Technology and Psychology: Helping Military Service Members, Veterans, and their Families David D. Luxton, PhD. M.S. Is affiliated with: University of Washington School of Medicine, Seattle, & Naval Health Research Center, San Diego CA

Agenda Research Highlights Caring Emails for Military Suicide Prevention Telemental health in the US Military Military Population Health and “Big Data” Future Direction (and opportunities in technology & Psychology) DISCLAIMER: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Navy, or the Department of Defense.

Areas of Research Focus/Highlights Mobile Health (mHealth) Technology Pilot study of videoconferencing telehealth on smartphones Clinical best practices when integrating into care Telemental health (to deliver treatments to military personnel/Veterans) Safety protocols Clinical assessment via technologies, best practices, etc. Military suicide prevention (DoD surveillance reports, research, etc.) Clinical trials & public health studies - PTSD, Depression, suicide, etc. Technology and Ethics

Problem: Military and Veteran Suicide Rising suicide rate in US military population since 2004 Suicide risk very high for patients who are discharged from psychiatric treatment Active-Duty (AD) Service member psychiatric patients 5 times the risk of AD population, 8.2 times risk in first month after hospital discharge compared to at 1 year (Luxton et al, 2012) Makes sense to target this group for intervention... Psychiatric Services. 64, 626-629. doi: 10.1176/appi.ps.201200413

Caring Contacts for Suicide Prevention Caring Contacts Intervention: Routine sending of brief, caring messages to high risk for suicide patients after treatment discharge (Luxton, June & Comtois, 2013) Original caring letters study (Motto,1976; Motto & Bostrom, 2001) Example Caring Letter: Simple expressions of care/concern Non-demanding Reminder of available resources/way to reconnect with care Dear ____: It has been some time since you were here at the hospital, and we hope things are going well for you. If you wish to drop us a note, we would be glad to hear from you.

Caring Contacts for Suicide Prevention Caring letters group showed significant < suicide rate in first two years, trended for 14 years. Other “caring contacts” studies show success (Luxton, June, & Comtois, 2013) “Caring Letters” intervention one of the only suicide prevention interventions with any initial empirical support Can augment other suicide prevention/intervention programs in various care settings (inpatient and outpatient) Crisis, 34, 32-41. doi: 10.1027/0227-5910/a000158

Caring Contacts for Suicide Prevention Caring Letters for Military Suicide Prevention (Luxton, PI) Military Operational Medicine and Research Program Grant funded multi-site randomized controlled trial (Military Treatment Facilities/ VA Hospitals) Sending “caring emails” Developed safety protocols

Problem: Access to Care and Stigma Military Health System beneficiaries in remote geographical areas Cost of travel, not having access to treatments Stigma associated with seeking care Injuries limiting mobility Home-based options (using videoconferencing to provide treatments in the home) Not presently standard of care in the U.S. military (needs policy to allow) Need studies to evaluate feasibility, safety and efficacy to inform policy decisions

In-home Telemental Health (Cont.) Grant funded (MOMRP) clinical trial in-home behavioral activation treatment for depression (compares to in-office care) (Luxton/Gahm PIs) Results show feasible and safe to deliver Informed leadership at the Defense Heath Agency

Problem: What are the short/long-term effects of military deployments on health? Millennium Cohort Study (Luxton PI) Examines effect of military experiences and deployments on health (Physical and Psychological) of US Service members, Veterans (and also families (Millennium Cohort Family Study) Largest (n=200,000) prospective health study in U.S. military history Comprehensive survey data collection every three years (web and paper formats) Links to enterprise database systems (“Big Data”) Informs policy in the DoD, VA, etc. Photo by SMS Lipp/US Army

Department of Veterans Affairs “Big Data” Environmental Exposure Data Deployment Data Mortality Data Pharmacologic Data Family Data Immunization Data e.g., DoD Birth and Infant Health Registry Recruit Assessment Program Civilian Inpatient and Outpatient Care Military Inpatient and Outpatient Care Survey Data e.g., Millennium Cohort and Family Studies Medical History DoD Serum Repository Induction Demographic Data

Future Direction Artificial Intelligence in healthcare Virtual humans for care Predictive analytics with big data Technology and Ethics

Future Direction Virtual Human Cancer Clinical Trial Assistant (Bickmore, Utami et al. 2013). Institute for Creative Technologies Relationalagents.com

Current/Future Projects Development/Consultation (2015 - Luxton Labs) mHealth development Web-based training UX design (user design) consultation, testing, and research Clinical applications consultation Suicide prevention mHealth apps Predictive analytics/AI algorithms for risk detection Virtual Intelligent Agents (Virtual Humans) for behavioral health care applications

Opportunities for Psychologists Develop technology-based interventions/tools that improve the health of people Collaborate with tech developers, etc. Research with emerging tech (e.g., virtual humans, mHealth, predictive analytics, etc.) Bring what we know as psychologists to technologies, e.g., Expert knowledge about human/social behavior Ethics

References Bickmore, T., D. Utami, B. Barry, L. Henault, K. Waite, R. Matsuyama and M. Paasche-Orlow (2013). Enabling Web Search for Low Health Literacy Individuals Using Conversational Agents. Health Literacy Annual Research Conference (HARC). Washington, DC. Luxton, D. D. (2014). Recommendations for the ethical use and design of artificial intelligent care providers. Artificial Intelligence in Medicine. 62(1), doi:10.1016/j.artmed.2014.06.004 Luxton, D. D., (Ed) (2016). Artificial Intelligence in Behavioral and Mental Health Care, Elsevier/Academic Press. Luxton D. D., Trofimovich, L., & Clark, L. L. (2013). Suicide Risk among U.S. Service Members Following Psychiatric Hospitalization, 2001-2011. Psychiatric Services. 64, 626-629. doi: 10.1176/appi.ps.20120041 Luxton, D. D., June, J. D. & Comtois, K. A. (2013). Can Post-Discharge Follow-up Contacts Prevent Suicide and Suicide Behavior?: A Review of the Evidence. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 34, 32-41. doi: 10.1027/0227-5910/a000158 Luxton, D. D., June, J. D., Sano, A., & Bickmore, T. (2016). Mobile, Wearable, and Ambient Intelligence in Behavioral Health Care. In D. D. Luxton (Ed). Artificial Intelligence in Behavioral and Mental Health Care. Elsevier Academic Press. Luxton, D. D., Thomas, E. K., Chipps, J., Relova, R. M., Brown, D., McLay, R., et al, (2014). Caring Letters for Suicide Prevention: Implementation of a Multi-Site Randomized Clinical Trial in the U.S. Military and Veteran Affairs Healthcare Systems. Contemporary Clinical Trials. 37(2), 252-260. doi: 10.1016/j.cct.2014.01.007

David D. Luxton, PhD, M.S. Ddluxton@uw.edu