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 Table of Contents  
EDITORIAL
Year : 2015  |  Volume : 20  |  Issue : 1  |  Page : 1-3

Use of smartphone apps for mental health: Can they translate to a smart and effective mental health care?


Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication8-Sep-2015

Correspondence Address:
Rajesh Sagar
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-8990.164791

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How to cite this article:
Sagar R, Pattanayak RD. Use of smartphone apps for mental health: Can they translate to a smart and effective mental health care?. J Mental Health Hum Behav 2015;20:1-3

How to cite this URL:
Sagar R, Pattanayak RD. Use of smartphone apps for mental health: Can they translate to a smart and effective mental health care?. J Mental Health Hum Behav [serial online] 2015 [cited 2019 Mar 18];20:1-3. Available from: http://www.jmhhb.org/text.asp?2015/20/1/1/164791

"The most profound technologies are those that disappear. They weave themselves into the fabric of everyday life until they are indistinguishable from it."

(M Weiser, 1991;The computer of 21
st century).

Smartphone (mobile telephone with computer functionality) is one such technological advancement and its utility is expanded by software programs in the form of third-party applications (apps). We may like it or hate it, but in modern times, it is almost impossible to escape the touch of various apps into our personal, professional and social lives. The smartphone ownership in India grew 54% during 2014, reaching 140 million in number and it is estimated to grow nearly 5-fold between 2014 and 2019, reaching 651 million in number. [1] Western figures cover as many as 2/3 rd of the population. Recent years has seen a growing trend of Smartphone Apps for health promotion, disease management and lifestyle, which are becoming the globally accessible platforms for client's health needs.

But, in practical terms, can it really translate into an effective, low cost, smarter health care? How will it integrate itself into the traditional models of care? Should it be on client initiative only, or should mental health professionals play a role in adopting its use, and if yes, to what degree? What about the research evidence for its effectiveness? Will it raise ethical concerns? What about quality standards and legal issues? These are just some of the several issues and considerations that both providers and consumers should be aware of.

Before we continue the debate further, first let us briefly have a look at the various ways in which Smartphone apps are currently being used.

In Medicine, the smartphone tools are being used for quite some time by patients (e.g. for diabetes management) as well as professionals (e.g. app-based medical calculators). In contrast, the adoption of such technology in mental health has been relatively gradual, but is on a steady rise. There are now many (and it runs into thousands) mobile phone apps, mostly for anxiety, depression, smoking, alcohol use, lifestyle (exercise, sleep, nutrition), parenting, cognitive performance, inter-personal relationships, etc., Apps are also available for self monitoring and help for eating disorders and PTSD. [2],[3]

Smartphone apps can be used for screening purposes, urging the user to seek professional help if they cross a particular threshold. For milder or sub-threshold problems, it may assist via self-help strategies or act as a virtual coach for therapeutic skills training e.g. muscle relaxation or breathing exercises. Smartphone apps can provide functions that complement, rather than substitute, conventional treatments. For example, patients can assess and monitor their own symptoms or behaviors (e.g. subjective mood ratings, sleep etc), which can be tracked over time and even shared with the treating therapist or a family member with a graphical display for trends. Apps can also assist in the day to day practical aspects to enhance compliance e.g. keep therapy appointments or medication reminders. Newer apps are relying on GPS coordinates of patients with dementia which can be sent to caregivers for locating patients if they wander away. Similarly, the GPS capabilities could be potentially used to increase behavioral activation, tracking the location of the client and providing suggestions. Also, physiological variables could be monitored by an app. Apps can also focus on psychoeducation, location of mental health facilities and resources, training, research and tele-health care. [2],[3]

But is it all "a lot of noise, but not enough music"? Certain issues and limitations must be discussed and addressed, which currently pose a hurdle to a wider adoption of smartphone apps as an integral and safe part of a mental health care delivery.

First issue is that as of now, there is minimal involvement of health professionals in development of apps and very inadequate evidence base to guide about the safety and efficacy of the mental health apps. Despite their widespread use, there is a concerning lack of scientific expertise associated with health apps. Few studies are available on content analyses or user experiences, but studies on efficacy of apps are too scarce. Recently, a systematic review was conducted for trials on mental health apps (with pre/post design or a control group). [4] Of the total 5464 identified abstracts, only 8 papers could fulfil the essential inclusion criteria, describing a total of only 5 apps targeting depression, anxiety, and substance abuse. While these few studies pointed to positive outcomes with low effect sizes, but the majority of apps lack any scientific evidence about their efficacy. The public needs to be aware on how to identify the evidence-based mental health apps available in the public domain.

Second issue is that of quality and its regulation. Most of the apps are developed with little or no transparency about process of development and are marketed without accountability, making it a 'product' for which often consumers bear the responsibility of use. [5],[6] Regarding content quality, apps need to (a) provide authorship credentials (b) list all references or sources of content (c) fully disclose any sponsorship or funding and conflicts of interest; and (d) ensure a full, non-biased coverage of facts and include up-to-date information. In a recent study by Hunbert et al., [7] authors developed a priori a set of seven criteria that define an ideal headache diary app intended to help headache sufferers. The app criteria were intended as minimum requirements for an acceptable headache diary app that could be prescribed by health care professionals. Of the 38 apps identified, not too surprisingly, none met all seven app criteria. Only 18% of the apps were created with help of scientific or clinical headache expertise. There is a need for some amount of regulation of the health apps to ensure both quality and accountability. The U.S. FDA intends to regulate the apps meant to be used with an FDA-regulated medical device (e.g. a blood pressure cuff), or ones that turn a mobile device into a regulated medical device (e.g. electrocardiography). [8] However, this regulation applies to a limited number of medical apps. As of now, largely, there is no regulatory mechanism for mental health apps, and consumers have no way of grading the apps and making an informed choice. Regulation should take place with involvement of all major stakeholders, including health professionals and consumers.

Third issue is that of usability and acceptance by the general public or psychiatric patients. While western literature suggests that initial acceptability is high among users, but in Indian context, some of the hurdles such as poverty and health literacy of population will make the access difficult for lower socioeconomic strata or illiterate people. It may still take a long time for mental health care apps to become popular. This is one of limitations for a wider reach in rural and remote areas, but as has been seen in other sectors e.g. banking and transactions, people eventually learn to use the technology if it offers substantial benefits. The Internet's reach to adolescents has already mobilized the online social media and related technologies, and smartphone apps for mental health care may be better received by the adolescents. The clinician's perception of a particular mental health app also affects the adoption by patients. A recent study investigated mental health clinicians' (n = 163) perceptions of a patient-facing smartphone app for prolonged exposure therapy for PTSD, before its public release suggested that clinicians were receptive to using the app. [9] But very few studies have made such an effort.

Fourth issue is regarding the ethical and confidentiality concerns about the data. [10] A related issue is regarding the ownership of the data and whether the user can delete it completely from system/servers if s/he wishes to at any point in the future. Breaches of patient confidentiality may inadvertently occur. The lack of transparency of the app developers may give rise to potential conflicts of interests, financial or otherwise. Many apps collect a huge amount of personally identifiable data e.g. phone number, email address, age, gender, and photos, which can be shared to unidentified third-party marketers and advertising sites. It raises serious concerns on their ability to protect the privacy and confidentiality of user information. Personal health information may be of potential use for cyber-criminals and insurance scams. [10] There are still no legal regulations to protect client's right and users. Privacy and ethical concerns become even more important in vulnerable psychiatric patients who may not be able to protect their own rights. Use of mental health apps by patients suffering from major psychiatric disorders without adequate supervision may come with its own set of problems.

Fifth issue is about the limitations of technology as a medium, for example, malfunctioning apps is a potential danger which could negatively impact on patient care. There is always the possibility of loss/theft, or malfunction of the mobile device that could have serious consequences when important data is entered without back up. Of course, a mental health app can never equate the visit to a psychiatrist, and is not meant to replace the clinical care by a professional.

The public health potential of smartphone apps is gradually being realized, but is filled with tremendous challenges as well as opportunities. Just to give an example, a free depression screening smartphone app (with Patient Health Question-9) was released globally and a total of 8241 participants from 66 countries downloaded the app, with a response rate of 73.9%. [11] Another app for self-monitoring of patients with eating disorders demonstrated population-level utilization with over 100,000 users over a two-year period. Almost 50% stated that they are not currently receiving clinical treatment and 33% reported they had not told anyone about their eating disorder. [12] A high prevalence of mental illness and high levels of mobile phone usage in low-resource countries has prompted use of "mobile technology-based mental health interventions" (mH2) in multiple settings and contexts. [13] In absence of research evidence, there is invariably a certain skepticism and justifiably so regarding their wider public health use for mental health care.

So, what can be done to make the smartphone technology more effective and beneficial for users?

There is a need for partnership between technology and mental health professionals, who can provide scientific inputs during the development of an app content and processes. There is a need to bridge the lack of evidence on their utility, effectiveness, and safety. Ultimately, some amount of leadership is needed from mental health professionals as well to develop a framework and guidelines for patients and clinicians. [14] Certain criteria need to be formulated to consistently review health-related app quality in a standardized manner. Further, it has been proposed that medical apps should be peer-reviewed by clinical experts. Various stakeholders, both public and private, must be involved in the process with the goal of providing mental health apps with a validated content and certification that can be used by patients to assess its quality and make informed decisions. Regulatory measures must be balanced enough so as not to interfere with innovation. [5],[6],[15]

The lay population must be made aware on how to choose the apps carefully and such a white-list for public consumption can be made available. The ethical and legal issues surrounding the use of mental health apps must be debated further, before these can be adopted at a larger scale.

Additional considerations involve the feasibility aspects in a multi-lingual society like India, where a large majority prefers to use their regional languages. The sheer task of translations and validations in different languages is a mamooth task in itself. The cost-effectiveness of these interventions is another issue in low-resource countries. Further, India still has a relatively low penetration of internet use interfering with large-scale adoption and acceptability of mobile mental health. In this context, an ongoing Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health Programme [16] is noteworthy which aims at assessing the acceptability, feasibility and preliminary effectiveness of a task-shifting mobile-based intervention. The key components include an anti-stigma campaign followed by a mobile-based mental health services intervention. The programme uses a mobile-based clinical decision support tool to be used by non-physician health workers and primary care physicians to screen, diagnose and manage individuals suffering from depression, suicidal risk and emotional stress. The lessons learnt from such initiatives in low-resource setting can be applied to the mental health service delivery models across similar settings.

Looking ahead, the smartphone technology is likely to acquire a dominant role in society, along with other smart-wearable devices. More evidence, framework and guidelines will be necessary before it can be adopted at wider scale in the field of mental health. Lastly, it is not likely in the foreseeable future that medical apps can act as a substitute for a conventional models of treatment and care, at best these can be used to supplement the efforts of a clinician and can act as tools for mental health promotion and awareness in the community at large.

 
  References Top

1.
Cisco Visual Networking Index: Global mobile traffic forecast update. Available from: http://www.cisco.com/c/en/us/solutions/collateral/service-provider/visual-networking-index-vni/white_paper_c11-520862.html [Last accessed on 2015 Mar 31].  Back to cited text no. 1
    
2.
Luxton DD, McCann RA, Bush NE, Mishkind MC, Reger GM. mHealth for mental health: Integrating smartphone technology in behavioral healthcare. Prof Psychol Res Pract 2011;42:505-12.  Back to cited text no. 2
    
3.
Torous J, Staples P, Onnela JP. Realizing the potential of mobile mental health: New methods for new data in psychiatry. Curr Psychiatry Rep 2015;17:602.  Back to cited text no. 3
    
4.
Donker T, Petrie K, Proudfoot J, Clarke J, Birch MR, Christensen H. Smartphones for smarter delivery of mental health programs: A systematic review. J Med Internet Res 2013;15:e247.  Back to cited text no. 4
    
5.
Buijink AW, Visser BJ, Marshall L. Medical apps for smartphones: Lack of evidence undermines quality and safety. Evid Based Med 2013;18:90-2.  Back to cited text no. 5
    
6.
Boulos MN, Brewer AC, Karimkhani C, Buller DB, Dellavalle RP. Mobile medical and health apps: State of the art, concerns, regulatory control and certification. Online J Public Health Inform 2014;5:229.  Back to cited text no. 6
    
7.
Hundert AS, Huguet A, McGrath PJ, Stinson JN, Wheaton M. Commercially available mobile phone headache diary apps: A systematic review. JMIR Mhealth Uhealth 2014;2:e36.  Back to cited text no. 7
    
8.
Barton AJ. The regulation of mobile health applications. BMC Med 2012;10:46.  Back to cited text no. 8
    
9.
Kuhn E, Eftekhari A, Hoffman JE, Crowley JJ, Ramsey KM, Reger GM, et al. Clinician perceptions of using a smartphone app with prolonged exposure therapy administration and policy in mental health and mental health services research. Adm Policy Ment Health 2014;41:800-7.  Back to cited text no. 9
    
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Giota K, Kleftaras G. Mental health apps: Innovations, risks and ethical considerations. E-Health Telecommun Syst Netw 2014;3:19-23.  Back to cited text no. 10
    
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Bin Dhim NF, Shaman AM, Trevena L, Basyouni MH, Pont LG, Alhawassi TM. Depression screening via a smartphone app: Cross-country user characteristics and feasibility. J Am Med Inform Assoc 2015;22:29-34.  Back to cited text no. 11
    
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Tregarthen JP, Lock J, Darcy AM. Development of a smartphone application for eating disorder self-monitoring. Int J Eat Disord 2015. [In press]  Back to cited text no. 12
    
13.
Farrington C, Aristidou A, Ruggeri K. Health and global mental health: Still waiting for the mH2 wedding? Glob Health 2014;10:17.  Back to cited text no. 13
    
14.
Chan S, Torous J, Hinton L, Yellowlees P. Towards a framework for evaluating mobile mental health apps. Telemed J E Health 2015. [In press]  Back to cited text no. 14
    
15.
Olff M. Mobile mental health: A challenging research agenda. Eur J Psychotraumatol 2015;6:27882.  Back to cited text no. 15
    
16.
Maulik PK, Devarapalli S, Kallakuri S, Praveen D, Jha V, Patel A. Systematic Medical Appraisal, Referral and Treatment (SMART). Mental Health Programme for providing innovative mental health care in rural communities in India. Glob Ment Health 2015;2:e13.  Back to cited text no. 16
    



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