How IOT is currently changing mental health?
- by Dhruv Apte, Farooq Ali Khan, ramachandran. ravishankar, and Sukant Khurana*
(*to whom correspondence should be sent at skgroup.iiserk@gmail.com)
Hello, Bonjour, and Hola! We are going to talk about IoT i.e. the Internet of Things and its applications in mental health. Before we dive head-first into the present world, let us take a step back. Actually, not a single but a few steps back, 20 years back in the past, to understand the developments that occurred in Internet of things. Twenty years back, no one would have imagined that IoT and mental health could have intersection.
A brief history of IOT
We loved the Back to the Future series. Seriously, ya’ll should definitely watch it! If you have, then you might have noticed a lot of stuff coming true. Flying drones, fingerprint scanners, and wearable technology. That’s really cool for a 1985 film, isn’t it? Well, who would have guessed all this could be true except the gifted Robert Zemeckis?
Did you know that IoT had a very humble origin as the simple coke machine at Carnegie-Mellon University connected to the computer to report its inventory and tell whether the loaded drinks are cold?
In 1989, at the INTEROP conference, John Romkey created a toaster that could be turned ‘on’ and ‘off’ by the internet as a part of a bet with Interop President Dan Lynch. As a competition, maybe or perhaps the curiosity influenced Quentin Stafford-Fraser and Paul Jardetzsky of Cambridge University to create a Trojan Room Coffee Pot that could monitor pot levels and display it on the server three times in a minute.
Coming back to more academic stuff, it was Mark Weiser, a noted Computer scientist who was the first guy to predict IoT. Would you believe it that this guy, afflicted to cancer constructed a water fountain outside his office whose flow and height mimicked the volume trends and price trends of the stock market? Not surprising that it was Mark who first penned works to harbinger IOT.
Another brilliant scientist, Steven Mann, Professor at Department of Electrical and Computer Science at MIT created a digital eyeglass called WearCam that could display the things seen by the eye on a computer causing the human eye to function effectively as an electronic camera and television display back in 1994; he continued his cool inventions with the Telepointer that could project any 3-D surface in 1995.
There were ideas of connecting stuff to computers that time in research papers and journals. Ideas of an intelligent transporting system or ITS started popping up in early-90s with the California Path System managed by the Institute of Transportation Studies, UC Berkeley. Similarly, Bill Joy, co-founder of Sun Microsystems envisioned device-to-device communications as part of his presented framework at the World Economic Forum in Davos in 1999.
A fascinating fact is that we are all talking about IoT and what it was in the 90s while the name itself was coined in 1999 by Kevin Ashton, the executive director at Auto-ID Center at MIT.
Mental health studies are older than IOT
Mental health studies and solutions to mental health problems have an older history than IOT. For example, levodopa had caused a paradigm shift after it was proven to help people diagnosed with Parkinson’s disease. Parkinson’s disease now might be known because of its famous patient, Muhammad Ali, the champ but it is known disease from much before. If you have not heard of it, it is a degenerative disorder of the central nervous system and generally occurs due to death of cells in a section of the midbrain. It happens to be second most common neurodegenrative disorder and one of the few passions of Khurana lab.
Another big revolutionary drug has been Phenobarbital being used in the treatment of epilepsy since 1912, followed by phenytoin since 1938. It is not just that mental health has seen developments in form of medicines but in form of genetics too, even before the big genomic era. In 1983, a joint team of American and Venezuelan researchers located the approximate location of the causal gene of Huntingdon’s disease. Now locating mutations associated with mental health problems is a much easier task.
From the 1990s, advances in neuroscience, psychology, and genetics took a giant leap forward. The development of cognitive behavioral therapy i.e. development of personal coping strategies to solve current problems has produced many positive results and also many pretenders who offer CBT without due understanding of its promises and serious limitations. Originally, the therapy was used to treat depression but emerged also emerged as mildly helpful for schizophrenia and psychosis. In 1997, the Food and Drug Administration of the United States legalized deep brain stimulation, a neurosurgical operation which implants an electrode in the brain for the cure of Parkinson’s. It was later approved for dystonia and OCD also.
Not all developments have been in finding new medicines, implanting electrodes, or finding causal genes. In 1997, Robert Palisano of Drexel University introduced the Gross Motor Function Classification system, a classification system that classified the motor function of people afflicted with cerebral palsy on the basis of self-initiated movements. The system has five levels ranging from Level 1 which means the patient can perform usual activities with reduced co-ordination to Level 5 which means the patient is impaired in all areas of motor function. The system quickly became a standard in North America, Europe, and Southeast Asia for mobility assessment analysis of cerebral palsy patients which could explain the way of therapy for cure.
How is IOT helping in mental health?
Many technologies that are fueling IOT are also fueling neuroscience. Not just that, IOT is directly also helping neuroscience. One of the biggest promise of IOT would be personalized medicine, with extensive records of patients, and use of AI alongside physicians in treating future problems. We think IOT would one day fix the skyrocketing costs of healthcare. This is not an article about future of IOT, so we would not elaborate on that here but we would pen bout it soon too. If you are interested in one specific aspect of mental health, rehabs and how we think future would be different, you can listen to my (Dr. Khurana’s) talk here.
Coming to what IOT is doing right now, let us explain how it works. IoT is connecting physical devices, buildings, and sensors to get data and control them remotely; creating more opportunities for direct integration of the physical world with computer-based systems for better efficiency, accuracy and economic benefit.
Controlling devices, such as electrodes for deep brain stimulation
We mentioned about deep brain stimulation (DBS), an operation where a electrode is implanted in the brain. The surgery has its own side-effects. These include disorientation, nausea, dizziness, sleep related problems, and serious complications including bleeding in the brain, personality changes, and diplopia. Patient with diplopia start seeing the world in double. So, the patients sometimes think that they are possibly drunk after the surgery! With long distance control of these electrodes, in part possible with the development of technologies that are broadly lumped as IOT, one can make the side-effects less severe. There is also another issue that IoT can fix: sometimes the calcification of implants takes place, a problem which can be monitored and controlled by sensors which dissolve with time. Researchers at the University of Illinois at Urbana-Champaign are working on these types of implants. Sensor and stimulators also malfunction. In 2011, Dr. P.K Doshi, a neurosurgeon published a paper that analyzed about 153 cases of DBS that occurred from 1999 to 2009. The results were not surprising: 24 cases developed complications within a follow-up of a year with another three cases diagnosed with the stimulation malfunction. In part the progress in DBS has been due to advances in electronics and computer sciences but other aspects of IOT are also helping.
Softwares
It is not just electrode implants that are benefiting with internet related technologies. Fast Forword is an educational software that is improving cognitive skills of children and is often used as a therapy to reduce the cognitive disorders rapidly replacing the traditional treatment by the Cognitive behavioral therapy.
Long-distance monitoring of patients
TeleStroke has been a first mover of its kind in the field of neuroscience and Internet of Things although its cost is currently prohibitive.
So, when we talk generally of a stroke, what comes to our mind? Put simply, when the brain does not get enough oxygenated blood, the brain cells die. The lack of oxygenated blood may be caused by a blocked artery or the bursting of a blood vessel. General symptoms include a headache, loss of vision in one side, inability to move and vertigo. Stroke accounted for 6.2 million deaths in the year 2015 during a recent WHO survey. Center for Disease Control (CDC), America has recognized a region comprising of the states of Carolinas, Tennessee, Virginia and seven more states in the south-western United States as a “stroke belt”. Stroke mortalities in these states are nearly 140–160 per 100,000 as compared to non-”stroke belt” states where it is 89 per 100,000. Strokes are diagnosed by a CT or MRI scan and then using an electrocardiogram or angiogram to detect clots. A Holter monitor is used to detect abnormal heart rhythms. IOT has helped in the prevention and diagnosis of strokes.
Let us briefly look at developments in stroke other than Telestroke. In 2001, researchers at UCLA designed a medical device to treat ischemic strokes i.e. stroke caused by a blockage in the artery due to a blood clot. Termed as “MERCI Retriever”, it was the short form for Mechanical Embolus Removal in Cerebral Ischemia. The retriever had a long wire with a helical coil at the end. A ballooned catheter was to be snaked into the affected artery where the retriever is fed through the catheter and the coil would be straightened to fit. Then, the coil would reform, wrapping the clot and pulling it outside. The method was approved by the FDA in 2004. Another method used for curing stroke is using tissue plasminogen activator or tPA. But this activator medicine is effective only when it is given in the first three hours after the stroke. The faster the patient receives the treatment, the better are the chances of recovery.
With TeleStroke at the Massachusetts General Hospital, Boston, stroke specialists examine patients at remote hospitals through an internet link using teleconference and image sharing. According to Dr. Lee Schwann, examining a patient using TeleStroke is like being in the same room! TeleStroke is composed of three components: the brain-imaging, remote examination, and a portal for synchronized requirements. The physician easily downloads the CT scan images from his computer sent from a remote place. Next, she determines whether the patient is eligible for thrombolytic therapy.
The technical components include ISDN phone lines, IP technology, and data compression technology. Numerous telemedicine and telecommunication systems have been developed to help TeleStroke reaches to the patient on time: these include BF Technologies, InTouch, and PolyCom. TeleStroke trials in the American provinces of Arizona and California have shown that more accurate and appropriate medical decisions were made via TeleStroke than simple telephone consultation. Later, in 2009 the American Heart Association established recommendations regarding the use of video-conferencing systems and stated that it is equally comparable to a bedside diagnosis.
Now you would be thinking, why, is TeleStroke not being implemented in my local district clinic? Well, folks, annual TeleStroke costs are about 46,000 US dollars. Another example of working but expensive technology is the REACH system which costs between 70,000 and 90,000 dollars!
The second issue with TeleStroke is the need of government licensing and accridition. Multiple licenses have to be obtained in case of inter-province or international treatment posing an administrative barrier to the process.
The third issue is the financial reimbursement. No country has provided regulations for financial reimbursement on TeleStroke, as of now. But in spite of such barriers, the future of TeleStroke is bright according to Dr.Feras Akbik, a neurologist at the Massachusetts General Hospital.
We think even if Telestroke does not do well financially, it would pave the way for several other such technologies which are going to be integral in medical practice in future. One such example of upcoming technology is Babylon, an app that acquired 25 million dollars in investment funding. Babylon allows users to talk with doctors, surgeons, and therapists who might not be available at the local clinic.
IOT and epilepsy.
Epilepsy is characterized by seizures that arise from excessive and abnormal nerve cell activity in parts of brain. Treatments include medications like phenytoin, carbamazepine, and valproate. Epileptic surgery is also an option. Some patients are also prescribed a high-fat, low carbohydrate diet and even operant-based biofeedback. All these treatments just help manage epilepsy.
myCareCentric Epilepsy is an initiative started by Graphnet Health and Shearwater Systems in association with the University of Kent. The initiative is backed by Innovate UK, a scheme run by the government that provides funding for innovative products. The product includes a Microsoft band wearable which is used to feed data back to clinicians. This data includes information generated by biological readings and also information that is inputted by the patient. For example, a patient inputs a data that he or she is feeling dizzy. The band inputs the information and immediately uses standard data points to analyze the situation and report back to clinicians. The project also includes a first-timer: it integrates information from the band with the patient’s clinical record. The system has received overwhelmingly positive response from patients using it. The patients say that this is helping them in becoming independent and helps them get a better control of their seizures.
Another invention just like the above one is Embrace, a band created by a start-up named Empatica headed by Rosalind Picard, a professor at MIT Media Labs. Prof. Picard has served as the founding member of the IEEE Technical Committee on Wearable Information Systems in 1998. Embrace picks up motion data from an accelerometer and combines it with skin conductance readings. A huge spike in the skin conductance indicates an upcoming seizure, for which the patient is better prepared now. Biologically, the band has small electrodes passing through the skin and measuring the stimulation of sweat glands. When the algorithm detects a seizure, it will straightaway vibrate and alert a list of contacts on his or her smartphone. Warren Lammert, chairman of Epilepsy Foundation believes that Embrace can lead to better insights on how different medications affect different patients and help in better produced after extensive clinical research. Similarly, Daniel Lowenstein, a neurology professor and Director of the Epilepsy Centre at the University of California, San Francisco says that Embrace could prove a ‘godsend’ to patients who can stave off seizures when they know that their stress levels are rising.
In India, a similar concept is being developed. T-Jay is built by Rajlakshmi Borthakur and supported by Intel India and Department of Science & Technology. T-Jay is a glove that transmits signals from the body and has three components: sensing temperature, checking bodily electrical current with respect to a reference and an accelerometer for seizure detection. T-Jay senses 11 types of signals and compares them with preset threshold values giving indications of an epileptic attack.
There are several more technologies that are contributing to predicting epileptic seizures. As research continues, we will have more and more better devices to cope up with epileptic seizures. Our own group is developing better prediction algorithms for seizure prediction and we know that the future is bright for prediction of disease events.
Self monitoring
Self-monitoring enables the patient to control his activities by himself or herself and helps prevent the confusion that often happens in hospitals and clinics. Leon Marsh, the CEO of Innova Design Solutions, a firm that specializes in body-sensing says that with the help of IOT, the issues will be apparent before they become life-threatening.
Brain mapping
In 2013, an advisory panel of fifteen scientists headed by Cori Bargmann, Rockefeller University and William Newsome of Stanford released a report titled “The Future of Neuroscience”. This report was one of the first reports to be released under President Obama’s BRAIN initiative. Francis Collins, Director of the National Institute of Health mentions that the focus would be on circuits and how the circuits allow the brain to send and receive impulses. Researchers from EPFL, Lausanne have virtually constructed a small slice of a rat’s brain, although we think there is a large room for improvement in brain mapping. Whatever be the direction of brain mapping, it would certainly gain a lot from IOT technologies being developed.
Brain machine interface
Imagine, a woman paralyzed from the neck down using a prosthetic arm and even performing well in flight stimulation. This is possible. Geoffrey Ling, director of biological technologies office at Defence Advanced Research Projects Agency or DARPA, Pentagon recently described how a system of microelectrode array was implanted in patient’s brain that controlled the arm’s movement easily so much that she was recently able to fly an F-35 in a flight stimulator.
But we have discussed the advantages that IOT has in neuroscience. What about the disadvantages IOT will bring when it revolutionizes the field of neuroscience?
Epidemiology
Our own group is trying to pioneer dynamic monitoring of mental health statistics and compare it with awareness. We are measuring awareness in the form of social media chatter, news reporting, TV coverage etc. We hope such pipelines would drastically change the way governments approach mental health or health in general.
Problems with IOT in neuroscience
When cognitive testing and imaging predict early symptoms, patients get confused and anxious. Thomas Insel says that researchers have to weigh the risk of labeling a patient, especially a child prematurely. In a recent conference at International Neuroethics Society, Geoffrey Ling raised the question that even if the patient is detected with mild cognitive changes and there is nothing doctors can do to cure the upcoming Alzheimer’s, will it be ethical to tell the patients that?
Another question that is being raised over and again is the security of the data of patients stored by IOT devices. Organizations need to adapt themselves to this IOT revolution and prevent leaks that occur in cases of both government agencies like the Montana Department of Public Health and Human Services leak in 2013 to private ones like the Anthem Inc. leak in 2015. People are wary of their data being stored that could be used by hackers for identity theft or blackmail and often oppose this storage. In medical sector, with Health Net, Nemours Foundations and Anthem Inc., reporting medical data breach of millions of subjects people have become highly skeptical of safety of current IOT. In a recent article in Hospital and Networks, popularly known as the H&N magazine, Dr. John Glaser, the vice-president of Cerner, a major supplier of health information technology solutions expressed fear that the huge amount of data collected made possible by IoT could potentially open medical devices to more disturbing aims like interfering with functions. He argued that hackers could do something on a larger scale.
Summary
More and more mental disorders can be cured or at least detected by IOT. More and more lives can be saved and those who are affected can live independent lives. As Geoffrey Ling says, the future of IOT and neuroscience is bright. With smart thinking we think it would be bright enough to eclipse its shortcomings!
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Dhruv Apte was an intern in Dr. Khurana’s lab.
Farooq Ali Khan is a postgraduate from NIPER and has been extensively involved in drug delivery, drug-discovery and public health policy. He worked as the Executive vice president of World Health Congress 2017. He is a researcher with Dr. Khurana’s group.
Dr. Ravishankar Ramachandran is an internationally renowned structural biologist and drug-discovery scientist working on TB. He is also leading several efforts of academia-industry collaboration. He is collaborating with Dr. Khurana on science awareness, application of blockchain, AI, IOT, and datascience for healthcare sector.
Dr. Sukant Khurana runs an academic research lab and several tech companies. He is also a known artist, author, and speaker. You can learn more about Sukant at www.brainnart.com or www.dataisnotjustdata.com and if you wish to work on biomedical research, neuroscience, sustainable development, artificial intelligence or data science projects for public good, you can contact him at skgroup.iiserk@gmail.com or by reaching out to him on linkedin https://www.linkedin.com/in/sukant-khurana-755a2343/.
Here are two small documentaries on Sukant and a TEDx video on his citizen science effort.
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