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Mental Illness: Is There an App for That?

"Jane" was recently diagnosed with depression by her family doctor, who prescribed an antidepressant and referred her to an outpatient mental health clinic. While on a waitlist for psychotherapy, Jane explored the availability of a mental health application, or "app," for additional support. She is not alone: A recent survey shows that half of all Americans with a mobile phone have downloaded a health-related app, and this number continues to increase (Krebs & Duncan, 2015). Moreover, there are now 318,000 mobile health (mHealth) apps to "help patients actively measure, monitor, and manage their health conditions" (Byambasuren, Sanders, Beller, & Glasziou, 2018). Broadly speaking, mental health apps provide one or more of the following functions: (a) psychoeducation on mental disorders, (b) delivery of basic psychotherapeutic techniques, (c) mindfulness or meditation exercises, (d) mood tracking, and/or (e) real-time anonymous or therapist-driven supportive therapy.

Jane found an app that would remind her to take her medications. She found several to help her set goals. She found others that could address the negative thoughts that are so common for her, such as "you will never be any good at that." She downloaded several apps but knew she would struggle to use them all. She hoped that once she could get an appointment with a therapist, she or he could help her know which one or ones were best.

Clinicians are hearing stories like Jane's more and more. The aim of this commentary is to consider the advantages and disadvantages of incorporating apps into clinical care and provide a few rules of thumb for clinicians who are helping their patients select the most useful app or apps. We then use this guidance to review three popular health-related apps.

One distinct advantage of apps is that they provide support when and where it's needed. Patients can learn, apply, and monitor their use of skills on their own schedule and without geographic limitations. This self-directed access and use may be appealing to many patients and may be particularly relevant to certain groups who face barriers to accessing psychotherapy, such as single parents, people in rural areas, and people experiencing disabling physical conditions.

Similarly, availability is an apparent advantage. Mental health care is often difficult to access in both private and public health care contexts. For example, studies have found that just 13% of Canadians with depression have received counseling or psychotherapy and that only about half get "potentially adequate care" (i.e., any antidepressant or some type of talking therapy; Patten et al., 2016; Puyat, Kazanjian, Goldner, & Wong, 2016). When psychotherapies like cognitive-behavioral therapy (CBT) are delivered by apps, they can be as effective as in-person therapy, provided that the Internet-delivered psychotherapy is guided by a therapist (Gratzer & Khalid-Khan, 2016).

A clear disadvantage to incorporating apps into clinical care is that they have variable quality. One study evaluated basic quality standards (e.g., citing one's source of medical information) and found that only one in four apps met these standards (Shen et al., 2015). In addition, apps are not well-used. For example, PTSD Coach app, developed by the U.S. Department of Veterans Affairs, boasts 150,000 downloads--yet only 14% of individuals used the app the day after downloading it (Owen et al., 2015). Finally, app costs can be significant ($19.99 for a monthly plan for one popular app) and thus inaccessible for patients with a limited income.

When patients like Jane ask for help selecting an app to be adjunctive to treatment, we recommend that clinicians talk to patients and their families about the challenge of selecting the right app and discuss these advantages and disadvantages. In addition, several organizations make suggestions about how to choose apps (American Psychiatric Association, 2018; Mental Health Commission of Canada, 2019). Using these as guidelines, we propose four simple topics for providers to discuss with patients and families when considering an app: fit for purpose, credibility, cost, privacy (see Appendix).

We now examine three different mental health apps for different psychiatric disorders (available on both the iOS App Store and Google Play Store) that meet the above criteria, including one that may be of interest to Jane and her clinician. Given the numerous apps available for download, we selected three that reflect the current mental health app landscape. We reviewed one for-profit app (Headspace, London, UK), one nonprofit app (Calm Harm, London, UK) and one government-developed app (PTSD Coach, Washington, DC). These apps are free, provide a good fit for most users, are developed by reputable organizations, and have clear policies regarding user privacy.

Headspace is a privately developed commercial mindfulness meditation app. It is among the most downloaded meditation apps worldwide. Though marketed as a mental wellness app for a general audience (and not mental health disorders per se) it has also been investigated for use in psychiatric inpatient units and resident physician burnout (Mistier, Ben-Zeev, Carpenter-Song, Brunette, & Friedman, 2017; Wen, Sweeney, Welton, Trockel, & Katznelson, 2017). These observational studies have suggested a reduction in depression and anxiety symptoms in participants. However, these studies only lasted several weeks and are limited by small sample sizes. The strengths of Headspace include its evidence base in mindfulness-based therapy (Carpena, Tavares, & Menezes, 2019; Chen et al., 2012). The app has an intuitive interface that invites users to explore various mindfulness exercises, which is like a music playlist. Although freely available, some content is accessible only via subscription (currently $12.99 per month), and in-app purchases are frequently encouraged.

Calm Harm is a free app developed by the U.K.-based mental health charity, stem4. It is also listed on the United Kingdom's National Health System (NHS) Apps Library, which vets apps using expert peer review and clinical, technical, and best practice standards. This app uses principles of dialectical behavior therapy. It offers a mood journal and provides tips for users on mindfulness exercises and managing thoughts of self-harm or suicide. Strengths of the app include its use of evidence-based interventions and a specific focus on adolescents. It has an inviting user interface and a password protection option for additional privacy. There is currently no published literature on the efficacy of this app, despite its popularity and positive feedback from user reviews.

PTSD Coach is a free app developed by the U.S Department of Veterans Affairs (VA) National Center for PTSD. The app provides management tools and psychoeducation for patients experiencing acute distress associated with posttraumatic stress disorder. The app has different functions, including health literacy, access to care, symptom tracking, and management. It has a simple, clutter-free user interface and personalization options such as adding personal photos and music. The management section provides coping tools such as meditation and access to crisis supports. Released in 2011, it is one of the earliest mental health apps and has an extensive body of literature supporting its efficacy. In pilot randomized studies that compare with waitlist conditions, it is effective in reducing symptoms and improving psychosocial functioning (Kuhn et al., 2014; Miner et al., 2016). As a result, it has been widely implemented and promoted within VA Medical Centers. The open-source code has allowed other countries to implement the PTSD Coach model and similar positive results have been obtained (Kuhn et al., 2018).

The apps reviewed here are all postulated to be effective by virtue of expert opinion or early pilot and preliminary studies. However, mental health apps need to be evaluated in randomized control settings, so clinicians can ascertain their efficacy and prescribe them to patients (Byambasuren et al., 2018). Most commercial apps limit evaluation to user engagement metrics (i.e., number of downloads, time using the app, or money spent on the app). Evaluation of clinical outcomes is becoming a closer reality with a new category of apps classified as prescription digital therapeutics by the U.S. Food and Drug Administration (FDA). For example, reSET (developed by Sandoz Global, Hilzkirchen, Germany, and Pear Therapeutics, Boston, MA) is a 12-week mobile CBT intervention for patients with opioid use disorder and became the first mobile app to receive FDA approval for treatment of substance use disorders. By linking an app with outpatient clinician treatment, psychotherapy and pharmacotherapy, patient outcomes can be clearly measured.

Despite the evolution of mental health apps in the last few years, clinicians must accept these apps as an augmentation--not a replacement--for their services. Thus, in the current landscape, it can be daunting for both clinicians and patients to find effective, safe, and evidence-based apps. We hope our practical recommendations point users in the right direction. For further assistance in choosing apps, we recommend reviewing the guidelines published by the American Psychiatric Association App Evaluation Model, the Mental Health Commission of Canada, and the U.K.'s National Health System NHS Apps Library.

After meeting with her therapist, Jane evaluates the apps she selected using these rules of thumb. She carefully reads the privacy policies and checks each app for its affiliation with academic institutions. Jane chooses an app that offers prompts about taking her antidepressants. This app also allows her to journal her thoughts and mood. She finds the latter particularly useful, as she routinely reviews her journal entries with her psychotherapist during CBT sessions.

References

American Psychiatric Association. (2018). Mental health apps. Retrieved from https://www.psychiatry.org/psychiatrists/practice/mental-health-apps

Byambasuren, O., Sanders, S., Beller, E., & Glasziou, P. (2018). Prescribable mHealth apps identified from an overview of systematic reviews. npj Digital Medicine, 1, 12. http://dx.doi.org/10.1038/s41746-018-0021-9

Carpena, M. X., Tavares, P. S., & Menezes, C. B. (2019). The effect of a six-week focused meditation training on depression and anxiety symptoms in Brazilian university students with 6 and 12 months of follow-up. Journal of Affective Disorders, 246, 401-407. http://dx.doi.org/10.1016/j.jad.2018.12.126

Chen, K. W., Berger, C. C, Manheimer, E., Forde, D., Magidson, J., Dachman, L., & Lejuez, C. W. (2012). Meditative therapies for reducing anxiety: A systematic review and meta-analysis of randomized controlled trials. Depression and Anxiety, 29, 545-562. http://dx.doi.org/10.1002/da.21964

Gratzer. D., & Khalid-Khan. F. (2016). Internet-delivered cognitive behavioural therapy in the treatment of psychiatric illness. Canadian Medical Association Journal, 188, 263-272. http://dx.doi.org/10.1503/cmaj.150007

Krebs, P., & Duncan, D. T. (2015). Health app use among U.S. mobile phone owners: A national survey. JMIR mHealth and uHealth, 3(A), e101. http://dx.doi.org/10.2196/mhealth.4924

Kuhn. E., Greene, C, Hoffman, J., Nguyen. T., Wald, L., Schmidt, J.,...Ruzek, J. (2014). Preliminary evaluation of PTSD Coach, a smartphone app for post-traumatic stress symptoms. Military Medicine, 179, 12-18. http://dx.doi.org/10.7205/MILMED-D-13-00271

Kuhn, E., van der Meer, C., Owen, J. E., Hoffman, J. E., Cash, R., Carrese, P.,...Iversen, T. (2018). PTSD Coach around the world. mHealth, 4, 15. http://dx.doi.org/10.21037/mhealth.2018.05.01

Mental Health Commission of Canada. (2019). Mental health apps: How to make an informed choice. Retrieved from www.mentalhealthcommission.ca/sites/default/files/2018-01/eMH_app_eng.pdf

Miner, A., Kuhn, E., Hoffman, J. E., Owen, J. E., Ruzek, J. I., & Taylor, C. B. (2016). Feasibility, acceptability, and potential efficacy of the PTSD Coach app: A pilot randomized controlled trial with community trauma survivors. Psychological Trauma: Theory, Research, Practice, and Policy, 8, 384-392. http://dx.doi.org/10.1037/tra0000092

Mistier, L. A., Ben-Zeev, D., Carpenter-Song, E., Brunette. M. R. & Friedman, M. J. (2017). Mobile mindfulness intervention on an acute psychiatric unit: Feasibility and acceptability study. JMIR Mental Health, 4(3), e34. http://dx.doi.org/10.2196/mental.7717

Owen, J. E. Jaworski, B. K., Kuhn, E, Makin-Byrd, K. N., Ramsey, K. M., & Hoffman, J. E. (2015). mHealth in the wild: Using novel data to examine the reach, use, and impact of PTSD Coach. JMIR Mental Health, 2(1), e7. http://dx.doi.org/10.2196/mental.3935

Patten, S. B., Williams, J. V., Lavorato, D. H., Wang, J. L., McDonald, K., & Bulloch, A. G. (2016). Major depression in Canada: What has changed over the past 10 years? Canadian Journal of Psychiatry, 61, 80-85. http://dx.doi.org/10.1177/0706743715625940

Puyat, J. H., Kazanjian, A., Goldner, E. M., & Wong, H. (2016). How often do individuals with major depression receive minimally adequate treatment? A population-based, data linkage study. Canadian Journal of Psychiatry, 61, 394-404. http://dx.doi.org/10.1177/0706743716640288

Shen, N., Levitan, M. J., Johnson, A., Bender, J. L., Hamilton-Page, M., Jadad, A. A., & Wiljer, D. (2015). Finding a depression app: A review and content analysis of the depression app marketplace. JMIR mHealth and uHealth, 3(1), el6. http://dx.doi.org/10.2196/mhealth.3713

Wen, L., Sweeney, T. E., Welton, L., Trockel, M., & Katznelson, L. (2017). Encouraging mindfulness in medical house staff via smartphone app: A pilot study. Academic Psychiatry, 41, 646-650. http://dx.doi.org/10.1007/s40596-017-0768-3

Appendix

Topics for Providers to Discuss

Is this app a good fit?

Apps serve many functions: Some apps may be more educational, others allow you to enter data for self-monitoring, goal setting, or journaling. Identify one that has the purpose and features that are right for you.

Is it credible?

Find an app has been developed and/or endorsed by reputable organizations or associations. Ask your mental health or medical provider for help in vetting apps.

What does it cost?

Some apps have costs when you download them, and others have costs associated with using certain functions or features. Check if you have to pay to use the app and if you consider the cost reasonable.

Is it private and secure?

Some apps require that you enter personal information or track certain functions of your lives: You may want to understand where these data are being stored and who has access. Check if privacy and security information is included under the user terms and agreements.

Received October 4, 2019

Accepted October 4, 2019

David Gratzer, MD, and Gillian Strudwick, RN, PhD

Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and University of Toronto

Anthony Yeung, MD

University of Toronto

David Gratzer, MD, Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and Department of Psychiatry, University of Toronto; Gillian Strudwick, RN, PhD, Centre for Addiction and Mental Health, and Institute of Health Policy, Management and Evaluation, University of Toronto; Anthony Yeung, MD, Department of Psychiatry, University of Toronto.

Correspondence concerning this article should be addressed to David Gratzer, MD, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON M5T 1R8, Canada. E-mail: david.gratzer@camh.ca

http://dx.doi.org/10.1037/fsh0000451
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Author:Gratzer, David; Strudwick, Gillian; Yeung, Anthony
Publication:Families, Systems & Health
Geographic Code:1CANA
Date:Dec 1, 2019
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