide Text based suicidal idea Photo based suicidal idea Humorous overtone Content of Suicidal Themed Images (n=9) 0 1 2 3 4 5 6 7 8 Poster was female Injury by cutting Bleeding cuts/Active cutting Advice for cutting Labelling cutting as beautiful Cutting as healing Content of Self-Injury Themed Images (n=7) -Recognize social media is popular among adolescents and is a vehicle many use for self-disclosure, including references to suicide and self-harm. -Recognize the lack of enforcement of the policies aimed at preventing graphic suicidal and self-harm imagery on social media sites, such as Instagram. -Recognize that the exposure to idolized and romanticized imagery of suicide, it’s methodology, and potential locations are linked to suicide attempts. -Recognize that social media may be a tool to identify those at risk for suicide and self-harm, to improve mental health stigma, and to provide valuable mental health resources. Results
  91. 91. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE IS NOW: FACEBOOK BUILT-IN SUICIDE FLAGS
  92. 92. @StevenChanMD @UCDavisHealth #DigitalMentalHealth SPARX CBT GAME MerryS,StasiakKetal.TheeffectivenessofSPARX,acomputerisedselfhelpinterventionforadolescentsseekinghelpfordepression: randomisedcontrollednon-inferioritytrial.BMJ2012;344doi:http://dx.doi.org/10.1136/bmj.e2598(Published19April2012)http:// www.bmj.com/content/344/bmj.e2598.Alsocoveredathttp://www.imedicalapps.com/2014/01/video-game-depression-anxiety-kids- diabetes-asthma-linkedwellness/
  93. 93. @StevenChanMD @UCDavisHealth #DigitalMentalHealth ADVANTAGES OF MOBILE HEALTH: CAN BE MORE ENGAGING.
  94. 94. @StevenChanMD @UCDavisHealth #DigitalMentalHealth ADVANTAGES OF MOBILE HEALTH: CAN BE MORE ENGAGING.
  95. 95. @StevenChanMD @UCDavisHealth #DigitalMentalHealth ADVANTAGES OF MOBILE HEALTH: CAN BE MORE ENGAGING. CurrPsychiatryRep.2014Dec;16(12):520.doi: 10.1007/s11920-014-0520-6. Theuseofelectronicgamesintherapy:areview withclinicalimplications.Horne-MoyerHL1, MoyerBH,MesserDC,MesserES. “The use of electronic games in therapy: a review with clinical implications”
  96. 96. @StevenChanMD @UCDavisHealth #DigitalMentalHealth Mental health is the new frontier for digital health.
  97. 97. @StevenChanMD @UCDavisHealth #DigitalMentalHealth http://www.technologyreview.com/news/541446/why-americas-top-mental-health-researcher-joined-alphabet/ “Technology can cover much of the diagnostic process ... Also, a lot of the treatments for mental health are psychosocial interventions, and those can be done through a smartphone.” — Thomas Insel, M.D., Sept 21, 2015
  98. 98. @StevenChanMD @UCDavisHealth #DigitalMentalHealth Fragmented systems create opportunity for new mental health platforms.
  99. 99. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HYPE CYCLE Source:Gartner:July2014.Hat-tipto KathrynHautanen,MS,SM,MBA,KaiserPermanente. expectations time Innovation triggers Peak of inflated expectations Trough of disillusionment Plateau of productivity
  100. 100. @StevenChanMD @UCDavisHealth #DigitalMentalHealth#DigitalMentalHealth THANK YOUSteven Chan MD MBA • UC Davis Psychiatry THANKS TO JOHN TOROUS, DON HILTY, PETER YELLOWLEES, LADSON HINTON, JAKE BEHRENS, SHIH-YEE MARIE TAN, APA/SAMHSA MINORITY FELLOWSHIP PROGRAM.
  101. 101. @StevenChanMD @UCDavisHealth #DigitalMentalHealth OBJECTIVES 1 APPS YOU CAN USE 2 EVALUATING TECHNOLOGY 3 BIG PICTURE TRENDS 4 HOW MIGHT WE
  102. 102. @StevenChanMD @UCDavisHealth #DigitalMentalHealth h/tNickDawson “We can’t…” “How might we…”
  103. 103. @StevenChanMD @UCDavisHealth #DigitalMentalHealth KAISER PERMANENTE INNOVATION
  104. 104. @StevenChanMD @UCDavisHealth #DigitalMentalHealth KAISER PERMANENTE INNOVATION
  105. 105. @StevenChanMD @UCDavisHealth #DigitalMentalHealth KAISER PERMANENTE INNOVATION
  106. 106. @StevenChanMD @UCDavisHealth #DigitalMentalHealth KAISER PERMANENTE INNOVATION
  107. 107. @StevenChanMD @UCDavisHealth #DigitalMentalHealth KAISER PERMANENTE INNOVATION
  108. 108. @StevenChanMD @UCDavisHealth #DigitalMentalHealth KAISER PERMANENTE INNOVATION
  109. 109. @StevenChanMD @UCDavisHealth #DigitalMentalHealth KAISER PERMANENTE INNOVATION
  110. 110. @StevenChanMD @UCDavisHealth #DigitalMentalHealth KAISER PERMANENTE INNOVATION
  111. 111. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  112. 112. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  113. 113. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  114. 114. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  115. 115. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  116. 116. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  117. 117. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  118. 118. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  119. 119. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  120. 120. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  121. 121. @StevenChanMD @UCDavisHealth #DigitalMentalHealth HACKATHONS & CHALLENGES
  122. 122. @StevenChanMD @UCDavisHealth #DigitalMentalHealth INTRODUCING
  123. 123. @StevenChanMD @UCDavisHealth #DigitalMentalHealth INSTANTANEOUS INTERPRETATION — ANY TIME, ANYWHERE I’m feeling depressed today.! Me siente depremido hoy.! Telepsychiatry Synchronous & asynchronous
  124. 124. @StevenChanMD @UCDavisHealth #DigitalMentalHealth INSTANTANEOUS INTERPRETATION — ANY TIME, ANYWHERE Telepsychiatry Synchronous & asynchronous In person
  125. 125. @StevenChanMD @UCDavisHealth #DigitalMentalHealth REAL-TIME LANGUAGE INTERPRETATION
  126. 126. @StevenChanMD @UCDavisHealth #DigitalMentalHealth UC DAVIS TRANSLATION APP
  127. 127. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: GOOGLE TRANSLATE
  128. 128. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS:
  129. 129. @StevenChanMD @UCDavisHealth #DigitalMentalHealth FUTURE TRENDS: SKYPE & CLOSED CAPTIONS
  130. 130. @StevenChanMD @UCDavisHealth #DigitalMentalHealth 2010 U.S. CENSUS 4.7%of the population (over 5 years of age) had limited English- speaking abilities. This is nearly the size of Illinois.
  131. 131. @StevenChanMD @UCDavisHealth #DigitalMentalHealth REAL-TIME LANGUAGE INTERPRETATION: WHY IS LANGUAGE IMPORTANT? •  In 2002, approx. 6 million immigrant adults aged 18-64 did not speak English well. More than 2.5 million did not speak English at all. •  Professionally-trained interpreters are often not available in community-based practices. •  Failure to use interpreters –  hospital admission rates –  use of testing –  poorer patient comprehension –  misdiagnosis and improper treatment
  132. 132. @StevenChanMD @UCDavisHealth #DigitalMentalHealth SACRAMENTO COUNTY LANGUAGES 90+non-English languages, like Spanish Miao Chinese Vietnamese Tagalog Russian Ukranian Hindi German Hmong
  133. 133. @StevenChanMD @UCDavisHealth #DigitalMentalHealth Patient Provider Live interpreter
  134. 134. @StevenChanMD @UCDavisHealth #DigitalMentalHealth Patient Provider Live interpreter
  135. 135. @StevenChanMD @UCDavisHealth #DigitalMentalHealth Patient Provider
  136. 136. @StevenChanMD @UCDavisHealth #DigitalMentalHealth Patient Provider Ad hoc • untrained staff • family • children
  137. 137. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
  138. 138. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
  139. 139. @StevenChanMD @UCDavisHealth #DigitalMentalHealth Patient Provider CAPTIONS SPEECH
  140. 140. @StevenChanMD @UCDavisHealth #DigitalMentalHealth ULTIMATE GOAL •  Analyze language as data. •  Create new clinical processes for in- person care and telemedicine. •  Create a better standard of care with improved interpreting, more efficiently, and less expensively.
  141. 141. @StevenChanMD @UCDavisHealth #DigitalMentalHealth PRELIMINARY TRANSLATION TESTS English Tell me about your girlfriends. They were animals. Pick one, and tell me about her. I met a woman last year; she was a stray cat. Why do you say she was a stray cat? She had no connections. What was it that you were attracted to? Her body. Okay. What kicked in about her personality later? What do you mean? If I met her, what would I notice about her? It's tough to answer. Her attitude. How was that? It was good. What do you think you'll be doing in five years, and what would you like to be doing? I'll probably be dead. I'd like to be a physician. From Daniel J Carlat’s The Psychiatric Interview 2nd Edition.“Obtaining the Social and Developmental History." pp.104-105
  142. 142. @StevenChanMD @UCDavisHealth #DigitalMentalHealth PRELIMINARY TRANSLATION TESTS English Tell me about your girlfriends. They were animals. Pick one, and tell me about her. I met a woman last year; she was a stray cat. Why do you say she was a stray cat? She had no connections. What was it that you were attracted to? Her body. Okay. What kicked in about her personality later? What do you mean? If I met her, what would I notice about her? It's tough to answer. Her attitude. How was that? It was good. What do you think you'll be doing in five years, and what would you like to be doing? I'll probably be dead. I'd like to be a physician. Bing Translator EN ES EN Tell me about your friends. C They were animals. Choose one and tell me about it. P I met a woman last year; It was a stray cat. P Why you say that it was a stray cat? P It had no connection. P What was it that attracted you? Your body. P, C It is ok. He kicked him later about his personality? N, P What do you mean? If I knew her, would count on it it? N, P It is difficult to answer. His attitude. P How was that? It was good. What do you think to be doing in five years, and what would you like to do? I will probably be dead. I'd like to be a doctor. Odd pronouns Non-sensical Critical error
  143. 143. @StevenChanMD @UCDavisHealth #DigitalMentalHealth PRELIMINARY TRANSLATION TESTS English Do you have any thoughts about what might have prompted your wife to call the ambulance? It sounds like you’ve been very sad since your mother’s death, and that her death after so many years of suffering has also felt like a relief. You look very sad. I know you have much to tell me, but I need to shift to getting some basic information. I see you’ve thought a lot about the previous treatment team, but could you tell me when you had that last hospitalization? From John Barnhill’s “Chapter 1. The Psychiatric Interview and Mental Status Examination”. The American Psychiatric Publishing Textbook of Psychiatry . 6th Edition.
  144. 144. @StevenChanMD @UCDavisHealth #DigitalMentalHealth PRELIMINARY TRANSLATION TESTS English Do you have any thoughts about what might have prompted your wife to call the ambulance? It sounds like you’ve been very sad since your mother’s death, and that her death after so many years of suffering has also felt like a relief. You look very sad. I know you have much to tell me, but I need to shift to getting some basic information. I see you’ve thought a lot about the previous treatment team, but could you tell me when you had that last hospitalization? You have any idea about what could be done for his wife to call the ambulance? C It seems that you've been very sad since the death of his mother, and that he also felt his death after so many years of suffering as a relief. C You feel very sad. I know that you have much to say, but I need to change to get some basic information. I see that you thought much about pretreatment equipment, but could you tell me when was that last hospitalization? N Bing Translator EN ES EN Non-sensical Critical error
  145. 145. @StevenChanMD @UCDavisHealth #DigitalMentalHealth INTRODUCING
  146. 146. @StevenChanMD @UCDavisHealth #DigitalMentalHealth Telemedicine 1999
  147. 147. @StevenChanMD @UCDavisHealth #DigitalMentalHealth SPECIALTY CARE VIDEO CONFERENCING
  148. 148. @StevenChanMD @UCDavisHealth #DigitalMentalHealth ASYNCHRONOUS TELEPSYCHIATRY Clinician Nurse, Counselor, Therapist, or Resident Patient Video is routed to psychiatrist.
  149. 149. @StevenChanMD @UCDavisHealth #DigitalMentalHealth EQUIPMENT IS MOBILE Cameras Videoconferencing software Dedicated speakerphone
  150. 150. @StevenChanMD @UCDavisHealth #DigitalMentalHealth ASYNCHRONOUS TELEPSYCHIATRY WORKFLOW PRIMARY CARE PROVIDER PATIENT-CLINICIAN “VIRTUAL VISIT” PSYCHIATRIST VIDEO CONSULT NOTE STORE ON VIDEO FILES STEP 1: Provider refers patient to telepsychiatry. STEP 5: We measure satisfaction, symptoms & outcomes every 6 months. STEP 2: A video of the patient interview is recorded STEP 3: Video & history sent securely to consulting psychiatrist. STEP 4: The specialist’s consult & recommendations are sent to primary care provider.
  151. 151. @StevenChanMD @UCDavisHealth #DigitalMentalHealth ATP SUMMARY OF FINDINGS Diagnostically reliable across differing language groups with translation Not suggested for therapy Can be used for monitoring treatment progress Easier management/admin/ scheduling Improved communication between patient and reporting provider
  152. 152. @StevenChanMD @UCDavisHealth #DigitalMentalHealth THE VCC TEAM •  Peter Yellowlees MD •  Alberto Odor MD •  Lorin Scher MD •  Michelle Parish MA •  Steven Chan MD •  Breanne Harris BA •  Glen Xiong MD •  Robert McCarron MD •  Andres Sciolla MD •  Anna-Maria Iosif PhD •  Paul Leigh PhD •  Bill Brady MD and Auburn Clinic staff – UCD PCN •  Scott MacDonald MD and J St Clinic staff – UCD •  Communicare FQHC staff •  CHT technical team – George Wu, Kalim Simon •  EMR Epic team – Mike Minear and Hien Nguyen MD •  Psychiatry Outpatient Clinic – Becky Mackey •  Don Hilty MD USC •  Jay Shore MD U Colorado
  153. 153. @StevenChanMD @UCDavisHealth #DigitalMentalHealth h/tNickDawson “We can’t…” “How might we…”
  154. 154. @StevenChanMD @UCDavisHealth #DigitalMentalHealth OBJECTIVES 1 APPS YOU CAN USE 2 EVALUATING TECHNOLOGY 3 BIG PICTURE TRENDS 4 HOW MIGHT WE
  155. 155. @StevenChanMD @UCDavisHealth #DigitalMentalHealth#DigitalMentalHealth THANK YOUSteven Chan MD MBA • UC Davis Psychiatry THANKS TO JOHN TOROUS, DON HILTY, PETER YELLOWLEES, LADSON HINTON, JAKE BEHRENS, SHIH-YEE MARIE TAN, APA/SAMHSA MINORITY FELLOWSHIP PROGRAM.
  156. 156. @StevenChanMD @UCDavisHealth #DigitalMentalHealth#DigitalMentalHealth #DIGITALMENTALHEALTH @StevenChanMD • @UCDavisHealth THANKS TO JOHN TOROUS, DON HILTY, PETER YELLOWLEES, LADSON HINTON, JAKE BEHRENS, SHIH-YEE MARIE TAN, APA/SAMHSA MINORITY FELLOWSHIP PROGRAM, UC DAVIS PSYCHIATRY & BEHAVIORAL HEALTH CENTER OF EXCELLENCE.

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