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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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