Avatars for mental health

Wired. Connected. Always accessible. More than ever, these words embody the current world of teens and young adults. While the constant stream of information and input enable both generations to learn, create, and discover like never before, it also raises their risk of emotional harm.

"Kids today can't escape," says Melissa Pinto PhD RN, an assistant professor and mental health researcher at the School of Nursing. "Gone are the days when teenagers had to drag the family phone into their rooms with their parents monitoring who's calling and how long they're talking. The boundaries between home, school, and their social lives are blurred. Young people today have a real peer audience all of the time, along with a worldwide platform."

With the pressures inherent for young people today, it comes as no surprise that depressive symptoms often begin during the teenage years and progress as teens reach their 20s, 30s, and 40s.

"Half of all people who develop a mental health disorder in their lifetime will have symptoms before age 15," notes Pinto, "and 75 percent of people who develop a mental health disorder in their lifetime will have symptoms by age 25."

To complicate matters, depression often goes unreported by teens and young adults, unscreened by health care providers, and unnoticed by parents.

"When young people go to get a checkup, they have their heart and lungs checked and maybe some lab work done, but unless the patients or their parents express a concern, they're likely not going to be screened for depression," Pinto says. "People, especially adolescents and young adults, have a hard time talking about it, even with their health care providers."

With this in mind, Pinto and a team of researchers from Case Western Reserve University and the University of South Florida pilot-tested an avatar-based program called eSMART-MH—short for Electronic Self-Management Resource Training for Mental Health—that immerses young adults into a virtual primary care environment. The self-management tool takes participants through the entire appointment process—from entering the waiting room and interacting with the front desk staff, to communicating with nurses and physicians about symptoms and concerns, to scheduling follow-up. eSMART-MH uses interactive technology familiar to its already tech-savvy participants.  

"We believe that we're meeting young people where they are with this technology," says Pinto. "We're able to give them assistance in a way that fits with their lifestyle and peer culture. We know that mental health has always been a sensitive topic. We're making progress on breaking the stigma that surrounds mental health. eSMART-MH is an effective dress rehearsal for talking to someone in an environment that is nonthreatening but still lifelike."

In Pinto's pilot project, 28 participants from ages 18 to 25 were randomly assigned to use eSMART-MH or a computer program on healthy living to manage their depressive symptoms. Study participants, primarily black females, lived in or near Cleveland, Ohio. After three months, eSMART-MH users showed a clinically significant reduction in their depressive symptoms. Those who used the healthy living program showed no change.

"The effects of depression on young people are devastating and can have a lasting impact on their academic performance, the behaviors they adapt, how they form relationships, and increased smoking and drug use," explains Pinto. "By using eSMART-MH, young people gain self-confidence in interacting with health care providers and become empowered to actively participate in their own health care."

Pinto and her team have received quite a bit of attention for their work. Last fall, she presented the results of their research during a White House conference on Technology Innovations for Substance Use and Mental Health Disorders. Pinto also participated in a roundtable discussion with policy-makers and health system administrators at the White House.

Her project builds on an earlier avatar-based platform funded by the National Institute on Minority Health and Health Disparities and developed at Case Western, where Pinto previously served on the nursing faculty. The Midwest Nursing Research Society/American Nurses Foundation and the Clinical and Translational Science Collaborative KL2 program of Cleveland supported her latest work. Pinto plans to expand use of the technology as time and funding allow.

"I like to think that eSMART-MH will get even smarter, meaning that it can remember participants' past responses, tailor information specific to participants, and become more widely available," she says. "It can be tailored to different ethnicities and cultures, and we can program the avatars to speak any language. We can also create avatar children to make eSMART-MH more appropriate for interactions with children. The possibilities are endless."