The Extremely Personal Computer: The Digital Future of Mental Health

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Meet your new therapist -- you're looking at it.

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It's 2018, and you're not feeling your best. Yesterday, on the phone with Comcast, you forgot your social security number, and had to call your mom to get it. She grew concerned. Your nightstand is full of half-finished novels, because it's easier to start fresh than to keep track of where you left off. And the fatigue -- last Thursday, you slept clear through your alarm, until Agnes in 8J pounded on your ceiling with a basketball. You've been here before; you know you're depressed. And you know what you have to do.

You fire up your PC and dig out your biomonitor wrist strap. "Welcome back, kiddo," Regina, your therapist avatar, greets you. Regina has shiny red hair and glasses, and the Australian accent of a Bond girl. "Let's catch up."

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As you launch into your compressed narrative -- the new job, the breakup, the fight with your brother -- and Regina nods in sympathy, you recall the days of Dr. Fitzsimmons' brick and mortar on 5th and 97th, when you'd have spent half the session (roughly $150.00) "updating the Fitz." It felt good at the time, but did it actually achieve anything? The Fitzman was hardly Freudian -- he was as cognitive as they come, with scales and homework and all -- and even so all that schmoozing required so much time. And, as he loved to remind you, he was one of the few psychiatrists left who even talked to his patients anymore. Just a day after the session, the sharing glow would wear off, and you'd have difficulty recalling what you had discussed.

About five minutes into your story, your biomonitor issues a gentle chime alerting Regina that, based on your lowered heart rate and blood pressure, the cathartic warm-up is complete. "I'm so sorry to hear what you've been through," Regina says, eyes wide. "I am here for you, ready to help you improve your mood and your mind."

Myndbot, which rolled out a few years earlier, was your first Regina. An antiseptic cross between an SAT program and the old school Atari, its primary function was to introduce users to the platform, which was revolutionary: Social simulations that could lesson your anxiety, an integrated cognitive behavioral iPhone app, adventure games that taught reframing of depressive thoughts -- all of it sounded too futuristic to work. 

Arguably, the first iterations were. Most early adopters continued seeing human therapists and taking their meds. But over time, leading firms like Posit ScienceDakim, Lumosity, Brain Plasticity, SharpBrains, and MoodGym improved the exercises and included biometrics. Thomas Insel, head of the National Institute of Mental Health, supported these efforts from the start, as an example of what he described to the Royal Society of London in 2011 as psychiatry as "clinical neuroscience."

We're at an extraordinary moment where the entire scientific foundation for mental health is shifting, with the 20th century discipline of psychiatry becoming the 21st century discipline of clinical neuroscience.

In the spring of 2012, the NIH offered its first grants in the field of video games as psychiatric intervention, a vote of confidence in this therapeutic direction.

By 2014, despite opposition and lobbying from the pharmaceutical industry, the FDA had approved Myndbot as a treatment for anxiety, and insurance began partial coverage. Nowadays, Regina's major competitors have partnered with pharma, the old foe, which has in turn rebranded itself "biotherapeutics." Many pharmaceutical companies manufacture the software's accompanying biomonitors, like iBalance, a genius phone accessory that monitors heart rate, sweat, and blood pressure and even, with an attachment, EEG brain waves.

Regina now offers you a series of surveys that will allow the program to track your progress over time. Are you feeling hopeless? One asks. You check the Y. On a scale of 0 to 5, how hopeless? You start to check a level 2.5, but as you do so, you recall that just two months ago, after a one-month tune-up with Regina, you went from a 2.5 to a 4.5. You click the timeline icon in the corner of the question to see this chart:

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It's enough to convince you to bump your current rating up to a 3. Already, Regina is working her magic.

Now she wants to know about your meds. You spent most of your twenties on Zoloft, but with Myndbot, you've been medication-free for three years.

"Are you ready to start taking BrainPrime again?" Regina asks.

Almost med-free. No one counts BrainPrime anyway. You pop two of the chewable orange-flavored tablets in your mouth. Your biomonitor wrist strap registers that you've taken the pills, and the program resumes. The pills always make your brain tingle the first couple of days back on the program. The compound is chemically related to caffeine. It primes the pump for enhanced neuroplasticity. Initially over-the-counter, the FDA had to start regulating these supplements after their combination with alcohol consumption lead to toxicity in adolescents. Your subscription with Myndbot includes a monthly supply of BrainPrime, as long as Regina approves the prescription.

You hit "Skip Instructions" and begin the opening exercises. Most of these you will never have seen before, as they are constantly revised and refreshed. Regina will have retained some of your favorites for continuity. As a series of differently colored shapes appear for sorting, KTkat997 messages you in the corner of the screen with a ping.

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You go invisible so you can finish the exercise, then check out KT's stats. Her depression scores are down several months in a row. You post an encouraging message on her wall. It took a while before you felt comfortable sharing your own data with others, but now everyone does it. Plus the more interactive you are, the more discounts you get on your monthly fees.

The bulk of the session is devoted to simulations: Kiddo712 in a virtual reality that closely resembles your non-virtual reality, negotiating all the situations that typically get you down or anxious, including novel scenarios formulated to address your most current stresses. You see your girlfriend, for example, and discuss getting back together. After rationally outlining pros and cons, and then reality-testing each item, you mutually concur that, while you have strong feelings for each other and parting will bring you sadness, it is truly in your best interest. The downside of virtual partners, you have learned, is that they can unreasonably raise your expectations of real ones.

For the final stage, Regina prompts you to put on your NeuroCap, a lightweight mesh EEG hat that fits snugly along your temples and the base of your neck. This is the neurofeedback portion. For many years, the technique had FDA approval for relaxation purposes only. But with the boom in commercial EEG devices like Neuroscan, Neurovigil, and NeuroAmp, and their increasingly common off-label use for anxiety and depression, the agency eventually followed suit.

Your cap in place, you watch as Regina displays a series of images that she knows will provoke anxiety or depressive feelings. At the base of the screen, an EEG strip shows your brain waves as your respond. In real time, you observe, spike by spike, your own freak out: a full auditorium -- public speaking! Ahhhh! Mouth. No. Work. Your brain waves mount a BMX course. With each spike, Regina cues you to contextualize. These are two-dimensional images, she reminds you. You tell your brain to chill out, and eventually, it starts to listen. Your waves relax into a less erratic ebb and flow.

"Good work, Kiddo," Regina says as you complete the end-of-session survey.

"Thanks."

"I'll be around today if you need me." She means via the wrist strap, which you will wear all day. When your vitals peak in an anxiety-like pattern, she'll text you tips, or pop up on your computer if you're online. "Otherwise, see you tomorrow?"

"Okay," you say. "Thank you. I feel a little better."

She tilts her ginger head sideways. "Thank yourself, Kiddo. You're the one doing the work."

It's true, of course. Once, back when you first started these programs, the compliment might have served as an uncomfortable reminder of the fact that Regina is nothing more than a series of zeros and ones. Nowadays you take it as a point of pride. After all, without you, the user, these pills, this software, this insane looking mesh hat -- all of it would just be so much science fiction.

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Gabriella Rosen Kellerman, MD, is a physician and writer based in Berkeley, California. She has written for The Discovery ChannelScientific American, and In Our Own Hands, a forthcoming documentary about technology democratizing health care.

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