Keywords

1 Introduction

On the morning of the October 2, 2006, 32 year old Charles C. Roberts marched into a one-room Amish school house ready to avenge a 20-year old grudge. Roberts instructed the boys to exit the classroom, leaving the remaining girls to cower in fear. During the course of the incident Roberts proceeded to kill five and wound seven female victims before committing suicide [1]. Though Roberts had no prior history of psychiatric illness, it was clear that he was suffering from some kind of mental health crisis. Had Roberts received proper psychiatric care, would this incident have occurred? This type of question, raised by the media after a mass shooting, often leads the public to stigmatize and criminalize all mental health issues. Metzl and MacLeish [2] detail four assumptions that often surface after mass shootings: “(1) that mental illness causes gun violence, (2) the psychiatric diagnosis can predict gun crime, (3) that shootings represent the deranged acts of mentally ill loners, and (4) that gun control ‘won’t prevent’ another [mass school shooting].” This overgeneralization, however, is often unfounded, as most mental health patients do not exhibit violent behavior and 95–97 % of violent acts involving guns are not committed by individuals exhibiting acute mental illnesses [3]. The flawed perceived association between gun violence and mental illness is perpetuated by the media, often feeding cultural, political, socio-economical, stereotypes, creating obscured views, and stigmatizing individuals diagnosed with mental health conditions [2]. In order to better understand the challenges facing both therapists and patients an evaluation of current method of treatments and the possibilities of expanding resources is required.

The National Alliance on Mental Illness [4] reports that one in four adults experience mental health issues (e.g., schizophrenia, major depression, and bipolar disorder) in a given year. However, because of social stigma, monetary limitations (e.g., costs of treatment, lack of healthcare), or inconvenience, individuals often resist seeking treatment or discontinue treatment prior to completion upon pursuing such treatment; this is particularly true amongst military populations [5–7]. The effects of these barriers and setbacks are evident as approximately one third of 40 million affected Americans receive treatment [8]. Additionally, those afflicted may fail to self-identify as having a disorder, may mistrust treatment as an effective option, may not wish to seek outside assistance, and/or may believe that the symptoms will dissipate overtime [9].

The present paper provides a brief literature survey of the current treatment options available for a subgroup of mental health conditions – Anxiety Disorders (due to the prevalence), as well as details recommendations for integrating these established treatment options with blended learning (multimodal) techniques, utilizing online, mobile, and wearable technologies. The purpose of this paper is to initiate discussion points for current technological capabilities within the mental health system that addresses accessibility and adoptability gaps, as well as list potential variables for longitudinal data collection.

2 Anxiety Disorders

Anxiety disorders are the most common type of mental health condition afflicting over 40 million Americans [10], with a specific (simple) phobia as the most common [11]. Diagnosis is typically determined through interviews and questionnaires to rule out whether other medical conditions/disabilities are present [12]. However, it is often difficult to diagnose anxiety disorders due to comorbidity (an individual with co-occurring of two or more disorders [13]). Meaning, several symptoms overlap between multiple disorders, such as general anxiety and major depression, as both types of patients typically exhibit symptoms of fatigue and insomnia [14, 15]. Although these conditions are similar in nature, the following paragraphs summarize and distinguish specific details between common anxiety disorders.

Generalized anxiety disorder has a prevalence rate within the U.S. of 3.1 % for the general population [14]. Those individuals afflicted with generalized anxiety disorder exhibit defining features and at least one coexisting condition – excessive worry and major depression [14]. Clinicians often observe generalized anxiety disorder patients citing somatic symptoms such as headaches or gastrointestinal distress, but these individuals rarely report worry [14]. Other symptoms include fatigue, insomnia, restlessness, difficulty concentrating, irritability, muscle tension, and sleep disturbances [14, 16].

Social anxiety disorder (social phobia), prevalent in 12 % of the population, involves fear and avoidance of social circumstances such as public speaking [17]. It encompasses the feeling of humiliation or embarrassment, as well as rejection [18]. Social anxiety disorder (social phobia) symptoms include blushing, profuse sweating, trembling, nausea, abdominal distress, rapid heartbeat, shortness of breath, dizziness, lightheadedness, headaches, and feelings of detachment [16]. Another common symptom of this disorder is elevated levels of anger, particularly while receiving criticism or negative evaluations [19].

Another prevalent disorder (12.5 % of the population) is specific phobia. Specific phobias are classified into four subtypes: animal, natural environment, situational, blood-injection injury, and other (provided for phobias that do not conform to the four subtypes) [20]. Those afflicted with a specific phobia show strong fear reactions and avoid common places, situations, or objects that have no danger [16].

Post-traumatic Stress Disorder (PTSD) is measured by three levels: acute (persisting for less than three months), chronic, and delayed (occurs six months after event) [21]. Several risk factors (i.e., intensity of trauma, pre-trauma demographics, and temperament traits) can help identify individuals that may potentially develop this condition. PTSD symptoms are classified into three groups: re-experience, avoidance, and increased arousal. To be diagnosed with PTSD, patients must exhibit these symptoms following the traumatic event; meaning, they should not have occurred prior to the event. In the present paper, specific consideration is given to the treatment of anxiety disorders, particularly utilizing multimodal and blended learning techniques combined with traditional therapy.

3 Current Treatments for Anxiety Disorders

Multiple treatment options are available for individuals diagnosed with anxiety disorders, including psychotherapy, medication, complementary or alternative treatment, support groups, and in severe cases, hospitalization [22]. The following sections provide a brief overview of common treatments.

3.1 Psychotherapy

Psychotherapy (also known as counseling) is the application of psychological principles indented to improve an individual’s behaviors, emotions, or cognitions. Much of the research on psychotherapy highlights cognitive behavior therapy, specifically prolonged exposure therapy and eye movement desensitization and reprocessing (EMDR) [23].

A common psychotherapy procedure for treating anxiety disorders is cognitive behavior therapy (CBT) [24]. It involves utilizing basic cognitive and behavioral principles to identify, understand, and change specific feelings, thoughts, and behaviors. Previous research suggests that CBT is more effective for alleviating physiological arousal, fear, and re-experiencing symptoms, than behavioral avoidance, impaired social functioning, anger management, and social skill deficits [25]. CBT (especially exposure therapy) is considered the most effective treatment for anxiety disorders, such as PTSD [25]. Prolonged Exposure Therapy (PE), is “the main components of prolonged exposure are in vivo and imaginal exposure to stimuli related to the traumatic experience, in addition to psycho-education and controlled breathing [26].”

3.2 Complementary and Alternative Treatment

In today’s society, increased open-access to healthcare information elicits an interest in homeopathic and alternative therapies. Complementary and alternative medicines (CAM) are considered to be methods used jointly with conventional medical U.S. practices. Typical types of CAM for anxiety disorders are relaxation techniques, yoga, and acupuncture. Although there is not sufficient evidence to support the substitution of clinical practices with CAM (nor would it be a favorable outcome), research has suggested several of these practices to be effective when paired with traditional therapeutic techniques.

3.3 Pharmacotherapy/Medications

The changes that occur in the hypothalamus-pituitary-adrenal axis, the serotonergic system, and the noradrenergic neurotransmitter systems as a result of PTSD are often treated with medications [27]. However, there is conflicting evidence as to the relative efficacy of most of the medications involved with this disorder. The majority of studies related to pharmacotherapy for PTSD support the conclusion that selective serotonin reuptake inhibitors (SSRIs) can improve symptoms and prevent relapse. There is also evidence to suggest that treatment with SSRIs may be beneficial in the long-term; as a result, this specific class of drugs is considered the first line agents in treating PTSD [27]. More specifically, patients who were placed under 24 weeks of treatment in a double-blind, placebo-controlled trial of fluoxetine improved significantly on the clinical and PTSD severity scores as well as in anxiety and depression symptoms [27].

4 Anxiety Disorders and Assistive Technologies

Assistive technologies are quickly evolving to include more capable devices for tracking a person’s day-to-day experiences. Specifically for mental health symptom management, assistive technologies can be implemented by professional therapists as a supplemental means of therapy. Typically assistive technologies refer to equipment that aid individuals with physical or cognitive impairments, such as hearing aids, brail keyboard, or braille embossers; however, in this paper, assistive technologies refers generally to technologies used to assist disabled individuals, including those with mental health conditions. The following paragraphs detail modalities of treatments including online platforms, mobile technology, simulation, and wearable technology.

4.1 Online Platforms

Online platforms allow individuals with mental health conditions the ability to asynchronously access useful and individualized symptom management information. These types of platforms also allow the individual distributed access to his/her clinician. Utilizing an online platform can replace some (not all) face-to-face sessions. These online sessions tend to be more cost efficient and convenient for the patient [28, 29]. Additionally, clinicians can organize online platforms to connect patient to additional resources, meaning the online platform can double as a distributed repository of symptom management techniques, group discussion boards (online support groups), and self-paced learning modules. This type of platform can also reduce the fear associated with others’ perceptions of clinical help (stigmas) [28, 29]. In particular, CBT has been shown to easily adapt to online platforms and some argue that online CBT sessions can be as effect as face-to-face treatment [29]. Psychiatrists can also benefit from the CBT online platform. Typically in face-to-face therapy, the clinician makes quick decisions throughout the session. Online CBT allows a psychiatrist the ability to take time and consider the best possible decision for a patient [29].

These benefits prove advantageous to both patient and clinician, but online CBT also has a few disadvantages. One disadvantage of online CBT is the impracticality of integrating particular components of CBT, such as exposure therapy into an online platform. Exposure therapy is best implemented under the guidance of a psychiatrist. Having a clinician present ensures that the patient will be properly cared for if an episode is triggered during exposure therapy. Alternatively, journaling thoughts, feelings, or emotions can work as effectively as exposure therapy [28]. Journaling is easily adoptable within an online platform. Further, another disadvantage of online therapy platforms is that alone these systems cannot fully replace the entire therapeutic process. Specifically, an online platform does not allow clinicians to formally diagnosis in accordance with the DSM and HIPAA laws [29]. In order to mitigate risks and reduce disadvantages, a blended approach integrating online CBT with traditional techniques should be utilized.

4.2 Mobile Technology

In an effort to continue treatment outside the therapy session, multimodal techniques should be implemented, integrating various aspects of the overall treatment plan into a patient’s life. CBT is readily adaptable to a mobile platform [25]. The rate of technology advancement (increased phone processor speed and open-source software development capabilities) has evolved quickly, making smart-phone mobile technologies “a very attractive tool for use in mental health interventions,” [5]. Mobile capabilities such as live connections to remote server and interface hardware to interact with user provide useful as treatment options as this allows for real-time and longitudinal data collection, as well as the option of pairing mobile technology with wearable devices further enhancing options for treatment. Application developers have already proceeded to create assistive mental health applications (refer to Table 1 for specific details on current and developing application for PTSD). For example, PTSD Coach is an online and mobile application assistive service. PTSD Coach categorizes specific mental health issues into separate modules, allowing psychiatrists the ability to provide an individualized treatment plan, designed to best meet the needs of the patient. The online application takes the user to a list prompting, “I want to work on my…” The user then chooses from a list of ten options (e.g., worry, anxiety, and disconnection). Choosing a topic takes you to an introductory video and various exercises enabling the user to manage symptoms appropriately.

Table 1. Current mobile application for PTSD symptom management
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4.3 Virtual Reality

In addition to both online and mobile platforms, virtual reality can also benefit mental health patients. Difficulty in using imagery and in vivo therapy has led to the use of virtual reality based exposure therapy (VRET). VERT exposes a patient to a specific fear or object that triggers anxiety in a safe and controlled (by the psychiatrist) environment [30]. By using auditory, tactile, and proprioceptive stimuli, VRET provides a versatile environment that can be modified for several types of anxieties [26, 31]. Meyerbroker & Emmelkamp [32] studied the efficacy of VRET for anxiety disorders. This analysis resulted in a review of 20 studies, of which two disorders, aviophobia (fear of flying) and acrophobia (fear of heights), had significant evidence for efficacy. Several recent studies have found VRET, for treatment of PTSD, to be as effective as traditional exposure therapy, and potentially offers additional advantages (e.g., reducing dropouts and aversion to prolong exposure) [26].

4.4 Wearables

While online, mobile, and virtual reality technologies can assist in the delivery of information, wearables are more commonly utilized for patient data collection or to mitigate episodes. An individual’s physiological response (heart rate, respiration, sleep pattern, etc.) to a particular event can be measured utilizing current wearable technologies (see Tables 2, 3 and 4 for specific measurement capabilities per wearable). Professional Clinicians can utilize wearables as a means of tracking different physiological symptoms that are associated with anxiety disorders. Wearable technologies are referred to as behavioral intervention technologies (BITs) and defined as the application of behavioral and psychological intervention strategies through the use of technology features to address behavioral, cognitive and affective targets that support physical, behavioral and mental health [33]. Throughout the treatment process, clinical psychiatrists sometimes request logs or journals of from each patient detailing behaviors, thoughts, and feelings. BITs can passively record daily activities and can detect instances in which intervention is needed [33]. The tables presented below includes a list of known wearables, specific features for each device, and recommendations as to whether or not the wearable could be easily integrated into a blended/multimodal therapeutic approach.

Table 2. Potential fitness devices for symptom management
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Table 3. Potential smart watch for symptom management
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Table 4. Potential heart rate monitors for symptom management
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5 The Future of Online/Wearable Devices in Therapy

Traditional therapy involves: traveling to a specific office and individualized treatment based on patient needs; however, active treatment typically ceases after the sessions ends. What if treatment progressed beyond the session? How can technology assist therapeutic implementation beyond these sessions? How can we adapt these methods for mental health issues? As we have already seen, these capabilities allow for the Therapists to transcend present therapy sessions, allowing greater access to current, and potential mental health patients. This strategy is similar to the “Blended Learning” technique found in pedagogical research, in which knowledge is presented online or via mobile technologies and allows for greater time in the therapy session to be dedicated to specific exercises for understanding ways in which a patient can mitigate triggers using cognitive behavioral therapy.

Currently, only a few mobile applications online assist users in managing mental health including PTSD, depression, and bipolar disorder. The majority of the health related applications are designed for the patient as a user, however just one application, MCalm, allows the therapist to track specific metrics and triggers. By providing this type of information the Therapist can tailor the sessions based on known triggers and may result in more effective treatment [34].

Another resource is the online-group therapy which is equivalent to student discussion boards where users can relate to each other and provide different perspectives on coping with their issues. It is a method that is easily accessible and users can log on anytime of day. Online methods are available as the first steps for individuals that may not be able to leave their house.

A blend of online and individual face-to-face therapy is an alternative method that meets individual patient needs while also reducing time, cost, and therapist workload. Allowing access to distributed information or long-distance therapists, provides higher quality interactions between therapists in the individualized sessions. This “Blended Therapy” approach utilizes multiple electronic modes for informing patients and caregivers about information on a particular mental health issue using a mix of online methods of treatment, mobile methods of treatment, simulation based treatment, wearables, and in-therapy sessions. Future treatment should aide both the therapist and the patient by providing multiple means of symptom management and detection.

6 Conclusion

Challenges to treating mental health issues arise from stigmas, healthcare cost, and patient unresponsiveness. Mental health disorders, specifically those related to anxiety, are prevalent issues that can be treated using several techniques, the most effective being cognitive behavioral therapy. Current technologies may provide alternative methods for continuing patient treatment outside of the clinic. By providing blended therapy and implementing multimodal applications the patient can benefit more from the individualized sessions. Several online tools and assistive technologies can supplement recovery and may prevent relapse. Future recommendations include providing specified blended therapy techniques for anxiety disorders.