Hello and welcome. I'm Alexia Wolf, Chief of Social Determinants at the Division of Substance Abuse and Mental Health and Social Determinants of Care Expert for SMI Advisor. I am pleased that you're joining us for today's SMI Advisor webinar, Using Smartphone Apps to Support Self-Management in Bipolar Disorder Opportunities and Challenges. Next slide. 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. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one Continuing Education credit for psychologists, one Continuing Education credit for social workers. Credit for participating in today's webinar will be available until October 31, 2022. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Now I'd like to introduce you to the faculty for today's webinar, Dr. Emma Morton. Dr. Morton, thank you for leading today's webinar. Dr. Morton completed her PhD and clinical training as a psychologist at Swinburne University of Technology, Australia, where she was awarded the Ian Wallace Research Medal for the most outstanding doctorate student. Dr. Morton presently works as a Canadian Institute of Health Research Banting Postdoctoral Fellow in the Department of Psychiatry at the University of British Columbia, Canada. She is a network member of the collaborative research team to study psychosocial issues and bipolar disorder, otherwise known as CREST-BD. Dr. Morton's research focuses on quality of life and digital tools for people living with mood disorders, and she is currently working with the CREST-BD team to develop and evaluate the Polar Us app for self-management and bipolar disorder. Her work in this field has been honored with a number of recognitions, including most recently the recipient 2021 Depression and Bipolar Support Alliance, Gerald L. Klurman Young Investigator Award, and a 2022 International Society of Bipolar Disorders, Samuel Gershon Junior Investigator Award. Thank you so much for that introduction. I have no relevant disclosures to bring up today. Next slide. I have a number of goals for today's presentation. On completion of this activity, participants will be able to summarize the role of self-management in bipolar disorders treatment, identify opportunities and challenges relevant to the use of smart phone apps for bipolar disorder, and apply strategies for appropriate and trustworthy smart phone apps to support bipolar self-management. Next slide. I'm going to be talking about the role self-management practices play in enhancing outcomes for people's bipolar disorder, and how digital interventions such as smart phone apps can address limitations in access to self-management education and support. I'll talk about the current state of the public app marketplace, and review practical approaches to identifying and evaluating apps suitable for use by people with bipolar disorder. Next slide. So, in terms of treatment approaches for bipolar disorder, this is a chronic mood disorder that is estimated to have a 2.4% lifetime prevalence globally, and has been ranked by the World Health Organization as the fifth leading cause of disease burden. However, accumulating evidence suggests that medications on their own are less effective than originally expected. You can click. However, 60% of people relapse within two years despite pharmacological treatment. Despite maintenance therapy, individuals with bipolar disorder will experience persisting sub-syndromal depressive symptoms up to 50% of the time. And additionally, impairments to functioning persist despite symptomatic remission. So, we know that about a third of patients achieve functional recovery post-episode, as compared to up to 90% who attain syndromal recovery from acute episodes. So, targeting symptoms alone is not sufficient to support overall wellness. We also need to support functioning and quality of life. Fortunately, we have a wealth of evidence to suggest that adjunctive psychosocial interventions can improve outcomes, including time to stabilization after a mood episode, delaying relapses, reducing symptom severity over time, enhancing occupation and social functioning, and improving subjective quality of life. Next slide. Randomized control trials have demonstrated the efficacy of a number of psychosocial treatments, including CBT, interpersonal and social rhythm therapy, and group psychoeducation. Although these various brands of psychotherapy differ slightly, they share these elements in common. They all aim to reduce self-stigma, developing acceptance of the disorder and increase hope, improve social skills, particularly in regards to communication within the family, build support networks, enhance medication adherence. They support the person to detect and respond to mood changes. This means that the individual becomes more aware when problematic mood changes are occurring before they escalate to a full threshold effective episode, and learns to apply emotion regulation skills to moderate mood changes. They also promote stabilization of sleep-wake cycles and other daily rhythms, such as socializing. And importantly, many of these strategies are skills that the individuals themselves take responsibility for implementing in their daily life. Indeed, research has shown that individuals with bipolar disorder who have generally successfully managed their symptoms implement these techniques as part of their stay-well routines. We can think of this collection of behaviors as self-management. It's an ongoing process of the individual monitoring and responding to the signs, symptoms, and consequences of a chronic illness, including the broader impacts to their quality of life. Indeed, self-management is now recognized as an important part of bipolar disorder care in all major treatment guidelines, and is also consistent with recovery-oriented approaches to care. Next slide, please. Unfortunately, there are significant barriers to accessing face-to-face psychosocial services that can provide this kind of self-management education and support. The large-scale UK STEP-BD study reviewed treatment history prior to enrollment and reported that of 500 participants receiving pharmacotherapy for bipolar disorder, only about 50% of people received any kind of psychosocial services, whether that was therapy with a psychologist, social worker, or peer support group. Some services within this study had access rates as low as 30%. This low rate of uptake may be for a few reasons. It is a well-known issue that traditional services can be inaccessible for many people, particularly due to their distance, cost, and complexity. Secondly, stigma is a prominent barrier to help-seeking, particularly for ethnic minorities, youth, and those who identify as male. Despite the noted importance of self-management education and support, access to psychological services that can facilitate this are sadly limited. Next. Increasingly, attention has turned to internet-based interventions and mHealth more specifically to address some of these gaps in provision of adjunctive psychosocial services and self-management support for bipolar disorder. So when I say mHealth, I mean interventions delivered by a mobile phone, so this could be text message-based, but in the current context, it's more likely to refer to smartphone apps, and that's what I'm going to be focusing on today. So you've no doubt heard some of the enthusiasm for how smartphone apps may overcome some of the barriers to treatment discussed earlier, especially access and stigma. Apps are low-cost, easy to disseminate, and are less visible than a worksheet or workbook, and could potentially be accessed independent of traditional services. Importantly, users can access information and tools in the context of their daily lives where it may be most helpful, as smartphones, unlike computers or workbooks, are almost always switched on and within arm's reach. Apps can be particularly helpful for mood and sleep self-monitoring, which are, as I mentioned before, core components of bipolar disorder self-management. Phone-based monitoring may be easier to complete, which can overcome some of the data quality issues that occur with pen- and paper-based self-monitoring, where people tend to backfill missed entries at the end of the week. Not only can smartphone apps help address the issue of access, their technological capabilities can help enhance the delivery of interventions. So you've probably heard a lot of excitement about how apps may facilitate the collection of passively sensed data relevant to the prediction of mood episodes, such as activity, location, use of social media, which can help inform the provision of, in the moment, personally tailored recommendations. Next slide. So there is a lot of preliminary evidence to suggest that app-based interventions might be feasible and acceptable in bipolar populations. We have evidence to show that smartphone ownership rates in this group are high, and a UK-based survey found that 93% of respondents with bipolar disorder own a smartphone. The acceptability of apps is also supported by a survey by this group, which reported that 77% of people with bipolar disorder have expressed willingness to receive an intervention delivered by mobile. And in terms of specific features that people would be interested in using, based on an international survey, and you can click here, you can see that many of these overlap with the self-management tasks endorsed by those mechanism studies earlier. So people in the survey reported that they'd be willing to use apps to do things like monitor mood and sleep, receive tailored support for episode prediction or psychoeducation, medication reminders, maintaining a healthy lifestyle, et cetera. So there is a lot of evidence to show that there's appetite for apps in this population. Next slide, please. So while there are a number of research-led app developments to initiatives to develop mHealth applications for bipolar disorder, unfortunately, none of these have been made available outside of the context of a research project as of yet. And this is in part due to research to practice translational lags, complex regulatory systems that are still unfortunately catching up to digital health developments, and the fact that grant funding typically doesn't cover dissemination or ongoing customer and technical support. And you can click here. Instead, the user is left to navigate the public marketplaces, the App Store or the Google Play services, where they're faced with a plethora of mental health apps, over 10,000 as of a study in 2018, and more are being added all the time. So that means that when your patients are searching for bipolar disorder on the App Store, they are faced with this, frankly, overwhelming amount of results in order to try to find something relevant. Next slide. This boom in commercially-driven mental health apps has been termed the Wild West, because they are largely unregulated, commercially-driven, and may present risks to an individual's privacy or well-being. And you can just click through to bring up all the information on this page. So the most recent review of the App Store landscape identified several issues. The researchers looked at the top 98 returned apps for the keyword bipolar. And they found that of these, almost half were not clearly relevant or specific to bipolar disorders, and a number of apps were categorized as entertainment or games. Only two apps were associated with the university or healthcare organization, and both were treatment guidelines for physicians. The rest of the apps were developed by commercial developers, and only one app had peer-reviewed literature to support its efficacy, and you can click through a couple of times to bring up. Concerningly, a number of apps contained potentially harmful or misleading content, including unmoderated forums, advice that did not align with treatment guidelines, apps offering a bipolar diagnosis on the basis of unvalidated questionnaires, and potentially stigmatizing or triggering content like an app that offered wallpapers with the words, I disappoint myself, and another which offered downloadable stickers of an unpredictable bipolar bear. Also of concern, only two-thirds of the apps evaluated contained a privacy policy, and of these, 41% indicated that they would share personal data with third parties, and transparency of these privacy policies was also poor, with an average reading grade of 12. Next slide. Another challenge that potentially limits the potential of apps for self-management of bipolar disorder is their ability to sustain user interest and engagement. Although not specific to bipolar disorder, an analysis of app store metrics found that 15 days after download, user retention in mental health apps was only 4%, and by 30 days, that had further dropped to 3.3%. It's hard to predict whether these dismal engagement statistics would also apply to apps for bipolar disorder. The only information we have specific to this user group comes from a study of research-led app evaluations, which found adherence rates between roughly 60% to 90%. However, these findings may be biased as a consequence of them being conducted in a research context where contact with RAs, payment, et cetera, may encourage retention. Next slide. However, I do want to temper these findings with some real-world context about how people with bipolar disorder are currently using apps. At CRESS-BD, we conducted a survey of over 900 people with bipolar disorder regarding their current use of apps and smartphones. This survey was known as Bipolar Bridges, which I mentioned because I'll be referring to it a couple of times today. You can click through to bring up the rest of the information on this page. We found that 42% of people in the survey reported using an app to monitor or support their mood or sleep. Of these, we looked at the top nine used apps to see how they compared to early reviews of the quality of bipolar apps more broadly. In a note about why it's nine, we intended to look at the top five endorsed apps for mood or sleep, but one app featured prominently in both of those lists. Not reassuringly, we found that these top nine apps all had privacy policies and most did not share personal information like name or date of birth. However, sharing de-identified information with third parties was still common. As compared to mental health apps in general, most of these apps had research to support their feasibility or efficacy. But a note of caution here, no studies used specifically bipolar samples and the outcomes evaluated were not all directly relevant to bipolar disorder and included things like stress levels, mindfulness, and attention. Really interestingly, only one of the top nine used apps was specifically designed and advertised for bipolar disorder. The rest were apps designed for the general population or for unipolar depression. And I'll talk more about those specific apps later, however, I do want to note that not everyone in the survey was using these reviewed apps. About 50% of the sample reported using apps not covered by these evaluations. So while we do have some reassuring findings about the quality of apps used, practitioners still need to be alert to the possibility that patients are using poor quality or untrustworthy apps. Next slide. Some of this heterogeneity in terms of the quality of apps may be explained by the concept of digital health literacy, which describes knowing how to find, evaluate, and use health information. People with less e-health literacy are less likely to take up digital health interventions and are more likely to overestimate the privacy protections offered by apps. So they are potentially more vulnerable and underserved group. And we also looked at this outcome in the Bipolar Bridges Survey. And we found that on average, digital health literacy was numerically comparable to the general population and other chronic health conditions. However, there was evidence of between individual variation. People with experience using mood or sleep apps and postgraduate education had higher digital health literacy, which suggests that patients who do not belong to these subgroups may need more support with identifying and using mental health apps. And interestingly, we found that frequency of use of apps in general was not associated with digital health literacy, which should be a caution against making assumptions that people with strong uptake of technology feel confident when it comes to choosing health apps specifically. While in an ideal world, there'd be more safeguards around the quality of mental health apps that are made publicly available, in their absence, individuals involved in providing mental health care play an important role in safeguarding patients, especially those with limited e-health literacy from unsafe or untrustworthy applications. Next slide, please. I'm going to use the umbrella term practitioner to refer to people who may play a role in supporting the use of mHealth, as this may be performed by GPs, psychiatrists, allied health workers, caseworkers and peer support workers. And you can click here. Just a note on the use of peer support, this is a really promising avenue to support the dissemination of evidence-informed mental health apps. In our survey, we found that 60% of people with bipolar disorder use recommendations from peers when choosing apps. And there's also increasing attention on the use of formalized roles often filled by peers to support with app evaluation, tech setup and app data review, such as the digital navigators role, which is being investigated by the Division of Digital Psychiatry in John Torres. But I know there's a specific webinar on that intervention, so I won't go into too much detail here. I just wanted to make a brief note about a potentially feasible strategy to implement some of the things I'll be discussing today in a healthcare setting. Next slide, please. Given the potential importance of practitioner recommendations, we also, in my Bipolar Bridges survey, asked healthcare providers what they thought about apps. And unfortunately, we observed that practitioner confidence in prescribing or recommending mHealth for bipolar disorder is low. Only 50% of the 80 respondents had discussed or recommended apps. You can click here. The main barriers to app prescription were a lack of knowledge of which apps are credible or useful for people with bipolar disorder, belief that patients do not have access to adequate resources, such as a data plan or a smartphone, and assumptions that patients do not have interest or motivation to engage with apps over the long term, particularly during depression. I'd like to spend the next part of this session addressing some of these barriers, especially this issue of identifying credible, trustworthy and engaging apps and show you some resources that can help support this informed decision making. Next slide, please. So, unfortunately, there is no single list of the best apps for bipolar disorder to present you with. Just as with pharmacological interventions, there's no one-size-fits-all app. Patient preferences and goals, clinical presentation, resources, and digital literacy will all inform the choice of app. To guide your decision making process, a number of frameworks have been developed, the most prominent of which is the American Psychiatric Association App Evaluation Model. And I'm not going to spend too much time talking about the different levels here because there are a lot of good tutorials on applying this framework and a guide to asking questions, which can be easily found online. But an important thing to note here is that this hierarchical shape is really important to pay attention to as you make your way through app evaluation. For example, so the things closer to the bottom of this pyramid have more foundational importance. There's no need to proceed with further evaluation, for example, if the cost of the app exceeds your patient's resources or if it doesn't run on their particular phone. Similarly, there's no need to go on to evaluate clinical background if inadequate data protection is offered. One challenge in applying this framework is the subjective nature of some of the questions, for example, whether or not an app is engaging. And to streamline the rating process, the Division of Digital Psychiatry has developed a series of 105 objective questions called the mHealth Index and Navigation Database Framework, which is also called the MIND Framework, based on this APA model. And all of the items can be answered with a clear yes, no or numeric reply. So, for example, when it comes to engagement, a rater would indicate yes or no to whether it had specific features like peer support, gamification, etc. And as an illustrative example of how the MIND Framework can be applied, I'm going to talk about two of the most commonly used mood apps identified in a bipolar bridges survey. The evaluations in this study were done by three raters trained in the MIND Framework, with discrepancies resolved by a consensus discussion. And I'm not going to cover all 105 questions here. I definitely don't have time to do that. But I'll just be bringing up some key items to demonstrate how the frameworks might be applied and how they might be used to compare the strengths and limitations of various apps. Next slide, please. And you can click through a couple of times to bring up more information. Thank you. So, one of the most commonly endorsed mood app in the bipolar bridges survey was Dailio. This is a mood and activity tracking app. It was nominated by 59 respondents. It does have positive ratings on the app store and it was updated in the last 180 days, which is a good benchmark for currency and quality. It has a commercial developer and the raters were not aware of any academic or clinical input. Dailio is free to download, but it does have in-app purchases, which open up the opportunity to additional customisation, goal setting features, and a pin lock. And unfortunately, there are no accessibility features for people who are vision or hearing impaired. In terms of privacy protections, there is a privacy policy and personal health information is not shared. All user input data is stored on the phone only. The user can delete their personal health information, but de-identified data such as app use metrics is still collected and shared. However, the user can opt out of collection of this data. Unfortunately, a big limitation that we identified with Dailio, particularly when it comes to recommending this app to people with bipolar disorder is that there is no crisis management features. Next slide, please. So, Dailio doesn't make any clinical claims in the app store description. It describes itself as a micro journal to facilitate mood and activity tracking. And the included features do support this, although they are quite basic. So, for example, you can log mood on a single five-point scale. Basic is happy to sad, but you can change this to represent pain, anger, or relationship quality. And users can only input whether sleep was good or bad, or whether an activity did or did not occur, and not the timing of it, which is something of a limitation when it comes to bipolar disorder and social rhythms. There is one feasibility study, but no research on efficacy. And the only potentially harmful content we identified was that if you recorded variability in moods, an achievement called complex person would be unlocked with the dual happy-sad theatre masks. And this is iconography that some people with bipolar disorder do find a little bit stigmatising. In terms of usability, it offers customisation, notifications, and some gamifications with a street counter. There is evidence to show that features like this can encourage longer-term use of technology. And in terms of data integration, users can choose to export data as an Excel file. PDF export is an additional paid feature. So, it is a little bit difficult to share this data in a format that the practitioner can easily make sense of. Next slide. The secondly most commonly nominated mood app in the Bipolar Bridges Survey, nominated by 45 respondents, is eMoods Bipolar Mood Tracker. This claims to be a mood, sleep, and medication tracking app appropriate for bipolar disorder, depression, and anxiety. As per Dalio, it's got positive ratings. It was recently updated. It is free to download, but users can pay for premium. Again, things like additional customisation. The app also has sponsored links to paid therapy services, which is an additional cost. It does have a commercial developer, but it is important to note here that the creator has lived experience of bipolar disorder type one. So, the content is informed by their experiences and what they found helpful. And it does have a couple of accessibility features for people with various visual impairments. It has a privacy policy, de-identified data, such as, you know, web pages accessed is collected, but a user's self-monitoring data is not collected and is stored locally on the phone only. Positively, there's a resources tab that redirects to crisis lines, both US and international, and support group information in the US specifically. And users can also input details of a safety plan in-app. Next slide, please. The Dalio is more specifically tailored for bipolar disorder. It asks for high and low moods on individual scales, which means it can capture mixed features. And it also allows the user to track anxiety and psychotic features and record their medications. There's one feasibility study, but unfortunately, no efficacy study. In terms of usability, graphs can be a little bit more challenging to interpret because of all the data that is collected. And besides notifications, there is very little in the way of engagement features, and it's quite an aesthetically plain app. But positively, in terms of data integration, eMoods is intended for use with a healthcare provider, and the app says as much. The users can send an Excel file or a PDF to a clinician or family members, and the PDF is fairly straightforward to review and interpret. And next slide, please. So, while it is important to know what app evaluation frameworks assess, and hopefully that recent demonstration gave you an indication of how useful they can be, this process can, of course, take time. And so, if you're interested, you can refer to the database established by the MIND team, which crowdsources app reviews using the MIND framework. Volunteers are trained in reliably rating mental health apps, and I think close to 300 apps have been evaluated by the team now. Results can be filtered by the presence or absence of particular features based on what's most important to your client. So, for time poor clinicians interested in mood or sleep self-management apps for bipolar disorder, this website is a really good place to start as you can filter for features such as mood monitoring or interventions aimed at improving sleep. One thing I would like to note here, though, is that, like the vast majority of app evaluation frameworks, this does have some gaps in coverage. For example, we know that people from low socioeconomic, diverse racial, ethnic backgrounds, and LGBTQ identified users face additional barriers to access and engagement with digital tools. Things like cultural tailoring of intervention content and representation of diverse user groups isn't assessed by both the MIND framework and other frameworks. So, at the moment, it is up to the app evaluator to keep those issues front of mind if they're relevant to a particular client. Next slide, please. Sorry, you can skip this one. Thank you. Although the MIND app database can help streamline the app evaluation process, there are some specific considerations to keep in mind when choosing apps for bipolar disorder. So, the MIND database indicates the presence or absence of specific features, but things like usability aren't covered because it is subjective. You can't answer that with a yes or no question. So, this is where it's important as a practitioner to download a few candidate apps and get familiar with them so you can tailor your recommendations based on the needs of people that you work with. So, for example, if your client experiences medication-related tremors, looking for apps with larger buttons and uncluttered displays might be important. And if your client struggles with cognitive or memory challenges, keep in mind the overall complexity of apps you recommend. And there's a list of design recommendations for serious mental illnesses, which suggests that looking for apps around a year 8 reading level and having as flat a navigation structure as possible is important. So, less screens to navigate through. You'll also notice that on the MIND apps database, there is no bipolar disorder filter, only choosing specific content that might be relevant, such as mood monitoring. But there are a few specific limitations to watch out for when using generic health or depression apps. Some therapeutic techniques may not be appropriate for people with bipolar disorder. So, for example, sleep restriction is a commonly used CBT for insomnia technique. People are instructed to reduce their time in bed to the amount of time spent asleep. But this is generally considered not appropriate for people with bipolar disorder because sleep loss can trigger mood elevation. Similarly, mood monitoring. Many depression apps only have a sad to happy scale, which may potentially miss problematic mood changes, such as hypomanic or manic elevation. That's not to say that generic depression or well-being apps can't be useful for people with bipolar disorder. It's just that practitioners do need to discuss and help their clients to review their data to interpret it in light of bipolar symptomatology. Next slide, please. The role of the practitioner in the use of mHealth for bipolar disorder is an ongoing one, and it does extend beyond unilateral app recommendations. Ultimately, as I mentioned, there's no one size fits all app, and the app marketplace is constantly evolving. Practitioners do need to balance limitations of commercially available apps with the fact that a great number of patients are interested in using apps to support their mental health. And in the absence of guidance, we'll likely self-select from a number of potentially inappropriate or unsafe options. So in the absence of clear evidence, healthcare providers and peer support workers do play a valuable role in collaborating with clients to identify apps that best suit their needs while managing the potential risks. Like with any treatment, collaborative decision-making is important and likely to support engagement. And if your client is already using apps, asking about them shows that you are interested in their self-management, which can help foster therapeutic alliance and gives an opportunity to discuss the potential strengths and limitations of the apps that they're using. So potential ongoing conversations include monitoring for adverse events. For example, sensitivity to reward. There has been some suggestion that an upwards ascent towards hypomania or mania can be triggered by technology use and gamifications like street counters may be of concern in vulnerable individuals. Additionally, monitoring depressive symptoms may also reinforce low mood or trigger adverse events for a small number of individuals with bipolar disorder, potentially through ruminating about depressive symptoms when prompted to do so by daily monitoring. And individuals with self-stigma may find the daily use of illness management apps confronting. Other ongoing conversations include ways to support engagement by initiating conversations about what the user hopes to achieve and any barriers to engagement. For example, disengagement during depression is of course really common. Normalising this can help reduce shame and open up conversations about compensatory strategies for low motivation, like setting reminders. And practitioner review and discussion of data might also help support retention as self-guided digital interventions have lower adherence compared to guided ones. Next slide, please. Finally, although my presentation today has centred on apps for mood and sleep, it is important to pull back to remind you that self-management and bipolar disorder encompasses more than symptom monitoring and management alone. It's also important to consider how bipolar disorder impacts other aspects of an individual's quality of life. And indeed, surveys have found that people expressed a desire to monitor more than symptoms. Things like finances, socialisation and exercise came up as really important. However, given how few bipolar-specific symptom management apps exist, it really isn't surprising that there are even less centred on quality of life and wellbeing. Seeking to fill this app, the team at CREST BD is currently evaluating an app that combines quality of life, self-monitoring and psychoeducation. The Polaris app itself was developed using a combination of lived experience, academic and clinician perspectives. I was very fortunate to be part of that development process and I can say that we've been very thorough about collating the best evidence-supported self-management information and resources for the quality of life domains valued by and impacted in people's bipolar disorder and presenting relevant self-management advice in an engaging and accessible manner. So individuals are able to track their quality of life on a regular basis and select which self-management strategies they would like to learn about and trial over a given time period. And as I mentioned, we're currently evaluating this app. Initial feedback has been really promising. Of course, we're still facing some of the challenges with engagement that I think all mental health apps have to deal with, but there are really positive reports from early users and we are really excited about contributing to the next wave of evidence-informed apps for bipolar disorder. Thank you. And thank you for such an interesting presentation, Dr. Morton. Before we shift into Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health reading scales, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org backslash app. And with that, we can move into the Q&A section. I was so intrigued, Dr. Morton, by your point about the potential of apps to support quality of life monitoring. And I'm wondering if you could expand on that and tell us a little bit about what might be on the horizon in that area. Sure. Yeah. So there's been a couple of surveys which have asked people with bipolar disorder what kinds of information they think is relevant to monitor their well-being. And while the traditional kind of indicators like mood and sleep and medication did come up, a lot of people have fairly personalized indicators of how they're doing. They can look to how their relationships are tracking as an indicator of their overall well-being. They might be able to gauge how they're doing by their general participation in life, in leisure activities, in work, etc. And so CRES-BD about 10 years ago looked at developing the first bipolar-specific quality of life self-monitoring instrument, which is called the QOL-BD. And in 2015 we developed a web-based platform that people could use. And part of my PhD research was actually talking to people who had used this tool. And people reported finding that it was really motivating. It helped them decide which self-management areas to focus on. And also that the fact that quality of life self-monitoring is so much broader than just symptom monitoring, people found it less demotivating or confronting because even if they had some areas where they were struggling, there were other areas where they were flourishing. And so it wasn't as confronting to check back on a monthly basis because they could see that there were areas of strength. And so that's been part of our motivation in developing the Polaris app, is that some of this early evidence that we have about symptom monitoring apps suggests that some people may find that confronting. And for those people, potentially something which is quality of life focused is a useful alternative. And probably for everyone is a really useful complement to specifically symptom-focused apps and interventions. So that's what led us into this project. Excellent. And given the promise of peer support specialists for implementing the strategies you've highlighted, how would peer recovery specialists gain fluency in digital health navigation skills? Yes. So the digital navigator program is one initiative that I'm aware of that is helping train people to train others in basic smartphone functions, evaluate what kinds of apps are out there and might be relevant for their particular needs based on what somebody's coming to the what somebody's coming to the digital navigator looking for support with. And I think it's potentially a really useful way to implement this in the kinds of app evaluation strategies that I've talked about in a healthcare setting, because one thing that always comes up when we talk about this with healthcare providers is, of course, the issue of time to go through apps and potentially a more specialized role might help address that. Although I know there's a I don't want to speak with too much authority on that issue because it is from John Torres and his team. And I know we've got a there's an SMI advisor webinar specifically on that topic if anyone's interested. Well, this has been wonderful information. And I'm looking in the chat for questions while people are taking a few minutes to add their questions to the chat. Your presentation was just so packed with with you. Useful information is, are there any points you'd like to expand on in greater detail as we do have a few minutes left? Sure. I'm happy to talk a little bit more about the Polaris app at the end here. I wasn't sure how much time we had remaining. I have spoken a bit about how the survey found that people with bipolar disorder turn to recommendations from peers about 60% of the time. There's other research to show that apps with some kind of peer delivered or peer representation tend to have better engagement. And so one of the things that I've been looking at is engagement. And so one of the things that we knew was important in developing the Polaris app was to emphasize the role of lived experience as we went through that development process. We didn't have the resources to support ongoing peer forums or any kind of social networking on an ongoing basis. But what we did instead was created a lived experience advisory group through the development process to provide input and consultation on everything from the icons and the features included through the name of the app itself. They also helped us co-author a large amount of the content in the app. So we had a team of academics and clinicians sourcing what the evidence tells us is the most effective self-management strategies and having that expanded upon and written by in collaboration with some people with lived experience as well. And they wrote over notifications in the app. So we have little positive affirmations, daily affirmations for the user that give positive quotes or tips from lived experience perspectives just to help people keep coming back to the app and feeling motivated and supported in their self-education journey. Thank you, Dr. Wharton. And we've had a couple questions come in in the chat. One of them is from someone who has a friend who is using an app but has not yet engaged with a doctor or psychiatrist. And what would you suggest that this person say to their friend? That's a really interesting question. I think a good start might be referring them to the MindApps database and just say, hey, I heard some apps might be potentially used in unsafe ways or it might be worth checking whether the one that you're using is on there if somebody is concerned. One positive thing about apps is that they can help people who might not be engaged with services in a traditional way. So potentially it could be a positive thing that somebody is at least trying to find some form of self-management, education and support. It's just worthwhile checking out whether or not that's one of the reasonably safe and effective offerings that we have. And the Mind website is a pretty accessible way to double check that. Excellent. And another question that came in is what aspects of bipolar disorder self-management would you recommend apps for? Thank you. I think mood and sleep self-monitoring is, as somebody who's worked as a psychologist previously, the worksheets to kind of track that on a daily basis can be really cumbersome and can be difficult to remember to fill out on a daily basis. I think that apps potentially make that a lot more accessible. And even things like if somebody is engaged in cognitive behaviour therapy, there are some reasonable apps out there where people can complete the kind of thought monitoring and challenging that you might traditionally do with a really large A4 worksheet. And that just kind of helps make those interventions more practical and accessible on a day-to-day basis. But I'd still recommend doing those in combination with a clinician support wherever possible. Another question is what potential issues exist when using generic health and wellbeing apps or depression-specific apps to support bipolar self-management? Yeah, so as I mentioned, one of the potential issues really comes down to that the appropriateness of the scales used to capture what's going on for somebody. So, for example, using an app designed for unipolar depression might, if somebody's logging their mood on a day-to-day basis and a depressive episode resolves, but some hypermanic symptoms set in, a scale that has one to five, I feel really terrible to I feel really happy, might not capture the elevation mood that we know is problematic for people with bipolar disorder. So potentially it's saying, this app is sending messages saying, well done, you're doing great, there might be something potentially going on that a clinician would want to check in about. So that's why I think that for somebody who is using an app designed for depression or stress management, one of the best things to do is potentially checking with a clinician and use that in combination with other forms of monitoring. So knowing your other early warning signs that might be indicative of mood escalation, still kind of keeping track of that in some form in addition to using this depression monitoring app. Thank you. Given the information presented today, how confident are you in the efficacy of the apps for long-term support of individuals with bipolar disorder? Unfortunately, there is really no evidence about long-term use of apps for people with bipolar disorder. Most of the, even the research led apps, development trials have largely only been funded to this point to look at the feasibility and preliminary efficacy. And so we don't have that kind of long-term follow-up. We do know that these are based, you know, being developed and based on principles which in face-to-face psychotherapy are helpful for people. So there's that theoretical backing, but in terms of research evaluation, that hasn't been conducted yet. The reason I really encourage clinicians to get familiar with what's available in the public app space, despite this lack of evidence, is the fact that your patients are very likely going to be interested in using apps, whether you talk to them about it or not. And so being aware of the strengths and limitations of what's out there is important to help guide people away from things that are potentially dangerous or might misuse their data towards things that we have a reasonable sense of, you know, at least this is based on theoretically sound principles. Perhaps there's some studies to show that when used by people with depression or the general population, it's engaging, it kind of helps manage low mood and proceed with caution on the basis of the information that we have. I see we have one more question in the chat. We have about five more minutes for questions, so please feel free to put remaining questions in the chat. And the question is, what mitigating strategies can be employed? So some of the mitigating strategies would be the kind of work that would still be done in the context of a clinician and client relationship. So whether you're a therapist or a psychiatrist or otherwise, you know, involved in the long term follow up with someone with bipolar disorder, you're probably used to doing regular kind of checks about mood, developing early warning sign monitoring and responding plans, which might help kind of address the gaps in what apps kind of currently monitor for people with bipolar disorder. So, for example, when we recommend, say, apps might potentially be really helpful in monitoring depressive symptoms or sleep. That's not to say stop using things like a early warning sign monitoring and responding plan. It's a way that we can help support and streamline part of that self-monitoring that's involved in an early response plan. But the other parts of it you might still need to rely on if the person has a support or family member who helps provide collateral information, the person themselves can self-report and look for individualised signs of effective episodes. So it's not a replacement, but it just helps add to some aspects of this usual clinical work. And in some of the more severe cases, do you foresee the ability for mental health professionals to monitor patients suffering from bipolar disorder from afar and then similar to the same technology being used to help treat those with diabetes? That is definitely something that a lot of researchers are looking into at the moment. It's not my area of expertise, but there are a lot of projects looking at what kinds of data does a smartphone regularly collect in terms of step count, light exposure, number of phone calls made, time spent on various social media apps, and how can we make sense of these enormous data streams to predict potential mood elevation or depressive periods and intervene early. So I have no doubt that in the future, some interventions along those lines will be developed. But I think that what we will then encounter is needing to partner with people with bipolar disorder to figure out whether that's acceptable to them, whether that's an acceptable way, something that they would feel comfortable with sharing their data for those purposes, and how to make that more nuanced and sensitive. Coming from a psychologist perspective, I think that that kind of self-monitoring element is always going to be really important for that person building their own skills to kind of develop a self-awareness of what's going on. But yeah, I think we're in a really exciting space, and it will be very interesting to see what's developed over the next five or 10 years. And I see there was a second part to a prior question about efficacy, which was, do you have any concern for patient outcomes using the apps? So, some small trials of self-monitoring apps in bipolar disorder have reported some negative outcomes, like worse depressive symptoms. There's kind of similar research in apps for people with schizophrenia, which have shown some adverse outcomes when it comes to self-monitoring. And so, I think it's important when you have a user who's interested in trying out a self-monitoring app for bipolar disorder to make a plan to check in about how they found it, because there do seem to be some people who are vulnerable to increased rumination on depressive symptoms, or who kind of experience some challenges reflecting on just the reality of living with a chronic mental health condition, kind of in their face on a daily basis with self-monitoring. So, it doesn't seem to come up for everyone, but it is something to be cautious about if you're making that kind of recommendation and just making a plan to check in and see how that person found it. Well, thank you again, Dr. Morton, for a wonderful presentation. And thank you to our participants for such great questions. And I'm going to turn it back over to Dr. For such great questions in the chat. With that, I will turn over to some additional information. If there are any topics covered in this webinar that you would like to discuss with colleagues in the mental health field, post a question or comment on SMI Advisors' Webinar Roundtable Topics Discussion Board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI Advisors' national experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It is a completely free and confidential service. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select Next to advance and complete the program evaluation before claiming your credit. Please join us next week on September 9th as Dr. David Derizotis presents Addressing Suicide from the Person and Environment and Social Justice Perspectives. Again, this free webinar will be on Friday, September 9th from 12 to 1 p.m. Eastern time. Thank you again for joining us today. Until next time, take care.

Smartphone Apps

Self-Management

Bipolar Disorder

Challenges

Mood Monitoring

Sleep Monitoring

App Evaluation Model

MIND Framework

Practitioner Involvement

Polaris App