Pocket Therapy: Do Mental Health Apps Work?

Deborah Brauser

August 27, 2012

August 27, 2012 — Smartphone users are inundated with all types of downloadable applications (apps) for their smartphones, including a myriad of so-called "mental health self-help apps." But are any of these actually helpful for patients with depression, posttraumatic stress disorder (PTSD), or other psychiatric disorders?

The apps range from Mobilyze!, created to track users' behavior patterns and activities (or lack thereof) to predict possible depressive episodes, to PTSD Coach, which responds with a relaxation exercise or the phone number of a crisis management hotline when stress levels exceed a certain number.

"Actually, I found that most of these apps were surprisingly good," Lori Simon, MD, a psychiatrist in private practice in New York City and a member of the volunteer faculty at the Payne Whitney Clinic at New York Presbyterian–Weill Cornell Medical Center, told Medscape Medical News.

"I don't see them as something to be used instead of being treated by a practitioner, but I see them as adjuncts or if the patients are fairly stable. And if a person is in between treatment sessions, these can be good for them," added Dr. Simon, who is also a volunteer member of the American Psychiatric Association's Committee on Electronic Health Records.

She noted that clinicians should think of these apps as just additional treatment tools.

"Everybody's different, and I have different styles of therapy for different people. This could actually be something to add to my toolbox. Overall, I think it would be worthwhile for practitioners to go and investigate the various apps in this area," she said.

Mobile Depression Intervention

According to ABI Research, 9 billion apps were downloaded to smartphones in 2010; International Data Corporation forecasts that there will be 76.9 billion global downloads by 2014.

Even the US Food and Drug Administration (FDA) now has a Mobile Medical Apps page on its Web site.

"The FDA encourages further development of mobile medical apps that improve healthcare and provide consumers and healthcare professionals with valuable health information very quickly," writes the organization.

Mobilyze! was created by researchers from Northwestern University to use "machine learning techniques" in tracking behavior patterns and social activities in an effort to stave off depression.

The app goes so far as to monitor ambient light and how often a user makes and receives phone calls, emails, and texts. In addition, it uses the phone's built-in global positioning system to monitor movement — to make sure the user is not lying around all day.

After learning and analyzing a person's daily rhythms, based on 38 sensor values, the app, which is still in development, will send out messages or suggested tools if it notices any significant changes in behavior.

Last year, the app's creators published results from a small pilot study of 8 adults with major depressive disorder in the Journal of Medical Internet Research. After using Mobilyze! for 8 weeks, the participants showed significant improvements on self-reported and interview measures of depressive symptoms (both, P < .001). In addition, they were significantly less likely to meet criteria for the disorder (P = .03) and showed decreased comorbid symptoms of anxiety (P < .001).

"To our knowledge, [this] is the first ecological momentary intervention for unipolar depression, as well as one of the first attempts to use context sensing to identify mental health-related states," write the study authors.

Dr. Simon noted that because this app is still under development, she was not able to fully review it.

"But it sounds like it might be a good adjunct for somebody who is at a certain level of depression or their meds haven't yet kicked in yet to help them get going in the mornings," she said.

"I try to have pep talks with my patients when they're with me, but I can't be with them 24/7. So Mobilyze! might have some applicability."

"Pocket Therapist"

The free PTSD Coach app was created by the US Department of Veterans Affairs' National Center for PTSD and the Department of Defense's National Center for Telehealth and Technology. It was originally designed for veterans.

Users enter problems that they are having, and on the basis of data entered, the app will respond with one of several prompts, including "positive self-talk," or anger management tools. If stress levels go over a certain number, it will even offer information on a crisis hotline. In addition, the app offers educational resources and a self-assessment for PTSD.

"I thought this was actually very good and very comprehensive. It touched on some of the techniques and things that people can use when they're having an acute episode," said Dr. Simon.

"I'm actually going to suggest this to one of my patients with PTSD because I think it might be helpful to her," she added.

For individuals suffering with obsessive-compulsive disorder (OCD), the app called "Live OCD Free" was created to help manage and minimize behaviors of the disorder — and offers versions for adults or for children.

Designed by Kristen Mulcahy, PhD, clinical psychologist and director of the Cognitive Behavioral Institute in Cape Cod, Massachusetts, Live OCD Free is described as "an interactive application designed to guide users through the only evidence-based treatment for OCD, Exposure and Response Prevention."

Dr. Mulcahy, who told Medscape Medical News that she has been treating OCD for 15 years, described the app as "a personal pocket therapist."

"It really guides you through the treatment and can be used as a self-help tool or as an adjunct to therapy with a professional. I developed it with this question in mind: as a therapist, how can I make treatment for my patients more effective?"

Clinically Meaningful

She added that there are currently 4 to 7 million people with OCD in the United States but only about 1000 therapists who specialize in treating the disorder.

"It's such an underserved population. Ideally you'd want them to be treated by a therapist, but some people just don't have access to one. Also, I've noticed with my own patients that it's definitely cutting down on treatment time," said Dr. Mulcahy.

The app version for adults includes motivational scripts, relaxation recordings, strategies for checking rituals, and guides for how to deal with symptoms after they occur or how to proceed after giving into a compulsion. It also includes progress reports that can be emailed to a user's therapist.

The other version uses kid-friendly cartoon characters to "guide you and cheer you on as you battle the Worry Wizard" in a game-like design. It features many of the same types of tools found in the adult version, but the information is given by a personal coach in the form of Sage the Owl and includes inspiring songs.

Dr. Mulcahy reported that preliminary research from a small pilot study showed that after 5 patients with severe OCD used the app on their own for 6 weeks, they had a 26% decrease in their symptoms. The decrease rose to 34% after 8 weeks of use.

"It was a very small study, but comparing it to past research, it seems to be clinically meaningful. But certainly we need more research."

She reported that McLean Hospital in Belmont, Massachusetts, is planning to soon start testing this app in their residential OCD program, as are "2 very large out-patient treatment centers" in New York and in Florida.

"I felt that this offered the same thoroughness as PTSD Coach and had some really good stuff," said Dr. Simon. But she did note that the $80 fee seemed expensive compared with other mental health apps out there.

Dr. Mulcahy reported that the fee includes downloads of both versions of the app, along with a 30-page user's guide, a tutorial video, and an illustrated children's audio book.

More Apps

WhatsMyM3 is a score monitoring app to be used for the possible detection of depression, anxiety, bipolar, and PTSD — or to monitor the progress over time of individuals already diagnosed with 1 of the disorders.

An M3 mental health gauging score is given to the participant "based on a research validated screen" that assesses risk for the disorders in 3 minutes time.

"After completing the short checklist, you receive a personalized confidential report sharing how much burden these symptoms may be causing you," writes the description on the iTunes app Web site, where it is downloadable for $2.99.

"I felt the name is a bit cryptic, but it's good," said Dr. Simon. "It's more of a diagnostic tool, but I thought it also covered things pretty well. Getting somebody to recognize that maybe they do have a disorder and to seek some help could potentially be good for a more general audience,"

Although she said she was surprisingly impressed with most of the mental health apps she reviewed, there was 1 app that she was "a little negative on."

Let Panic Go is described as an app that should be launched when an individual feels a panic attack coming on. Then, the person is supposed to tap the screen's visual cues in sync with each breath. In its description on the PC World Web site, the app is said to have been designed by a group of psychiatrists, clinical researchers, med students, and patients.

"Designed to interrupt the cycle of thoughts and body sensations that fuel a panic attack," the app incorporates both mindfulness and cognitive behavioral techniques and guided exercises to bring relief. "Together these methods make room for the fear to pass, all on its own," writes the descriptor.

However, Dr. Simon found the concept to be "too simplistic" while the app was difficult to use.

"I think that if someone is anxious and hasn't crossed that line into panic, it might be okay, and could even be an adjunct to the OCD app. But if they're in the throes of a panic attack, I don't think it would work so well. There also wasn't enough instruction," she said.

A Smart Next Step

Dr. Simon said that before reviewing these apps for Medscape Medical News, she had not really investigated mental health apps.

"But now it makes me want to go and see what else is out there."

She added that although it might be thought that these apps would be most helpful for younger patients, she doesn't necessarily agree.

"Obviously somebody who is tech-phobic won't respond to this, and it might be easier for younger people. But if an app is well written and if you actually walk through it with your patient, especially if they're older, I think it could work really well."

Dr. Mulcahy said that it seems that people are now using their mobile apps for everything imaginable.

"We're at the point where almost everyone has a smart phone. And these devices are so sophisticated with such great functionality that it just makes sense for us to utilize the various apps," she said.

"Many of us see a patient an hour a week, and the rest of the time they're on their own. So to give them a tool that they can use on their own as an adjunct makes sense and is a smart next step in treatment."

Dr. Simon has disclosed no relevant financial relationships.

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