Artificial Intelligence in mental healthcare

Artificial Intelligence in mental healthcare design strategy for people

Thesis Master Studio_Material Performance_Workspaces of the 21 st century_Krassimir Krastev_Alvaro Valera Sosa_by_Djamila Pietzner

Contents 1 Introduction 1.1 Abstract 1.2 Introduction

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2 Research/ Background 2.1 Current situation in mental health care-Portugal 2.2 Characterization of personality disorders 2.3 General trends and needs in mental health systems 2.4 Case study Trieste mental health 2.5 Supportive technologies for mental health care

15 19 27 31 37

3 Thesis statement

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4 Methods 4.1 Manual and computational network design strategies 49 4.2 Strategy of centralized and decentralized systems by the use of AI technology

54 5 Protoype Mental Health Center 5.1 Architectural Development 5.2 Visualization Images 6 Conclusion

61 73 87

7 References

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“The fact that psychiatric hospitals do not meet the objectives of assistance and care, since they operate according to the rules and laws of public order and social control; in effect they are the producers of the disease.� Franco Basaglia

Abstract This thesis project deals with new technologies in mental health care treatments. Combining common ways of treatment, looking at architectural typologies in psychiatric care, including evidence based design strategies and adding the use of Artificial Intelligence technologies, this thesis project develops a different view on how patients can be accessed and integrated into the society. Taking the mental health care system in Trieste Italy as a case study, this project will create strategies to improve mental health care workflows, enable a 24/7 access to mental health care treatments and create a balance between staff and patients. It will try to improve the current mental health care strategies, by proposing a new way of an adaptive systems by the use of Artificial Intelligence technologies which will be combined with the existing strategies of treatment.

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Introduction “Personality and personality characteristics of a human being are an expression of its typical behavior and interaction patterns that correspond with the socio-cultural requirements and expectations and to fulfill his interpersonal relationships in search of a personal identity with meaning.”

In Portugal the majority of resources are concentrated in 3 major Portuguese citites, and allocation of resources to other parts of the countryhas proved dificult. Psychiatric hospitals in Portugal still consume the majority of resources (83%) , despite evidence indicating that that community based services as in Trieste Italy are more effective and acceptable for users and families. In 2010 the WHO says that , people with mental illnessess like schizophrenia, bipolar disorder,depresseion alcohol use disorders , intellectual delays e.g. , besides their vulnerability are largely been overlooked by development programs.

The WhO estimates that 152 milion people suffer from depression, 26 milion from schizophrenia, 125 milion form alcohol use disorders, 40 milion fromepilepsyand 24 milion suffer from Alzheimer and other demtentias.There are yearly probably 844 000 cases of suicide. Therefore in lowincome countries , depression is a major issue, closed to malaria (3,2 % vs 4.0%), but still funds invested to combat it are are a very small fraction of the total allocated. Furthermore the World Health Organization assumes that depression is predicted to be the second leading cause of global disability burden by 2020.

To provide the best architectural circumstances to its user the knowledge of an architect should not only come from the architectural site of things and should also be aware of the disorders, its symptoms and ways of treatment, but mainly focused on the patients, family and staff needs during a stay in those kind of care centers. These days in our society we have to deal with a high rate of different mental disorders, which is due to the redevelopment of psychologists, being more accurate in defining diagnostics to individuals that show an “abnormal” behavior according to society expectations on the one hand, on the other hand due to the rapidly changes.in our society and the treatment to people in different state of ages the same as experiences ( psychotics, loss etc. ) in life which brings some people out of the control of the environment they live in. As an _4_

example in Germany the range of mental problems goes up to almost 50 % percent of the german society. Which goes from low mental problems in case of stress up to high mental problems which deals with different personality disorders from anxiety over depend to antisocial disorders, that makes the patient not only harmful to himself, followed by suicidal behavior same as uncontrolled behavior in front of others which can go from psychologically stress to highly uncontrolled harmful behavior to others. Therefore this thesis projects focuses on the one hand on a system that integrates the client within the society and illustrates the necessity of Artificial technology integration.

While Artificial intelligence for people unfamiliar with, may think of AI technologies as mysterious computers that occur at some for of time in the future, AI technologies and techniques are in fact already at work all around us. The field of artificial intelligence was given its name by the computer scientist John McCarty who along with Marvin Minsky, Nathan Rochester and Claude Shannon , organized “The Dartmouth Conference” in 1956.

AI technologies are for example used in manufacturing and finance functions, automobiles and aircraft guidance systems, smart mobile devices like Apple´s Siri (voice recognition software) AI technologies enable us to solve problems and perform tasks in more reliable, effective and efficient ways, than it has been possible without them.

Behavioral and mental health care fields are also already benefiting. For example AI technologies can assist health care professionals with clinical decision making, diagnostics and testing. Robotics for example has an enormous potential to improve how care is provided. Furthermore the integration of data from other intelligent devices such as environmental sensors, wearable and biofeedback devices, can further customize services to the clinical needs of patients.

What is digital technology able to do, to improve the way services are delivered?

Improving the mental health of the population is a significant challenge digital techologies may provide us with new ways of promoting positive mental wellbeing and earlier intervention. A big amount of people do not currently seek treatment. The Centre for Economic Performance’s Mental _5_

Health Policy Group report estimates , that 75 per cent of people experiencing depression and anxiety-related problems do not access treatment.

While on the other hand more and more people now use online resources to check symptoms, find out information about NHS services, and what treatment options they might commonly expect to be offered. Additionaly people are increasingly accessing the internet through their mobile phones.

The functionality of Smartphones and tablets continues to evolve a way that enables new types of healthcare services to be developed. Most of the people carry their smartphone with them wherever they go, making them the default device for many types of activity. Users check their smartphone on average 150 times a day (or once every six minutes), demonstrating the intimate nature of their relationship with their device.

Additionaly most smartphones have built-in capabilities for determining movement, high-definition imaging features and even thermometers, which can support a number of health and wellbeing support requirements.

As innovation continues in the mobile sector, new types of devices in development are going to appear in the next couple of years as alternatives to the current smartphone format as they are able tolearn patterns and preferences of users. This will include internetconnected ‘glasses’, most notably Google Glass, and a range of ‘smart watches’ and other wearable devices that offer alternatives to carrying a smartphone device. Natural language speech and fingerprint recognition and gesture control will offer new ways to engage with technology and opportunities for supporting better health. Work is already underway on examining the opportunities presented by personalised ambient monitoring (i.e. using wearable and environmental sensors to track behavioural data) for the management of mental health problems this is providing an early warning system for potential upcoming episodes of illness – raising both some very novel possibilities for enabling independent living, but interesting ethical questions too.

Benefits would include Advantages to deliver services via Ai technologies is accessibility, efficiency, improved self-monitoring. Better efficiency and access into appropriate care, reduced travel time, convenience and helps users and carers to be more in control of treatment. Furthermore for example computing methods for learning, reasoning and understand_6_

ing can assist health care professionals with clinical decission making , testing, diagnostics and care management. Subsequently computer sensing technology could also asses things that are not dectectable by the human eye, for example changesin body temperature recognized by infrared cameras or blood flow through the face with high resolutin digital video processing techniques.

Network design advantages via Cloud computing Cloud computing is a relatively new technology whereby computing and storage data are not based on one local computer, but accessed via a network such as the internet. Therefore it improves the access to a vast amount of data by including mobile technologies such as wi-fi, bluetooth and cellular (LTE, 4G e.g.) which could be used to better access behavioral informations about mental illnesses on seperate disorders for better understanding and intervention. research

input data

mental health issues

mobile technologies

Datacloud Behavior

human interaction

output data medical support

Economic benefits of AI technologies CDSS (Clinical decision support system) can reduce demands on clinicalstaff time and therefore improve the overall efficiency of medical care, by speeding up decision-making processes. Additionaly AI systems can help to reduce healthcare costs via stepped care approach. Stepped care is the _7_

system where the least resource intense care is provided to the most people first , with more intensive care provided to patients who need it the most. Which would improve efficiency and reduce economic burdens on healthcare systems. Another positive aspect is that intelligent machines can easily be replicated which increases accessibility and lower costs and may provide more opportunities to long-term treatments. Such users could also have periodic check-ups followed by reduced costs to healthcare providers. It is hoped that AI technlogies will provide evidence based and effective alternitives to adress the current limitations in of modern health care.

For now the global costs of mental illness was estimated to be nearly 2.5 trillion US dollars in 2010 and is projected to exceed 6 trillion dollars by 2030 according to the report of the World Economic Forum.

Methods The biggest issue in case of mental health care is the access from the site of the patient as a care seeker to recieve mental health treatment without long waiting lists .This system asks for three steps according to the mental state of the patient. The highest mental issue always needs a medical treatment, therefore the patient needs to be in a station with a high professional treatment without keeping him isolated like in a prison and a high level integrated landscape architecture as well as activity areas, but not unreal spaces to ensure safeness and silence. Common clinical typologies unfortunately represent stations to the patients controlled by cameras, barely access to nature, rare privacy places for clients and their relatives, long corridors and less territories that gives the client the feeling of being an insane . Therefore already the design of a patient room plays an important role in the whole structure, which will change according to different states of treatment ( centralization to decentralization).

Based on the elaboration of the Trieste mental health care system, which goal it has been by devoloping the law 180 to eliminate psychiatric hospitals, to bring health care services into the community, this thesis project is conceived from macro to micro. It starts with looking at the urban scale. Therefore an urban network is going to be created, by seperating Portugal into care zones, based on area, inhabitants and urban locations.

This method is based on using the grasshopper plug in Configurbanist and a manual recalculation of the zones to ensure short paths to the centers and an outbalanced availability of beds and treatment opportunities. _8_

The next step is the devolopment of a strategy how a decentralized network could be implement into the system as a decentralized strategy to access as much patients as possible fom there homes. Therefore this thesis project proposes support by AI devices to connect a homeplace with the prototype of the mental health center and answers the question how it is possible to bring the hospitals to the care seeker´s place. By an installation of a thermostat, artificial light and smells it will be used as a method to prevent uncontrolled crises. To close the the circle of this system these facilities combined with the support of mobile devices, as for example a wearable device that connects with a mobile phone and the possibility of connecting to a virtual therapist. While the room adapts to the needs of the patient by changing, temperature, light and smell. This data will be collected in the mental health center to make a decision about following steps. In case of a treatment needed at the center. The center prepares itself for the arrival of the patient. All MHC´s will be technically connect with each other, that on the one hand a patient can enter into any center where he is closed to, while the Centers communicate with each other based on machine learning.

By embeded AI technologies in the building it will collect data of the patient to submit information of their behavior to the psychologists and staff. As the building will be able to recognize patients in case of location, condition and their behavior ,which will help doctors to adapt the individual treatment, it stands like a big learning machine in this scenario interconnecting with the human.

Combined with the proposed decentralized network the mental health center itself aslo needs a network that inside that ensures a better connection between staff and patients, as it is quite unbalanced until now.

Therefore this thesis creates a staff workflow strategy which facilitate the staff by working with data collection calculated by an artificial system that learns autonomously from data added by nurses, doctors and psychologists. Analysis data, rearranges work schedueles, medicamentation and service delivery by the use of service robots. To ensure as a result more time for patient treatment.

Based on the network strategy adapted by the Trieste mental health services, which has proved over years that not only psychiatric hospitals will be needed but also great outcomes in cases of costs and healing outcomes for individuals, all data of each mental helath center will be send in _9_

between the network to produce more research data and optimize treatment for individual patients inside a mental health center and through the urban network. Therefore this thesis project is making use of different AI technologies in case of prevention and selfcare facilities.

Another problem is how patients can affectivly be controlled without threatening privacy issues. To solve this issue, a use of sensors embedded into the buiding is unavoidable. These sensor can be embeded into walls floor and also into beds. This thesis project will take advantage od these opportunities to provide security andprivacy cases and to facilitate the nurse workflow.

Another isssue this thesis wants to solve is a problem which is illustrated in general trends and needs of health care. To avoid sharp and breaking edges the prototype of the mental health center tries to avoid sharp edges as much as possible and is designed smooth and curvy to become more dynamic and reassuring on the other hand. To get rid of the hospital effect landscape architecture and the oppportunity to deliver as much natural light as possible, the mental health center will be separated in different units connected by green spaces in- and outside the building.

Design decisions The decision of the chosen location is made by facilitating a better access via private, public transport as well as walkability. The curvy appearance of the center is to avoide as much sharpangles as possible and offers the possibility to add green space trerrasses to the building. By cutting through it allows more natural light to enter to the treatment spaces. Furthermore the high transparency and use of glass and wood is to enhance a natural emergence of the mental health center like the dynamic flow of water. In addition the community building connected with a bridge to the main center intends to symbolically close the gap of general attitude of thoughts according to healthy people and people with illnessess. It tries to connect these to goups on the one hand for patients to interact more with healthy people and on the other hand to decrease prejudices in front of those called “insane�. The building program also proposes a higher quality of selfcare possibilities e.g. spaces for meditation, art workshops and lectures about disorders ( in the community building) _10_

Conceptual explanations Artificial Intelligence The target of AI is to build machines that are capable of performing tasks that we define as requiring intelligence . Such as reasoning, learning,planning, problem- solving, and perception.

Machine learning

Machine learning (ML) is a core branch of AI that aims to give computers the ability to learn without being explicitly programmed.

Natural language processing

Is the capability of machines to interpret and process human (natural (NLP) language

Affective computing Affective computing is a sub- discipline of computer science which focuses on emotion recognition by machines , emotion modeling, affective user modeling and the expressions of emotions by robots and virtual agents

Virtual augmented reality Virtual augmented reality is the use of technology for clinical assessment and treatment purposes.

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2 RESEARCH/ BACKGROUND

Current mental health care situation in Portugal Portugal population 10,732,357 SUICIDE RATE: males 17.9 per 100,000 population females 5.5 per 100,000 population estimated 804,000 suicide deaths worldwide in 2012, representing an annual global age-standardized suicide rate of 11.4 per 100,000 population, according to the most recent data available from the 2014 WHO Portugal, neuropsychiatric disorders are estimated to contribute to 25.6% of the global burden of disease

The distribution of psychiatrists between psychiatric hospitals and psychiatric and mental health departments in general hospitals continues to be very unbalanced (2.6 and 1.1 doctors respectively per 25 000 inhabitants).

Regarding 12-month estimates, Northern Ireland, and Portugal have the highest rates of mental disorders (more than 20% of the general population) Regarding the prevalence estimates of lifetime mental disorders, Portugal, France, Northern Ireland, and the Netherlands have lifetime rates higher than 30%

12 MONTH PREVALENCE AND SEVERITY Conutry Portugal

Mild Moderate Serious All 7.7% 15.5% 6.3% 22.9

Germany 4.5% 3.3%

1.2%

9.1

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Graphical representation-Comparism of the mental healt services WHO Model Model Pyramid Pyramid WHO

Logn-stay Facilities & Specialist Services Community Psychiatric Services in Mental Health Services General Hospitals Mental health services through Psychiatric health centers

Informal Community Care Self-care

Quantity of of service service needed needed Quantity

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Portugal MH Services Structure (2007)

Logn-stay Facilities & Specialist Services Psychiatric Community Services in Mental General Health Services Hospitals Mental health services through Psychiatric health centers

Informal Community Care Self-care

Quantity of service available

“The quality of services, according to the assessment made with the WHO evaluation tools, lies at a level below reasonable. Compared with inpatient units, the level of quality of outpatient services is even worse.�

Treatment Gap % of people with severe mentall illness without treatment 33.6% % of people with mid mental illness without treatment 64.9% Median delay for the beginning of Depression 5 years _15_

“We all have some idea of what an asylum would be, and we hold that as the treatment of the insane is conducted not only in, but by the asylum, so no architect is competent to plan the building unless he possesses some knowledge of the treatment of the inmates.� William D. Fearless 1861

CHARACTERIZATION OF MENTAL DISORDERS IN CLUSTERS Cluster A Schizoid PD -designates a natural tendency to direct attention toward one’s inner life and away from the external world -is detached and aloof and prone to introspection and fantasy -has no desire for social or sexual relationships -indifferent to others and to social norms and conventions -lacks emotional response

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Schizotypal PD -avoid social interaction -have no desire to interact with others or find interacting with others too difficult -often fear social interaction, think of others as harmful -oddities of appearance, behaviour, and speech, unusual perceptual experiences, and anomalies, suspiciousness, and obsessive ruminations

Paranoid PD -pervasive distrust of others -easily feels shame and humiliation -persistently bears grudges -tends to withdraw from others and to struggle with building close relationships _18_

Cluster B Borderline PD

Borderline PD Borderline Type Borderline PD Impulsive Type

-one of the most difficult personality disorders -cannot be cured -lacks a sense of self, and, as a result, experiences feelings of emptiness and fears of abandonment -intense but unstable relationships, emotional instability, outbursts of anger and violence , impulsive behaviour, self-injury -lies on the ‘borderline’ between neurotic (anxiety) disorders and psychotic disorders such as schizophrenia and bipolar disorder -often results from childhood sexual abuse

Narcistic PD -person has an extreme feeling of self-importance, a sense of entitle ment, and a need to be admired -is envious of others and expects them to be the same of him -If he feels obstructed or ridiculed, he can fly into a fit of destructive anger and revenge.

-can have disastrous consequences for all those involved _19_

Histrionic PD -lack a sense of self-worth -take great care of their appearance and behave in a manner that is overly charming or inappropriately seductive -can place them- selves at risk of accident or exploitation -sensitive to criticism and rejection, react badly to loss or failure

Antisocial PD -characterized by a callous unconcern for the feelings of others -disregards social rules and obligations, is irritable and aggressive, acts impulsively, lacks guilt -relationships are usually fiery, turbulent, and short-lived -most closely correlated with crime _20_

Cluster C Avoident PD -socially inept, unappealing, or inferior, and constantly fear being embarrassed, criticized, or rejected -strongly associated with anxiety disorders -excessively monitor internal reactions, both their own and those of others, which prevents them from engaging naturally or fluently in social situations

Dependent PD -lack of self-confidence and an excessive need to be looked after -needs a lot of help in making everyday decisions and surrenders important life decisions to the care of others -sees himself as inadequate and helpless, and so surrenders personal responsibility and submits himself to one or more protective others -imagines that he is at one with these protective other(s), whom he idealizes as com- petent and powerful -maintain a naive and child-like perspective; -have limited insight into themselves and others; This entrenches their dependency, and leaves them vulnerable to abuse and exploitation

Anankastic PD -excessive preoccupation with details, rules, lists, order, organization, or schedules; perfectionism -typically doubting and cautious, rigid and controlling, humorless, and miserly -anxiety arises from a perceived lack of control over a world that eludes his understanding; and the more he tries to exert control, the more out of control he feels -has little tolerance for complexity or nuance, and tends to simplify the world by seeing things as either all good or all bad _21_

Histrionic PD -lack a sense of self-worth -take great care of their appearance and behave in a manner that is overly charming or inappropriately seductive -can place themselves at risk of accident or exploitation -sensitive to criticism and rejection, react badly to loss or failure

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General trends and needs in mental health systems

General Trends in Mental health Design 1. Bringing the service to the patient and maximize therapeutic opportunities 2. Creating Non-InstitutionalTreatment Environment 3. Private patient roomsand bathrooms 4.Flexible Census Units 5. Mall treatment and neighbourhood concepts 6. On stage and off stage design 7. Use of technology

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GENERAL NEEDS IN MENTAL HEALTH STATIONS

-open design to manifest -clear structure -second emergency exit for staff (nurses are often the target of patient aggressions) -light ambience -integration into personalized room design -small units

patient_staff_balance

central overwiev through the station entrance/exit corridor

centralized point -short ways -fast accessebility -Presence of staff - quality improve -better orientation for patient and visitor

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Intense care case example

Light and material It is a general need for every room in mental workspaces to admit natural light, naturalmaterials and colours wherever possible.

Security No sharp or sharp breaking edges, as patients with severe illnesses tend to harm themself or commit suicide.

Visual privacy Giving patients as much visual privacy and control over it as much as possible.

Noise reduction Providing an adequate acoustic privacy from noices of other patients, traffic, mechanical noises etc.

Access to nature

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Viewing nature induces positive emotional and phydiological and diminishes negative emotions through changes in bloodpressure and heart activity.

Partly centralized care station medium mental problems

Artificial and natural light stay needed in all cases Visual privacy It is very important that patients start to be carefully integrated back into the society.

Noise reduction Providing an adequate acoustic privacy from noices is still needed to ensure a helthy treatment environment.

Visual and physical Access to nature Needs to be integrated in every treatment phase and health condition.

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Decentralized scenario (low mental problems)

Patients with low mental problems are not in need of noise reduction.

The most important in these cases are supported or non supported health care technologies. Trechnologies in mental health care are an important need in every mental stages. While GPS devices can monitor a patients movement which decreases the need of being controled by staff. Mobile technologies are becomming an inovational influence to health care. The following pages will give an overview of possibilities in patient and staff support by illustrating interactions of Artificial Intelligence based technologies.

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Case study Trieste mental health system

Trieste mental health care system-The Reform of Psychiatric care Law 180 Law 180 established that no one can be hospitalized in psychiatric hospitals. Therefore it is the first law that bans mental asylyms. The goal has been to eliminate psychiatric hospitals, to bring health care services into the community, to change the place of treatment and to change methods of care.

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Historical background In 1971 Franco Basaglia became director of the Provincial Psychiatric Hospital of Trieste. There he started his work on the transformation and construction of alternitives of the whole psychiatric system, formed a working group made of young doctors, sociolists, socialworkers, volunteers and students form different Italian and European cities.

By 1980, under the supervision of Franco Rotelli, the new community services had already replaced the old assistance methods. The first mental health centers where activated in Health districts in 1975-1976. The psychiatric hospital in Trieste has been replaced by 40 different structures and tasks,such as home care for patients. In case of needed hospitalization, the treatment is carried out by the Psychiatric Diagnoses and Treatment Services of General Hospitals.

Trieste mental health Departments These mental health Departments are rooted in areas of about 300.000 inhabitants and encompasses a number of components: 1.: 4 community health centers Each one equipped with 4 beds, one with 6 beds and 2 of them with 8 beds.

There are about 40-46 staff per centre. Each ofthese centres areresponsible in a geographic area with a population of about 60.000 people.

2.: Psychiatric Diagnosis and Treatment Service in General Hospital (open 24/7) acute units (15 beds)_______1/10.000 It provides psychiatric consultancy for emergencies at the General Hospital Emergency Service and offers advice to the hospital´s Departments on request. The aim of the Service is to minimize the duration of hospitalization, which in any case is not considered as an alternitive or a substitute for care by territorial units. _31_

3.: The University psychiatric Clinic -carries out teaching, research and assistance activities in the field of mental health. It has 12 beds, for both inpatients and outpatients.

The clinic is home to the School of Psychiatry and carries out epidemiological, clinical and psychopharmalogical research on psychiatric disorders. Activities focus in particular on the psychopathological aspects of mood, problems related to suicidal behavior and eating disorders. As regards dementia, the Clinic is apoint of refernce for the Trieste Health Agency and the Agencies of other Italian regions.

4.: Residential and Rehabilitaion Service This Service, which works closely with all the MHC´s, cooperatives and training agencies, carries out rehabilitatio, training and work placement activities. The Service set up a Daycenter, which organizes workshops and offers artistic, crafts and culture. There are teachers, art teachers, artists, cultural and voluntary associations. It is open to citizens that are making use of mental health services, but is also accessible to all.

5.: Group homes 2/10.000 with a wide range of support up to 24hr (17.000 beds in Italy) These centers carry out following activities: -night Accomodation/ daytime Accomodation (in response to crisis situations) -Outpatient services/ Homeservices -Individual therapeutic work/ therapeutic work with the family -group activities -Rehabilitation and prevention/ support for the most disadvantaged and their families economic benefits (social integration. job training...)

-support for rehabilitation at home -consultingactivities in health services -responses forcalls for urgent help

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Timeline of inpatients in psychiatric care -1971: 100.00 inpatients in Psychiatric hospitals -1978: 48.000 inpatients in Psychiatric hospitals -2000: all Psychiatric hospitals closed

System Improvement The importance of non hospitalization and deinstutionalisation in psychiatric care as shown in Trieste mental health service Non hospitalization: is the reduction of numbers beds, while deinstutionalization is a complex process of gradual reallocation of economic and human resources from a mental hospital to a range of community based services. Community mental health centers are open door (unlocked) community hospitality centres and every effort is made to establish a trusting relationship with the user and ensure consent for treatment.

Furtheremore the budget of management for the psychiatric hospital in 1971 has been approximetely 55 million euros. While the management of the local services (mental health department network) which is 79euro per capita. In 2011 has been approximetely 18 million euros. Compared to the costs of the management of a psychiatric hospital in 1971 has been appr. 28 million.

Outcomes As Trieste services provides an easy accessibility system without prioritisation or screening refferals, it has impressive results in avoiding seclusion and compulsion. The staff working in these centres are providing overnight hospitality, early intervention, ongoing treatment, informalsupport and home based care.

Trieste has achieved verylow levels of compulsory treatment, high engagement of re-engagement in community life with without barriers, _34_

which is one of the most important points in the health care system Trieste has developped. Community mental health have become the central component of the decentralized system used as a tool against hospitalization to provide a flexible response to the users across a complete lifetime.

These CMHC are open to anyone 24/7 and care seekers are considered guests.

The non-bureaucratic, demedicalised approach to crisis reduces hospitalisations, favours a more rapid return to stability and reduces relapses.

Instead of standarized responses and protocols the system focuses on on reconstructing social relationships and networks, enhancing personal resources and capacities and aim at quality in every aspect of the therapeutic work in order to guarantee a quality relationship.

1,182 hospital beds became 140 beds distributed throughoutthe entire are. The suicide rate has decreased considerably from 8.3 per 100.000 population in 1993 to 5.1 per 100.00 in 2010.

In 2010, only 16 persons under involuntary treatments (7/100.000 inhabitants), the lowest in Italy (national ratio: 30/100.00); 2/3 are done within the 24 hrs. MHC -open doors, no restraint -no psychiatric users are homeless -social cooperatives employed 600 disadvantaged persons, of which 30% suffered from a psychosis -suicide prevention programme lowered suicide ratio 50% in the last 20 years (average measures) -no patients in Forensic Hospitals

Access to Mental health support -no waiting lists (first interview takes place within 24 of request) -application is recieved by the staff on duty and the first assessment -initial interview is conducted by a psychiatrist or psychologist, in collaboration with the team _35_

Supportive technologies for mental health care

Room installation Considered PD e.g.: Borderline PD (impulsive, only for patients who do not sufferfrom halluzination), Antisocial PD,or any kind of PD with characteristic of agreesion and depression

Artificial and natural light -provides a warm atmosphere for patients with depression

Motion sensors integrated into the floor are detecting nervous behavior of a patient and can call emergency

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personalized room design to create comfort zone and terretorial space

dorrs and windows Interactive liquid wall with sensors that will not close as long their is something in be-including patients with tween. high aggression behavior Avoiding self harm -excluding patients with behavior halluzinations!

C H

S

Center for cognitive Humanoid Systems

2

1

?

3

3

1- activity monitoring 2- fall detection 3-Bathroom A solution has to be found how it can work correctly under tiles in the bathroom. This project proposes pressure sensors that work under hard materials as tiles to recognise aggression behavior or fall downs based on keeping the dignity and privacy of a patient in a private space. _38_

Prevention strategies Szenario activity monitoring and fall detection Proximity sensors will be integrated into the floor. It differentiates the person standing , determines direction and velocity of movements and sends data feedback to a computer. The sensors in the floor will send an alarm to the nurse station in case a person is falling down.

C HS C These H sensors can be laid under flexible floor coverings such as PVC or Center for cognitive Humanoid Systems

AI Intense care

S and under rigid coverings such as laminate or parquet. carpet Center for cognitive Humanoid Systems

AI Intense care

Szenario aggression monitoring

As there are patients with personality disorders that have an aggressive outcome, sensors in the wall will track the patients behavior.

In this case material has to be tested. _39_

Mobile technologies improving the quality of Self-care

Digital technology has the potential to transform mental healthcare by connecting patients, services and health data in new ways. Digital online and mobile applications can offer patients greater access to information and services and enhance clinical management and early intervention through access to real-time patient data. One of the biggest cahallanges in using AI technologies in mental health care will to ensure that the opportunity provided by data sharing between patients, carers and clinicians does not threaten privacy and undermine public trust. However, with advancing research and awareness geared towards mental health issues, more companies are innovating in this space than ever before.

Emerging trends in recent years have the potential to completely change the health care environment for those struggling with mental health conditions. The health pyramid published by the WHO demonstrates the big gap of selfcare services in Portugal. Which could avoid the appearance of mental health issues in many different cases. This thesis projects wants to take the advantages of mobile technologies in mental health care to fill this gap as much as possible.

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Facial tracking SimSensei

C H

SimSensei is VH (virtual human) interaction platform that is able to sense real-time audivisual behavioral signals from user interacting with the system. This system is espacially designed for clinical interviewing and healthcare support by providing a face to face interaction between the user and Vh that can automatically react to the inferred state of the user through analysis of behavioral signals gleaned from the user´s facial expressions , body gestures and vocal parameters. It uses a range of sensors (e.g. webcams, Microsoft Kinect, and a microphone) AI day care, decentralized care

S

Center for cognitive Humanoid Systems

Advantage: This technology gives the patient the opportunity to to access mental health support at any place in a 24/7 rythm. In contrast to a real therapist, a virtual human has no awarness of judgement and allways appears frienfly and polite. Which opensthe opportunity to a person with mentalhealth issues telling secrets they suffer from, which often they are not able to tell to a real person.

Usage:All data from VH will be collected at the MHC´s so the computer can analyse the data to propose better treatment strategies for the indiviual patient. The VH can be used inside the MHC or as home installation.

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Electrodermal activity Spire Spire uses a pressure sensor to track subtle movement. Spire is listed under mobile respiration measurement devices. It can also be used to monitor the breathing rateas part of biofeedback interventions. EDA has been widely used in psychophysiology research and in clinical apllications to asses schizophrenia, emotional states, sleep, epilepsiyand stress. This technology will be a base point of usage for patient and staff implemented into this thesis project. It will play an important role to ensure self control in all stages and influence staffs workflow in an mentalhealth center.

Advantage: This technology is a wearable devices that gives a bio feedback whenever your condition changes and will give solutions what would be a good opportunity to do, to improve a healthier condition. Once emotion is detected, this device will send a notification to your phone with suggestions on how to relax or other wellness tips. It reconnects to the users body and to be more productive, and helps in case of insomnia.

C H

Usage: Spire will be used 24/7 h in and outside the MHC by staff and patient. All data will be send to the main computer machine of one of the Centers wich will beAIdirectly sended further day care, decentralized care on the other centers.

S

Center for cognitive Humanoid Systems

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zĞƚ ĂŶŽƚŚĞƌ ŝŶŶŽǀĂƟǀĞ ĚĞǀŝĐĞ ĐŚĂŶŐŝŶŐ ƚŚĞ ŵĞŶƚĂů ŚĞĂůƚŚ ŐĂŵĞ ŝƐ ƚŚ Fisher Wallace Stimulator &ŝƐŚĞƌ tĂůůĂĐĞ ^ŝŵƵůĂƚŽƌ͕ ĂŶ & ͲĂƉƉƌŽǀĞĚ ŶĞƵƌŽƐƟŵƵůĂƟŽŶ ĚĞǀŝĐĞ ƚŽ ŚĞůƉ ƚƌĞĂƚ ĚĞƉƌĞƐƐŝŽŶ͕ ĂŶdžŝĞƚLJ ĂŶĚ ŝŶƐŽŵŶŝĂ͘ ĂƐĞĚ ŽŶ Ă ƌĞĐĞŶƚ ƉŝůŽ Yet another innovative device changing the mental health game is the ƐƚƵĚLJ Ăƚ DŽƵŶƚ ^ŝŶĂŝ ĞƚŚ /ƐƌĂĞů͕ ƚŚŝƐ ĚĞǀŝĐĞ ŵĂLJ ĂůƐŽ ŚĞůƉ ƚƌĞĂƚ ďŝƉŽůĂ Fisher Wallace Simulator, an FDA-approved neurostimulation device to ĚĞƉƌĞƐƐŝŽŶ͘ LJ ŐĞŶƚůLJ ƐƟŵƵůĂƟŶŐ ƚŚĞ ďƌĂŝŶ͕ ƚŚĞ ŚĞĂĚďĂŶĚͲůŝŬĞ ĚĞǀŝĐĞ ƚŚĂ help treat depression, anxiety and insomnia. Based on a recent pilot study at Mount Sinai Beth Israel, this deviceƚŚĞ mayďƌĂŝŶ also help bipolar LJŽƵ ƉůĂĐĞ ŽǀĞƌ LJŽƵƌ ƚĞŵƉůĞƐ ƐƟŵƵůĂƚĞƐ ƚŽ treat ƌĞůĞĂƐĞ ƐĞƌŽƚŽŶŝŶ depression. By gently stimulating the brain, the headband-like device that ĂŶĚ ĚŽƉĂŵŝŶĞ͕ ǁŚŝĐŚ ƌĞĚƵĐĞ ƐƚƌĞƐƐ ĂŶĚ ŝŶĐƌĞĂƐĞ ĨĞĞůŝŶŐƐ ŽĨ ŚĂƉƉŝŶĞƐƐ you place over your temples stimulates the brain to release serotonin ůƚŚŽƵŐŚ LJŽƵ ŶĞĞĚ Ă ƉƌŽǀŝĚĞƌ ƚŽ ĂƉƉƌŽǀĞ LJŽƵƌ ƵƐĞ͕ ƚŚĞ &ŝƐŚĞƌ tĂůůĂĐ and dopamine, which reduce stress and increase feelings of happiness. ^ƟŵƵůĂƚŽƌ ŵĂŬĞƐ ŝƚ ƉŽƐƐŝďůĞ ƚŽ Ɛŝƚ Ăƚ ŚŽŵĞ ĂŶĚ ƌĞĐŝĞǀĞ ƚƌĞĂƚŵĞŶƚ͘ dŚŝ Although you need a provider to approve your use, the Fisher Wallace ĐĂŶ ŚĞůƉ ƉĂƟĞŶƚƐ ƚŽ ďĞ ŶĂƚƵƌĂůůLJ ƚƌĞĂƚĞĚ ǁŝƚŚ ƌĞƐƵůƚƐ ĂůŽŶŐ ƚŚĞ ƐĂŵĞ ůŝŶĞ Stimulator makes it possible to sit at home and recieve treatment. This can help patients to be naturally treated with results along the same lines ĂƐ ŵĂŶLJ ůŽŶŐͲƚĞƌŵ ďĞŶĞĮƚƐ ŽĨ ĂŶƟĚĞƉƌĞƐƐĂŶƚ ƚƌĞĂƚŵĞŶƚƐ͘ as many long-term benefits of antidepressant treatments.

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Mobile app technology

Pacifica This mobile app is a self-help resource for anxiety, the most predominant mental health diagnoses next to depressions all over the counrtries. Innovation in the treatment and long-term care of anxiety is vital. As more people are living with and trying to manage their anxiety by themselfs, apps like Pacifica can help them to live healthier lives by using therapeutic technology through a mobile app. Pacifica incorporates principles of cognitive behavioral therapy 1, relaxation and wellness to break the cycle of anxiety, as well as helping users achieve real results to combat anxiety and improve wellness. By breaking unhealthy thought-feeling-action cycles through engaging users with relaxation tips and goal setting, this innovative app is one to watch as it helps users combat their anxiety.

1

-Cognitive -behavioral Therapy -treatment approach mustinitially identify type and objective (short-term or long-term therapy) -short-term: focused on reduction of the most severe and problematic behaviors -long-term: to emphasize interpersonal and interpersonal relationshipsandutilize ththerapeutic relationship tochallenge childhood issues, espacially those related to abuse and attachment concerns

Pala-Linq Pala-Linq is a mobile app with wearable and Web components that provide support to those recovering from alcohol and/or drug addiction. By tracking mind, body and spiritual activity levels, this technology will keep users close to their support network and on track with recovery goals to prevent relapse.

Internet plattforms e.g.

-kooth -big white wall -ieso digital health -outcomes 52% recovery to the expected 46% _46_

Thesis statement This thesis deals with the existing system of mental helath care in the society of Portugal. By comparing the existing network of Trieste mental health services and evidence based design in architecture, followed by designing a prototype of a mental health community center, this thesis project will illustrate a proposal of change which is needed in Portugal and will use existing facilities in artificial intelligence technologies to give prove to an outcome, how new technologies would effect the system of mental health care services in Lisboa and the architecture of a mental health center in a positive way for both staff and most important the patient.

Network design strategies

Urban Network strategy Each health zone is calculated by building spaces, distances and population density .Once by the grasshopper plugin Configurbanist and manu ally recalculated.All of them will have different amounts of beds for overnight staying based on the number of inhabitants living inone zone. Fur-

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thermore each center is located close to parks to allow access to green spaces. All Centers are connected with each other to share analysed data via Cloud computing.

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Zones according to the Triestemental health system 1978

Direct Connection MHC´s Daycenters

Zone 01 University Psychiatric research Center Area: approx. 16.8 km² Population: approx. 91.000 inh.

Zone 02 2 MHC´s; 1 Daycenter Area: approx. 24 km² Population: approx. 131.000 inh.

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Zone 06 2 MHC´s; 1 Daycenter Area: approx. 16.62km² Population: approx. 22.000 inh.

Zone 05 2 MHC´s; 1 Daycenter Area: approx. 15.9 km² Population: approx. 87.000 inh.

Zone 04 1 MHC; 1 Daycenter Area: approx. 8.4 km² Population: approx. 46.000 inh.

Zone 03 1 MHC; 1 Daycenter Area: approx. 4 km² Population: approx. 22.000 inh. _52_

Excerpt healthcare zones proposed according to estimated number of mental health issues in 2016

Example 1: walking distance from outer point of zone area walking distance: 1.1 km walking time approx.: 17.5 min

Example 3: walking distance from outer point of zone area walking distance: 1.3 km walking time approx.: 22 min

3-Igreja de Santa Catarina area: 2.5 km² population approx.: 5.740 walking distance: 2-3: 1.93 km walkingtime approx: 32 min walking distance: 3-1: 1.99 km walkingtime approx: 34 min MHC: 3 beds proposed

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-maximum distance parameter 1.8 km 1-Avenida Duque de Loulé City Center Lisboa, Portugal Center point as suggested MHC prototype area: 2.5 km² population approx.: 16.000 walking distance: 1-2: 2.39 km walkingtime approx: 40 min MHC: 5 beds proposed

-average pace 1M/s (3.6 km/h) -average walking distance within the zones: 30min shortest path closest access to a MHC via public transport

Example 2: walking distance from outer point of zone area walking distance: 1.9 km walking time approx.: 33.5min

2-Area: Jardim Augusto Gil area: 2.5 km² population approx.: 7.400 walking distance: 2-3: 1.93 km walkingtime approx: 32 min MHC: 3 beds proposed

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Connecting the urban strategy with residential spaces How the hospital comes to your place Optimizing Homecare Services via Artificial Intelligence

HOME

Installation at home wearable device

-Thermostat -Light -Smell

Internet

Computer/Smartphone

Adaption: -light -temperature -smell _55_

MHC

connection to virtual therapist

Reciever decision: -can stay at home -registration -shortest path to next station Emergency: -Staff will be send over to patients place

Information about condition Information send to closest mental health center

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Staff workflow Nurse check-in

Glasswall Computer

Preparing patient data...

Data send to robotic arm Patient check-in

continious condition check Patient/ Staff

Wearable device (Spire)

The diagram illustrated in the workflow illustrates how to avoid paperwork, creates a sustainable network between patient, staff and AI. And allows more time for the staff spend with the patient. _57_

Medicament delivery

Service Robot delivers medicaments to patient room

Sends patient condition and needs to to main Computer

Data analysation

NLP allows the system therapeutic approaches and with the use of predictive analytics, the system would know when to apply best treatment for intervention

Data Treatment analysation ptoposal sent over

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Prototype Mental Health Center

Site Adress: Avenida Duque de Loulé City Center Lisboa, Portugal Area net: 1400 m² The chosen location is situated in the city center, next to the Embaxiada de belgica and close to the Parque Edoardo VII. to allow multi access to green spaces and by public transport.

Av .D

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gl Embaixada de Belgica

Pa rk ing

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lot s

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Parque Eduardo VII

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The central challenge is to connect both sites to create a center with community spaces to close the gap between healthy people and patients.

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1

2

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u uq

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Masterplan The building allows spaces with pricacy and green spaces inside out and tries to avoid sharp edges as much as possible. The bridge from the health center to the community center stands also as a symbol to directly connect patients with healthy people as much as possible to open a better transperancy to people with non visible illnessess. The same wants the building with its open spaces and lots of glass (transperancy) and natural material (wood) combined with landscape architectural spaces based on evidence based architecture,to create more a health park than a buidling.

1-Entrance emergency 2-Mental health Center 3-Connection bridge 4-Daycare Center/ community center 5-Entrance

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Groundfloor

1

2

3

1-Administration-Acute station 2-Administration-mental health center 3- community building _63_

1 st floor

1

2

1-Acute station 2-Daycare

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2 nd floor

1 2

3

1-Intense care 2-Group therapy 3- accesslevel bridge

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3 rd floor

1

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1-Intense care 2-Daycare 3- workshop space

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4 th floor

1

2 3

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1-group therapy 2-group therapy 3- individual therapy 4- workshop space _67_

5 th floor

1

1

1-Research level

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Sketches

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Visual Images

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Community space building with crossover connection to the MHC

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Nurse station

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Landscaping

Betula_pendula birch tree -flat roots - needs earth deeepness of only 61 cm -exterior

small bushes providing shadows -exterior/interior

boxwood-small growing interior/ exterior

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golden cane palm-interior/ exterior

satureja douglasii indian minthanging flower for balconies for covering / exterior

Lavender-national flower of Portugal

Green living walls for interior spaces

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Conclusion In conclusion the mental health system not only in Portugal, but all over the countries does not adapt to the patient and the workspaces as much as it is needed. The gap between “functional and dysfunctional poeple” must be dereased by reducing “fenced” Psychiatric hospitals. Therefore this Thesis illustrates possibilities how to connect private spaces with a centralized institution by the use of Artificial Intelligence to redesign a psychiatric building structure, and increase availability and comfort, to optimize health workflows and most important comfort for patients.

References Artificial Intelligence in Behavioral and mental healthcare_David D. Luxton Personality Disorders_Daniel J. Fox Persönlichkeitsstörungen_Fiedler http://www.forbes.com/forbes/welcome/#1af122022cc2 http://www.eph-psychiatrie.de/grundlagen Universitäts Klinikum Hamburg estimated number of specific mental disorders in germany 2013 Eppen dorf http://www.triestesalutementale.it/english/doc/BrochureTriesteENG.pdf http://www.triestesalutementale.it/english/mhd_department.htm http://www.ft.dk/samling/20121/almdel/%C2%A771/bilag/91/1249292.pdf 1-s2.0-S0272735814000993-main.pdf Robot therapy danger and advantages.pdf chd428_researchreport_behavioralhealth_1013-_final_0.pdf 1249292design_guide.pdf Healing Architecture.Stefan Lundin NCBI National Center for Biotechnology Information the_future_digital.pdf comparism trieste new zealand.pdf