Wednesday, May 30, 2012


What’s your mental health number?
This is the question that the Bipolar Collaborative is asking, using its WhatsMyM3 screening tool [PubMed]. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.
~from Clinical Psychiatry News

Today's USA Today newspaper ran a story titled, "Screening for mental illness? Yes, there's an app for that," by Michelle Healy.

WhatsMyM3 is a validated, 3-minute tool that screens for symptoms of depression, bipolar disorder, PTSD, and anxiety, and can be used to monitor changes in symptom severity over time.

One of the developers, Michael Byer, approached me about a year ago for my opinions on development and use of the screening tool. Disclosure: After reviewing the research and seeing how useful it is, I have become more involved in the organization, becoming an adviser to the group that was started nearly ten years ago by past NIMH chief, Robert Post MD. (listen to podcast #63)

It differs from other mental health screening tools, such as the PHQ-9 and the MDQ, in that these are all unidimensional -- they only measure one domain of symptoms. The M3 is multidimensional, measuring four areas of symptoms. Furthermore, when compared to results from the standardized interview tool, the Mini International Neuropsychiatric Interview (the MINI measures for 15 different mental illness diagnoses), WhatsMyM3 provides a total mental health score that is 83% sensitive in finding true positives and 76% specific in finding true negatives. In addition to the total score, there are four subscores, one each for depression, bipolar, PTSD, and anxiety.

Put another way, the negative predictive value of the total score is 89%, meaning that if you score under the threshold, there is an 89% chance that you do not have any mental health diagnosis by the MINI. As with most screening tests, you want the negative predictive value to be high so that you don't have to subject the "negatives" to more specific testing. The positive predictive value, or PPV, is generally lower for screening tests. It is 65% for WhatsMyM3, meaning that if you score positive (total score >= 33 and positive for functional impairment), the odds of you having a diagnosis is almost two-thirds. A clinical evaluation can then help to determine if you do have a diagnosis. (Note: this tool cannot give you a diagnosis; it can only describe your relative risk of having, or not, a diagnosis.)

What people have found to be most helpful is using WhatsMyM3 to monitor their symptoms over time once they do have a diagnosis. This can be done for free on the website, or for $2.99 using the iPad or iPhone apps, or the Android app. For mental health clinicians, they can download the free M3Clinician iPad app and then screen their own patients. For about a dollar per screen, they can register their patients who want to track their symptoms over time and share their scores with the clinician. Primary care providers also purchase screens, and can even obtain insurance reimbursement by billing for an annual health risk assessment. The patient reports can be viewed by logging into

A sample report for a fake patient can be viewed here.

I think this sort of tool, or app, is exactly the sort of mHealth thing that empowers consumers to better manage and become engaged in their health care needs. This is happening in other areas, like diabetes, heart disease, and obesity. Mental health is also making great strides in mHealth.

I should also point out here that the folks at M3 Information were the only ones to take us up on our offer of a free "advertisement" on Shrink Rap in return for donating at least $200 to our NAMIWalk for Mental Health Month (we don't typically accept display ads). A logo ad will be running soon on Shrink Rap soon for two weeks in recognition of their charitable donations. It will look like this and link to the iPhone and Droid apps. [We received no money ourselves from M3 nor from NAMI. We've never accepted any money from Pharma companies, nor does M3.]


rob lindeman said...

More evidence that an MD is not necessary to label someone, or oneself, with a diagnosis of mental illness.

Turns out you don't even have to be human.

Elizabeth said...

I journal and have people I care about tell me when I'm going off the deep end if I don't realize it first. I always find screening tools a little weird - I mean, low sex drive, insomnia/hypersomnia, dissociation, flashbacks, and so forth scream "I have a problem." I can't help but wonder if people are either that unaware of their thought processes or that far into denial.

rob - There was a stick I peed on a little less than four years ago that told me I was pregnant before I missed a period. I noticed I was feeling a little off and eating more than usual, and there was that not using birth control because we were trying to have a child thing. The stick was indeed correct. Which reminds me, I need to write up invitations for my daughter's third birthday party this afternoon.

That said, I agree we pathologize people a lot. And I feel there is a biological component to psych things in general - the brain is physical, thoughts are physical, interacting with the world causes physical changes to the brain. It isn't unreasonable to assume that the brain can be susceptible to dysfunction without getting a baseball bat taken to it.

However, we (psych community) have historically made the assumption that positive thinking is healthy, thus negative thinking is pathological. Everyone thinks negatively, and most people aren't overly impaired by it - since we look at pathology in terms of impairment when we decided whether or not we're going to treat something, the idea that negative thinking is unhealthy is pretty useless. Existential angst, judgments towards the self and others, emptiness, uncertainty, and questioning meaning are normal behaviors. In one context, these can imply clinical depression. For example, "I want to die because I'm a vile person without purpose" is a bit different than, "Life is exhausting at times, and I wonder what it would be like if I were dead." To someone without time and/or training, as well as a fear of facing existential matters such as meaning and death, diagnosis can be rather confusing.

Another example - High IQs and boredom in children can be mistaken for AD/HD - bored kids act up. Everyone and their brother seems to think they're a therapist or psychiatrist (there are some school teachers I'm looking at here), which doesn't help matters.

And insurance companies, politics, and lawsuits, which have fueled a lot of the DSM crap we're dealing at the moment. A lot of people in the field are finding it quite tiresome.

rob lindeman said...


You don't need to be a doctor to diagnose pregnancy either

Sunny CA said...

I think it is a terrific idea. The idea cited in the video, that busy GP's use it as part of the patient physical sounds like a great idea. The physician could still ask why the patient appears to be so down, but I think it would be time-saving and cover more ground than is generally done in an annual physical. My internist does not seem to assess mental health in his annual physicals, or else I pass the casual assessment he makes, because he has never commented nor asked.

Dinah said...

Ugh. One more checklist of symptoms. Yesterday, I guess I did something wrong, because it told me I had bipolar disorder and offered to call a suicide hotline for me. Today, my score was 13 and I have a low chance of having a disorder.

But like "Have you ever felt excited or revved up?" Like who says No to that? Dead people?

I worry that primary care docs will use this as their tool for diagnosis. Psychiatry isn't about checklists, nearly all psychiatric symptoms occur in the context of normal human emotions and have some variability. These checklists eliminate the question of context (just as the DSM does) and sure, you can say it's a screening tool, but I'll be there will be people who are handed a script on the basis of the number, without a comprehensive evaluation or other options being presented.

Oh, no....I'm becoming one of the haters!

And I hate proving I'm not a robot. 2 seconds in a room with me and damn it, you know I ain't no robot.

Elizabeth said...

rob - Same with a broken arm. While surviving a broken arm, a pregnancy, and psych issues is likely, it doesn't mean that death isn't a possibility or at the very least seeing a doctor can make these things a lot less miserable.

Dinah - I'm not a fan of checklists either. Since I have experience working in psych settings and I have training in diagnosis, as well as dealing with this crap for entirely too much of my life, I see what they're getting at. But a lot of people don't, which makes these tools a bit scary.

I'd really like to see a checklist that is a tad more descriptive. Examples:

"Have you ever acted like someone on methamphetamine - rapid and at times incoherent speech, two days without sleep, putting holes in walls, etc. with a crash into sadness - though stimulant drugs were not involved?"

"Have you ever taken an antidepressant and it resulted in speed-induced-esque behavior (see above) but stimulant drugs were not involved?"

"Do you have images of violence towards others, pedophilia, having sex with your grandmother, or other things you find so morally repulsive the fact that they even cross your mind make you want to slit your wrists and end it all?"

"Do these thoughts take up enough of your day to make your life miserable, affect your social life, and/or make you cry in a corner and do Hail Mary's for atleast two hours straight under the hopes they'll stop even though you're not Roman Catholic?"

"Do you think you're [insert prominent religious figure here]?"

"Do you have the ability to watch the entire Naruto series thus far in a weekend with only breaks to sleep, use the bathroom, and make sandwiches, and yet sitting down to do ten multiplication problems makes your mind wander off and either 1) contemplate what will happen next in Naruto and then how to steal your brother's latest copy of Heavy Metal and maybe going outside to do some skate boarding and man, does some Pepsi sound good right now - should I go get some or would Sprite be better? or 2) jump on the dining room table as your parents threaten to send you to your room and put a lock on the outside of your door? (Though they'll likely forget you can escape through the window)"

"Is the amount of crap in your house so prolific that everyone you love won't talk to you and even your pet fish jumped to their death because the mess was so intolerable?"

"Have you ever felt like you were stuck in this endless loop of [insert fly-on-the-wall-style indie film here]? Is this experience frightening? Or better yet, it happens so frequently that it this point in your life you find it just plain irritating? Oh, and drugs aren't involved."

"Did you blow so much of your inheritance on plastic surgery that now your friends call you Porno Barbie, and yet somehow you think a Porno Barbie would be way hotter than you?"

Hm, this is too amusing to me. Ya know you've spent too much time in psych work when...

Sarebear said...

I think there's some value in these things. Are they perfect? no. Do they replace a clinician's assessment and judgement? no.

We've got to try to measure something, some time, in some way, and if these tools are available to people, at the least it could start a useful discussion between them and their health care provider. Even if the data is flawed or doesn't math what the doctor thinks; it's just something to get you talking to your doctor.

Dinah said...

Elizabeth, You've Got the M4 started!

Sunny CA said...

I love Elizabeth's list. LOVED it!

frenetic said...

LOL! Thanks for that great comment Elizabeth. I think I identified with one too many items on your list!!

Sarebear said...

Yeah, what frenetic said.

Elizabeth said...

Yeeahhh. I can relate to a few too many myself.

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fishofdeath said...

I think this could be a really useful tool, not necessarily for diagnosis, but for tracking and monitoring, which seems like what it's designed for anyway. I find that it can be hard to see the symptoms of depression in myself, and I think something like this would be helpful.
"Wow, I've said I'm usually tired/hungry/anxious/sad for the last four weeks, maybe it's not just a bad day and I should talk to my doctor."