OpinionOpinion
In recent years we have witnessed two novel directions of development
that promise a fascinating future for the world of psychiatry:
the first encompasses technological innovations and the
second includes scientific advances in the field of research called
“neural computation”. We live in a new technological world of
sensors that are networked through the internet and are capable
of measuring and tracking information and activities of the users.
Daily activities of each and every one of us, reflect, among other
things, our psychological states. Changes in user behavior can be
detected, measured, and monitored and can be used to diagnose
possible development of psychiatric disorders. Psychiatric diagnoses
are based on signs and symptoms. Symptoms include the
subject’s complaints and signs reflect the examiner’s observations.
The observation may include appearance, facial expression, behavior
(motor movements), spacial mobility, speech, judgement,
and cognition. In the technological age, it is possible to extract a
comprehensive observation of all of the above via the smartphone.
Appearance and facial expressions are easily extracted from the
camera on the smartphone; behavior and spacial mobility are measured
with the GPS and analysis of the user’s typed responses to
various activities may indicate cognition. Symptoms, or patient’s
complaints, can be evaluated via questionnaires that the user is
asked to complete, conveniently, using existing apps. Every psychiatric
disorder has distinct characteristics. These features can be
collected via the smartphone, stored, monitored, and analyzed so
that an automatic continuous diagnostic process enables the psychiatrist
to diagnose, monitor and even treat, remotely.
This can all be accomplished without the need for a physical
visit to the clinic. Collection and statistical processing of the data
naturally enable the development of accurate diagnostic measures,
based on the characteristics of the complaints and observations
of a large number of subjects. Once sufficient data are collected,
artificial intelligence learning systems are activated to diagnose,
detect, and monitor the patient’s response to treatment, in a way
that to date has not been possible. The introduction of intelligence
systems in conjunction with a digitized sensor network promotes
professional psychiatric efficiency that is several degrees higher
than that of the individual psychiatrist. Digital psychiatry, of the
type described here has a significant advantage in clinical practice,
with emphasis on clinical surveillance of response to treatments.
Conventional practice of physical follow-up visits in the clinic does
not provide for a continuum of clinical evaluation, however, digital
psychiatric monitoring allows for continuous clinical monitoring.
When it comes to measuring exacerbation or treatment response,
every change is revealed in real time in the continuous assessment,
while waiting for a clinic-based assessment might take quite a long
time and lead to missed or late detection of changes in patient status.
Similarly, treatment response is affected by digital assessment.
Continuous measurement of response to treatment beginning with
treatment initiation saves the patient unnecessary and tedious
waiting for a clinic appointment and reduces the possibility of delay
in revealing a reaction related to effectiveness of the treatment.
The benefit to the patient is enormous, since it is possible to
assess the efficacy in the initial stages of treatment and then decide
whether to continue, adjust, or change pharmacotherapy. These
benefits may potentially circumvent much pain and suffering for
the patient. Alongside the numerous benefits of digital psychiatry, a
principle innovation in comparison with conventional psychiatry is
still lacking. The true psychiatric innovation will arrive when digital
technology will unite with advances in the understanding of the brain – as a cause for psychiatric illnesses. Until recently, understanding
of brain-related causes for mental disorders was lacking.
That is why psychiatrists base their diagnoses on signs and symptoms
rather than on laboratory tests and existing objective imaging,
as in most fields of general medicine. This is also the reason that
the psychiatric diagnostic system is not etiological (etiology means
that the name of the disease is the cause of the disease. For example,
intestinal obstruction is a medical diagnosis. The name of
the disease indicates its location in the body – the intestine, and
the pathology is the obstruction). A psychiatric diagnosis such as
“depression” is not associated with a part of the body and does not
describe a pathological mechanism. In the absence of knowledge of
the cause of psychiatric disorders, the diagnoses remain descriptive
- of the symptoms.
This may all change when the brain-related causes of psychiatric
disorders are revealed. An evolving body of knowledge in
brain research called “neural computation” will enable the understanding
of the higher brain activities, often called mental or emotional
activities, which function as complex “neural networks” of
the brain. The brain is constructed as a complex system of neuronal
networks (nerves). These networks spread throughout the
brain, enabling organization of the brain with regard to emotions,
thought, perception, consciousness, and cognition. In practice, the
neural network activity supports the same higher mental functions
that we attribute to the term “mental”. When neuronal network
organization is impaired for some reason, the higher mental functions
are affected, with an impairment that might impede emotion,
mood, perception, consciousness and cognition and reality testing.
These are all characteristics of psychiatric disorders, which as
noted are still described in the diagnostic framework of signs and
symptoms. In order to describe the complex relationship between
the organization of neural networks in the brain and mental functions
and psychiatric disturbances, the metaphor of an orchestra
can be used. Just as the orchestra creates music via coordination,
synchronization, and complex timing among the musicians, so the
neurons in the brain organize the networks and create the connectivity
necessary to synchronize and coordinate higher mental and
emotional functions. Without coordination among the musicians
the music will be discordant.
The same goes for the brain: the more the neural networks are
impaired in terms of coordination and synchronization, the more
the mental activity will be impaired. If coordination among the musicians
is lost, the music will become noise. In the brain, severe
damage to organized neural network activity can result in the loss
of higher mental abilities, as indeed is the case with severe psychiatric
disorders. The field of neural computations has already offered
quite a few insights regarding mental functions in psychiatry. One
example is the brain’s adaptation to stress states and the depressive
response. For many years it has been known that anti-depressive
agents stimulate the growth and development of nerve cells. The
importance of the brain’s adaptation to new, stressful, and painful
situations is also well known. We also know that depression is associated
with suffering and stress and nerve cell growth, in response
to anti-depressive agents. However, until recently the relationship
between these findings was not understood. With the help of neural
computation, we are now able to understand that the growth and
development of multiple nerve cells allows the brain to better adapt
to situations of stress and suffering. In fact, the field of neural computation
teaches us that the brain acts as an adaptation machine in
that it predicts changes in the human environment and then adapts
itself! The brain updates the internal representation of the external
environment. The better the adjustment and adaptation of the
brain to a person’s changing life events, the better his or her stable
mood is maintained. In contrast, impaired brain adaptation (due to
impaired nerve cell growth) will be manifested as a reduction in
the capacity of brain adaptation, leading to a decline in mood. This
insight from the field of neural computation explains both the action
of antidepressants and the importance of reducing stress in the
treatment for depression. These insights pave the way for planning
new therapeutic interventions not previously considered, based on
the brain’s role in nerve development and growth.
Confucius said: “The beginning of wisdom is to call things by
their proper name”. In the spirit of this ancient saying, the time has
come to call psychiatric diseases by their proper names, the names
of the cerebral mechanisms that cause them. By consolidating the
fields of knowledge of neural computation and conventional psychiatry,
a real revolution in the understanding and treatment of
mental illness will soon be possible. In order to close the gap between
the above insight and general medicine, and to understand
the inherent therapeutic direction, the new approach to psychiatry
can be compared to other fields of medicine, such as cardiology.
Heart failure can be caused by a disturbance in the heart rhythm.
The treatment will include insertion of a pacemaker to regulate the
rhythm, in order to treat the symptoms and restore normal heart
rate until the heart patient is cured. Similar to this example, psychiatric
disorders can be compared to various forms of insufficient
brain function caused by disorders of the neural networks in the
brain. Development of a brain pacemaker (neuromodulation) will
enable “repair” of the cerebral “rhythm disturbance” (that is disturbances
in the neural network organization in the brain) and thus
eliminate the symptoms and functional limitations.
The understanding that brain pacemakers will play an important
role in curing psychiatric illnesses in the future raises the question
– where do we stand today in terms of technology that allows
for intervention and control of the brain? Indeed, brain intervention
technology exists and is developing very rapidly, for example
neurotechnology, neuromodulation, brain stimulation (electrical
magnetic) and more. Direct electrical stimulation of the brain via
implantation of electrodes directly into the cortex has been known
for many years as a treatment for Parkinson’s and a number of other
brain diseases. Non-invasive technologies such as Transcranial Direct
Current Stimulation (TDCS) and Transcranial Alternating Cur rent Stimulation (tCAS) also facilitate the relief of numerous medical
indications and quality of life issues. At the same time, in recent
years, this technology has undergone vast improvements with the
experience of Elon Musk (yes, the entrepreneur from Tesla and
Space-X) with Neural ink and others to directly connect the brain to
the computer. This is a familiar well-known field of brain-computer
interfaces. Neural ink is currently developing tiny, delicate robots
capable of transplanting 10,000 electrodes in the cortex in less than
an hour. Because it is invasive, the technology of brain transplants
can discourage patients and caregivers.
Thus, there are already even more innovative developments
based on “neuronal dust”. These are tiny (like dust) components
of “nanotechnology” that can be dispersed in brain tissue through
injection into the blood or spinal fluid. These particles can be activated
externally by weak magnetic fields or weak ultrasound energy.
When activated, these particles can activate and measure the
neurons in their environment by sending a repetitive signal that is
measured using appropriate sensors. Neuron dust - which both activates
and measures brain activity, may well be the basis for the
future pacemaker, which requires a response-measuring circuit
to stabilize and reorganize brain activity. Beyond that, this kind
of penetrating technology will be more appropriate and safer for
broad use, as needed. It is important to understand that the cure
of psychiatric illness using remedial technology for brain efficiency
does not have to end in the field of pathology. This technology
opens the door to brain empowerment, which is the basis for success
in the modern, competitive, and complex era. Everyone can
actually benefit from enhancing and empowering their cognitive
and emotional abilities. In summary, it is important to emphasize
that psychiatric-digital measurement and monitoring and psychiatric
diagnosis based on neural computation and neuromodulation
technology are interrelated. In order to validate brain-based neural
computational diagnosis, it is imperative to gather a mega data
base, possible only through digital psychiatry. In order to activate
an effective “brain pacemaker” it is vital to accurately diagnose the
“disturbance of the brain rhythm” which is possible only via neural
computation. There are currently quite advanced tools that enable
rapid effective diagnosis alongside use of relatively simple non-invasive
tools for various treatments.
