Design of Health Technologies lecture 17

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Design of Health Technologieslecture 17
John Canny11/07/05
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IT for Mental Health

• Q Why computer therapy?
• A Many cases of depression and anxiety disorders
  go untreated patients are ashamed to seek help,
  and may fear the consequences at work and home.
• A Therapy is expensive and beyond the reach of
  many patients.
• Computer therapy is very cheap and available by
  comparison. It looks like a good option, as long
  as it works

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Marks et al.

• CBT (Cognitive Behavior Therapy) via Computer.
• What is CBT?
• CBT is a method used to treat depression and
  anxiety via a recognition of distorted
  thinking, and cognitive restructuring. It may
  also involve classical conditioning when used to
  treat Obsessive Compulsive Disorder.

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Marks et al.

• Considered 4 systems, which patients were advised
  to use at least 6 times over 12 weeks
• Fearfighter for phobia/panic
• Cope for depression/anxiety
• Balance for general anxiety/depression
• BTSteps for Obsessive Compulsive Disorder
• Patients had some direct contact with therapists
  for advice, and help with the system.

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Marks et al.

• Fearfighter was PC or web-based.
• Cope and BTSteps were phone-based. The system
  used voice, while users responded with phone key
  presses.
• Balance was PC-based using a CD-Rom.

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Marks et al. Outcomes

• Improvements were found in all groups.
• Typical improvements were 20-40 in standard
  measures of anxiety or depression.
• Significances were not high, and there was a
  large variation in difference (meaning some
  patients reported getting worse).
• Nevertheless, this kind of treatment seems to
  have worked well.

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Marks et al. Outcomes
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VR and Phobias (North et al.)

• VR therapy via SD (Systematic Desensitization) is
  becoming very popular.
• SD is a process of gradually introducing a
  disturbing stimulus (e.g. view from a high place)
  in otherwise pleasant surroundings.
• This process gradually suppresses the anxiety
  response.

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VR and Phobias

• VR for SD has several advantages
• Patients often have difficulty imagining the
  stimulus themselves.
• They are often afraid of experiencing it directly
  which may also be expensive and time-consuming.
  
• VR affords patient privacy and confidentiality
  during treatment.

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VR and Phobias

• Several case studies reported in the North paper
• Aerophobia (flying) two subjects reported
  improvements
• Agoraphobia (described as a fear of situations
  from which it is difficult to escape) study with
  60 patients, showed strong improvement in the
  treatment group.
• Acrophobia (heights) with 20 college students,
  strong improvement in the treatment group.

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VR and Phobias

• Physiological signs in patients undergoing VR
  therapy typically mirrored real reactions
• Anxiety, muscle tension, palpitations, shaking,
  sweating and dizziness.

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VR and Phobias

• A very high degree of realism did not seem to be
  necessary for effective VR therapy.
• Most environments had simple graphics, limited
  sound and vibration effects (and no G-forces
  apparently).
• Subjects sense of presence in the virtual world
  increased spontaneously with repeated
  treatments.
• This generally follows the therapeutic trend.

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VR and imagination (Vincelli et al.)

• Imagination and memory play a central role in
  classical therapy.
• Most psychotherapy is based on the analysis and
  modification of mental images.
• Many anxiety disorders result from the
  maintenance of oppressive images (Beck).
• Imagined stimuli elicit most of the physiological
  responses of real stimuli pulse, pupil size,
  muscle tension, blood glucose, skin temperature,
• Penfield (1963) showed that imaginative stimuli
  arise in areas of cortex devoted to sensory
  perception.

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VR and imagination

• Some specific therapies using imagination
  include
• Projection in time rationally reconstructing
  the future
• De-catastrophizing an image modifying a
  disturbing image
• Image modeling and substitution interrupting
  a negative train of images
• Covert conditioning subtle conditioning using
  imagined rather than real stimuli

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VR and imagination - SD

• Systematic Desensitization (SD) is one of the
  more popular approaches in VR therapy.
• SD consists of placing the patient in a pleasant
  state, and then introducing an anxiety-provoking
  stimulus. As this process is repeated the anxiety
  response is inhibited.

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Limitations of VR therapy - Milton

• Acknowledges successes in many areas
• Phobias
• Body Image, eating disorders, sexual dysfunction,
  treating autism.
• But there are some major limitations to more
  widespread use.

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Limitations of VR therapy

• Cost of building models
• Virtual worlds require some kind of 3D CAD
  system. These tools are notoriously hard to use.
• Detail is needed not only in visual appearance,
  but also in their physics (objects should behave
  normally if the user picks them up).
• Human models (avatars) can be enormously complex,
  but are mostly rigid manequins.

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Limitations of VR therapy

• Cost of rendering environment
• The original systems used a CAVE, and array of
  screens with 3d input devices, and costs running
  into millions.
• More recently, stereoscopic displays and 3D mice
  are available at low cost. But the level of
  immersion is much lower.

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Limitations of VR therapy

• Limitations of Study methods
• Many studies of VR methods have not used careful
  enough criteria for defining the condition under
  study acrophobia, aerophobia. Most often
  patients self-submit to the experiment or are
  referred because of existing treatment.
• Tools such as DSM-IV could be used to more
  carefully chart the condition in the patients who
  participate in studies.

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HutchWorld (not in readings)

• Hutchworld is a virtual community attached to the
  Hutchison Cancer Research Center.
• Designed to provide social support for cancer
  patients and their families.
• Based on Microsofts Vworlds system.

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HutchWorld

• Built on an earlier system called CHESS
  (Comprehensive Health Enhancement Support System)
  that provide information for chronically ill
  patients, esp. those with HIV.
• Researchers found that CHESS users used the
  system more than once per day. They also found
  that users made heavier use of the social support
  functions of the site, more than the
  informational functions.

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HutchWorld Design Guidelines

• Recreating the actual building was more
  effective than an abstract environment.
• Access was restricted to patients, caregivers and
  their families.
• Information was restricted to publicinformation
  , not sensitive or specialized medical
  information.

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HutchWorld Design Evolution

• The 3D Vworlds version had some serious
  shortcomings
• It was difficult to achieve a critical mass of
  users and the space often appeared empty.
• Users could not lurk in the space since their
  avatar was visible if they were there.
• Users did not return after a negative first
  experience.

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HutchWorld Design Evolution

• The second prototype was designed to support
  asynchronous communication.
• This allowed patients to check in when they
  wanted to many patients were awake in the early
  hours of the morning. The Hutchworld system
  provided a social channel even if no-one else was
  online.
• Information portal functions were integrated in
  the system so users could do much more than
  message. They still had a visible avatar while
  visiting the site.

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HutchWorld Design Evolution

• The second prototype was designed to support
  asynchronous communication.
• This allowed patients to check in when they
  wanted to many patients were awake in the early
  hours of the morning. The Hutchworld system
  provided a social channel even if no-one else was
  online.
• Information portal functions were integrated in
  the system so users could do much more than
  message. They still had a visible avatar while
  visiting the site.

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Discussion Questions

• Mental health is an important topic in itself,
  but also interacts with other medical therapies
  (e.g. as in Hutchworld and CHESS).
• Discuss ways of integrating mental health support
  with other health care delivery systems.
• A lot of research is directed at high-end (VR)
  therapies, but several successful systems were
  much simpler. Discuss means of deploying
  low-end computer therapies, and what kinds of
  conditions might be treated with them.