Alexa, should I increase my dose of Celexa?

The evolution of depression care management programs can be described in terms of task shifting. Initial Collaborative Care programs actually shifted some tasks up to specialty providers.  Psychiatrists and psychologists joined the primary care team and assumed responsibility for routine follow-up of antidepressant treatment.

After that, the task shifting was all downhill. Care managers, either nurses or masters-prepared mental health clinicians, took on responsibility for outreach and care coordination. Then those tasks (including actual psychotherapy) shifted from in-person visits to briefer telephone contacts. Finally, follow-up of antidepressant treatment shifted to online messaging, relying on human care managers supported by simple decision rules.

Our MHRN Automated Outreach pilot project will take that task shifting one step further. People overdue to refill an initial antidepressant prescription will receive an automated outreach message, including an assessment of depressive symptoms, current medication use, and side effects. Assessment responses pass through a simple algorithm (including 29 possible clinical scenarios) to generate an automated response – with advice ranging from, “We are happy you’re doing well, and we will check with you again in a few weeks” to, “It sounds like you are still having significant problems with depression.  We recommend you should contact your doctor about trying some different treatment.”

Last week, Amazon announced a new collaboration with JP Morgan and Berkshire Hathaway to develop new delivery models to lower healthcare costs. The discussion about care processes ripe for disruption specifically cited the traditional requirement to see a physician in order to renew a prescription. I immediately thought of our Automated Outreach project. We already know a good bit about convenient, efficient, and effective models for routine follow-up of new antidepressant prescriptions.  I suspect that Alexa might improve on the tools we already have.  For example, more people might respond to Alexa’s live voice than to our plain text messages sent through the EHR patient portal. And Alexa can hear tone of voice when people respond. Amazon’s predictive analytics could probably improve on our 29-line algorithm for treatment adjustment.

Maybe it is time for some more radical task-shifting: turning routine follow-up of a first antidepressant prescription over to Alexa (or Siri or Cortana or OK Google).  Simple automated outreach programs would often be adequate, and would certainly be more convenient.  We could then reserve expert clinicians for more severe or complicated mental health problems. Unfortunately, there are more than enough of those complicated problems to go around.

Greg Simon

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