Hello and welcome. I'm Tristan Grindow, Deputy Medical Director and Director of Education for the American Psychiatric Association. I am pleased that you are joining us for today's SMI Advisor webinar, Stepping Forward Using Mobile and Wearable Technology to Increase Physical Activity. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. John Torres. Dr. Torres is a member of SMI Advisor's Clinical Expert Team and is the Director of the Digital Psychiatry Division in the Department of Psychiatry at Beth Israel Deaconess Medical Center, a Harvard Medical School-affiliated teaching hospital where he also serves as a staff psychiatrist and academic faculty. Dr. Torres is board certified in both psychiatry and clinical informatics. John, welcome back to our webinar series. I'm so pleased you're leading today's webinar. Thank you, Dr. Grindo, and thank you, everyone, for tuning in. We're going to learn a lot about physical activity and technology and SMI. A disclosure is our group is doing investigator-initiated funding around the medication of Otsuka, but we won't be talking about that today. What we will be talking about is physical health and mental health and how technologies like smartphone apps, like wearables, like online web portals can or maybe they cannot help our patients achieve greater fitness. So we'll talk about physical health and mental health, apps and wearables for increasing exercise and steps, and we'll look at a series of case examples for apps and wearables and how they may be helping some people with SMI. The picture on the right you can see is one of these different wearable technology things saying great job on the zero seconds of walking you just did. And certainly that's what we want to avoid. Things that make us feel like we've done a lot of physical activity when maybe we've actually done absolutely nothing. So we're going to look at case examples that are both good and those that are not as good. And the goal is that you'll come away of this understanding what are some things you could try with your patients? What are some things that you're curious about? If you want to dive in deeper, we have consults as well. We'll have question answers, but I would love to get some consults through SMI advisor website and we can talk about individual ones you're interested in. So our learning objectives are we want to list three benefits of increasing physical activity in patients with SMI and think of three different technologies that could help facilitate such. We'll talk about a lot more than three, but think of at least three in the talk that could be of use to your patients. To be balanced, let's also kind of look at some benefits, but also risks of using technology to increase physical activity. And at the end of the talk, we'll talk about using the APA app evaluation model towards making a better decision about, is that a fitness app? Is that a wearable tracker I want to use my patients or not? So before we get started on this slide, I just want to review what are kind of the national broad guidelines for physical activity. And it's about 150 minutes of moderate intensity physical activity or 75 minutes of vigorous intensity physical activity per week. And in general, it's accepted about one in four adults globally does not meet physical activity recommendations. And again, those are numbers for the general population. And it's a little bit harder to know what is the state of physical activity and for patients with SMI. And a recent review that came out in World Psychiatry in 2017 said there's a mean of 476 minutes per day, basically eight hours during waking hours of sedentary behavior for patients with schizophrenia, bipolar disorder, and major depression. And patients of SMI are significantly less physically active and spend only an average of 38.4 minutes per day in moderate or vigorous physical activity. And of course, that's a global average. Imagine each of us has patients that are much more active, but some of us may have patients that are less active. But I think that number, if it sounds low of 38.4, we'll talk about this later on. But again, that's something just take note of and maybe check your assumptions on how active or not active all our patients are. And a third interesting quote from that paper is approximately half of people with severe mental illness do not meet the recommendations of at least 150 minutes of moderate physical activity per week. And it said, perhaps globally, one in four adults in the general population are not kind of meeting these physical activity recommendations. But in SMI, it may be almost 50% are not meeting it. So certainly there's some unmet need. So we're going to talk about different ways to get people active. In prior talks, we've talked about a different type of gym called Mood Gym. This is an online CBT program, and we'll have future talks talking about this. But in this case, we're actually talking about physical gyms and actually exercise and getting people to take more steps. So I have this slide here, because exercise, physical activity, SMI, we certainly know it's important, but there's a lot that we're still learning and we don't know. The book that I have pictured here, I have no affiliation with it, it actually came out only last year, and it's one of the first books really focusing on exercise based interventions for mental illness. And that tells you if we're kind of in the early phase of books coming out, we're still learning a lot about this. So we're going to talk about recent evidence-based papers in this talk. And as I said, but I think if you really want one kind of source that you can put on your desk and read, this may be an interesting book to consider. So to think about the broad picture, if we look at schizophrenia and say, what is mortality and schizophrenia, what is driving it? And certainly from the most recent data is suicide in age 15 to 24, accidents in 25 to 44. But if you look at between 45 and 74, it's heart disease, it's actually the number one cause of mortality. And that makes you realize for many of our patients, really increasing physical activity and making sure their physical health is optimized is very important, because cardiovascular disease is going to be one of the largest threats. We certainly have heard in earlier webinars through SMI advisor that there certainly is a mortality gap, especially for people with SMI and with schizophrenia especially, and you can see heart disease. So again, this is motivating us. We really do want to make sure that our patients are active and optimizing their physical activity. And we talked earlier, we had that same thing, maybe people with SMI are perhaps only one in two are meeting the physical activity recommendations. And this was a very interesting study from 2016. And what they did is they looked at physical activity in people with SMI, but they did in two ways. One was they had objective measures of sedentary behavior, which was basically wearing a wearable tracker, something I was keeping track of steps. And they also had self-report, people saying, how many hours or how many minutes do I think that I wasn't active today? And this is a busy slide, but if you look at the middle part of it, where it says sedentary behavior measurement for self-reported patients said, you know, on average, maybe 6.85 hours is what I'm sedentary for. When you looked at the more objective measurement with one of these trackers was actually 11.75. So going from 6.85 to 11.75 really tells you that we can perhaps learn some important information. And this could start a very interesting discussion with patients going, where do you think you are on physical activity? If there's a difference between self-report and what say a wearable, a tracker means, what does that mean? Does it mean the tracker is wrong? Does it mean people are underestimating? That's something that only you'll learn with a discussion, but certainly interesting. And this paper actually breaks it down into diagnosis of schizophrenia, from psychosis mixed and bipolar, you can see different amounts of sedentary behavior. But the point here is that perhaps depending on how you measure or ask, you may learn some different information. And what are the mental health consequences around exercise? This is actually, you may have seen this paper, this paper in the newspaper last fall, and this was interesting. You can actually read it in Lancet Psychiatry, but the authors looked at 1.2 million people. They took CDC data from 2011 to 2015, and they concluded looking at CDC data based on self-report about exercise and self-report about mood. They said those who exercise had 43.2% fewer days of poor mental health in the past month compared to those who did not. And again, the caveat is this is self-report data. But I think what they found has relevance to us is that, you know, any exercise people get is certainly better than no exercise around mental health. And they tried to look at different types of exercise, and they said the one that seems to have the most mental health benefit may be social exercises, team sports. And I think all of us can understand that makes sense, that certainly if we can get physical activity and we can get social activity together, that's a double win. What you can see by the graphs, too, is what the authors show, and it's cross-sectional data, so it's hard to make causation statements from it. But they show that there's kind of an optimal point of physical activity around mood, and if you're doing too much, perhaps it's not as beneficial for mood. And I said it's hard to fully interpret it, but you can kind of see that U-shape, especially, say, on graph A, where they're saying that perhaps the right exercise is around 45 minutes. And if you're doing a little bit more, perhaps the mental health benefit is a little bit less. But certainly a very interesting paper. You don't see it here, but they actually did exploratory analysis, and they showed that yoga may have more benefit in their study than even just walking. So if you have patients who are interested in yoga, certainly this is one study you can point to or say you can support to say, hey, this may, in terms of at least depression, offer some benefits. But again, the caveat we have to be careful of, this is self-reported data, and this is self-reported mood data and physical health data. As we saw from the prior slide, it may be that some people, it's tricky to estimate how active you were. So another study that you also may have seen that made the newspaper actually in January of this year was in the headlines speak for itself says exercise may help fend off depression. And I bring this up because it's rare that we kind of see studies talking about prevention. I think all of us really want to move mental health towards prevention and certainly not always be reacting. And what this study did is they kind of used genetic markers in people as a way to randomize people. And they were basically looking at in the headlines as to jogging for 15 minutes a day or walking or even gardening for somewhat longer than 15 minutes could help protect people against developing depression. So it's an interesting idea. And again, because they could begin to randomize it, they kind of had a very large population model and certainly again, lending some credits to I think what we all inherently know what we're likely telling patients. But I think the preventive aspect is very exciting. And I think we'll see more work in this coming this year and certainly next year that we'll keep track of. I think what's also interesting about depression, especially for schizophrenia is the effects are not only in physical health, but they can be in cognition as well. I think we certainly know that schizophrenia has positive symptoms, negative symptoms, and sometimes the cognitive symptoms don't get as much focus. And this was an interesting meta-analysis that came out in Schizophrenia Bulletin. And what the author showed is exercise significantly improved the cognitive domains of working memory, social cognition, and attention vigilance. Effects on processing speed, verbal memory, visual memory, reasoning, and problem-solving were not significant. And that's not to say there weren't effects and get a meta-analysis. Sometimes you don't always find all the things, sometimes samples are small. But the point that we can tell people that there are already pro-cognitive effects in SMI of exercise, I think is something that's very important because a lot of our traditional treatments and especially medications, they don't always have this. Sometimes for some patients, they can be challenging for cognition, for some people they can help. But I think certainly we can help our patients understand that there's benefit to exercise and just the cognition, that's another win. And a new area of research, one that hasn't been explored, but I think is very interesting is what is kind of the immediate response to exercise? We're learning a lot. We've been seeing news releases about ketamine, kind of antidepressants that work quickly. But there's a small amount of research, and again, not large, it's still evolving, but saying do people with schizophrenia have a very strong effective response right after exercise? And this we found out will improve their mood very, very quickly. And this was a small study that was done in 2016, but really showed that, again, you're kind of getting a quick mood boost when people are doing exercise, which again, you're not going to see in sitting, so it could be kind of a rapid intervention for people. And this was another study, again, small 2014, but high aerobic intensity training uses an acute intervention to improve positive affect to well-being and reduce distress and state anxiety in patients with depression and schizophrenia. And I think the key here is, again, this was really something that was happening acutely. They were looking at 15 minutes and they were looking at three hours. So we've talked a little bit just early about kind of these long-term benefits of physical health and being active, but I think helping patients understand that this is something that could make them feel better, perhaps even within 15 minutes is very powerful. So that brings us to a technology question, is can smartphone apps increase physical activity? We would like to get our patients to be more active for many reasons we just discussed. And how can we help do that using technology? And this is the first study I want to talk about. It came out in this year, in 2019. And what the authors of the study did is they said, we've had a lot of small studies looking at fitness trackers and do they help people take more steps at smartphone apps? But they said, we're only going to look at randomized control trials in the study. We're only going to take what we consider to be the highest quality studies that really have a control group, that randomize people, that really do things in a very, very rigorous way. And the author said, now in 2019, we have enough studies to begin to do this. So in the end, they basically looked at 1,700 people in this. And the result was they said, you know, overall, people using smartphone apps become more active. And this included the broad population. So it wasn't actually directly people with SMI, but they only took 476 more steps. Unfortunately, you can see it wasn't significant. That diamond is kind of touching zero. And what is interesting, the authors said they found that people doing these interventions with apps increased steps. It was more effective in the first three months. And after three months, the effect kind of began to be less. And I think what's really relevant to all of us here is they said, apps that try to do everything, that try to make you physically active and diet, to kind of combine all these things together, those actually weren't as effective. The apps that kind of appeared to be most effective were the ones that focused on one thing. So in this case, kind of being more physically active, not also including diet and including mindfulness, kind of focusing on a single thing. You can see on the slide, there's one study that actually was fully positive. The, I'm going to mispronounce it, SK Skirpnik et al., 2017. And that study actually did look at people with pain and also assessed mood. So the one that comes closest to SMI actually was positive. But again, when you put the picture together, we're seeing that an app alone may not be a panacea or kind of a magical change-all solution for helping people take more steps. So again, the conclusion of this kind of pretty good study was in comparison with control conditions, smartphone app-based produced a non-significant to p-values greater than five increase in participants average steps per day, which is good. But again, it really didn't differ from a control group. So, but I said, so it's worth keeping in mind what that means. And I think that gets to the point of why is it maybe that a smartphone app alone will look at our technologies, aren't getting people to be more active. And this was an interesting study with two of the authors are also on our SMI advisor team. And they were looking at how if you want people to kind of be more active and to lose weight, really what are, where do they have to be? Is it self-efficacy kind of, they're going to take charge and do this, or is it readiness to change? What kind of state does the patient have to be in? And what's interesting is looking at the study, they said self-efficacy significantly correlated with intervention participation, but readiness to change and not predict significantly over and above self-efficacy. So it's interesting that, again, readiness to change is important and kind of having a device because you're ready to change, you go out and you buy an app or wearable may be important, but I think it's still, it looks like the evidence is kind of going to say for our population that self-efficacy may be the most important thing to focus on. Helping patients can develop self-efficacy, getting them to that point could be very important. So it's not to say readiness to change doesn't matter, but again, that self-efficacy could be more what we want to focus on. I think in terms of talking about physical activity and technology, I think I'd be remiss if I didn't mention Pokemon Go. There certainly aren't as many people playing it today in Boston as there were several years back. It was huge here. But since Pokemon Go came out, there've actually been a couple of small studies that have begun to look at what was the impact on physical activity. And I don't believe there's any that specifically looked at SMI patients. I know several of the patients I worked with were interested in playing it and did take more steps. But I think what's interesting about this study is they looked at people in the general population and they said, does Pokemon Go make people more active? How much are they using it? What is the impact on it? And what the authors reported is they said during the course of study, 78.7% of participants started to quit or reduce game time during the duration of the survey. So people kind of got the quick boost of physical activity, they're playing it, but it didn't last too long a time. And I think what really is relevant to all of us in this study is they said, the people who kind of were most active, it's actually people who perceived a safety level and walkability of your neighborhood to be high. So even if you were motivated to be physically active and the Pokemon Go app came out, you really want to go use it and take more steps. In this study, it really depended on your neighborhood, how safe you felt going out. And you can imagine that's something that certainly impacts a lot of our patients too. If it's a neighborhood where people don't feel safe, where there aren't as many sidewalks, that may be challenging. And again, it's going to be hard to ever develop an app or technology perhaps as engaging as Pokemon Go for that burst. But even Pokemon Go couldn't really get away from the core issues of kind of walkability of environment that people live in. So again, a case in point that it can help, it can get some people active. But it's not going to kind of take away from the underlying social determinants of mental health that certainly impact many of the patients that all of us work with. And this certainly leads to a question of realizing that maybe an app isn't going to solve everything, but what type of app may help people actually become more active? And this was a very interesting paper done by someone called Eric Heckler, who's now at UC San Diego. And what he wanted to do is say, I want to basically figure out what type of framework around an app will help people take more steps. And he basically made the same app, but what he did is he made three versions of it. One was analytically framed that you can see in green. And the analytically framed app basically gave you your data. It showed you, here's how many steps you've taken, here's how many steps you want to take. It was very number heavy. And then he also made a socially framed app that basically said, you know, your friends have taken this many steps or there's so many steps that your group has taken, your cohort, it kind of framed physiologically in terms of socialness. And he had an affectively framed app that basically had a little bit of gamification, it had notification, there was a little bit of attachment, you had characters. And as a control, he had a diet app. And the goal was to see in older patients and older adults, who would kind of take more steps? Would it be people that got this, again, data heavy app, the social app, or this kind of affectively framed kind of working on games and mood and attachment? And as I said, the answer was the social app actually helped people be a little bit more active. And I think we inherently know there's something very motivating in socialness, the whole social network idea we talked about in our last talk that you can go find on our SMI advisor website, really talked about the power of kind of social media, and how we can harness it. And it's the case here, where social seems to kind of be a very powerful way to get people to take a couple more steps. That's not to say analytical, giving people data doesn't matter. And the affectively framed doesn't matter. Certainly different people respond to different things. But overall, in this case, it was the socially framed app that won. And this, again, begs the question, is there anything else that can help people take more steps? And this was an interesting study of direct relevance to all of us working SMI is this group gave people fitness trackers. You can kind of see in the first box, there's 200 who are assigned to a control group, but the other group got a Fitbit, then the third group got a Fitbit plus money, and the other group got a Fitbit and money that was given to charity. And the idea was to see what helps people take more steps. Is it just, is it wearing a Fitbit, which everyone had, or does adding money on top of it, adding money going to charity, what is this actually going to do for people? And what's interesting is that at six months, compared to the control, the cash group was a little bit more active, and the difference between the Fitbit and the control was not significant. So actually giving people cash, thus you see kind of the picture there, for the first six months seemed to be a little bit more motivating in terms of getting people to take more bouts of physical activity. And what you can see on the graph here is you can see that dotted line is where six months happened. And blue is the cash group. You can see the cash group is doing pretty well. And at six months, everything kind of drops down, and that's when the incentives went away a little bit. And what's interesting, at 12 months, the Fitbit group logged an additional, they had more bouts of physical activity, and they actually had, compared to their baseline, a little bit more. This graph is looking at steps. So steps did decline, but people were at least doing more kind of, more bouts of physical activity. But you can see that the point is, once you take away external incentives, having these devices alone, it's useful, but it's not overly transformative. So it's an interesting study to read. It was done in a population with diabetes, which many of our patients do have, but they didn't directly look at SMI. It's also interesting saying, well, do these fitness trackers help anyone take more steps? And this was a small study. And I think what's interesting is it was actually done in clinicians. It was done in resident clinicians, and they were claiming, from this, the physical activity tracker did not increase the overall self-reported median number of steps per day. And again, you can see that people use them, but the long-term effect isn't quite there. And we're gonna talk about some case examples soon that show how these actually can help patients. And the missing ingredient, and the reason you're seeing this curve where it always starts to go backwards, you see it going down, is that giving the device alone is probably not enough. But using a device in conjunction with you, making it part of the treatment plan, making it something that people know that you want to check on, that you care about, is going to be important. And I think it can be a little bit tricky to say, well, if I do want to use these wearables of patients, I'm gonna kind of make it something we check in on, we're gonna talk about steps. Then maybe it's a useful thing, but which wearable do I even pick? And this graph is just to show that there's a lot of these devices coming onto the market. And every couple of weeks, I feel there's a new device that kind of has a lot of publicity, where there's certainly Apple Watches, there's ones that come out on a yearly basis. Now there's many Android watches, Garmin has them. And I think there's not any one in particular that may be better. I think what we really want to be using our patients is really anything that helps us get out a number of steps is going to be pretty useful. So it may be starting with an inexpensive one that doesn't cost too much money, maybe the best bet. And if someone really gets excited by it, then it may be kind of looking into the details of what has the most features. But I think initially, anything that kind of gets us two steps is good because there's a lot of these things on the market. Certainly from our prior talks, we've talked about evaluating technologies and apps and wondering which one should I use? And we've always talked about clinical integration is important. We wanna be using these technologies, but we want that step count in this case to come back and be something we talk about in the clinical visit. We don't want to not tell people to do something and not follow up on it. This was an interesting study at Cedar Sinai Hospital in California, where they actually opened up their electronic medical record, which is epic by chance. And they offered nearly 80,000 people the chance to kind of sync up their fitness tracker data into the medical record. And the interesting thing was only 499 people, or basically less than 1% of patients actually uploaded their fitness tracker data into the medical record. So it's a case in point that patients weren't overly excited to share this data. And the study didn't quite dive into why that was, but part of it may be is people really only wanna share data if they feel that their clinician is going to help them use it, or if it's gonna be meaningful towards their treatment. Certainly we can capture a lot of different types of data. And this study actually came out just a couple of weeks ago saying, who do people wanna share data with about kind of their, about their fitness? And this is data gathered from a smartphone. In this case, actually lower is better. So patients were most comfortable sharing sleep data from say a smartphone and mood. You can see physical activity was a little bit, they're less comfortable with a doctor. And you can see that those arrows are kind of higher for electronic health record, and people are a little bit less comfortable sharing it with family members. But you can see people are most comfortable sharing information about mood and sleep. Physical activity was a little bit less and higher up as social activity. But certainly I think there is most comfort sharing with a doctor compared to directly with electronic health record and compared to a family member. So it's not that patients don't wanna share this data, but I think as this Cedars-Sinai study shows us, if your healthcare system, if your hospital invests in this kind of massive system where people can give data, if you build it, they may not come. You probably have to help people understand how it's gonna be useful for their health. You have to work with people to estimate and say, here's why we want to collect this data. Here's why it's going to be important. And again, this slide is showing that people are interested in sharing it with clinicians. And I think the question is, if you're going, there's a lot of stuff happening in this kind of wearable technology space. It's true. And in some ways what the slide going primary outcome measure is actually cognition and neurology, which really in this study comes with mental health. We really are at where a lot of the research is happening around kind of all of these physical activity things. There's a lot more studies coming out. That's what the other graphs of A and B are showing is there's a lot more research coming out. This space is really accelerating and picking up to a point where it certainly can be hard to keep up with all of the different pieces. But as you're seeing, there's not as much done in SMI yet, but certainly there will be. And what I want to focus on now is saying, how can we actually be using these apps, these wearables, these trackers with patients, with SMI? How could they work? And I think now that you have some context of what they do, what are the benefits of them? What are some of the caveats that again, if you hand them to someone, they may not work out of the box. What can we make of these cases? And the first case is a small study. This was actually done at McLean Hospital in Boston, and they had an app that was called WellWave. And it was an interesting app. It was basically designed to promote physical well-being in adults with psychiatric disorders. And it was a four-week study. And the app was really composed of a little bit, it tracked how many steps people took, but had educational interventions. And in general, seven of the 10 people in the study really were, they were increasing their steps and people liked it. They actually found it easy to use. They wanted to keep using it when the study ended. And as you can see from the quote, what's interesting is it worked very well in people over age 50. Sometimes there's this assumption that only younger patients want to use technology and older patients will be confused by it. They won't like it. It won't be helpful. And again, this study actually was the patients with SMI who are over 50 that actually benefited the most. And again, so I think the point being these things can work directly kind of for patients in SMI treatment. Again, this was a small study, but it's nice to see actually a focus directly on SMI. This wasn't done to general population. It wasn't done in studies of diabetes. And again, overall, the study was very positive. And this was a case report actually from Ipsit Fahia who coincidentally is also at McLean Hospital now that I'm thinking about it. And it was a case report in American Journal of Psychiatry. And what Dr. Fahia had is there was a patient who came to him and was reporting severe depression, but the patient's family and his clinician, his primary care firm were also unsure is this kind of signs of early dementia. And the patient was kind of arguing that maybe early dementia and no one could really figure it out. So what Dr. Fahia did was he gave a jawbone device. And for those of you that don't remember jawbone actually is one of these wearable manufacturers that unfortunately went out of business. But again, it was basically a step counter. And that's actually a picture from that Dr. Fahia published in this paper. But this was actually the patient's number of steps per day. And you can see this patient was having about three minutes of active time. And one meter was kind of about as far as they went in a day. And this really helped Dr. Fahia in a clinical sense realize that this patient had very severe depression and it really wasn't early dementia. And again, this was data to kind of help make a diagnosis that really was impossible to get because the self-report information was a little bit contradictory. And it kind of gets back to that initial slide we have where when you measure people's physical activity via objective measures and self-report, sometimes there's a difference. In this case, that led Dr. Fahia to really directly talk to the patient and say, hey, you tell me that you're a little bit more active if you're getting out of bed. This wearable is saying that your longest active period was one meter. In essence, you're really not leaving the bed. In that case, the patient then really was able to kind of understand that maybe this is depression. He was treated and did well. So again, a different approach where a well way, first case example was kind of helping patients with SMI take more steps. Here we're seeing a wearable device really helping with diagnosis. What's very interesting is you may not soon even need a wearable device. And we'll talk about that soon to be measuring steps. So this is a study that was done in patients with schizophrenia by Jorben Zees, who's now at the University of Washington in Seattle. And what he was showing is actually you can use a smartphone app, and we'll talk about this shortly, to kind of get a proxy for how many steps you took. You can imagine some people don't keep their phone on them all the time. Some people go for a walk and they leave their phone. So the phone's not gonna record every step that you do, but the phone can get some idea of how far you did. And the phone can also offer surveys. So in this case, what Dr. Benzies was looking at is kind of relationships of just kind of how does, how far someone walked in the data or physical activity, in this case, perhaps correlate with hallucinations. And I think there's more work that's gonna be published, but the point is that anyone that may have a smartphone today, it may be possible to collect this type of information and kind of begin to get that symptoms and kind of get people's experience of SMI as well as their distance. So this isn't quite around physical health, but I think it's important to realize this is a whole nother opportunity to use this in. What's also very interesting is another study by John Naslund, who was at Dartmouth when he did this work. He actually gave 34 people patients, and you can see it was a sample of people with SMI, some with schizophrenia, some with major depression, some with bipolar, and they were in essence given Fitbits to wear, and they were given a little bit of coaching. And what he showed was that six months, people who took more steps basically had greater weight loss. They didn't have improved fitness, kind of the impacts of weight loss, but certainly improved weight loss is important. And it's nice to see that dose effect that kind of helps us understand the causal relationship. People who took more steps were getting better outcomes in terms of weight loss. And again, that's the type of relationship that we wanna see. And again, this was a case where it was done in 2016, that again, we're not gonna harm people by certainly giving them a fitness tracker, letting them use it and learn about it. And in some cases we can do a lot more than just giving people a device. This was another interesting study that was done by Alex Young, who's on our SMI advisor team, and Amy Cohen, and they had an intervention called Web Move versus Move SMI. And what's interesting here is Web Move, as you can imagine, is more internet-based, and Move SMI is more in-person. And Web Move actually kind of incorporated peer coaches of lived experience of serious mental illness, helping people via technology kind of be more active compared to in-person, and then compared to usual care, which is a control group. And what they showed was that Web Move versus usual care, that people were more physically active at six months. So you can see it's a nice way that you can, there's peer involvement, there's technology involvement, and at six months you're seeing outcomes that certainly help people. As you've seen this talk, there's a lot of ways to measure physical activity and fitness and the impact of it. And based on a similar study, the same group kind of looked at that and said, if we look at BMI, again, kind of a measure of physical health, and they looked at, again, Web Move versus kind of Move SMI to in-person, actually the group that got the online version, Web Move really had much greater improvement in BMI compared to the in-person and compared to control group. So this is a really interesting case where giving people peer coaching, a pedometer to track steps in intern education can be a very effective intervention in reducing BMI. And again, this was very nice. That really was a patient population with SMI. And certainly it doesn't have to be restricted to the usual things that we think about or a fitness tracker. A very exciting study, certainly for many patients, is this one that was done by David Kimhi. And what he did was actually, he had people play video games as part of intervention to kind of help people get more physically active. And so this was basically letting people use an Xbox, or an Xbox was actually the thing that people spent the most time on. And some of you may have seen these kind of different devices where it has a kind of sensor on it that measures physical activity. So it's almost the Nintendo Wii, which we'll talk about next. But that actually was an effective way for helping people get physical activity. And he was showing it in a study that you can read that people really enjoyed it. There was high adherence. So he had adherence of 79% of sessions, which is pretty darn good for anything in the exercise kind of physical activity world. And again, patients really enjoyed it. So again, we can almost begin to think outside the box on what is physical activity, and kind of thinking of using technology in these certainly very creative ways. This was actually a very small study case report out of Asia, but it was interesting looking at the Wii Fit. So I said this study involved the Kinect and the Xbox. This was Wii Fit. And they were just looking about how, again, this is something that people with schizophrenia in this study, they enjoyed using. It kind of did increase their number of steps. And again, only a case report, but when it was kind of taken away, the steps did decrease. So it does kind of lead to questions of the next step is if we give people these kind of things like video games or these new technologies to increase physical activity, what happens when we take them away? Or is that something that we give to people we put in their homes, that we give groups and coaching around? So that's almost an open question. But I think certainly just important to consider that if you have patients that like video games or are excited by it, I think there's, we could certainly say that there's evidence of support that I'll go back a slide again. Video games may be a very good way to write one to kind of increase physical activity and help people get those benefits. So in terms of now, just think about some broad clinical uses today, what you could be kind of using this technology for patients. So we're gonna go over some examples are actually from that book chapter that we showed at the very beginning of the talk. And we're quickly gonna look at some apps. There's no apps here, actually, that we as SMI advisor are endorsing. They're kind of just here as examples. And if you remember that from prior talks, we talked about looking for apps, really what's most important is we want ones that are safe and effective, that's the first level. The second level is we want apps that are evidence-based, that are actually gonna help. The third is we want apps that are usable, that our patients can engage in a meaningful way. And the fourth, we want apps that will share data and kind of engage us in discussions, not fragment care. But I think what's interesting is a lot of apps, we can kind of use them. If your patient's bringing you a smartphone today, it really can help with goal setting around exercise. You can imagine that we can transition from having a calendar of what someone's goal is to helping them use the calendar phone to set alarms. Let's say, you know, today I wanna take a walk and take so many steps. On the weekend, I wanna try running. I wanna try biking. I wanna try, hey, even going around the house, taking so many walks around the apartment. And again, this is something you can do pretty easily, no matter what type of phone someone has, it likely has a calendar with alarms. So you can really help support exercise with goal setting. And this is nice because it costs nothing. Again, even the simplest phones will have it. And sometimes helping people goal setting is a really important way to get them on the first steps towards being more physically active. What's also interesting, some patients have more modern smartphones or have updated their phones. And if anyone has updated their phone, likely almost now I'd say within the last 12 months, if they have an Apple or a newer Android phone, the phone actually may be collecting a lot of physical health information automatically, whether you're asking it to or not. Really, it's around steps. Heart rate, there's not as much data being collected. But what's interesting is if you just look under the health feature on an iPhone, or you look at the same equivalent on the Android phone, you actually could ask a patient who comes into your next appointment, can we look at this data together? Would you be willing to show me the screen? And again, as we talked about, a phone is not a perfect way to count steps because some people don't take their phone everywhere. Some people don't keep their phone on them at all times. But certainly you're gonna get a proxy for steps. You're gonna get a window. And again, if they've had their phone for a while, you may get kind of historical data over several months of how many steps people are taking. So what's nice is you don't have to download an extra app. This is kind of being collected. And some patients may not realize again, they're kind of bringing all the step count data to your visits every day or every time they see you is being collected. So they may not, so self-monitoring can be done very well. I think we talked about social support just being something that some apps can do. This was actually something we've talked about in a prior talk around social media. If you look at the motivating factors for physical activity and exercise in patients with SMI, again, the least motivating factor is social app. And again, that's something where perhaps that if people need a social boost, that could be a good way to help people kind of become more, be exercised or take more steps, be more active. So again, it could be a case that people can get social support via these technologies. And that may be the missing piece for some patients and helping them kind of take those first steps towards being more physically active. So again, social support is something these phones can do. These are screenshots from different apps. There's actually a lot of physical activity apps out there. It's a huge, huge amount. It's constantly changing. But what's nice is some of these apps can actually give you feedback. And I think if you saw on our first slide, I started with where it said, good job on the zero steps of walking you just did today. Not all these apps are accurate. Their feedback isn't always perfect. Sometimes they are based on algorithms that are still being developed or not perfect. But you may have some patients that really want some feedback in the moment, that wants some feedback after they take a number of steps. And there are a number of apps out there that can, again, get people feedback right away. And again, if you're interested, it's probably something that may be most appropriate. We can consider doing a consult. You can do that through the SMI Advisor website. We can talk about individual apps because it takes some thought. But you can imagine some people really do want feedback and these apps can give it to you in a very nice way. Some people just need help with instructions because it can be a little bit complex to remember what to do, how to do it. And I said, there's a lot of apps that actually kind of give you step-by-step instructions, how to do exercise, which can be very useful. And some of them can really help with prompts and cues. They can, again, really help you think, what are the first steps to it? What am I gonna do week by week? Give you a lot of information. So you can imagine that there's a lot of ways that we can use people's phones already from simple self-monitoring to really giving people almost things that they can follow that could be helpful. And again, not all of these will be helpful for all patients, just like not every therapy is helpful for all patients, not every medication. But I think there's a lot of different things that we can offer patients today that may already just be on their phone. So with that, I wanna say thank you, and we'll transition to some questions.

mobile technology

wearable technology

physical activity

serious mental illness

individualized goal-setting

social support

self-efficacy

fitness trackers