Solve for happiness: Some thoughts on big data/AI and mental health

We are hearing a lot about the use of big data at the moment, mostly that it has been an underhand way to manipulate people politically, that has been used by those with no ethical compunctions to get people to vote against their own best interests*, and in favour of Brexit and Trump. Cambridge Analytica and AIQ seem to have commercially exploited academic research and breached data protection rules to try to nudge political behaviour with targeted messaging. Whether or not that was successful is up for debate, but to the public the narrative is about big data being bad – something technocrats are exploiting for nefarious reasons. I can understand that, because of the associations between gathering data on people and totalitarian political regimes, and because of concerns about privacy, data protection and consent. There is increasing awareness of what had previously been an unspoken deal – that websites harvest your data and show you targeted advertising, rather than charge you directly for services, and the new GDPR means that we will be asked to explicitly consent to these types of data collection and usage.

But what about the potential for big data to do good? I know that DeepMind are doing some data crunching to look at whether AI algorithms can help identify indicators that determine outcomes in certain health conditions and point doctors towards more effective treatments. Their work to identify warning signs of acute kidney injury was criticised because of breaches to data protection when they were given access to 1.6 million medical records without individual patient consent, but whilst the data issues do need to be sorted out, the potential for projects like this to improve health and save lives is undeniable. Computers can look through huge amounts of detailed data much more quickly and cost-effectively than humans. They can also do so consistently, without fatigue or bias, and without a priori assumptions that skew their observations.

Research often highlights findings that seem counterintuitive to clinicians or human researchers, and that means that using the data to generate the patterns can find things that we overlook. One example I read about today was the fact that admitting offending behaviour does not reduce the risk of recidivism in sexual or violent offenders (in fact those who show most denial offend less, whilst those who demonstrate more disclosures and shame are more likely to reoffend). But this is also true about telling people they are being given a placebo (which will still produce positive placebo effects), using positive mantras to enhance self-esteem (which seem to trigger more negative thoughts and have a net negative impact on mood and self-esteem) or about expressing anger (rather than this being cathartic and leading to a reduction in anger, it actually increases it). Various fascinating examples are listed here. There is also the well-known Dunning Kruger effect, whereby ignorance also includes a lack of insight into our own ignorance. As a population, we consistently overestimate our own ability, with people in the bottom percentiles often ranking themselves well above average.

I often refer to the importance of knowing the boundaries of your own competence, and identifying your own “growing edges” when it comes to personal and professional development. We talk about the stages of insight and knowledge developing from unconscious incompetence to conscious competence, and finally to unconscious competence where we can use the skill without conscious focus. Confucius said “Real knowledge is to know the extent of one’s ignorance.” And it may well be that when it comes to solving some of the big problems we are limited by our own frame of reference, what we think of as relevant data, our preconceptions and our ability to build complex models. Using giant data sets and setting technology to sift through and make sense of them using various paradigms of AI might help open up new possibilities to researchers, or find patterns that are outside of human observation. For example, certain medications, foods or lifestyle traits might have significant impact on certain specific health conditions. I am reminded of a recent article about how a third of antidepressants are prescribed for things other than their primary function (for example, one can seemingly help with inflammatory bowel disease that has very limited treatment options). A computer sifting through all the data can pick up both these unintended positive effects and also rare or complex harmful side-effects or interactions that we may not be aware of.

What difference could this make in mental health? Well, I think quite a lot. Of course many predictors of mental health are sociopolitical and outside of the control of the individual, but we also know that some small lifestyle changes can have very positive impacts on mental health – exercising more, for example, or having a healthy diet, or getting more sleep, or using mindfulness, even just getting outdoors more, learning something new, doing something for others, or spending more time with other people (and less time on social media) can have a positive impact. There are also many therapy and therapist variables that may make an impact on mental health, for people who engage in some form of talking therapy, although variance in outcomes seems to actually boil down to feeling heard and believed by a therapist who respects the individuality and cultural context of the client. And of course there are many medical treatments available.

So is there a way of using big data to look at what really works to help people feel happier in their lives? I think the potential for apps to collect mass data and test out what makes impact is enormous, and there are a proliferation of apps in the happiness niche and more that claim to help wellbeing in a broader way. They seem to have found a market niche, and to offer something positive to help people make incremental life changes that are associated with happiness. What I’m not sure of is whether they reach the people that need them most, or if they are evaluating their impact, but presumably this is only a matter of time, as real life services get stripped back and technology tries to fill that gap.

I think there is huge need to look at what can make positive change to people’s wellbeing at a population scale, and I think we need to be tackling that at multiple levels. First and foremost, we need to make the sociopolitical changes that will stop harming the most vulnerable in society, and encourage greater social interconnectedness to prevent loneliness and isolation. We need to increase population knowledge and tweak the financial incentives for healthy lifestyle choices (eg with much wider use of free or subsidised gym memberships, and tax on unhealthy food options). And we need to invest in preventative and early intervention services, as well as much more support during pregnancy and parenting, and in mental health and social care. But I can also see a role for technology. Imagine an app that asked lots of questions and then gave tailored lifestyle recommendations, and monitored changes if the person tried them. Imagine an app that helped people identify appropriate local sources of support to tackle issues with their health and wellbeing, and monitored their impact when people used them. As well as having a positive immediate impact for users, I’m sure we’d learn a lot from that data that could be applied at the population level.

*I think the evidence is strong enough that the demographics who voted for these people/policies in the greatest numbers are the very people who have come out the worst from them, so I am just going to state it as a fact and not divert into my personal politics in this blog, given I have covered them in previous topics about Brexitmy politics, “alternative facts”, Trump, why and what next, the women’s march, and Grenfell and the Manchester bomb.

What is wellbeing?

A typical GP appointment is 7-10 minutes long. Therefore it was no surprise to me that when I started talking to my GP about my blood pressure a couple of months ago and diverted to talk about my lack of energy, I was referred to the “wellbeing worker” linked with the practise. There was a five week wait for an appointment. I sat in the waiting room at the designated time wondering if this was a new name for a practise counsellor, or an offshoot of IAPT linked to physical health, or whether it was a specific scheme designed to get people eating better and doing more exercise. When she invited me in the wellbeing worker introduced herself and said her remit was to work with people about “diet, exercise, smoking, drug use or to improve your wellbeing”. She asked me to rate my wellbeing on a likert scale for six variables.

So I diligently explained that since being rear-ended by a lorry 2 years ago, I have not been able to make a full range of movement with my left shoulder. This meant I had been unable to continue weight lifting. I also had to have 3 teeth removed and then had a very severe ear infection, causing some other health complications I detailed in an earlier blog. I told her that I have had intermittent earache, headaches, and a feeling of being underwater, which are exacerbated by changes in pressure or getting my ears wet so I had stopped swimming. I have also had ripples in my peripheral vision and a general lack of energy and motivation. I explained that the combination has meant that I had stopped my three times a week gym-and-swim habit and reduced to a fairly sedentary lifestyle with occasional longer walks.

I mentioned that been overweight for my whole adult life, and I had drawn some psychological links to the root of this. I explained that I am fairly comfortable with the idea of being overweight but that stress may have contributed to my more recent problems. I was of the opinion that there is clearly a significant physical component to my health issues, as it has transpired I am anaemic and vitamin D deficient as well as having high blood pressure. But I acknowledged that there is also a lifestyle component, as I had reduced activity and gained weight over the preceding months, and I acknowledged a substantial stress component too.

I noticed that the wellbeing worker had not taken any notes beyond “weight” and “exercise”, so I paused and tried to clarify her role. I asked what professional background she came from, expecting to hear she was a nurse, health worker or psychology graduate. “I’m an admin” she said, and explained that she had taken the job during a reorganisation, having been told that it was predominantly administrative. She said she had initially worried about what she would do if told about problems she didn’t know the answer to, but her manager had been reassuring that it wasn’t her job to solve everything and she could report any concerns to the appropriate person.

It turned out that her job was to identify which pathway to put people onto, from a choice of weight management, exercise, smoking cessation, drugs or alcohol and then fill in the paperwork to make it happen. She booked me in for the weight management group, and gave me a referral to the local council run leisure centre for 12 weeks free membership.

Don’t get me wrong, those things are good low-level interventions. The weight management group is friendly and non-shaming, even though it is pitched at a simplistic level, and I completely endorse exercise on prescription schemes for improving physical and psychological wellbeing. But where was the space to actually talk about what was going on my life? The website for the wellbeing service says:

‘Wellbeing’ means feeling happy, healthy and content in life. Our wellbeing can be affected by our physical and mental health, the people around us, the place that we live, the money that we have and how we spend our time. Our Wellbeing Workers can help you to identify and prioritise changes you might want to make to improve your overall health and wellbeing. They offer lots of support to help inform, motivate and empower you [including through] … Support with confidence issues and to improve self esteem

They offer services to reduce social isolation and assistance to address issues such as debt, housing and education (though this branch appears to prioritise people who have an intellectual disability or socio-economic deprivation) but the only mention of mental health or psychology is in relation to the specialist branch of the weight management pathway for people with BMI over 45 and those considering bariatric surgery. There are also leaflets linked from the weight loss section of the website which talk about “finding happiness” (helpful habits) and “mastering your thoughts” (basic CBT intro) and “relaxation and stress relief” (mindfulness, visualisation/anchoring, breathing exercises). But I was never even told these existed, and even when on the website I had to use the search feature to find them, and as far as I could tell there was no connection to the local IAPT service.

Six weeks later the wellbeing worker rang me up again, to see how I was doing. But again, she didn’t really want to know how I was doing psychologically in any meaningful sense. She wanted to know if I had followed the pathways she had offered. She asked me to give the six ratings again. It felt pretty hollow giving more positive scores, as I didn’t feel like the services provided by the wellbeing service were responsible for the changes – I had lost 10lb in weight before I joined the weight management group (and 2lb since), and feel better because I have more iron, more vitamin D, lower blood pressure, more energy and less pain.

So I was left feeling that it was a service that I was glad existed, but it seemed to tackle symptoms in isolation to their causes, and didn’t seem to connect physical and mental health. I’m guessing that is because public health is still local authority commissioned, whilst mental health is within the NHS. Wouldn’t it be nice if there was a single point of entry to this kind of wellbeing service and IAPT? Surely that would reduce stigma and mean that both symptoms and cause could be addressed, and patients would be able to tackle the interwoven issues of mental and physical health together.