Should you trust mental health apps?

By Stephen Schueller

Image courtesy of Pixabay.
If you were to search the Google Play or Apple iTunes store for an app to help support your mental health you’d find a bewildering range of options. This includes nearly 1000 apps focused on depression, nearly 600 focused on bipolar disorder, and 900 focused on suicide (Larsen, Nicholas, & Christensen, 2016). But how much faith should you have that these apps are actually helpful? Or to take an even more grim position, might some apps actually be harmful? Evidence suggests the latter might be true. In one study, researchers who examined the content in publicly available bipolar apps actually found one app, iBipolar, that instructed people to drink hard liquor during a bipolar episode to help them sleep (Nicholas, Larsen, Proudfoot, & Christensen, 2015). Thus, people should definitely approach app stores cautiously when searching for an app to promote their mental health.

One reason people might believe such apps could be helpful is that Google Play and the Apple iTunes store list them within the “Health & Fitness” category rather than as entertainment, games, productivity, or social apps. One’s expectations of benefits are likely tied to how things are presented. If we looked elsewhere for examples of responsible uses of technology and mental health, we find a growing example of online mental health tests. Google, for example, has started providing tests for depression (Duckworth & Gilbody, 2017) and posttraumatic stress disorder in collaboration with the National Alliance on Mental Health and Mental Health America tests for various mental health problems in their screening platform. One would expect that these tests could be helpful and would tell you something valuable about your mental health. BuzzFeed tests, on the other hand, probably would not. Although some BuzzFeed tests might be loosely based on psychological concepts and theories, these tests function as entertainment meant to generate interest and clicks and not to promote useful health-related knowledge.

Google and Mental Health America, on the other hand, have collaborated with clinical scientists to select validated and widely-used tests that represent the gold-standard within the field and thus have proven value for mental health. This comparison is useful because it demonstrates what app stores are not doing prior to allowing an app to be added to the “Health & Fitness” section. Stores review the app for some aspects but do not ensure it is validated, represents widely-used best practices, or has any proven value. Instead, they verify that the app meets their guidelines of technical, content, and design criteria. These guidelines lead to rejecting apps that risk physical harm, but not mental nor psychological harm. Furthermore, the review teams lack the expertise needed to truly evaluate the apps using a higher standard. Where might people turn then to get the necessary information to make informed decisions about mental health apps?

Image courtesy of Max Pixel.
Over the past few years we’ve led a project that aims to fill this gap. Our goal at PsyberGuide is to empower consumers to make informed decisions to lead them to effective, usable, and safe mental health apps. Each app is rated on a variety of aspects: its credibility (direct and indirect research evidence and the quality of the development team), its user experience (aesthetics, usability, functionality), and its transparency and quality of its description of data security and privacy. Furthermore, for many apps we provide narrative reviews from experts in the field to help people better understand how and why to use that particular app. Through this process, we’ve learned some important things about the current state of mental health apps (Neary & Schueller, 2018).

Most apps that have direct empirical support (e.g., a scientific study evaluating that app itself) do not become publicly available. Of the many apps available, and again, there are numerous (van Ameringen et al., 2017), few have direct empirical support. Some app developers justify this by translating another technology-based treatment, like a web-based platform, into an app. This is the case for reSET®, which received FDA approval based on data drawn from a web-based version of the intervention (Campbell et al., 2014). Other app developers claim their apps draw on evidence-based principles, such as cognitive-behavioral therapy. But researchers who actually evaluate the content within apps find this is rarely the case (Huguet et al., 2016). Therefore, having an independent third-party review the evidence supporting an app produces a useful benchmark.

Even though an app may have direct research evidence, that does not mean it has a good user experience. In fact, in our ratings we find that credibility and user experience have a very low correlation (Neary & Schueller, 2018). It is not surprising, then, that many mental health apps experience low levels of real-world engagement. Clinical experts such as academic teams rarely have the expertise, funding, or incentives to build an engaging mental health app. Commercial app developers rarely have the expertise, interest, or incentives to conduct rigorous scientific evaluations. It is worth noting that the absence of evidence is not the evidence of absence and it could be that apps that do not currently have research support might later be supported by research. It is also possible, however, that popular apps might not lead to significant benefits when subjected to rigorous scientific evaluation, as was the case in a recent study of Headspace (Noone & Hogan, 2018). Clearly, more research is needed but also more researchers need to team with experts in fields such as design, human-computer interaction, gaming, and software development to build more engaging products that might result in not just benefits in research studies, but also use in real-world environments.

Lastly, although many apps exist, few receive many downloads. Therefore, a project like PsyberGuide might have the largest impact by focusing on better understanding the most popular apps and raising awareness regarding their strengths, limitations, and expected benefits, and helping point people towards specific apps that might be helpful for them. We need to be careful not to overhype the potential of technology to deliver effective mental health treatments while also advancing the science and practice of this field to help people find apps that might actually benefit them.
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Stephen Schueller, PhD, is an Assistant Professor of Preventive Medicine at Northwestern University and a member of Northwestern’s Center for Behavioral Intervention Technologies (CBITs). He also serves as the Executive Director of PsyberGuide, a project of One Mind that aims to identify, evaluate, and disseminate information about digital mental health products. His research broadly looks at increasing the accessibility and availability of mental health services through technology. He has developed, deployed, and evaluated digital mental health interventions including Internet websites and mobile apps for the treatment and prevention of depression, anxiety, and smoking cessation and the promotion of well-being including positive affect and happiness.

References

1. Campbell, A. N., Nunes, E. V., Matthews, A. G., Stitzer, M., Miele, G. M., Polsky, D., ... & Wahle, A. (2014). Internet-delivered treatment for substance abuse: a multisite randomized controlled trial. American Journal of Psychiatry, 171(6), 683-690.

2. Duckworth, K., & Gilbody, S. (2017). Should Google offer an online screening test for depression?. Bmj, 358, j4144.

3. Huguet, A., Rao, S., McGrath, P. J., Wozney, L., Wheaton, M., Conrod, J., & Rozario, S. (2016). A systematic review of cognitive behavioral therapy and behavioral activation apps for depression. PLoS One, 11(5), e0154248.

4. Larsen, M. E., Nicholas, J., & Christensen, H. (2016). Quantifying app store dynamics: longitudinal tracking of mental health apps. JMIR mHealth and uHealth, 4(3), e96.

5. Neary, M., & Schueller, S. M. (2018). State of the Field of Mental Health Apps. Cognitive and Behavioral Practice.

6. Nicholas, J., Larsen, M. E., Proudfoot, J., & Christensen, H. (2015). Mobile apps for bipolar disorder: a systematic review of features and content quality. Journal of medical Internet research, 17(8), e198.

7. Noone, C., & Hogan, M. J. (2018). A randomised active-controlled trial to examine the effects of an online mindfulness intervention on executive control, critical thinking and key thinking dispositions in a university student sample. BMC psychology, 6(1), 13.

8. van Ameringen, M., Turna, J., Khalesi, Z., Pullia, K., & Patterson, B. (2017). There is an app for that! The current state of mobile applications (apps) for DSM-5 obsessive-compulsive disorder, posttraumatic stress disorder, anxiety and mood disorders. Depression and anxiety, 34(6), 526-539.


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Schueller, S. (2018). Should you trust mental health apps? The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2018/05/should-you-trust-mental-health-apps.html

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