Technology and Mental Wellness with John Naslund, PhD Instructor of Global Health and Social Medicine at Harvard Medical School

I just want people to know that this prevention is possible for mental wellness.

Yeah, absolutely. It most definitely is. It's, I think, one of the most under-recognized areas is around prevention. I think we're always reactive to problems, and certainly when we talk about mental health, it's usually when once it gets so severe, that's when we usually jump into action. I couldn't agree more that prevention is absolutely critical, especially in young people starting early. Pregnant mothers and, and the perinatal period. If you had only $1 to spend on mental health care, that's where you would spend it. I'm quoting another researcher who's done a lot of work in the perinatal period. In terms of all childhood development and lifelong success, addressing it even while the mother's pregnant, making sure she is healthy, that her mental health is, is good, thinking of mothers coming from difficult backgrounds. So that entire period, the pre and post That's the first area to target. That'll directly impact how the child does, how the child develops, how they learn.

This is RxChill Pill. Now is the time to stay well. Each episode teaches your brain how to become resilient with amazing stories, knowledge from experts, and short meditations you can do anywhere, anytime to elicit your relaxation response. I'm your host, Dr. Juna Bobby MD, resilience and stress management physician and mother of two amazing kids. That's Dr. John Naslund, an instructor in global health and social medicine at Harvard Medical School. Dr. Naslund is an expert in mental health epidemiology, and he's interested in social disparities in mental health and the role of digital devices. This is incredibly important work. The World Health Organization estimates 1 out of 4 people are affected by mental or neurological disorders. Around the world. And in the United States alone, according to NAMI, National Alliance on Mental Illness, 1 in 5 adults are experiencing mental illness each year, and 1 in 6 kids aged 6 to 17 experienced a mental health disorder each year. And suicide is the second leading cause of death among people aged 10 to 34. With the pandemic and the economic hardships, it's more important than ever to educate people about mental health and wellness. Fortunately, research has shown that behavioral and cognitive simple interventions are pretty powerful for many people. Sadly though, these non-pharmaceutical and easy-to-learn treatments are not available widely, especially in prevention and in early disease when it really counts. This is where Dr. Nazlan comes in. He wants to use technology to train a wide variety of healthcare providers to bring this knowledge out to the people, people who would normally get no mental health support at all. In his most recent project, he teamed up with mental healthcare providers in Madhya Pradesh, India to do just that. Dr. Nazlan has also led many projects testing novel digital methods to address the symptoms of mental illness and to assess for risk factors of early mortality in persons living with serious mental illnesses. He has over 65 peer-reviewed publications and has contributed to projects in United States, Canada, Colombia, and India. He's a passionate advocate for community mental health providers and for advocating for the rights, dignity, and quality of healthcare for all those living with mental illness. I'm so grateful that he's here to speak to me today and that he's dedicated his expertise and career to this incredibly important and timely topic.

Okay. Hi, John. Thank you so much for being here.

Hi, Juna. Thank you for the invitation. I'm delighted to join you today.

I wanted to start off with this quote from your editorial paper in the Frontiers of Public Health, February 25th, 2020. It's called Designing Technologies for Youth Mental Health. And the first sentence reads, Mental health conditions pose a major challenge to healthcare providers and society at large. The World Health Organization predicts that by the year 2030, mental health conditions will be the leading burden of disease globally. That was striking to me. So we're projecting in 10 years that mental health conditions are gonna be the leading burden of disease globally.

Yeah, so in many countries, mental health issues, mental disorders broadly, are already the leading cause of disability or one of the leading causes of disability. And the way that that's partly calculated is looking at— so actually, there was a report that came out in 2016 that took the Global Burden of Disease studies. So the Global Burden of Disease work looks out of University of Washington, looks very carefully at what are some of the leading contributors to disease burden. And actually, their estimates are likely an underestimate for mental health, which is something that has been really very striking. So even though that statistic is from the World Health Organization that you're citing, I actually believe that that's an underestimate of the burden of mental disorders. One of the reasons why is because often when we calculate burden of disease, we fail to recognize some of the long-term repercussions of mental disorders, as well as the impact of mental health on physical health. And mental health actually has an impact on other parts of our lives. So something like depression or substance use or anxiety disorders or trauma, it affects us in many, many different ways, which affects how we can do work, how we can do school, how we can engage in relationships, how we can really do all the things that matter most to us on a daily basis. And actually, there's many, many other impacts on our physical health. So if you can imagine, if you can't engage in activities that matter to you, how will your physical health suffer from that? And some of the impact on physical health, so things like the way your heart functions or the way that your the rest of your body functions actually can be impacted by poor mental health. And one thing that's often not recognized is that people who live with mental illness are at far greater risk of having physical health issues and actually have a considerably shortened life expectancy, uh, compared to people who don't have those mental health issues.

So for example, if you're like depressed or anxious, maybe you're not going to the gym as much and you're not eating as healthily. Is that what you're referring to?

Well, it's a fairly— it's actually fairly complex, so that could certainly be part of it. It also happens more when the mental illness is chronic and enduring. So when I mean chronic, it means it lasts a long time and it has an impact on how you function. And when that happens over many years, or many years, decades, then that has a long kind of gradual detrimental impact on your overall health. And you're right, you might not exercise as much. It also then has many— there's many social factors. So for example, if a mental illness prevents you from going to school or getting a job, then you're not going to be able to earn an income and support yourself. So then you'll be in many more challenges related to poverty. On the flip side as well, often some of the consequences of living in violent neighbourhoods, exposure to trauma, are actually very, very bad for your mental health. Which then have this very negative effect on your well-being. And then one other comment too. So there's the physical health part that's often not considered when we think of mental health. The other side too is also the burden due to suicides are not captured in some of those studies that say, that talk about the impact of mental health on global burden, as you cited in the beginning. So what I'm getting at is that that's likely actually an underestimate, and it is most likely that actually mental health is already a leading cause of disability, if not the leading cause of disability worldwide. And of course, it does vary from country to country, though consistently it's a serious problem in all regions of the world.

And of course, substance abuse ties into mental health, right?

Absolutely. So under the umbrella of mental disorders includes substance use, and that also includes alcohol use disorders sometimes as well. It depends how they're— they may be lumped together. Um, these are—

if you're having anxiety or depression, you might be using substances to alleviate that, right? Absolutely. So it's like a vicious cycle.

Yeah, and they certainly are, uh, hand in hand. And then there's a variety of social factors as well that sort of, um, play— you end up with this very complex, uh, sort of interrelationship where the impact of mental health results in a worsening of quality of life and well-being, which leads to possibly this deleterious cycle where you end up using substances, whether it's alcohol or, or it's coming out of an abusive environment, a home environment where substance use might be common. Then that triggers a cycle where the individual may end up using substances, which may then lead to an increased risk of depression, anxiety, or suicide. So there, there isn't really one clear path. Except that there's many co-occurrences of these things. So what I mean by that is that often these things happen together. They don't happen alone. So when we think of them together, it's not like there's just one path to getting a mental health problem. It can actually be from a number of different ways.

But this burden, we're talking about all different people from different socioeconomic backgrounds.

Absolutely, yeah. So this is something that is universal across all income groups, racial groups, ethnic groups, but there are differences in how serious it is. So in most settings that I'm aware of, in the research that I've looked at, it's a lot more severe in lower income groups. So income is a major, major driver. And it's a little bit complicated because it's— there's studies showing that low income, so poverty is one really good example, is a major risk factor for developing a mental illness. But then the other, the reverse also can happen. Development of mental illness can result in very high risk of slipping into poverty through, you know, loss of employment, not able to look after family responsibilities. So there is sort of a relationship between the two, but very much consistently in, you know, all societies, it's income income, lower income is a, is a far greater risk factor for, uh, for mental health problems.

Mm-hmm.

Is there any idea why this is so spinning outta control? I mean, there's definitely an increase, or is it more increase in diagnosis, or is it, it's like we're catching more people, or is it actually increasing?

Yeah. So it's, um, it's likely a combination of both. Mm-hmm. Uh, so one of the things is that we've observed, um, Globally, as there's been more of a transition towards chronic health conditions as being the leading causes of burden, disease burden, and leading causes of death. And this is happening, it's a global phenomenon. We're seeing as societies develop and advance and become more, as populations age, we're seeing that there's, you know, very much an increase in risk of non-communicable diseases, is what they're called. So things like heart disease, diabetes, and mental health is often, it's a chronic condition oftentimes. So there's, that's one contributing factor. Factor is just sort of as a global trend, which usually means we're moving away from infectious diseases, although I recognize now we're in a slightly different scenario. But before 2 months before now, this is certainly the case worldwide. So with that is also coming greater recognition of these issues. That is definitely true. More people are talking about them. In the United States, substance use is absolutely out of control. So that is a new phenomenon. So there's no doubt that the opioid epidemic So this country was already fighting an epidemic before COVID came along, and it's almost not even been recognized now that this has sort of taken the headlines. But the opioid crisis is something that has not gone away at all, and it's something that has really, really been a severe impact on thinking of the burden attributed to mental disorders. So that's one example. Another factor too is there are economic factors that play into it. So I think what we're seeing is there is a combination of increased recognition, but there's also a very high burden of mental health issues in young people. And we're noticing these more now, but I also think there are some factors that are contributing to these increases. And that's partly driven by— there's a lot of pressure on young people to, you know, to do well in school. I mean, to achieve, you know, very high marks or to achieve, to meet what their expectations are. And then on the other side, there's also a lot of many parts in this country where there's, you know, economic stagnation. So for young people entering that type of situation, there aren't a lot of prospects. So that is—

why is there so much more, um, more achievement pressure? Do you think that's increased? Is it, is it due to the fact that people could, um, apply to all different colleges from all different parts of the world now because of the internet? Or what is causing this increased, you know, drive and pressure?

Uh, that's, uh, that's a great question. I don't know if I can, uh, fully answer the exact reasons, but I think there's a variety of things. I think there's certainly a lot of social comparison pressure. We're seeing that, which I think we'll get to in a minute with the social media and how we interact with technology. So that certainly comes into play. There are also, you know, there is a lot of competition when we're thinking of college education. There's a lot of stressors for paying for college education. Getting into the right college. So all of those really compound, and they can create a situation that is prone to contributing to mental health issues. I'll just comment a little bit on other countries. So I know in a setting like in India, where I also do a lot of work, a lot of my research is based there, there's immense social— there's immense pressure on young people, certainly from middle class where their families, or lower middle class where their families are investing a considerable amount of their savings so that their child can go to— can get into a university or a college, there's a huge amount of pressure for them to do well. There's a huge amount of competition to get into these schools because there's not many spots. So it creates a situation where you have just, you know, a lot of pressure on kids to perform because almost the entire economic well-being of their family is on the shoulders of a, you know, of an 18-year-old. Wow. So that puts a huge amount of pressure and is one of the, you know, one of the contributors, contributing risk factors for the high rates of suicide. Depression or suicide risk that we're seeing. And we see the same here in the United States as well. And then I think between that and the combination, you know, almost the flip side of where there's very, you know, poor economic growth, for example, communities that are not thriving for young people growing up in those areas, there aren't many prospects. So it creates a very challenging situation in that way. And then that combined with the opioid epidemic that we're seeing, so you kind of end up with these economically depressed areas where there's easy access to substances, it kind of creates a situation that can be very, very high risk for young people. And that's certainly something that we're observing. And I think that is something that is a little bit, that has been emerging over the last few, last few years.

And then in these young people, we're talking about teenagers mainly, so their brains are at increased risk, right, for early onset of mental disorders, right? As, as their brains progress in development, this is a time when they're very sensitive sensitive, right, to mental health disorders.

Yeah, so the vast majority of mental health problems, mental disorders, the onset is in adolescence and early adulthood. So usually before age 25 is the vast— I think about 3/4 of mental illness happens in that age range. So if we're looking at an age group that we really, really want to work with and think about prevention, I know we mentioned, we were talking a little bit earlier about prevention, this is really an important age group to target because that's— the other thing that's really important to highlight is that, well, prevention is, it works, and treatment works too. So they both do, and I'm happy to talk more about that. But what I think is also really important is targeting these individuals early because they have, you know, a whole life ahead of them. So if you can address problems in their teens or early you know, early adulthood, you can help them adopt habits that are important. You can help address these problems before they become chronic and sort of lifelong, and then contribute to the other, you know, serious health issues that we talked about just a few minutes ago.

So I love that word that you mentioned, habits. So when we're talking about even mental health disorders, the word habits come into play for you. Can you elaborate on that a little bit?

Yeah, so mental health and lifestyle and habits, the way, you know, things that we do on a daily basis are very, you know, closely linked in many ways. And we think of habits, it can be anything from like sleeping habits, for example, exercise, diets, social interactions with others, how we engage with other people. These are all things that, you know, for many of us, we are able to, we can have some control over these, and they also do have a direct impact on our wellness, our overall health, but also our mental health as well. Thinking about whether we're using substances or not, you know, these are the kind of things that can turn into very serious habits and behaviours and then lead to, you know, very serious consequences. You know, trying to, you know, promote better decision-making early on or trying to help educate young people. That's another thing too, about what decisions they make, how it might impact their health. There's ways to, to think about that as well, you know, as well, and learning from the experiences of others. So that's something that's really become a very important area, is like learning from a peer, for example. Peer support. Can you learn— can you learn better habits from someone who maybe has the same experiences as you, or same, um, you know, life circumstances, but they have maybe faced some of these challenges and found a way to overcome it? So they might have some behaviors that they use to cope, but that are healthy coping behaviors. Can other young people— I'll use young people as an example, it doesn't have to be young people— but can they learn from this peer, from this person who they can relate to, for example? So that's one other way that we can think about how to influence habits or behaviors or lifestyle. I think these all kind of blend together and have a really important outcome in terms of our health, both our physical health, but also really importantly, our mental health.

So would you say that mental habits are like thinking patterns is a mental habit?

Yes.

Or how we react to certain situations?

Yeah, that's certainly part of it. And when we think of something like depression, that's very common. That often, you know, that's typically the result of very negative thought patterns and negative thinking. And many of the successful treatment methods— so just to highlight, I think even just across the board is really emphasizing that mental health issues, mental disorders are treatable and we have very good treatments. Actually, they work very well. And they actually are— we can talk about this as well, but they're actually not even very expensive to deliver. The challenge is not many people get them. So I think that's another key thing that I may not have mentioned is that there really is a barrier to getting these treatments to people who need them.

But they're low-cost treatments, you're saying, right?

Well, they're not low cost for the individual if you have to pay out of pocket, but they're low cost for, you know, if a health system or a, you know, of a public insurance provider were thinking of covering mental health treatment, it would be one of the lowest cost items with really, really excellent return on investment. So if we're thinking of government health systems, or, you know, it could be a private insurer, what is it— what is an important treatment to make sure that you cover? Because it'll have huge benefits on all aspects of your, of your clients, people who are your, your insuring, uh, to make sure that they do better, mental health is one of the absolute, you know, should be one of the first things that's on the list. Although we're seeing that it's usually not. It's usually one of the last, or if it is covered, it's not covered fully, which then it does mean costs for the individual, which are usually a huge problem and they're prohibitive. But from a societal perspective or a health system perspective, you know, treating depression is something that can be done. That you don't need a psychiatrist to do it, for example. You can deliver programs very effectively.

And that's your specialty, right, like using social media and technology to deliver these low-cost mental health habits to many people?

Yeah, so social media, we don't know how well it works for actually delivering these treatments that I'm referring to. So that's still an area that's under exploration. The work that I do is thinking about how technology that can support the delivery of mental health care to either make it reach people who maybe cannot access it easily.

So can you specify which ones you're referring to then, the low-cost mental health care?

Yeah, so if we're thinking— we're thinking of treatments for something like depression, which is incredible.

Or anxiety.

Or anxiety as well, yeah. So there's brief psychological treatment. So another common way to call them is a talk therapy. And it's— usually talking to a therapist, and there are structured modules and structured content that the therapist can walk, walk through with the individual and can help them address their challenges. And they can work very, very well.

And you mean like cognitive behavioral therapy, or—

Yeah, CBT is one. Behavioral activation is another for depression, for example. And so we were talking a little bit earlier about the negative thought patterns. Behavioral activation is really focused on addressing that. How do you help someone reframe their thoughts in a more positive way and then engage in activities that can help move them towards, you know, more positive feeling and better mental health and addressing the depressive symptoms. And it can work very well. Again, there are some more complex conditions where these don't necessarily work, but for the most part, they're very effective. And this has been shown in most settings, you know, all around the world. So some of these treatments have been developed here in the United States, and they've worked very, very well across, you know, all different population groups. And then they've been tested in other parts of the world. So they've delivered them in different countries in, in sub-Saharan Africa, for example, or in India, or in, in Southeast Asia, for example.

So in depression, it could be as simple as even though you're having depressive thoughts, you get moving, try to reframe the situation and get yourself moving, right? I think that's one of the main tenets, whether, whether it's an action to, like, call a friend or go exercise, one of those healthy behaviors.

Yeah. So it's not so much ignoring the thought because that's not always the best thing, but it's to, to think a bit about it and where it comes from, and then what are some of the activities that you can do in life that actually might be positive, and then to try to engage in those. And then you— it's, it's, um, requires multiple sessions, so it's, it's delivered over time through multiple sessions, and there's different phases where you help walk the individual through step by step. And usually, even through as few as 6 to 8 sessions, which can take, you know, a few weeks, you can really see noticeable improvements for individuals.

And when you say this is low cost, though, that means that you're delivering it from any tier of healthcare worker other than a psychiatrist, right? You don't have to be a psychiatrist, you said. But there must be differing expertise. Right? So I'm just wondering like how your social media or your technology would be able to deliver this on a wide-scale basis and make it affordable.

Yeah, it can be low cost when you train, you know, a non-specialist provider. So someone, really any type of health provider who is not, uh, specially trained in mental healthcare, for example. So, and specialty providers would be like a psychologist or a psychiatrist.

Uh-huh.

And they have specialized training in, in treating, uh, mental health issues, but there's very few of them. We don't— we just really don't have access there. It's not easy to access a psychiatrist or a psychologist, and it's expensive, and that is expensive. So that is absolutely expensive. But some of these treatments, uh, like brief psychological treatments, when they— when they do not require medications, can be delivered by, you know, other types of providers. And what we're seeing is that even community health workers can be trained to do these programs very well. And that's been demonstrated in studies here in the United States, but also in the global literature. So even health workers with a fairly basic level of training can take additional training and learn how to deliver these programs.

Like a nurse's aide or—

Yeah, nurse's aide, nurses. You can think of, you know, midwives are another example. Other types of community health workers, social workers. I mean, it's really a broad range.

Did anybody look at peer?

So peers can also be trained. So peers can. There are many efforts focused on training peers to deliver these programs as well. So people who have lived experience and who have recovered. That is another, yeah, very much a very thriving area. I think there is a certain level of requirement in terms of just understanding of the material and like a literacy and education level. So there is some, I think, minimal requirements in that sense. But in terms of learning the content, it's something that many people can do and master. But in order to do that, they also need support. So that's one of the things where the expert can come in and be really important is helping give them extra supervision and support and helping with guidance. And that is one of the things that we all, we focus a lot on is how to make sure that when we have, you know, these non-specialist providers trained to deliver mental health care, that there is an expert or a specialist provider who's there to offer some support.

Mm-hmm. And this is something that you delivered in India, right?

Yeah, that's absolutely right. So right now, um, in India, I, I'm leading a project where we're training community health workers, uh, to deliver a program that's, uh, shown to be very, uh, very effective and potent for treating depression in primary care settings. What I think is very exciting about is we're using technology to train the health workers. That's another, another story is how do you, um, make training more widely available. But I'll just circle back to your comment about use of technology or social media for delivering these types of programs. So one thing is that there are online versions of these programs, and they can be delivered in two ways. One can be kind of like what we're doing now. It can be, you know, almost like telepsychiatry or tele—

you know, telehealth.

Telehealth, yeah. So that can work. It works just as well as in person. But there's also versions that are more self-directed or, you know, asynchronous support with a, you know, through an online online platform or a mobile app. And there's increasing evidence showing that these work very well as well. And they follow the same principles that are outlined in the programs that we're training the health workers to do in person.

So is there like a chance that AI could take over or no?

So that's a great question.

I—

artificial intelligence—

there's a lot of research looking at it right now. So thinking of like chatbots, for example, that's one of the very active areas. I'm a little skeptical on the research so far. It certainly isn't showing doing. I mean, they're mostly small studies, a lot of industry involvement, um, so I'm a little skeptical on what we're finding.

Yeah, chatbots, I mean, I don't find them helpful even if I'm trying to shop for groceries, so— oh no, I don't know if it could be helpful in mental health right now. Not sure.

Yeah, I can't imagine.

Yeah.

Having said that, it'll be interesting to find out, I think, from patients what, what they prefer. I, I do think patient preference has a— plays a really important role here.

Um, but maybe you also get a hybrid, right? You get like the some chatbot and then somebody overseeing it, like a person?

I think so, yeah. Something like that potentially could work, although I certainly would not be advocating chatbots at this point. I would have to see more evidence on this.

Prompts, I mean, like more like prompts, like asking them questions or about how you're feeling.

Yeah, so those self-directed ones. So that's not the same as, I think, replacing it with AI, for example. There could be AI support supported apps that help direct you to the materials that might be most beneficial. And I think something like that could work very well. Um, but thinking of it just being a robot or something, that's the only person you're in touch with, I'm not, I'm not totally, I'm not sold on it yet. Although of course things are changing very fast, so I, I don't want to totally discount the idea.

And how are you, how are you training your workers in India? And then how, what are they delivering? Is it modules? Is it like lessons? It's really education, right? Psychoeducation?

Yes. So we are training them on a smartphone app, and they access educational content that, that's typically video-based, has, you know, images, animations, PowerPoints. And the, the content is really focused around building skills and knowledge on how to treat depression. So how to detect it, how to, how to measure it, how respond to crises, and then how to deliver a structured treatment for depression in primary care. You know, it's self-directed on the phone. You know, we've been testing different ways to— how do we— how can you help people get through the educational content? So using, um, you know, like a coach who phones or texts, sends a text message saying, you know, trying to offer encouragement, helping people get through the program successfully so that they can gain the skills that they need so that they can deliver care once they're back in the field. But I just want to circle back to your point on the social media because I know I think that's something you're really interested in as well. And so social media is an interesting thing because everything I've talked to you about so far is really more related to delivering what we know are evidence-based treatments. So ones where there's fairly strong evidence showing that they work, collected from randomized trials. And also they're delivered in a fairly systematic way. Social media is a different thing. I, I have not really seen, um, you know, there— it has not been used in the same way to deliver, you know, these same types of treatments to individuals. Wouldn't say that social media is something we can use for that, but I do think there are really, really exciting opportunities to think about how social media can help us with, you know, mental health promotion or helping people access services or to reach people who might be at risk. So I do think there are, there are opportunities there. But it's not, I don't think, like a replacement for treatment in that way.

So your most recent review paper, Social Media and Mental Health: Benefits, Risks, and Opportunities for Research and Practice, there's this talk about digital phenotyping. Can you tell me a little bit about that?

Sure.

That sounds a little bit frightening and helpful at the same time.

Sure. Yeah, I'm happy to talk about that. So yeah, so social media and mental health, is kind of an interesting thing. And I think I just will first say that the way we think of social media and mental health, I think there's a combination of pros and cons. I think there's no way around it. And I, you know, I'm interested in social media. It's something I've done, you know, a lot of research on and specifically around how to reach people who have mental health issues. And I think there are certainly a lot of risks that we have to take very, very careful, you know, think about really seriously. And I'm happy to kind of talk more about those. But what I also think though is we're all on social media.

We're all, you know, I mean, a lot of the kids use it to communicate with each other.

Exactly. So every kids are already on social media. So even if we know that social media has, there's risks, uh, and it could result in detrimental impact on mental health, which I, it can in some ways, and it affects girls more, right? Oh yes. Yeah. So there's certainly studies where there are things like cyberbullying, um, risk of victimization and things like that can— are, are more common, uh, in, in young girls. And certainly thinking of social comparison pressures, um, like where you see things on social media and then feel bad about yourself because you see how other people are living their lives. And there are— there can be a fairly vicious cycle with those. I think though, still at the end of the day, people will use social media. It's a popular activity. So we have to then think— we kind of have to frame our thinking rather than social media is dangerous, you shouldn't use it. We have to kind of shift our thinking. Social media has risks, but how can we use it in the safest way possible?

So it can be, it can be helpful, right? I mean, you can get social support from social media at times. Yeah, I've seen so much support on, you know, some of the Facebook groups with physician moms, and we have been sharing information like crazy, and it's so fast. Fast and real time with the COVID situation. You know, people have been like volunteering for efforts to help healthcare workers on social media. It's— I don't know how it would have happened so quickly if we hadn't had these groups.

Yeah, I couldn't agree more. There's certainly, you know, there are positive things on social media and specifically related to mental health and thinking about how to promote, you know, better mental health, how to help people who have, you know, very serious mental health issues. And I've talked to a lot of people who use online forums or support groups on Facebook, and they've really found a lot of, you know, a lot of support, and it's really helped them through some really difficult times. So those are, I think, where there's positive sides on social media. It's trying to think about how to, you know, minimize the risks while figuring out how these positives can be most beneficial and helping people, and then helping people navigate these platforms so they can actually benefit in that way. So that's the other thing too. I think there's a little bit of being open to them, but also being— how do we communicate that there are risks, but that there could be benefits if you use it in certain ways, I think.

And being cautious. And you were going to tell us about digital phenotyping.

Yeah. So when we think of social media, you mentioned the— we're using it all the time. We're using it to communicate with friends or with other people. What happens is— and actually any digital device that we use, everywhere we go, it leaves a digital footprint. Right? So anywhere you use your phone, anywhere you go, you leave, you know, like a trail of, you know, where you were, your map data, your GPS data, any kind of communication that you send through social media. There's a track record of all of this interaction with your device. And what that tells us is, you know, the device can tell us a lot about our activity, about our socialization. So like, who do we talk to? How often do we talk to them? It really gives a, you know, a pretty comprehensive overview of everything you do in your life with your device, which is now almost everything for most people. So, digital phenotyping involves capturing all of this digital data to try to understand health patterns. So, can we take a look at, you know, your activity through your phone or how often you talk with people to understand maybe how your mood is or how you're feeling, maybe your activity Maybe you start and you're really active every day, and then suddenly your activity stops and you're not socializing very much. Could this be something that's related to a change in your mood?

Or you're Googling like, you know, drop by my friend group. Yeah. Or versus like, is he cheating on me? Right? So they can tell what you're thinking about when you Google these things.

Exactly. So if you have like a situation where, you know, your search patterns on Google, um, and your, you know, how you're using these different platforms, um, and give it— they might offer some insights about your, about your health, uh, and that's, that's really what digital phenotyping is focused on.

Wow.

And who's looking at this? Like, who is looking at everybody's phenotypes, and can they identify you? Is it anonymous? Um, you mentioned, or one of the authors mentioned in this paper about how the digital phenotyping can predict users' depression and maybe be able to figure out if somebody's depressed before they even know it, maybe.

Yeah, so that's an area of very much of active research, even looking at social media posts and seeing if your patterns of communication, say, on Twitter, for example, or on Reddit, or even on Facebook, for example, if your communication patterns sort of change, can that be— Can that give us some idea if you might have had, you know, you might be changing, if your mental health might be changing? I think this research is still really kind of in its infancy. There's still a lot of, you know, a lot of caveats. What we're finding is that most of the studies are kind of retrospective. They're looking at— so we know the person either has depression or has another mental health issue, and then it looks backwards at their posts. Rather, it's not so much— I'm not sure if we're really at the stage yet where we could actually say, predict that one person will get depression because of the way they communicate online. I also do— I agree 100%. There's a lot of privacy issues with that idea that I think are, yeah, they're a little bit frightening actually to think about someone monitoring, you know, your risk of getting depression based on how you talk online.

Right, or what you're researching. Maybe you were looking it up for your friend, right? It was for my friend.

That's right. Or maybe you stopped using your— you lost your phone, so there's going to be gaps in the data. Or I don't know, there's a variety of things that could happen. One thing that is sure, for sure though, just about how people use social media is that we're seeing that there are differences, like in the way people communicate online, that are linked to mood, which kind of makes sense. I mean, we know in the real world—

Give us an example.

Well, we know that the types of Communication is different between, you know, people who say have a mental illness and then who don't. Or if your mood is very low, someone doesn't necessarily have to have depression, but if they're very, you know, if they're feeling angry or sad, they'll communicate differently online than if they're, say, happy. Or, you know, when we think of the spectrum of emotions, it does— it can be reflected in the way we communicate, which is not a huge surprise. I think it does that in real life too. So I think it's just kind of translated onto online platforms.

And right now, pretty much there's people reporting each other if they see something— somebody who seems suicidal or who seems like they might be at harm to others. Is there anybody actually collecting all this big data right now? It seemed like there is.

Yeah, so that, that's a, that's a great question. So, so I'm not totally sure what gets— what happens to data that is collected directly from from these platforms. I know that there are ways to kind of monitor for communication about suicide. I know Google will push like a notification to an individual. They'll send them like access to a helpline. And I know just from talking to people who've worked on these helplines that that's often a way that actually they end up getting callers is because they might have been Googling for, you know, looking something up on the internet, and then they get this, you know, push notification comes up with the, with the link to the helpline. So that, that's a pretty common way to get people on the helplines. In terms of the data that's actually online, I don't think there's any way to really access that data to, um, to monitor these things very easily. And I think it— then you start getting into that really kind of dangerous area around privacy. So if someone is posting, you know, suicidal suicidal thoughts online, there usually is a, you know, it's flagged and I think there is someone who reaches out to them. But I don't know to the, I don't know the extent to which that data is captured. A lot of what does happen with data, certainly in the research world, is that it's looked at after the fact. So it really is kind of, if there are posts related to suicide, they're looked at afterwards. So they wouldn't really, it wouldn't really be much help.

So there's nothing going on proactively right now anyway.

Yeah, except these notifications that come up. And I know that there are, even on Facebook as well, they notify you right away, like, to try to have you call a crisis line. And I think that that does appear to offer some benefit, but the effectiveness of these, are they effective at actually preventing suicides? I don't know. At least from what I've read in the literature, I have not seen evidence on that yet. Oh, we can't—

it's so hard to measure something that's prevented.

Well, there's that too.

Yeah.

How would we know? But exactly. Yeah. And, but I think we'd have to look and see if there's, you know, determining how many calls there are to suicide helplines. Does that correlate with some kind of reduction in completed suicide?

In the rate. Uh-huh. What about people who seem like they're posting things that are dangerous to others? Do they flag those also? And reach out to the individual or do they reach out to someone else?

Well, so yeah, I'm not totally sure how posts are flagged. I mean, I know that there's a lot of stuff that circulates. So this is one of the harms to mental health that I, I think I mentioned some of the risks is that when there's derogatory or hurtful or hostile comment, uh, comments and content that's shared online, um, I know other users can flag that content, um, but I also know that it still is visible to a lot of people and I think that That's actually been one of the major criticisms of platforms like Facebook is that they don't put a muzzle on this type of content. They haven't— when we think of hate speech and things like that that get circulated, they've done very little to actually stop that. And we know that that has— I mean, there's clear studies showing that that has correlations, at least, impact on mental health. But then we also know just anecdotally from what we've seen in the news when And when things like this are perpetuated on social media, it has a terrible impact on entire communities and well-being. Mm-hmm.

Any word of prevention on that? Like, I know you can change your privacy settings and things like that, right?

A colleague I work with who uses Instagram, there are now new policies on Instagram. Like, if you block certain posts, you'll never see them again. Or if you block certain people, your posts are never seen, and they're, you know, they can never view them again, even if they try. Partly because Instagram came under a lot of fire last year, I believe, for some really hurtful content that was posted and then resulted in a suicide. I think that was in the UK. So—

Well, they're part of Facebook now too. What got you interested in this line of work?

Yeah.

Was it— so how did you get interested in this?

So my background is not so much in mental health but more on really looking at how socioeconomic disadvantage, how, you know, how do historical injustices contribute to disadvantages in health? You know, when I say it that way, it's how are historical policies or just the way, you know, socioeconomic factors, things like poverty or homelessness, and how do these different societal factors contribute to someone's health and well-being? So my background comes at it more from a sociological perspective, and I initially became very, very interested interested in mental health because of— through severe mental illness. So I've done most of my work and my background is working in severe mental illnesses, which are— they affect a smaller portion of the population, but they have debilitating effects on functioning. So when I say severe mental illness, I'm thinking more— this refers more to schizophrenia, bipolar disorder, major depression can be, you know, some trauma disorders can be very serious. So really it just means it really affects someone's functioning. But the impact of the mental illness, at least in my learning, what I've learned is the impact on the individual's livelihood and how they do has less to do with the symptoms of the mental illness than the actual repercussions from society. And when I—

You mean the stigma?

So the stigma is huge. The stigma is very big. You know, the poor access to health coverage living in impoverished settings, the environment that they're in. So the socioeconomic factors actually end up being a lot more detrimental on the individual's health than say just having an experience of, you know, hearing voices, for example, with schizophrenia, or having delusions. The actual mental health issues, even though they're very serious and they're debilitating, they don't have as severe an impact, at least in the individuals I've talked to, than what actually happens in their their daily lives, which I think to me is really fascinating because we almost— I mean, we fixate so much on the mental health issues that then you kind of lose sight of the, the broader issues that affect these individuals. So that, that's— that was my entry into mental health. And I think it's absolutely true with everything I've— we've talked about here today. Uh, when we think of depression, uh, yes, depressive symptoms are, are incredibly serious. And I mean, they can be, but they can also be treated, and they can be treated very easily. But it's sort of the issues around accessing care that are a problem. Is it being in an environment that contributes to greater risk of these depressive symptoms? So there's so many other factors that come into play that just the depressive symptoms on their own are actually— don't seem— I mean, they're actually something that can be relatively easily managed. But when we have to think of it in kind of in the context of everything that's going on in the individual's life—

The whole lifestyle.

Yeah.

So even with the very, very severe mental illness patients, um, there is research that lifestyle matters, right? And even these non-medical, um, treatments like reframing your thoughts can help them even as well. Is that true?

I, I think, yeah, absolutely. And I know in, in some of the individuals I've talked to, um, there's cert— there are medications. They do work for some individuals. I, I don't wanna—

Yeah, no, medication's great.

I love that.

Yeah.

Suggest that they don't work.

Yeah.

Or, or suggest that, you know, access to a, a, a good psychiatrist is, you know, that is very, very important.

Yeah.

But lifestyle is also very important, uh, and we know that. And, and it just again really highlights how your brain and the mind and the body are all connected. I mean, this idea that, you know, we should be seeing a separate doctor for our, our mind or our brain and, and then a separate doctor for our heart is kind of, uh, I mean, it's, it kind of doesn't make a lot of sense when the two are connected. Problems with each happen together. So, um, absolutely, lifestyle is really important. And then it goes back again to some of these social determinants and social factors. We know also in many people who have severe mental illness, they have worse access, say, to, you know, to have recreation opportunities, poor access to, you know, some of the ways to engage in healthier lifestyles.

And social support, right? They lose social support.

Yeah, there's a lot of social isolation that can happen. And then these are further compounded by the stigma as well. So, you know, someone may have symptoms or they have side effects from the medications can be very serious. And then other, you know, other people can fear them. I mean, it creates this kind of a very vicious cycle.

Right.

I know a lot of psychotic disorders, the onset is early, uh, it's in the teens, early 20s. That's the most common age.

So when should we start looking for these? If you're screening your child, or when should you start paying attention? What would your ideal scenario be? Like, you would catch them at, you know, 2 years old. You'd make sure that they start having the lifestyle habits of eating well, sleeping well, having the emotional intelligence to be able to have social support When would that all start and what would be ideal for you?

Yeah, so that's a, that's a great question. I think, um, I think you have to go back even earlier than you're looking actually at, um, pregnant, pregnant mothers and, um, and the perinatal period. I mean, I don't think there's a time if you had only $1 to spend on mental health care, that's where you would spend it. I'm quoting another researcher who's done a lot of work in the perinatal period in terms of all childhood development and lifelong success addressing it. Even while the mother's pregnant, making sure she is healthy, that her mental health is, is good, thinking of mothers coming from difficult backgrounds. So that entire period, the pre and post, that's the first area to target. That'll directly impact how the child does, how the child develops, how they learn, and helping her cope with some of the, you know, things that come up during pregnancy, especially again thinking of mothers coming from difficult backgrounds. They are at greater risk as well. You think of risk of things like trauma, violence, these types of things really have a really devastating impact on the, on the fetus and then the newborn, and then also right after birth. So the, you know, the postnatal period as well is incredibly important. So that entire period, the pre and post, that's, that's the— for— that's the first area to target. So even before child and adolescent, absolutely, because that has— that'll directly impact how the child does, how the child develops. How they learn, you know, how their cognitive development, their behavioral development. And then it also impacts the mother. And we know we need a healthy mother to look after a healthy child.

And then we would do this with education. Is that the most important thing? Because I mean, people don't think of— I don't think most people think of thoughts or healthy thoughts as mental habits, or that it's a prescription, let's say, that's powerful as drugs or medication and surgery.

Yeah. So there are, um, the same brief psychological treatments that I, I mentioned earlier and the ones that we're training health workers to deliver, um, are similar. They're changed a little bit, but working with mothers who are pregnant, uh, so the perinatal, so call it perinatal depression. Uh-huh.

It's gonna be the number one global health issue in 10 years. Could we, you know, maybe educate everyone across the board? Isn't it something anyone could benefit from? Emotional intelligence.

Yeah.

Positive reframing.

Yeah, so that, that's another fantastic area is thinking just even more broadly about our understanding of mental health. And that's also very important for addressing things like misconceptions and stigma related to mental health. So education at a population level or within schools is really, I think, another fundamental area to target. And I, and I think with, when we're thinking of kids in schools, there, there's certainly a growing interest We're seeing it in college-age kids about how important mental health is to them. And I know that many, you know, college campuses are reacting to the demands by students. And I think that's because of increased awareness. So trying to encourage this type of awareness about mental health, you know, making it something that people feel comfortable talking about. I mean, that's another thing too. It should not be something that's, you know, kept secret. It should not be something that we're ashamed to talk about. By addressing those types of things, it will go a long way around prevention, around seeking help, So if someone does have a problem, a lot of the time they're afraid or concerned about getting help because they're worried they'll be judged. So this idea of education, I couldn't agree more. It's so important. And even in young children, thinking of educating them about how these feelings can be normal, you know, when to know it's a problem, and who to go to talk to if you need help, and not feeling ashamed to do that. So—

Because, I mean, most normal people go through periods where they're anxious and depressed.

—Yeah, absolutely. Yeah, it's a normal part of life. It's when it is prolonged and doesn't get addressed and becomes something that interferes with how— Yes. —how you function and what you do on a daily basis. That's when it can be very serious. And that, that's when it can really get out of hand. And that's, you know, trying to make sure that we catch people early is, is incredibly important.

Can I ask you why you became so curious about mental illness?

It's really been, um, looking more at health from a more holistic perspective, thinking more from a societal perspective, thinking of how different societal influences affect our health. And that's something that I've, I've been really interested in. And then now a major interest in mental health. To me, it's something that's treatable. It can be treated very easily, very effectively. Um, it's remarkable how much evidence we have that we can do so much for people who live with mental illness. Um, but so few people get access to that kind kind of treatment. And I think that is something that there— if there is one of easily one of the greatest, you know, gaps in implementation of something we know works, that it's out there. And I think one thing to highlight is that any of the individuals I've, you know, whether it's a severe mental illness, whether it's depression, whether it's trauma, there are programs that work well. You can help these individuals. They can live, you know, a productive and fulfilling life. They can hold a job, they can go to school, they can have a family. All of these things any individual can do, but they need the proper treatment and care and support. And the issue is they're not— there's just a gap. We're not— those people aren't getting access to those. And how do we help make sure that these types of programs and services are available? That's why— that's the challenge I'm interested in.

And you're trying to cover that gap with technology.

And I think technology has to play a role. I mean, more than ever, there's no question that technology is incredibly important. At this time, so.

I was wondering, what is your projection now? What are you worried about now that everybody's been home and people are talking about mental health issues increasing with the COVID isolation? They will, there's no question.

I have no doubt that mental health is, will be a huge challenge when we think of the response to COVID-19. I see it actually in two ways. I think there's, right now there's certainly the anxieties and the stress just around, you know, not knowing what's happening. No doubt in my mind that that's been very disruptive for all of us and certainly more disruptive for some people than others. I'm thinking of people who've lost their jobs. It's hard to self-quarantine if you don't have good living situation or if you're living in, you know, an abusive household or facing domestic violence. I have a lot of concerns for those individuals. What could people do though to help themselves? Resources we can put links to or? I would look up COVID-19 mental health resources. I've come across a couple but I haven't, I don't, I don't know the names of them by heart. Okay. I'm on a lot of email chains related to COVID-19 and mental health.

There's a lot of free help now, right?

There's a lot out there. There's definitely a lot out there. I think trying to, you know, weigh whether it's from a, you know, a reputable source is really, really important. But when I think of COVID-19 and mental health, the area where I'm, I think, most concerned is what's going to happen afterwards. I think there'll be a period of readjustment to whatever, you know, how we reintegrate or how we restart our lives. But then I think the real challenge will also be the economic impact of COVID-19 and just the inevitable recession that we're entering. And we know that these types of economic events have really a serious impact on mental health. We saw that in the 2008 recession. But I think this will more or less eclipse what we saw then. So that, I do believe, is something that really thinking of mental health, we have to be very proactive about this and think about how— So again, that same challenge I mentioned just a few minutes ago, the big issue is that people who need services don't have access to them. How can we leverage technology? And I think we have to use technology now. We can't rely on in-person contact. We have to think of technology as absolutely has to be a tool to help make sure we get mental health services that work to people who need them.

Yeah, even in these times, like the positive reframing and all of those tools work.

They absolutely can. I think now it's still, you know, very much like a time of a lot of heightened stress and anxiety, so there are certainly ways to help think of stress management, helping with that, you know, really be ready for that sort of second wave. This is the epidemic now, but what's the epidemic of mental health and potentially substance use issues that could arise afterwards?

But also people who are just listening could maybe just proactively start to work on these positive skills. Yeah, I think if you're—

certainly can looking after your own health and well-being. I think we all have to at this time, you know, it's really important to be thinking about that. Small steps now certainly could work with, you know, developing resilience for some of these issues in the weeks and months ahead.

There's no question. Mm-hmm. Thank you so much, John.

Thank you, Juna. Stay well. You too. Yeah, stay well, and hope you and your family are well and staying safe in these very uncertain times. Thank you for your time, for being here.

Sure.

Sure, no problem at all. All right, take care.

Stay safe.

Thank you so much for listening. I want to remind you to share with your friends and family and download episodes, subscribe on Apple Podcasts, and leave a review. Your support is so important in keeping this podcast going, and I have amazing guests coming up. And you can ask me questions or them questions simply by emailing me at info, info@ go at mindbodyspace.com. You'll also be the first to know about our awesome courses coming up to stress less, do more, and be happier for teens and adults. This is Dr. Juna Bobby MD wishing you all wellness until next time.