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VOLUME 3, ISSUE 4     PSYCHNEWS INTERNATIONAL      December 1998
                   -- AN  ONLINE  PUBLICATION --
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SECTION F: ARTICLE
 
                   COMPUTERS IN PSYCHIATRY --
                WHAT HAPPENED TO ALL THE HYPE?

                 Martin Briscoe & Mark Johnson

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With the arrival of personal computers in the early eighties,
many clinicians had great hopes that within a short space of 
time these machines would take over much of their work. It 
was believed that they would rapidly become better than 
clinicians at diagnosing ailments and suggesting treatments. 
It was not uncommon for people to speculate that within a 
short time doctors might be redundant.

Nearly twenty years on computers are now thousands of times 
faster and are able to store millions of times more data but 
the takeover hasn't happened and we all still have jobs. A 
quick glance at many hospital computers systems would suggest 
that in many cases the computers do no more than the basic 
typewriter and card index did 80 years ago.  

This paper examines the current state of computers in mental 
health services to see how much progress has really been made. 


COMPUTER SYSTEMS IN HOSPITALS AND THE COMMUNITY

Greist (1995) felt that managing our information determines 
what we can do and how well we do it and that computers, 
properly programmed, are capable of dramatically enhancing 
management of information in psychiatric systems. Perhaps, 
it can be argued, that the real benefit of computers within 
psychiatry has been missed, that of improving communication 
between professionals and informing practice through shared 
information. It is only in the very recent past that high 
speed, reasonably priced technologies, have become available 
to support this application. Now that the technology has 
"caught up" with the demands of psychiatry, implementation 
difficulties, resources, lack of suitably qualified Clinical/
I.T. professionals and the paucity of systems designed 
specifically to support mental health practice contribute 
to the relatively poor coverage of information technology 
systems within the mental health setting, especially in the 
community. The multifaceted and often multi-sited nature 
of psychiatry and the difficulty in the measurement of 
outcomes make developing an information system specifically 
for mental health services problematic.

The imposition of generic hospital based information 
systems on clinical staff in the UK, with no regard to 
the requirements of clinicians working within the specialty 
has meant that negative attitudes towards information 
technology and psychiatry have been fostered. The behaviours 
of an individual are influenced by their attitude. Learning 
can influence attitudes and attitudes in turn influence 
learning. Attitudes influence the individual's choice of 
action and determine the mental state of readiness to learn 
(Gagne and Briggs, 1979). This in turn, makes the 
introduction of information technology very difficult 
to achieve. 

Often psychiatric services are an afterthought in the 
implementation of main hospital systems, or lip service 
is given to the specialty by the addition of unsatisfactory,
"bolt on" mental health modules. This serves once again to 
alienate clinical staff and does not promote ownership of 
the system. Ownership and user involvement are universally 
regarded as the key components of successful systems 
implementation (Sauer, 1993; Landauer, 1995). Access to 
financial resources has been a significant determinant 
of system success within the UK National Health Service. 
Year 2000 preparation has diverted funds away from any 
major clinical information technology procurement. Many 
hospital "Patient Administration Systems" (PAS) have been 
found to be non-compliant, necessitating business system 
replacement. It is often true to say that systems providing 
excellent billing and business management functions make a 
poor contribution to supporting assessment, diagnostic and 
other clinical work. The costs of adapting these large 
systems to meet the needs of clinicians are often 
prohibitive and thus they remain unchanged and ultimately 
unused as clinical tools. 

The situation is changing though. There is a slow recognition 
of the need to share patients' data, only effectively done by 
the use of information technology. The UK Government White 
paper "Information for Health" (1998), requires the 
development of electronic patient records, access to 
knowledge databases, links with primary care and ultimately 
the development of an individual electronic health record. 
Due in 1999, collection of the "mental health minimum data set", 
will encourage providers of mental health care to invest in 
systems. The development of primary care groups and the 
integration of services will all serve to spur on providers 
to look more and more at the use of electronic media for 
record keeping and communication.  

A number of systems do exist within the mental health field 
today, the majority being legacy systems from the late 
eighties and early nineties. Many are simply data collection 
tools that offer very little feedback for users (EG PAS systems, 
stand-alone systems). The recent "buy out" and amalgamation of 
hospital system providers have meant that these legacy systems 
are either no longer supported, or demand that a substantial 
investment is made to upgrade them to "21st Century compliance". 
There exist, within the UK, really only three main, very large, 
hospital system suppliers, HBOC, Siemens Nixdorf and SMS. Since 
the Private Finance Initiative (PFI) halted procurement in 1995, 
nine key players have dropped out of the market (Computing - 
The NHS and the Bomb, 4 June 1998). This has had the effect 
of making developments in information technology systems for 
mental health cost-ineffective, becoming business-case-led, 
rather than clinical-need led. 

A number of mental health specific companies do exist however 
but these tend to be companies of a much smaller stature, e.g. 
Usable Systems, Protechnic , Systems Team, Conway etc. Health 
care providers are also developing their own, often extremely 
functional "home-grown" systems. These contributions are 
invaluable for moving the application of I.T. into the mental 
health field. For example, the Institute of Living's system 
CEMS (Clinical Evaluation and Monitoring System) which acts 
as a automated decision support system was developed "in-house" 
and offers a range of functions including guidelines, checklists 
and assessment, whilst Usable Systems' AMIGOS (Advanced Medical 
Information Guidance and Organisational System) is developed by 
a system supplier working closely with users and offers enhanced 
communication and a mental health electronic patient record. 
Both these systems are reported by the users (of which MJ is 
one) to work extremely well and are examples of what can be 
done with application, consultation and thought. Both also 
are in continuous development and evaluation, reflecting 
mental health practice in the real world. 

Hammer and Champy (1993) quoted a 19th century French economist, 
Jean Baptiste Say who observed that supply creates its own 
demand. People do not know they want something until they see 
that they can have it: then they feel they can't live without 
it. Exactly the same is true about information systems. We 
see little use for them until we can have them, once we begin 
to use them, we can't do without them. The systems must develop 
and change to compete with our continuous demands on them. Any 
system that does not change will eventually be unable to offer 
users useful output and will cease to be used, just like many 
systems we see within mental health services today. 


ASSESSMENT AND TREATMENT PROGRAMS

16 years ago Selmi, Klein and Griest (1982) showed that an 
interactive program for cognitive treatment of mild depression 
was as effective as treatment provided by a therapist. A short 
while later another group (1984) found that computers could 
be used to treat phobias. Since then a number of programs have 
been developed but none has posed any threat to human 
therapists and most are still in the research stage.  

In London's Maudsley Hospital, FearFighter (www.ex.ac.uk/cimh/
fear.htm) is now regularly used in the "Self Care Clinic" where 
people can come and use it without having to contact their 
family doctors first. This is a computer program designed to 
treat agoraphobia and panic by guiding patients step by step 
through self-behavioural therapy.

In the same hospital, the BTSTEPS treatment program 
(www.ex.ac.uk/cimh/btstep.htm) for treating OCD has 
been running for over a year. 

In the US, Reid Hester's Behavioral Self-Control Program 
for Windows (www.ex.ac.uk/cimh/bscpw.htm) is now in 
clinical use. This interactive software program teaches 
the user how to moderate their drinking behaviour.

Also in the US, Cognitive Therapy: A Multimedia Learning 
Program (www.mindstreet.com) was developed by Jesse Wright, 
Aaron Beck and others. This program was developed to be an 
adjunct to cognitive therapy. Studies have found that the 
program can reduce by half the amount of therapist time 
needed. It is understood that some people are now using the 
package as a stand-alone treatment program 

Whilst these examples are interesting, it remains somewhat 
surprising that so few programs are available. The authors 
believe a number of factors are responsible:

1. Computer programs are very time-consuming to write and 
   do not easily lend themselves to the rather unstructured 
   approaches used in psychiatry. It is interesting to note 
   that the programs described above centre around behavioural 
   techniques which are some of the most rigid treatment 
   techniques in the field. 

2. Dr Jesse Wright, in a personal communication, indicated that 
   researchers found that many of the earliest systems 
   attempted to interpret human responses and this often 
   led to the computers making stilted replies or even worse, 
   major misunderstandings. More recently programmers have 
   tried to avoid this technique by developing more 
   educationally oriented programs. One way of doing this 
   is to 'look in on' a patient being treated. This technique 
   is used in the Cognitive therapy program. 

3. Such programs are only likely to be useful in areas where 
   therapists are in short supply. In the US, the worlds largest 
   developer of software, many would suggest that there are too 
   many therapists around. In the UK, therapists are in short 
   supply but the National Health Service has very tight financial 
   constraints which has held back computerised developments 
   which in the short term are not a cheap alternative to people.


CONCLUSIONS

Many mental health clinicians in the 80s had a dream that one day 
computers would be playing a vital role in their jobs. Like many 
dreams it didn't happen. There are some excellent examples of 
technology playing an important role in health but it has taken 
us a long  time to realise that virtual psychiatrists are just as 
much a dream now as they were 20 years ago. Computers can play a 
vital and important role but their utility lies in their ability 
to sort, store and display information rapidly and effectively and 
to act as a resource for clinicians and patients.


REFERENCES

Greist J.H. (1995, October). Computers and psychiatry. 
        Psychiatric Services, 46(10), 989.
Landauer, T. (1995). The Trouble With Computers. Cambridge, MA: 
        MIT Press.
Gange, R.M., & Briggs, L. (1979). Principles of instructional 
        design. New York: Holt, Rinehart and Winston.
Sauer, C. (1993) Why information systems fail: A case study 
        approach. Henley-on-Thames: Alfred Waller Ltd.
Hammer, M., & Champy, J. (1993). Reengineering the Corporation  
        A Manifesto for business revolution. London: Nicholas 
        Brealey Publishing.
Ghosh, A., Marks, I.M., & Carr, A.C. (1984). Controlled study 
        of self-exposure treatment for phobics: Preliminary 
        communication. Journal of the Royal Society of Medicine, 
        77, 483-487. 
Selmi, P., Klein, M.H., & Griest, J.H. (1982). An investigation 
        of computer-assisted cognitive-behavior therapy in the 
        treatment of depression. Behavior Research Methods Instruments, 
        14, 181-185. 


USEFUL LINKS

www.ex.ac.uk/cimh - Computers in Mental Health
www.imc.exec.nhs.uk/publication_frame.shtml  NHS IMG publications directory
www.imt4nhs.exec.nhs.uk/index.htm  -  Information for health
www.doh.gov.uk/modern.htm    - Modernising mental health services


Martin Briscoe (www.ex.ac.uk/~mhbrisco) is a consultant 
psychiatrist in Exeter, UK. He has been involved in computing 
applications and mental health since 1980. 

Mark Johnson is a trained general and mental health nurse. 
He became involved in IT in 1983 while working in ICU. 
For the last four years, he has been responsible for the 
information systems in Psychiatry at Manchester Royal 
Infirmary, UK. He has has written  many articles on IT and 
Psychiatry. He is a member of the project team for 
Key Performance Indicators in Old Age Psychiatry.

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