There are currently more than 10,000 depression and anxiety-related self-help apps available to download, the American Psychiatric Association estimates. But less than 1 per cent have been professionally evaluated.
Cause for concern? Well, yes. But not a cause for depression, says Harvard Medical School’s John Torous, who leads the association’s working group on smartphone app evaluation.
In fact, he sees great promise in digital mental health technologies.
“We can begin to push evidence-based interventions through smartphones,” he says.
“And we have the potential to capture a lot of exciting real-time data that may give us clues about how people are feeling and how they are functioning in real life, in the community.”
Mental health apps, Dr Torous predicts, will eventually play an important supplementary role to conventional face-to-face therapy, with particular benefits for those living in remote areas.
His enthusiasm is shared by Helen Christensen, the director of the Black Dog Institute at the University of New South Wales.
Professor Christensen says there is a growing body of research indicating that well-designed apps are as effective as face-to-face therapies.
Online tools designed to help alleviate or prevent mental illness take many forms.
Some work to give people a better understanding of the physical warning signs for anxiety, like an increased heart or breathing rate, for example. Others are used to help a person moderate or change their behaviour.
Professor Christensen and her researchers have been developing and evaluating various online applications, including apps that employ what psychologists call Cognitive Behaviour Therapy — known colloquially as the Talking Therapy.
“We are moving into a different arena where chat bots are getting more and more intelligent and they are capable of helping people to manage their own mental health,” she says.
But without any professional assistance, it can be difficult for those experiencing a mental health problem to find a digital tool that suits their specific needs.
Be strategic when choosing a mental health app
The American Psychiatric Association doesn’t recommend specific applications, but it has developed a four-level evaluation framework.
- Step 1: Risk/privacy and security.
- Step 2: Evidence.
- Step 3: Ease of use.
- Step 4: Interoperability (which refers to the ability to share the data generated by the app with a trusted medical professional).
Dr Torous says many apps cleverly position themselves outside the medical regulatory framework in order to gather personal data and then share it with commercial interests.
“A lot of these are free because you’re telling the app what medication you are on, what therapy you are on, where you live, where you are going, and that information is being collected by the app and the app will legally own it,” he says.
He says it’s crucial that a person is confident in using the app they choose.
“There’s strong evidence that a lot of times people will download an app, but they will never use it more than once,” he says.
“No mental health app, no matter how safe and how effective, is going to be useful if it’s only used once.”
So what apps are out there?
Professor Christensen believes there’s currently a disconnect between consumers and researchers.
Many of the most popular apps, she says, are yet to be properly assessed, while those that have been evaluated tend not to have broad appeal.
“We have to remember this is a very new field. This explosion of apps is only really in the last three or four years,” she says.
“We need to work harder to co-design apps with those who use them.”
There’s also a need for greater consistency with the evaluation process, she argues.
Professor Christensen recommends choosing a mental health app in consultation with an accredited therapist. And a good starting place, she says, is the website Beacon — an online portal developed by the Australian National University.
All the mobile apps and websites listed on Beacon have been categorised, reviewed and rated by a panel of health experts.
SHUTi is another app evaluated by the Black Dog Institute.
According to Professor Christensen, use of the app has shown a reduction in suicide ideation and depression by using behaviour therapy to help improve sleep habits.
A third self-help initiative she recommends is called Brave. Brave is operated by beyondblue and has a specific focus on depression and anxiety in young children.
Online therapies developed by the Black Dog Institute include the interactive self-help websites moodgym, myCompass and BITE BACK.
The next step for researchers and developers is ensuring the products they create are better integrated into systems of care, Professor Christensen says.
“The idea is that it’s not just out there for people to find, but we actually try to integrate it into areas in which people with mental health problems or depression symptoms do reside,” she says.
The Black Dog’s myCompass app, for example, is now being used by suburban doctors as a first step screening initiative when patients arrive at their local clinic for a regular consultation.
“We know that 90 per cent of people see a GP every year,” Professor Christensen says.
“So this is a good place to catch people and offer them an opportunity to do an online program we know is well evaluated.”
The news on depression is not all black
While demand for self-help apps is increasing, that shouldn’t be taken as a sign that levels of depression and anxiety are necessarily increasing too.
Greater awareness of mental illness coupled with a decrease in stigmatisation has arguably made depression seem widespread, but Professor Christensen says she doubts mental illness rates are on the rise.
“My reading of it is that it’s not getting worse, though we don’t have very good datasets. So, we’ve only really done proper population data collection over two occasions. The last time was in 2008. And basically the prevalence of depression has not increased,” she says.
But that’s not to say the problem is diminishing. Latest research suggests that more than 50 per cent of all mental illness emerges before the age of 18.
In that vein, using smartphone technology to help counter or prevent the symptoms of mental illness seems particularly well-matched.