Disclaimer: 

***Please be advised that this episode discusses depression, social anxieties and suicide, if you or a loved one are struggling with your mental health, don't hesitate to contact the National Suicide Prevention Lifeline (https://suicidepreventionlifeline.org) or the Samaritans (https://samaritanshope.org).***

Brigid: Good morning everyone and good evening! I’m Brigid -

Sam: And I’m Sam, and we are your hosts for this installment of Coffee and Conversations!

Brigid: Welcome! Coffee and Conversations is a monthly interactive sit-down event hosted by CSOFT. Every month we’ll feature honorary guests and experts from a diverse range of industries and fields to lightly discuss topical themes important to the life sciences and language services industry. So, sit down and relax, pour yourself a coffee or a hot drink and enjoy! 

Brigid: This month, we are joined by our special guest, Dr. Nelson M. Handal from Clinicom to discuss the importance of mental health awareness.   

Sam: Mental health issues are truly global in nature. Before the COVID-19 pandemic, 1 in 10 people around the world suffered from mental health disorders. In the current Covid-19 crisis, the number of people, particularly young people, living with a mental health Illness is rapidly increasing worldwide. To give those suffering from mental illness the help they need, delivering an accurate diagnosis quickly is vital. 

Brigid: That’s so true, Sam. As it is such a global issue, with so many people impacted, it is also important we all learn about how to help a loved one in need. 

Brigid: Ok, now let us introduce today’s guests: Dr. George Handal and Ms. Shunee Yee.

Sam: Dr. Nelson Handal is the Founder and President of Clinicom, Clinical Faculty at the Alabama College of Osteopathic Medicine in Dothan, Alabama, a Distinguished Fellow of the American Psychiatric Association (DFAPA) and is a Diplomate of the American Board of Psychiatry and Neurology. For the past 20 years, Dr. Nelson M. Handal has been the Founder, Chairman, and Medical Director for Dothan Behavioral Medicine Clinic - a large and modern mental health clinic in Alabama. He is also the Founder and Medical Director of Harmonex Neuroscience Research, where he participated in clinical research as a primary investigator in over 80 clinical trials for the past 14 years. Dr. Handal has won numerous awards, including the Heroes in the Fight Award given by Mental Health America, and Excellence in Public Mental Health Award given by the National Alliance on Mental Illness (NAMI). In addition, Dr. Handal has been recognized as one of America’s Top Psychiatrists given by the Consumers’ Research Council of America.

Welcome, Dr. Handal! We’re glad you can join us today!

Brigid: Ms. Shunee Yee is the President and CEO of CSOFT International and CSOFT Health Sciences, which provides end-to-end medical translation services for all phases of the product lifecycle, market access consulting, medical writing, and CTD/eCTD submissions with the FDA, EMA, and NMPA. Shunee is passionate about education and has contributed to Michelle Obama’s Let Girl’s Learn Initiative, the Hopkins-Nanjing Center for Chinese and American Studies, and the Dexter Southfield School. Additionally, Ms. Yee serves as co-chair for the Joslin Diabetes Center’s A Taste of Ginger 2021 committee, supporting the Asian American Diabetes Initiative (AADI).

Welcome Shunee, thank you for joining us!

 Shunee and Dr. Handal, the floor is all yours!

Shunee:  Thank you so much, Brigid and Sam for that nice introduction. Good morning Dr. Handal!  

Dr. Handal: Hi Good morning!

Shunee: Good. Thank you so much for joining us today, Dr. Handal. Before we get started, for those of you who may not know, Clinicom is a transformational digital technology, using adaptive machine learning algorithms to offer online assessment for over 55 mental health conditions. It customizes questionnaires for targeted mental health assessments to provide physicians with precise information prior to seeing the patient, eliminating misdiagnosis. So, Dr. Handal, do you mind sharing with us what was your main vision behind Clinicom? What has Clinicom accomplished so far? Where do you see more opportunities ahead for Clinicom?

Dr. Handal: First of all, thank you for inviting me to participate in this podcast, thank you to Sam and Brigid and thank you to you, Shunee - it's been a real pleasure to meet you!  So, what prompt me to think about Clinicom 14-15 years ago, was the fact that in psychiatry, we need a lot of information, and the information needs to come from the patient. We don't have x-rays or lab work, we didn't, now there is a little bit of technology we can use - like pharmacogenetics and things like that. But at the end of the day, the important thing is to get as much information from the patient as you can. So, over the years, we have been limited in terms of time and the expectations of time to assess patients and the expectations that our patients need to get to the psychiatry to get medicine as quick as possible and refer them to therapy - the paradigm that most doctors use. I became really concerned - this is not what we want to do because we want to learn as much as possible from these patients. We want to know about their upbringing, their childhood issues, trauma issues, we want to know if they were prenatally exposed to any factors that may be afflicting their growth, we want to know if their education...what does education look like for them? It can be a huge stressor for some patients. Then we want to know their family history, we want to know their job history, you know not having a job is a big deal, you know. So, if for instance, you ask a patient, 'Ok, what is the reason you are coming here?' 'Oh, you know it is because I am depressed', there are 9 questions for depression, if they have 5 out of 9 questions for 2 weeks, and those are impacting their life, you give them the medicine, that's it. And it cannot be like that. We were, before, when I trained, we were trained to assess the patients for several hours but then if you assess patients for many many hours, maybe don't come to a conclusion, and you don't offer a solution, you know as they expect. Plus, the insurance companies will not pay you to assess patients for hours and hours and hours and not decide what you are going to do. So, I thought about Clinicom as a solution for that. Back then, 10-15 years ago, it was impossible to do Clinicom the way it is now. But overtime, it become what it is now, we had a lot of challenges, I thought it was going to be easy, you know. One thing is to just digitize a form, an inert form with questions, and the other thing is the make questions that are intelligent, that go from here to here based on the answer. The other huge challenge, ok, you want the patient to sit down maybe one time and see if you can illicit us as many conditions as the patient may have, instead of just doing one questionnaire for depression, or one questionnaire for anxiety. So that has been the challenge - you have to have all the questions, but you have to be mindful of the time. So, these questions need to be answered within a very reasonable time. 

Shunee: Yea, so Dr. Handal, I remember you told me, ‘Better treatment from better data'. So we all know how difficult it is to ask questions and ask them smartly when you're seeing a new patient. Can you describe how Clinicom enables objective data collection? And how does your machine learning algorithm customize those questionnaires for target assessment, for both new assessments and for follow up assessments? Let me ask Sam or Brigid to bring up, we have some screenshots of what the Clinicom report looks like. Dr, Handal, if you don't mind, could you share your perspective on how Clinicom's AI could become a gamechanger in mental health diagnosis and wellness - saving lives! 

Dr. Handal: Right, so you know, Clinicom has a feature that is the gamechanger, basically. Once the conditions are suggested, based on the answers of the patient, the clinician can look at the possible conditions, like you see on the right side, and then accept or reject, rule out or deny the condition. So, based on the answers the clinicians give, then the matching learning process can start, you follow me? This is a patented technology where we learn based on the physicians accepting or rejecting the conditions. On the other hand, if the patient, let's say, has a very close possibility of a diagnosis, but it does not meet criteria for that diagnosis, then we can talk to the patient and see if the answers were consistent with the diagnosis or not. For instance, if you need six positive answers and they have five, but they show that it is impacting them, we can modify the question in a certain way so that patients may have an easier time in terms of answering. All the questions are rated by teachers who teach eighth grade level so the question quality and then quality of the clinicians responding to accepting or not the diagnosis is the key to everything. Over time, we have had the opportunity to use Clinciom for so many years in sort of pilot programs, let's say, we had 40 pilot programs and they would give us feedback on what was not working right and what questions didn't work right. It is extremely difficult to have this algorithms work. We have developed our own algorithm builder. So, you need a platform that you need to put the questions on, and the questions need to have an algorithm guide. So, because it was so difficult to use other algorithm builders, the first one we used was out of Germany but with time we developed our own, that is absolutely the key. With our algorithm builder, you can visualize where the questions are going, how the questions will be answered. We have a meeting once a week where we look at the algorithms, if anything is not working right and we have to discuss how to fix a question or condition, so it is very intensive work. One this is the technology, the AI, and then the other is the clinical part. So, the fact that we developed Clinicom in a clinical setting and a research setting, is extremely important!

Shunee: Yes, thank you, Dr. Handal! So just to follow up on this question on technology, you know, like you said, each time, you see a new patient, it takes one hour, it's hard to build the report within an hour to ask the questions. I remember one of the stories you told me, how drastically different the assessment was when a mother brought her teenage boy in and using Clinicom and using the traditional way to assess, there were completely different results so that matter is so critical to saving lives. Could you elaborate, tell our audience that story? I thought that was so vivid and gives people an idea on just how the subjective/objective data collection is so critical. 

Dr. Handal: Yea this case, it really illustrates the value of Clinicom. Briefly, this patient is 15 years old, extremely shy. He has what we call social phobia so he, on telehealth, he couldn't even be on the camera. He was trying to hide on one side or the other, he wouldn't even be able to talk to you straight. If we would have had that patient in the office, I am sure he would not talk to us, he would have shut down completely. But we, the mum did Clinicom and he did his part of Clinicom, which is important because Clinicom can be used by the third party, like this mother, or the grandmother, or whoever, starting from 5 years of age, adolescents they can do their own piece and the parents can do their own piece. So, in this case, I talked to the mother first, I looked at her Clinicom and she was worried that he was depressed because he was not talking to people, he was in his room all the time. She felt that he was interacting less and less and less with other people and with the family. So bottom line was that she saw him as a depressed teenager, never said a word about him trying to commit suicide or having psychotic episodes or hallucinations, absolutely none of it. When we looked at the Clinicom that the patient completed. Now I can make a parenthesis - for a lot of young people, especially young teenagers, the screen is where they connect well. For instance, a lot of kids can play video games and talk to other people playing that video game, but you want to talk to them, and they will shrug their shoulders, it is not something that they are very familiar (with), believe me! They smile more at the camera and at the screen than with other people. So, this young man, completed his Clinicom in a really, very elaborate way, so elaborate that the mother was shocked, I was shocked, because he was reporting that he had attempted to commit suicide, several times. The mother started crying. She said that there was family history of schizophrenia in the family and that was shocking because if I had listened only to the mother, if this kid didn't have the opportunity to use Clinicom, we would never have known what was going on. That is the bottom line, really.  

Shunee: Yea, thank you Dr. Handal. That is a great story. So, when we talk about Clinicom and really trying to eliminate misdiagnoses, I remember we were talking about, particularly in the young generation or in a particular age group of a population (they) have social anxiety, ADHD, bipolar, and often people, patients come to you saying, 'I cannot sleep'. So how does Clinicom actually objectively diagnose and avoid misdiagnosing, you know, (instead of) subscribing sleeping pills, so can you elaborate on that one?

Dr. Handal: Thank you, that is another extremely good question, Shunee. So, for instance, a patient can come in and say, 'I have problems sleeping', like you were saying and then if I am just a regular psychiatrist without Clinicom, I would say, 'Ok, we will look for depression, anxiety, sleep disorder, restless leg syndrome, all of these things'. But if you have Clinicom and the patient says they cannot sleep and they put there that they have nightmares, and that the nightmares are associated with some traumatic event that happened, and you look at PTSD symptomatology on Clinicom, they may have PTSD because of a trauma that they didn't want to tell anybody else (about). They feel a little more comfortable to do it on Clinicom. Or, they may have bipolar disorder and they don't sleep because they have bipolar disorder. Clinicom asks all the questions for bipolar disorder. It takes eight years for an average patient with bipolar disorder to be diagnosed, that is unfortunate, it's just mind boggling. So, the value of Clinicom is...I'll give you another example, let's say a patient comes, a middle-aged woman comes with problem of sleep and problems of anxiety. They do their Clinicom and they meet criteria for ADHD, never diagnosed before. We did Clinicom study looking at the data and 67% of women who have ADHD have insomnia associated with ADHD and nothing else. We really didn't know much about innate insomnia associated with ADHD. So because of Clinicom, you know, I say, 'You have symptoms of inattention, that are severe, has anyone talked to you about it?' Then they start thinking, 'Oh yea, and I had to quit college, and I have relationship problems because of my attention problems, I was fired 3 times in the past 7 years.' If you don't treat the ADHD, that this patient didn't come complaining about, then this is not going to get fixed. If you don't have Clinicom, you will not find out.
 
Shunee: That is an excellent example! So this has actually led me to one last question as we do want to open the floor for audience to ask questions. So you told me Clinicom used to receive an average 12-15 calls for new patients per day but after the pandemic now you see the calls you have received have tripled, now you see 35 calls from new patients per day. How are your patients effected by the pandemic, what are the age groups effected most, and do you have any tips on how to overcome stress and anxiety during this challenging time? 

Dr. Handal: So that is absolutely true. You know, the levels of anxiety and depression tripled with the pandemic, this is data that is published. We have seen it in our clinic, in research. The problem with the pandemic, is that people were isolated, that is the number one problem. They were lonely and loneliness and hopelessness are the main contributing factors for suicide, so it is a perfect scenario. You are lonely, you cannot talk to your family in person or your extended family or your friends. You are hopeless because you don't know when the pandemic is going to end. What is going to happen?  I am talk about several months ago, right? But I have family in Spain and they still don't know how things will end. So, they still feel hopeless. So, hopelessness and loneliness, those are the contributing factors for suicide, but those are the factors that increase anxieties and depression, and psychosis too. So, we have 800,000 deaths due to suicide around the world. Sam was talking about that, a moment ago. So, the statistics are absolutely crazy and if you think about it, if you think about it, at least in the US, 1 in 5 Americans have problems with mental health but that number is now higher. So, in the age group from ages 15-29, suicide is the second leading cause of death. So, what happens with 15-29 years olds? They are starting to get out of the house, becoming social with big groups first when they're 15, they start having relationships, all of that was almost cut off, and they couldn't do what intrinsically they are supposed to be doing which is go to the world, check it out, get some relationships out there, they couldn't do. That effected that age group tremendously. I think it is probably the most effected age group. The second group that was tremendously effected are mothers who are in their 20-40s because they have to take care of the kids, they have to work, probably remotely. They are, I have so many nurses that are my patients, one of them was living in a hotel because she didn't want to go to hospital, work and then bring COVID to her children, at home. Women were tremendously affected. I feel extremely bad because to go to work, they need childcare, and there was no childcare. They couldn't leave their children with the grandparents. It was absolutely devastating and still is in many parts of the world. I think those are the two age groups that are mostly affected but I don't want to say that they are the only groups effected, but the groups that were most effected.
 
Shunee: Thank you, Dr. Handal. Let me just give it back to Sam and Brigid. I know we kind of starting to see so many questions. I want to make sure the audience has the opportunity to answer some of their questions. Sam and Brigid, take it over.
 
Brigid: Thank you so much for such a very interesting discussion, Shunee and Dr. Handal. We do have some exciting questions that we would love to ask you, Dr. Handal. They are a mixture of...there are some questions about Clinicom, there are some questions about mental health and then there are some questions close to people's hearts, about their family. So, I will start with the Clinicom ones. So, number one: Are there any other digital assessment tools similar to Clinicom's and if so, what sets Clinicom's technology or Clinicom's digital assessment tool apart?

Dr Handal: Ok, I think there are some, but I think they are very limited to certain conditions. They may be for depression and anxiety, or they may be for quality of life. What sets Clinicom apart is that in one setting you can assess more than 55 psychiatric conditions, at one time. That is the big difference that Clinicom offers. Another difference is, for instance there is a suicide assessment online, but you know to do a very thorough suicide assessment, it's so important to see who...you remember Ernest Hemingway, his dad committed suicide, his sister committed suicide, well the risk increases if there is this level of suicide in the family. Clinicom asks that question, if you have more than two or three or four psychiatric conditions, your risk of suicide increases. So as Clinicom is assessing the number of conditions, it is putting more weight on the risk. If you drink alcohol or use drugs the risk is much higher. So those are the things that, the psycho-social component of Clinicom and putting the weight on the suicide risk items, that is what makes Clinciom completely different among other things.
 
Brigid: Right, no that sounds so impressive! Thank you so much. S,o the second question I'll do on Clinicom and then Sam can move on and ask you some of the Mental Health questions. The second one is, and you spoke about this in your discussion with Shunee, what were the biggest challenges in developing and choosing the right questions to include in the diagnostics tool?
 
Dr. Handal: That was the most difficult part, honestly. Ok for instance, developing questions is an art. After doing this for so many years, I realized it is not so simple, to just ask a question. Even as a psychiatrist you sort of polish your way in terms of asking questions: do I ask an open-ended question, or do I ask a direct question? You have to know exactly how to ask questions. So, to do it in a digital way, in a digital format, it brings all these challenges, so definitely asking questions the right way was very difficult. You have to also think about this also, this needed eighth grade level questions. But are you formulating the question in a way that really looks for the answer that you're looking in and not other answers? I can give you some examples of that, but we really don't have too much time. On the other hand, the other issue with developing question, when you're expecting the patient to answer a question and you have two or three or four possibilities, they have to be clearly different. They cannot be, like in a test, they can be sort of the same, and there is one correct answer, you cannot do that with these questions, they have to be clearly different. Just with experience and patients telling you, 'Oh I didn't understand,' that is how you learn to polish those questions.

Sam: Thank you very much, Dr. Handal. We have a couple of questions here to ask about Mental Health. the first one is: Do you have any advice for how to reassure members of the Mental Healthcare community to help them prepare for helping so many patients this summer/fall in the US? 

Dr. Handal: We have two types of patients: the patients who prefer to do it online on telehealth and patients who are dying to see you again. The patients who want to come in are not only patients who saw you before, these are patients who you've never seen. I saw a patient first the first time yesterday that I have never seen in person, and I have been treating that patient for eight months and they're so glad to see you. We need human connection! I came to conclusion that it is so important to see these patients live. On the other hand, it is important to give them the option of doing telehealth because they may live far away, they may be very scared to drive, there are so many points. So, the best advice I can give to other clinicians is as long as you can, because of the insurance issues, let your patients choose if they want to do telehealth or if they want to do in person, let them choose, that is the most important thing I can say.
 
Sam: Thank you. You know it's very important, a lot of what we do at CSOFT comes back to patient centricity and it sounds like that is exactly what you are describing as doing what is best for the patient. One other question then I will leave it to Brigid to ask the last one about Family. One question that was pretty interesting is, we'd like your insight on, is, do you have any tips for overcoming lack of motivation during the pandemic, or what would you say to that?
 
Dr. Handal: So, a lack of motivation can be...the cause can be that you don't have full blown depression but, lack of motivation can be one of the symptoms. Lack of interest, lack of motivation, lack of drive and other symptoms associated with energy. I see depression as your energy is going down, because you use your brain too much, so you don't have enough energy and that can lead to a lack of motivation. So, motivation can greatly improve if we eat right, if we exercise, if we are outside, and if we socialize. So, if you don't have motivation, call a friend! Just a call and see how they're doing, what they're doing, try to get a morning coffee like we're doing today. I am sure everyone is more motivated today after the talk than before the talk! Connecting with people, we're social beings, I think that is a big lesson from the pandemic. So, I have for instance three very good friends, and we see seldom see each other. My wife has very good friends. What we have seen is her friends get together more often, our common friends. I think taking the step to activate your connections is the most important thing you can do to improve your motivation... along with going outside, getting sun, seeing nature, eating right. I became a vegetarian two years ago, it's hard but It's a good way to start.
 
Brigid: Right, it's so true to keep those connections for sure. So, there is one from the collection of family-centered questions that I will ask. What can parents do to monitor and improve the health of their teenagers?
 
Dr. Handal: The most important thing a parent can do to improve the mental health of their teenagers is to listen. If your teenager wants to talk to you, they need to feel that you're listening. They need to develop trust and a firm relationship with the parent. Naturally, by nature, teenagers devalue their parents because they're getting ready to exist the home. So (they'll say), 'You're not that good, you don't know, what do you know?' So, all these things that are associated with being a teenager, we have done the same thing, I have even done that! I have four sons; they all did the same thing. If I am ready to listen to whatever they want to talk about. I am not going to judge them, and I will advise them if they want (me) to. I think that is the best advice to give parents to deal with their teenagers. I have seen so many parents who are extremely judgmental of their kids. One thing is to be judgmental that is associated with being authoritarian and the other is to be open and authoritative, which is different. So that level of connection with your teenagers is so important. From their own inertia, they are trying to exist the house - 'You're not good', So (they) devalue you, 'I am going with my friends'. On the other hand, you have to as a parent have this very delicate balance between having the independence that these teenagers want versus safety. You have to find that balance between them both.
 
Shunee: That is an amazing comment, Dr. Handal. I have a teenage boy by the way, being able to listen to them and listen carefully and balance that, that is so important. So, I just want to ask one last thing, I know mental health has such as global impact and so I know you just released Version Eight of Clincom in English and are working on different languages. We know many of the audiences are coming from outside the US, what are the other languages you are working on and how soon can we see that released to the market.
 
Dr. Handal: So, Version Seven already was translated into Italian, Spanish, Chinese and Portuguese. So, we have to work very hard to make that available in Version Eight. We want to translate it in as many languages as possible. We have the University of Alabama helping us with some of that. That is why I admire you, Shunee. This is amazing what you do - people don't understand how hard it is to do translation into as many languages as possible! From a research program wanting to do the same research in Beijing to Holland - no problem! My goal is that I wish every possible thing we can do to translate in as many languages as possible. next year we will have probably have 10 languages, you're the expert on that, Shunee, I'll have to talk to you!

Shunee: Wow, thank you, Dr. Handal! I think we are all so inspired how you want to bring this technology worldwide, thank you so much! Going back to Brigid and Sam.
 
Sam: Thank you very much, Shunee and Dr. Handal. Unfortunately, I think that is all the time we have for questions today. On behalf of CSOFT Health Sciences, we sincerely thank you Dr. Handal and Shunee, for this fascinating and insightful discussion on mental health as well as some of the resources available for people just to get help.
 
Brigid: So true. If you loved this podcast episode, tune into our next one on June 24 on medical affairs with a special focus on collaboration without borders, the same theme as the upcoming DIA Global Annual Meeting held from June 27th-July 1st.

Sam: So, whether it is morning or night, thank you so much for joining us and we hope you are all have a good day wherever you are. We hope to see you next time!

Brigid: Thank you so much, everyone!
 
Shunee: Thank you so much - thank you Dr. Handal!
 
Dr. Handal: Thank you!

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