In a recent KevinMD piece, physician executive Thomas Powell argued that alert fatigue is a design problem, not a vigilance problem. When clinicians override 49 to 96 percent of drug-interaction alerts, he wrote, they aren’t being careless. They’re responding sensibly to a system that buries the rare important warning under a pile of trivial ones.
One of his tests for retiring an alert stopped me: If no one will claim it as its clinical sponsor, it shouldn’t exist. I read that as the mother of a daughter with schizophrenia, and I thought: Psychiatry is about to learn this lesson the hard way.
Between-visit monitoring is arriving fast. In one pilot study, the behavioral anomalies a smartphone picked up were 71 percent higher in the two weeks before a schizophrenia relapse than at other times. The FDA has just cleared Motivista, the first prescription app for schizophrenia. Medicare has paid for clinician-supervised digital mental health treatment since 2025 and expands those codes in 2026.
So the question I closed with at Harvard Medical School Grand Rounds last week matters now: When the alert fires, who is watching?
Real physician voices, twice a week
Free, and one click to unsubscribe.
Nobody tracks that directly. The best proxies are sobering:
- Fewer than 20 percent of behavioral health practitioners, and 17.9 percent of psychiatrists, routinely use symptom measures to track progress.
- Collaborative care, the clearest model of someone assigned to watch a caseload between visits, reached fewer than 0.003 percent of commercially insured people from 2018 to 2022.
- In early 2025, Medicare’s new digital mental health treatment codes were used for 99 patients nationwide in three months.
And passive data, in practice, is unwatched data. At Vanderbilt, the same suicide-risk flag led to an assessment at 42 percent of visits when it popped up, and 4 percent when it only sat in the chart.
My fear isn’t that psychiatry will ignore relapse alerts. It’s that we’ll switch them on without owners, drown in them, and conclude the technology doesn’t work.
Meanwhile, families are already the alert system. We’re the ones who notice the 3 a.m. light under the door, the texts that stop, the meals left untouched. In my Grand Rounds talk, I told the story of Maya, a composite patient who was stable by every measure her clinicians had. Her sleep tracker showed the slide two weeks before her 2 a.m. emergency room visit. The data existed. It just had nowhere to go.
Before your clinic turns on any between-visit monitoring, borrow Powell’s discipline and answer six questions:
- Who owns this alert? A named role with a name in it, not “the team.”
- What happens at 2 a.m. and on weekends? If no one is watching then, tell the patient and family plainly, and make sure they know what to do instead: the crisis plan, 988.
- Is the family in the loop? Get consent to share before the crisis, not during it. Patients’ willingness to share relapse data with family and staff is real but not automatic, so ask early and ask again.
- Where does the alert land? If it isn’t in the chart and the daily workflow, it’s a dashboard nobody opens.
- What’s the override rate at 90 days? If clinicians dismiss nine out of ten, redesign the threshold or retire the alert.
- Who’s paying for the watching? Collaborative care codes and digital mental health treatment codes exist. Most practices have never billed them.
None of this needs new technology. It needs a person, a threshold, and a plan, decided before the first alert fires.
Powell is right that alert fatigue is a design problem. For families like mine, so is alert neglect. A signal nobody owns doesn’t protect anyone. It just leaves a record of what we could have known.
Nicole Drapeau Gillen is a mother, advocate, and author who translates the fast-moving landscape of technology in serious mental illness (SMI) care into guidance families and clinicians can use. Thrust into caregiving for a loved one with SMI, with no direction on how to help, she turned that experience into a mission, writing two books and building an ongoing effort to bring families and clinicians into the conversation.
Her first book, Schizophrenia and Related Disorders: A Handbook for Caregivers, is a reference for every stage of caregiving, endorsed by Dr. E. Fuller Torrey as a must-read for SMI caregivers. Her second, Connected Care: A Practical Guide to Technology for Serious Mental Illness, maps apps, artificial intelligence tools, telepsychiatry, and brain-based treatments for a field moving faster than anyone can track. Dr. Akira Sawa, director of the Johns Hopkins Schizophrenia Center, has said the book “directly addresses” significant gaps.
