Mental Health Apps: Boon or Bust?

Batya Swift Yasgur, MA, LSW

March 25, 2019

The use of mental health apps is dramatically expanding, but while they are promising tools, many are ineffective in reducing symptoms, do not offer evidence-based approaches, and potentially compromise patients' privacy, new research suggests.

Investigators reviewed over 70 studies of mental health apps using two leading frameworks to analyze information such as price, updates, developer information, safety, and the evidence base behind the interventions included in the app.

They found that common strengths of available apps included symptom-tracking features, psychoeducational components, and higher user engagement. Common weaknesses include insufficient privacy settings and little integration of empirically supported treatments, outside of scientifically developed apps.

"There are tens of thousands of apps out there that purport to cover mental health, and we located more than 70 different reviews of different portions of mental health apps, trying to extract general themes that characterized problem areas," lead author Joshua Magee, PhD, assistant professor of psychology and director of the Studying Cognition, Obsessions, and Unwanted Thinking (SCOUT) Lab at Miami University, Oxford, Ohio, told Medscape Medical News.

"Overall, we found that finding effective apps that are easy to use, evidence-based, and that protect personal information is very challenging, and we think that this is best done in tandem with some sort of health professional," he said.

The study was recently published in the journal Current Treatment Options in Psychiatry.

Privacy, Security

Magee explained that his group "wanted to take a snapshot of the mental health app marketplace right now, focusing on 3 critical areas: how apps adhere to best practice guidelines, user experience, and privacy and security," calling the task "daunting."

His group "wanted to first introduce readers to two leading, reliable frameworks for evaluating mental health apps," he said.

The American Psychiatric Association (APA) App Evaluation Model provides an evaluation method and corresponding online course for use in evaluating mental health apps.

The model, designed for healthcare professionals, uses several "key dimensions" to analyze each app:

  • Price, last update, and developer

  • Safety (privacy/security of data)

  • Efficacy and usability (eg, evidence supporting the app)

  • "Interoperability" (how the app may allow data sharing among healthcare professionals and patients)

The second framework is PsyberGuide, a nonprofit website that rates mental health apps based on credibility, transparency, and user experience.

"Clinicians and clients can search [PsyberGuide] by problem area, by cost, and by platform — for example, iPhone vs Android — and can try to figure out, according to expert ratings, which apps they may trust and feel most comfortable using with their clients," Magee noted, adding that the database is constantly being updated to handle the ever-changing marketplace of apps.

Some Helpful, Some Harmful

The researchers reviewed existing papers focusing on apps, and reached several conclusions about the role of apps in mental health conditions.

The researchers found surprisingly few "well-regarded" apps for anxiety disorders, with only 52 functional apps that went beyond text or audio information to offer psychological techniques for reducing anxiety.

While some of these apps are successful with anxiety reduction, there is "unclear empirical support" for apps targeting specific anxiety disorders, the authors say.

An exception is posttraumatic stress disorder (PTSD), where apps such as the PTSD Coach intervention may be more "promising."

Some data support the use of an app-based version of the Patient Health Questionnaire (PHQ-9) for assessment of depression, and there are several monitoring apps to track depressive symptoms.

Otherwise, there is "no strong evidence supporting publicly available apps" for depression treatment, Magee said, and evidence-based treatments appear to be present in only about 10% of depression-oriented apps.

Moreover, "a number of apps, such as those for eating disorders, provided advice that was not only inaccurate and lacking in evidence base, but actually harmful, providing users with strategies that can deepen rather than improve the disorder," Magee noted.

Some alcohol use-related apps actually encouraged alcohol consumption, the authors state, either directly or through "motivating drinking by virtue of users' desire to check their blood alcohol content."

The suicide prevention apps were promising, possessing "some elements of best practice guidelines" and only a few contained "potentially harmful elements," the authors report.

However, few apps had interactive content and few were scientifically evaluated.

"Anti-suicide apps have a lot of potential, due to all the functions our phones can do at this point," Magee remarked.

"In addition to providing people with effective advice and tips when they may be struggling with risk factors for suicidal thoughts or self-harm, phones may point people to resources near them, or may have other types of interactive functions that potentially could provide them with support to help with their problems," he said.

Magee acknowledged that "it's still early, and we're not seeing a lot of apps that are even getting at that, but the reviews talked about apps under development that can integrate geolocation and other capabilities, which are very exciting."

Tracking and Monitoring

The greatest strengths of several apps involved the ability to facilitate monitoring and tracking — eg, alcohol use or mood symptoms in bipolar disorder — thereby serving as "an adjunct for health professionals who are delivering evidence-based treatment," the authors state.

Limitations include insufficient technological capacities to share insights gleaned from the app with healthcare providers; privacy issues; and technical failures.

Smartphone apps for schizophrenia proved useful, however, providing symptom monitoring, mental health self-management, and physical activity promotion; results of a review of five independent studies of these apps showed "low dropout, high levels of self-initiated app usage, and high perceived helpfulness of the app by patients," the authors write.

"These results…suggest that despite concerns about the capacity of patients with schizophrenia and psychotic disorders to use mental health apps, these patients are capable, engaged with smartphones, and may benefit from careful implementation," the authors comment.

Stress-relief apps are promising, since there is high adherence to evidence-based strategies, high usability, and roughly half of the reviewed apps seem to be transparent in the source of confidentiality, privacy, and other information, the authors report.

By contrast, pain-relief apps have typically been developed by software designers or laypeople with little input from healthcare professionals and little reference to evidence-based guidelines.

The researchers note that of the hundreds of "mindfulness" apps, only about 4% include both mindfulness training and education components.

"Mindfulness apps are very popular, but our main concern was lack of evaluation — a mindfulness app may be put out by a leading expert or could be created by your neighbor, who has no training in this area," Magee said.

"Like many of these categories, they have great potential, and apps targeting stress have relatively more support than other areas, but we found a very small percentage that actually incorporated effective techniques that a clinician might train you on, and it can be difficult to differentiate between a mindfulness app based on effective practices and one that isn't," he said.

"Because many of these apps are not generated by health professionals, there is often little attention paid to privacy, in the sense that health professionals would term it," Magee remarked.

Questions include what the app might do with sensitive data — eg, information about alcohol or drug use or sexual activity.

"In face-to-face therapy, we have practices [about] how to manage that information and keep it confidential, but with apps there is no similar guarantee, so our recommendation would be to look at frameworks like PsyberGuide to help users evaluate a manufacturer's level of transparency around security," he advised.

Magee urged psychiatrists and other clinicians to "assess for current app use, which may uncover information about what apps your clients are already using, since it might be important to know what is helpful or unhelpful information or techniques that they are getting through these sources."

"Be Cautious, Savvy"

Commenting on the study for Medscape Medical News, Stephen Schueller, PhD, assistant professor of psychological science, University of California, Irvine and executive director of PsyberGuide, called it a "very thorough review of some of the apps that are out there for a variety of different disorders, showcasing well a lot of work that has been done."

Schueller, who was not involved with the study, noted that the conclusions and limitations were "a little short, overlooking some of the serious challenges we face in terms of actually using these tools in benefiting people's lives."

Nevertheless, the paper "did a nice job and highlights a lot of excitement that's there, and the huge potential — and 'potential' is a good word because it has excitement, but a negative word because many things are not yet realized," said Schueller, who is a member of a team evaluating an Innovation Technology Suite Project in California that explores the use of apps to improve county mental health services.

He noted that, depending how one defines a "mental health app," there are about 10,000 to 30,000 apps currently available.

"I encourage clinicians to be cautious but savvy, and if you're going to recommend an app, go through it, pilot it, and use it yourself," Schueller advised.

He pointed to two major ways to incorporate apps into clinical practice.

"One is to track and monitor or reinforce treatment you're already providing," he said.

"The other is to cover areas you may not be able to cover in session — for example, if a client has depression and insomnia and you're focusing primarily on depression, you might recommend an app for insomnia as a helpful adjunct or supplement to what you're doing in session," Schueller said.

Magee recommended that clinicians "begin to develop a portfolio of apps they become familiar with and update over time, such as the app's features and limitations, so they can fully inform clients, and should carefully engage in ongoing monitoring as they roll them out together."

Magee reports receiving grants from the National Institute for Health supporting this research. The three coauthors and Schueller have disclosed no relevant financial relationships.

Curr Treat Options Psychiatry. Published online July 16, 2018. Abstract

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