Podcast: What Are Prescription Digital Therapeutics (PDTs)?

Dr. Michelle Patriquin is the John S. Dunn Distinguished Professor and Associate Professor in Psychiatry and Behavioral Sciences at McGovern Medical School at UTHealth Houston, and serves as Assistant Dean of Digital Health & Innovation in the UTHealth Houston School of Behavioral Sciences. She is also Co-Director of Research for the John S. Dunn Behavioral Sciences Center, the largest academic inpatient psychiatric hospital in the United States. She is a board-certified clinical psychologist and researcher focused on digital mental health: bringing data-driven, tech-enabled mental health care into real-world clinical setting – especially intensive and inpatient mental healthcare – to improve safety, recovery, and access. Her work is widely published and is supported by state, federal, and foundation funding.

John Torous, MD, MBI, is director of the digital psychiatry division in the Department of Psychiatry at Beth Israel Deaconess Medical Center (BIDMC), a Harvard Medical School-affiliated teaching hospital, where he also serves as a staff psychiatrist and associate professor. He has a background in electrical engineering and computer sciences and received an undergraduate degree in the field from UC Berkeley before attending medical school at UC San Diego. He completed his psychiatry residency, fellowship in clinical informatics, and master’s degree in biomedical informatics at Harvard. Dr. Torous is active in investigating the potential of mobile mental health and AI technologies for psychiatry, and his team supports mindapps.org as the largest database of mental health apps, mindApps.ai for benchmarking AI chatbots, mindLAMP technology platform for scalable digital phenotyping and interventions, and the Digital Navigator program to promote digital equity and access. Dr. Torous has published over 300 peer reviewed articles and 5 book chapters on the topic. He directs the Digital Psychiatry Clinic at BIDMC which seeks to improve access to and quality of mental health care through augmenting treatment with digital innovations. Dr. Torous serves as editor-in-chief for the journal JMIR Mental Health, web editor for JAMA Psychiatry, and a member of various American Psychiatric Association committees.

Our host, Gabe Howard, is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author. Gabe is also the host of the “Inside Bipolar” podcast with Dr. Nicole Washington.

Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without. To book Gabe for your next event or learn more about him, please visit gabehoward.com.

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.

Gabe Howard: Hello, everybody, and welcome to the podcast. I’m your host Gabe Howard. Calling into the show today we have John Torous, MD, MBI, and Michelle A. Patriquin, PhD, ABPP. Dr. Torous is the director of the Digital Psychiatry division in the Department of Psychiatry at Beth Israel Deaconess Medical Center. And Dr. Patriquin is the John S. Dunn Distinguished Professor and Associate Professor in psychiatry and behavioral sciences at McGovern Medical School at UTHealth Houston. Dr. Torous, Dr. Patriquin, welcome to the podcast.

Michelle A. Patriquin, PhD, ABPP: Thank you. Thanks, Gabe.

John Torous, MD, MBI: Thank you for having us.

Gabe Howard: Oh, you are so very welcome. Thank you both so much for being here. And I also want to give a great big thank you to the Anxiety and Depression Association of America or ADAA for bringing us together. You know, I got to tell you, it’s hard to remember a time before smartphones. We’ve really become accustomed to using our phones for everything from ordering pizza to scrolling through memes to checking on the weather. But what if your phone could actually be part of your medical treatment plan? And I’m not talking about a basic meditation app or a mood tracker that you found on a whim. I am talking about prescription digital therapeutics, commonly referred to as PDTs. These are FDA cleared, doctor prescribed tools that are changing the way we handle mental health. Now, today, we’re breaking down what they are, why they work, and how they may help you bridge what you need while waiting for that next doctor’s appointment. Let’s go ahead and get us started. Why are they called prescription digital therapeutics?

John Torous, MD, MBI: Yeah. So, it’s not a great term, this prescription digital therapeutics, it’s an industry made up term that try, tries to kind of explain what they could do. We’ve done a review of FDA cleared apps or software as a medical device, and there aren’t that many that have been through FDA clearance or have got that approval. And of those, not that many are available to people, even me as a physician, to prescribe. So I think that it’s a term I personally don’t think is useful to call them PDTs.

Michelle A. Patriquin, PhD, ABPP: Yeah, I think I totally agree with John. I think the, the prescription part of that makes it seem very official and that the outcomes are going to be beneficial for an app or whatever app or device. Dr. Torous has done a ton of that work on really thinking about benchmarks around app use, app use for mental health, AI use for mental health and what are like the safeguards in, in really conveying that I think to the public as well. How do we communicate that in a way that is in line with the research?

John Torous, MD, MBI: At least in the current system, when software gets an FDA clearance or approval, It’s being approved as a medical device, which is different than a therapeutic. And if you kind of say, well, what type of medical device? It’s a class II, that would be the same as a contact lens or say, a tampon. Contact lenses are generally safe. But but I think we have to kind of say, well, what does it mean if we are calling it that and has that level of evidence? And I think we want to help people to find the most effective tools, the safest tools. And I think is we all want technology to do more, to be better, to be safer. But I think that means we have to demand that it’s better and safer, and it’s an evolving space.

Gabe Howard: Okay, but they are called prescription. So does someone actually need a prescription from a doctor to utilize one of these? Because, for example, you don’t need a prescription from a doctor to buy tampons or novelty contacts.

John Torous, MD, MBI: Yeah, in some ways it’s like it’s just interesting to say, can you even if you go ask a physician, can you prescribe me one of these apps? It’s not even clear how you actually prescribe them. It’s like we haven’t actually built the infrastructure of how to prescribe them. And my sense is every major insurer. I’m usually not pro insurance per se, but I don’t think they cover them because what they said is they don’t seem to have evidence that they actually work. And again, you say, well, they’re FDA cleared. How could that be? When you’re a class two medical device, you have to have a very low bar of evidence. We call it a prescription digital therapeutic, we’re kind of inflating of these kind of high quality, double blinded, multiple drug studies that you have to do. But when you’re a medical device, it’s a different bar. I’m not opposed to a different bar, but when we conflate contact lens evidence with a higher one, you can see how it’s confusing for everyone. And in the end, no one may win. Right. The FDA just says it’s so chaotic, we can’t make sense of it. You’re all banished to the wellness space. The word Wild West gets thrown around a lot. So it’s interesting times.

Michelle A. Patriquin, PhD, ABPP: I think it’s also interesting to think about, you know, I’m a psychologist, I’m not a psychiatrist. And the FDA does not regulate psychotherapy. And I’ve asked the FDA in the past, why don’t you, why don’t you regulate psychotherapy and evidence based treatment? Right. But a lot of these apps are also, it is psychotherapy. It is just a different delivery. Right. Or psychoeducation psychotherapy. And they don’t. They don’t regulate individual therapy. And check for fidelity that you’re using a CBT model for example for certain diagnoses. Yeah, I think it’s a really interesting kind of conundrum a little bit. Because do you want to go down the path of then regulating psychotherapy? Well, psychotherapy modalities, evidence based treatment? I think the answer is probably no. They’ve said like, wait, what? No. Well, but people ask them all the time, would you ever regulate that? And, and as a psychologist, I don’t prescribe apps. Right. But I will recommend them. I will put them in my reports at the end. For example. I think this app would be really helpful for social skills development or whatever. And I cite the evidence, but I’m not prescribing them. I’m recommending them. And so also there’s an interesting and this is where, John, you know, I don’t prescribe like, what is the definition of prescription and how do we, you know, what is, is it meaningful?

John Torous, MD, MBI: It’s confusing to physicians as well. They go, wait, which app is good evidence, which is bad evidence? What does it mean if it’s approved? Does it reimbursed? It’s a complete mess and it doesn’t it doesn’t need to be that way.

Gabe Howard: I can see where it would be very difficult for a layperson who is struggling, especially let’s, let’s, let’s anchor this firmly in mental health, right? So you’re suffering from depression, right? We can conjure up the idea. It’s 3 a.m., you’re all alone. You haven’t gone to work in several days. You’re, you’re contemplating your, your, your life and all the gravity of this. You’re all alone. You load up your app store and you say, help me with depression. I need help right now. And you’re going to get 20,000 apps. You’re going to get 30,000 apps. You’re going to get just pages upon pages upon pages of apps. And the app that you’re going to see first is not going to be the best one. It’s not going to be the one with the best results. It’s not going to be the one that is most likely to help you or save your life. It’s going to be the one that’s sponsored. It’s going to be the one that paid. Now the second, third, and fourth choices. They may be the more popular ones, but there are many things that are popular that don’t work. They don’t work at all. They’re just super popular. Is this what this is trying to resolve? I mean, if we get away from, you know, it’s not a great name. Is is this what we’re trying to resolve so that somebody could actually enter their symptoms and get some reasonable expectation that the thing that they’re downloading is not just a profit center, but actually has a chance of helping them?

Michelle A. Patriquin, PhD, ABPP: I will chime in and say, I actually think somebody at 3 a.m. is not going to download a bunch of apps. They’re going to go to ChatGPT or Gemini and they’re going to engage that way. People are really relying, I’m hearing a lot of anecdotal stories about people going immediately to ChatGPT, especially in the evenings. And I think there was a study just that came out about that as well, using AI to provide support. You know, unusual times that maybe when therapists weren’t available.

Gabe Howard: As I’m sitting here listening, I got to tell you, I know that everything has risk and benefits and I agree it’s buyer beware. Right. But I know these apps are beneficial. I have personally used them and millions of people have used them. Let’s switch gears and talk about all the ways that finding the right app can benefit you. I’d like to spend some time on that because I again, in the mental health space alone, it can take months to see a psychiatrist. It can take weeks to get into a therapist. Your therapist can go on vacation, maternity leave. You can run out of funding, etc. so having an app can really be a game changer for folks.

Michelle A. Patriquin, PhD, ABPP: Gabe, I totally agree. I actually have slides that I showed in presentation and I show if you just Google continuum of care, levels of care and mental health and you’ll see these like beautiful triangles and it’s all connected. It’s like inpatient residential partial hospitalization program, Intensive outpatient program, IOPs, and outpatient. They’re all connected like nice little arrows. And so I’ll show that and I’ll show different figures, just images I pull from online. All these nice connected images come up. And then I take one of them and I pull all of the pieces apart and I just put it in a mess on the PowerPoint. And I said, this is what it actually looks like in terms of levels of care and the connection between them, right? We have so much disconnect, and we often lose people when they go from different levels of care. And to me, I’m in an inpatient psychiatric hospital. One of the most beautiful things that and benefits of apps and technology, kind of like what you’re saying, it can fill these gaps in a really powerful ways that can provide support when there may be, for whatever reasons, right? Whatever variables there somebody can’t have care. And so it can really provide like kind of a low cost, really readily accessible way to have mental health support. And that I think is phenomenal.

Gabe Howard: Hi, listeners. Your host, Gabe Howard here. And I want to let you know about a fantastic free resource I recently learned about. If you or someone you know is struggling, or even just wants to learn more about mental health, check out the Anxiety and Depression Association of America’s website at ADAA.org. The ADAA has tons of free resources and even a Find Your Therapist tool to help you find support close to home. Their website again is ADAA.org. That’s ADAA.org.

Gabe Howard: And we’re back with Dr. John Torous and Dr. Michelle Patriquin.

John Torous, MD, MBI: We we recommend and use apps as part of our outpatient treatments. So. So we believe in it so much as part of how we deliver care. And I think, again, we all know that homework is part of therapy. If you learn a skill, you have to practice it. And apps are a tremendous way to help people practice and reinforce what they learn in a clinical setting outside in the real world, where is where you want things to get better. So I think there’s a tremendous amount of practice people can do. And again, I don’t think it matters tremendously once you figure out what you want to do, if you use app A, B or C. It probably makes no difference. The other part of it is even for the patients I see again once a week or once a month. A lot of stuff happens in the world. People have new stressors, new things happen or sleep changes. The phone can capture a lot of that. People can take surveys in real time. The phone can capture how much exercise people are getting, how much sleep people are getting, how much screen time people are getting. So, so I can actually, as a psychiatrist, have really fantastic new information that I can work with someone and say, hey, let’s interpret this together, let’s talk about this together. And that gives me as a psychiatrist, so much more context for what’s happening. And it gives people a way to kind of share things that may not come up before and say, oh, that is interesting.

John Torous, MD, MBI: Let’s look at how sleep and mood work together. And so I think it’s fantastic to use these apps as both new tools to practice and reinforce things, but also new tools to really collect new data and bring new information into the clinical session. And that becomes twice as revolutionary, right? So we’re not saying don’t use them, but we’re saying there’s a lot of different tools out there to practice homework skills, a lot of tools to track one. We’re not here to endorse any of them, but it’s unclear if an FDA approved one or wellness one is going to be best for you. Well, I think Michelle and I are both saying is it’s ideal to use it as part of a treatment plan grant. As you said, there’s a waitlist. Not everyone can get into treatment. So it makes sense. You’d be practicing. You’d be learning the skills. But after decades of research on these smartphone apps, our team has written many of these reviews. We’ve read the papers about the papers. They only get you so far. And I think if we look at the honest, highest quality evidence, there are about half as effective as an antidepressant, which is not bad. Like they do something, but they often don’t do enough of use in a self-help manner to transform your care. So I’m not saying they’re harmful in that sense, but you’re not going to get the same boost as of clinical care. What I do think is if you use clinical care, when you get to it, you will get a bigger boost with it. So I think app alone is okay. App plus clinician is wildly turbocharging what you can do.

Gabe Howard: I love the way you said that. And I got to tell you just and this is my personal experience, I’ve been going to therapy for a long time. I’m not trying to date myself, but when I first started going to therapy, every time I would walk in, they would give me a clipboard and, you know, on the clipboard would be the paper that I filled out. And some of the days, more than half the days, all of the days, right? That kind of thing. But over the last few years, that’s moved online. Now, I know that’s not quite an app, but it moved online and I fill it out. And a couple of years ago, the first time that I was sitting in therapy and I said, I don’t think I’m getting any better. And my therapist spun her monitor over and said, you think you’re getting better. And it had charted every time I filled that out online. And it showed me the chart and the the line was moving upwards. Slowly, but it was moving upward. That made a real impact on me because I’ll call a therapist out and say that they’re misrepresenting how well I’m doing, but I’m not going to call myself a liar. So and I think that’s what you mean by the conjunction method, right? Like, don’t avoid doctors, therapists, and the medical community and download an app, but also don’t avoid the app just in favor of the medical community.

John Torous, MD, MBI: Yeah, exactly. And to your analogy of filling out those kind of weekly or monthly things with a phone, you can get them hour by hour. We don’t need data every hour, but maybe weekends are really different and there’s some stressor that comes up. Maybe or something. It happens in evenings. So when you kind of take that graph that you had, that was again, a not crude, but just kind of not high resolution. It’s a world where this is amazing. We now have a high resolution graph that lets you learn more unless your therapist learn more. And that becomes very exciting because now we’re not saying, well, this is how depression works. This is how depression for this person works in this situation, at this time, in this context. That becomes the exciting part is you’re doing something that you just cannot do before. You’re using an app to really do something new, to learn more, as you said about yourself, about what’s happening.

Michelle A. Patriquin, PhD, ABPP: I love that. That’s one of the most exciting things to me about technology is making our measurement more accurate regarding someone’s experience. Developing better insight, I think for the clinician and for the patient.

Gabe Howard: So as a patient, as a consumer, where do I go from here? For our listeners, how should they choose which app to use?

John Torous, MD, MBI: What I tell people too is test drive a couple of them. There’s thousands of apps. It’s a buyer’s market. You can give three of them a shot and see which one works for you. Figure out when you’re going to stick with and engage with. It’s kind of like picking a gym as one analogy. If you can use it, it’s probably going to be good and helpful. But if it’s going to be hard for you to stick with, it just doesn’t feel right. That’s going to be a really tricky thing to do. There’s enough out there that you can be a picky consumer on that and look for test drives and say, look, I know I’m someone that loves audio and I want ones that really give me great audio content, give them a shot. Because again, like all times when you’re trying to change your behavior patterns, it’s a habit, right? You have to do it over and over again. No app is going to give you kind of you download it and you have like a transformation immediately. The biggest sticking point of apps is it’s been hard to kind of stick with them for more than most people end up dropping them after a week. But again, you say, that’s fine, there’s more out there. And so be willing to test drive them and to be curious.

Michelle A. Patriquin, PhD, ABPP: I think that’s really good advice. I the only addition I would add would be I really do like the thought of it really being used within clinical care. Never losing the importance of a clinician. I know we talked about using technology to kind of fill the gaps sometimes when mental health care might not be accessible. But I like what you said, John. Really the boost is when you have a clinician and the clinician is using the app. And I think that’s just a really important thing to remember within the context of clinical care. And that you use it. That’s a more important thing. Like you have that, that you use it, you like it. And right. There’s a famous quote from, I think a former surgeon general about medication. It’s like people don’t something about people don’t get better from drugs if they don’t take them. And same thing has to do with apps. If you don’t use it doesn’t matter.

Gabe Howard: And when it comes to finding apps to test drive? Dr. Torous, I understand that you actually have an online database that our listeners can access.

John Torous, MD, MBI: Our team runs a database called MindApps.org, that’s MindApps.org. We have about 500 mental health apps. All $10 or less, don’t need a prescription. And we have about 100 questions for each app. Is it free? Is it not free? does have a privacy policy. Not have a privacy policy? Does it do cognitive therapy? Does it not do it? Does it listen to your microphone? Does it not listen to your microphone? Is it in Spanish? So you could again say, Gabe, you could say I really want an app again that’s in Spanish. It has great videos. It tracks my mood and it gives mindfulness. And we’d say, well, let’s see what exists. So the idea is, we have a lot of tools out there, we can definitely customize and find ones that may be useful to you.

Gabe Howard: Thank you both so much for your time today. Dr. Torous, Dr. Patriquin, where can our guests find you online if they want to learn more?

John Torous, MD, MBI: Our team is at DigitalPsych.org. It has links to almost all the things we talked about, including the database of apps.

Michelle A. Patriquin, PhD, ABPP: And you can find me on UTHealth Houston’s website or on LinkedIn.

Gabe Howard: Awesome. Once again, thank you both so much for your time today.

John Torous, MD, MBI: Thank you.

Michelle A. Patriquin, PhD, ABPP: Thanks so much for having us, Gabe.

Gabe Howard: Oh, you are very, very welcome. All right, everybody, that is our show for today. Thank you so much to our listeners for being here. And once again, I want to give a great big thank you and shout out to the ADAA, the Anxiety and Depression Association of America for sponsoring this episode. My name is Gabe Howard and I’m an award winning public speaker, and I could be available for your next event, and I’d love to come and see you. I also wrote a book. That book is called “Mental Illness Is an Asshole and Other Observations.” And you can get it on Amazon, but you don’t want to you want to get a signed copy and get some free swag. And you can do that by heading over to my website, gabehoward.com. Wherever you downloaded this episode, please follow or subscribe to the show. It is absolutely free and you don’t want to miss a thing. And listen, can you do me a favor? Recommend the show to everyone you know. Share your favorite episodes on social media. Bring it up in a support group, send somebody a text or an email, because sharing the show with the people you know is how we’re going to grow. I will see everybody next time on Inside Mental Health.

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