Is your mental health app backed by science?

 

Is your mental health app backed by science? 

Photo by Sarah Gualtieri via Unsplash.com

When choosing a mobile app to help you in your mental health journey, look for features and design choices that are supported by scientific evidence.

• In this blog post, you will read about which mental health app features are common in apps according to a 2017 meta-analysis study, some of which are backed by scientific evidence.

• You will know which features are supported by science and which need further studies.

• Look for an app that uses data-driven design and contains evidence-based activities that improve mental health. Use an app in conjunction with a licensed therapist to get the most out of your mental health journey.

• After reading this blog post, you will be able to make evidence-based and informed decisions about the apps you choose and trust with their mental health.

We looked at a meta-analysis that identified common features in mental health apps across 45 research articles and here is what the study found:

First, some background: Not all software developers use scientific evidence as the foundation for designing and building apps, and apps on the Play or App Stores don’t need to be vetted or reviewed before launching. This means that many mental health apps might not be as efficient as they could be, or worse, might not actually be helpful even if they were made with good intentions. In fact, improperly designed apps can actually lead to no change, unintended consequences, or even harm. An example of this was found in a 2014 study by Mikael Gajecki and his colleagues in Sweden, who found that an app designed for measuring blood alcohol content meant for reducing risky alcohol use actually found that it had the opposite effect in its male participants.

So how do you know if an app is legit? Reviews can be faked or bought, but if the developers are able to show...

• That they’ve done the research

• Can point to academic literature that supports their design choices, and/or

• That they work in conjunction with licensed medical health professionals

… those would be steps in the right direction. 

Luckily, there is a growing amount of research available when designing a mental health app so that evidence-based apps can exist. The meta-analysis and systematic literature review we discuss below is one such example. This study was conducted by Fabian Wahle, Lea Bollhalder, Tobias Kowatsch, and Elgar Fleisch (2017) from Switzerland in the Journal of Medical Internet Research. In it, they reviewed 45 studies from around the world to identify which features are used in mental health apps and of these, which should be standard of care.

Photo by Kelly Sikkema via Unsplash

The mental health app features (components) identified:

Wahle et al. identified 15 features (or as they called them, components) commonly found in mental health apps. Though not all of them had strong evidence to support their use in affecting mental health outcomes in these apps, the following approaches were found to be statistically significant in improving overall mental health outcomes:

1. Tailoring (Personalization): there is no such thing as one-size fits all when it comes to people, and the ability to personalize your goals, strategies and feedback systems are absolutely crucial for making progress. This was confirmed in a meta analysis study by Noar et al (2007). Look for apps that will let you input your own goals and change behaviors so they can be perfectly personalized to your needs. 

2. Supportive Messages (Praise): Research by Agyapong et al (2012) looked at a program using supportive text messages that showed promise for people who experienced both depression and alcohol overuse. While we don’t think that these messages must be provided only through SMS text messages, having positive, practical, and customizable messaging using an app has shown to be a helpful tool.

3. Reminders: Sometimes we get so wrapped up in a situation that we forget to take care of other business. In the study by Whitton et al (2015, the authors concluded that reminders are a powerful, cost-effective tool for users engaging in and sticking with mental health interventions. Seek out apps in which you can customize your reminder systems to help you get to a rhythm that works for you.

4. Workbook/Homework Assignments: Homework assignments given by therapists are commonly used in standard care, and are an important part of why cognitive-behavioral therapy (CBT) works. After all, for many people the goal is to be able to regulate their own thoughts, feelings and behaviors for everyday situations. LeBeau et al (2013) concluded that “improvement of homework compliance has the potential to be a highly practical and effective way to improve clinical outcomes in CBT.” Having the homework assignments in fillable forms on your device allows people to reach for their strategies instantly and the habit becomes more automatic.

5. Symptom Tracking: Tracking symptoms, either objectively using sensors or by means of self-reports was identified as an important feature according to the authors. Wahle et al (2016) found a significant decrease in depression scores for participants after they used an app that allowed tracking of depression symptoms and other information using their mobile phones. Look for apps that will help you track mood, symptoms, and other measures (ideally that you can personalize) that can help you track progress for your goals health care plan.

6. Online Diary: Necessary for self-reflection and self-monitoring, online diaries can take many forms. Look for one that is easy to use, has good privacy settings, and ideally allows you to download your own data and share it with your therapist if you choose to, with safeguards so that nobody but you can access your personal thoughts. While this particular study didn’t go into details of the effectiveness of diaries on mental health, they did include online diaries as an important component of mental health apps, and other resources include diaries and written activities in CBT as a significant part of clinicians’ overall treatment plan (Tallon et al, 2019).

7. Gamification: The authors cite Brown (2008), Wang (2011), and Deterding (2012) as supporting the use of gamification, which produced positive outcomes in the first two studies, looking at technology-based health interventions. Brown (2008) says that gamification of health apps could especially be helpful for personalized goals.

8. Animations/Virtual Assistant: The study authors suggest that virtual agents or avatars could be used to support self-management among patients, and that more literature has been looking at the relationship of virtual agents and their users, potentially having lots of opportunities for providing motivation and promoting mental health maintenance activities.

9. Case Studies: Case studies are established learning tools for taking people through examples of a person experiencing a problem and solutions that may help someone who identifies with a similar problem, and may contribute in part to improving clinical outcomes (Titov et al, 2013).

10. Summaries: The authors found that studies that utilized progress summaries or summarized modules of content topics were helpful for people to understand what they are focusing on and why, which may also contribute to self-monitoring and self-reflection (Padesky, 2020).

Features that were commonly present in apps, but did not have data listed to support their inclusion:

The authors also listed the following features as being present in mental health apps, but did not provide the evidence in this particular paper for their effectiveness. It doesn't mean that they are not effective, just that these features need more studies to confirm that they are statistically significant in assisting people who are working on their mental health:

11. Downloadable Material: Do you prefer your homework analog (pen and paper worksheets)? A good app will have its activities and strategies in the app, but a more comprehensive one will have the option to download and print out summaries, lessons, or homework if that’s your preference which might improve the efficacy of the strategies, and we would love to see future studies to confirm this.

12. Audio/Voiceover: Conclusions for having audio or voiceover in a mental health app were missing from this study and the authors didn’t elaborate on what or how the audio or voice overs worked in the studies they looked at. The authors mentioned that Walther et al (2010) found that audience feedback (i.e., YouTube comments) are a valuable tool to enhance users’ perceptions of health-related YouTube clips but gave no evidence as to how users changed their health behaviors. That doesn’t mean that this feature/component shouldn’t be included, as there are implications for people who would benefit from auditory processing of mental health strategies. This particular study was just unable to provide scientific data from the studies they looked at.

13. Peer Support: The authors were unable to find consensus with respect to effectiveness of online peer support, such as in forums or chats. While we can see the common sense behind having peer support, most apps just aren’t able to provide the monitoring and moderation necessary to keep the chats supportive and prevent toxicity and harm. If you are the kind of person that would benefit from peer support, try looking for trusted friends and family members who would be willing to help provide that or look for an actively moderated forum that has clear rules and prioritizes community safety.

14. Illustrative Content/Video: Little evidence was provided for including visual content in the apps, though the study authors speculated that “illustrative content in the form of graphics, photos, illustrations, comics, or video clips might increase the appeal of interactivity and visual attractiveness of Internet-based programs”. The evidence for increased engagement with visually attractive interfaces might be found in design studies, but was absent in this study.

15. Channel of delivery: This one might seem rather obvious, but an important component identified in this study of mental health app technology is, well, using technology. To work, the app needs to be accessible by mobile or tablet and be designed with mobile users in mind to navigate and use the app intuitively, or else poor design might be a barrier to people using it.

Other features that are absolutely crucial

       Photo by Christina @wocintechchat

The authors of the study didn’t list these two features as part of their study, but we feel that they are absolutely crucial in deciding which app to use for your mental health journey:

Privacy & security

The last thing you want is for your private thoughts and feelings to be stolen, spied upon, or stolen. That’s why, when comparing apps, try to determine how your data will be used and protected. You can look at the privacy policy, settings, and any information and permissions that the app will ask for. Where is the server located? Does it comply with health or personal information privacy laws, such as HIPPA or PIPA? For example, you might be okay with the app having camera permissions so that you can add photos to your journal, but not if that means the company now holds ownership or copyright over the photos you post there. Being clear and having the option to customize your settings based on your level of comfort and trusting that the app is secure is a must-have feature in our book. 

Transparency

You will also want to look at the terms of service in the app that you choose to make sure that your data will not be shared with third parties (who would want ads based off of your private thoughts? Yikes!). Look for an app developer who tells you what and why they need certain information so that you can make an informed decision. An example would be providing a login with a secure email address, so that you can recover your password if you forget it. Some apps might not ask for this information, but if you forget your password with no way to retrieve it, your hard work could be lost forever. However if they ask you for other personal information, think critically about why they might need it. The less an app asks you for, the less chance there is of leaking (or selling) that data.

Once you’ve made the decision to move forward with actively working on your mental health, we highly recommend working with a trained therapist in conjunction with the app to get the most out of your efforts. CBT apps could enhance in-person therapy by helping you stay accountable. They can also provide the convenience of having strategies easily accessible, and you can share your data with your therapist to interpret, analyze and make a tailored plan to help you facilitate your progress.

[We are big advocates of therapy and want to put out the disclaimer that mobile apps are a supplemental tool, not a replacement for in-person, trained therapy.]

What are your favorite features of mental health apps? Was there anything that wasn’t listed in this study that you thought should have been included? Let us know what features keep you motivated, on track, or help you feel grounded!

Citations

• Agyapong, V. I. O., Ahern, S., McLoughlin, D. M., & Farren, C. K. (2012). Supportive text messaging for depression and comorbid alcohol use disorder: Single-blind randomised trial. Journal of Affective Disorders, 141(2), 168-176. doi:10.1016/j.jad.2012.02.040

• Brown T. (2008). Design thinking. Harvard business review, 86(6), 84–141.

• Deterding, S. (2012). Gamification: designing for motivation. interactions, 19(4), 14-17.

• Gajecki, M., Berman, A. H., Sinadinovic, K., Rosendahl, I., & Andersson, C. (2014). Mobile phone brief intervention applications for risky alcohol use among university students: A randomized controlled study. Addiction Science & Clinical Practice, 9(1), 11-11. doi:10.1186/1940-0640-9-11

• LeBeau, R. T., Davies, C. D., Culver, N. C., & Craske, M. G. (2013). Homework compliance counts in cognitive-behavioral therapy. Cognitive Behaviour Therapy, 42(3), 171-179. doi:10.1080/16506073.2013.763286

• Noar, S. M., Benac, C. N., & Harris, M. S. (2007). Does tailoring matter? meta-analytic review of tailored print health behavior change interventions. Psychological Bulletin, 133(4), 673-693. doi:10.1037/0033-2909.133.4.673

• Padesky, C. A. (2020). Clinician's Guide to CBT Using Mind Over Mood. Guilford Publications.

• Tallon, D., McClay, C., Kessler, D., Lewis, G., Peters, T. J., Shafran, R., . . . Wiles, N. (2019). Materials used to support cognitive behavioural therapy for depression: A survey of therapists' clinical practice and views. Cognitive Behaviour Therapy, 48(6), 463-481. doi:10.1080/16506073.2018.1541927

• Titov, N., Dear, B. F., Johnston, L., Lorian, C., Zou, J., Wootton, B., . . . Rapee, R. M. (2013). Improving adherence and clinical outcomes in self-guided internet treatment for anxiety and depression: Randomised controlled trial. PloS One, 8(7), e62873-e62873. doi:10.1371/journal.pone.0062873

• Wahle, F., Kowatsch, T., Fleisch, E., Rufer, M., & Weidt, S. (2016). Mobile sensing and support for people with depression: A pilot trial in the wild. JMIR mHealth and uHealth, 4(3), e111-e111. doi:10.2196/mhealth.5960

• Wahle, F., Bollhalder, L., Kowatsch, T., & Fleisch, E. (2017). Toward the design of evidence-based mental health information systems for people with depression: A systematic literature review and meta-analysis. Journal of Medical Internet Research, 19(5), e191-e191. doi:10.2196/jmir.7381

• Walther, J. B., DeAndrea, D., Kim, J., & Anthony, J. C. (2010). The influence of online comments on perceptions of antimarijuana public service announcements on YouTube. Human communication research, 36(4), 469-492.

• Wang, H., & Sun, C. T. (2011, September). Game reward systems: Gaming experiences and social meanings. In DiGRA conference (Vol. 114).

• Whitton, A. E., Proudfoot, J., Clarke, J., Birch, M., Parker, G., Manicavasagar, V., & Hadzi-Pavlovic, D. (2015). Breaking open the black box: Isolating the most potent features of a web and mobile phone-based intervention for depression, anxiety, and stress. JMIR Mental Health, 2(1), e3-e3. doi:10.2196/mental.3573