Visiting the app store for a mental health app can be mind-boggling today.
With more than 10,000 apps for mindfulness, stress relief, depression, anxiety, bipolar disorder, and substance abuse, how do we choose which one to download? How do we know if the app we are about to download is safe to use? Are the tools offered by the app evidence-based? Has the app been tested in a research trial to make sure it is effective?
That is what our team in the Centre for Population Health Sciences (CePHaS) in Singapore sets out to study. I am a medical doctor, currently completing my PhD where I performed in-depth evaluations of apps found in commercial app stores that may be used by people with depression. Together with my supervisor, Prof. Josip Car, we are based in the Lee Kong Chian School of Medicine, a partnership between Nanyang Technological University, Singapore, and Imperial College London. We have been researching health apps, to systematically evaluate them, using carefully defined criteria based on evidence-based clinical practice guidelines. Over the last five years, we have assessed apps for diabetes, eczema and suicide prevention for their agreement with best-evidence practice, privacy, how easy to use and accessible they were, and more.
Seeing the ever so growing number of mental health apps in the app stores, we decided to focus on cognitive behavioural therapy (CBT) based apps for depression, and this is what we are going to talk about in this blog.
Why is depression important?
There are more than 300 million people, or about 4.4% of the global population, affected by depression. However, the majority afflicted with depression do not receive treatment. The figure is staggering, with about half the people with depression in high- income countries and up to 80–90% of those living in low- and middle-income countries not seeking treatment. There are many reasons for this, including the lack of adequate care available, the fact that treatment can be time-consuming, expensive, and often not covered by medical insurance, and the stigma of having a mental health disorder, all of which might prevent many of the affected people from seeking help.
Mental health apps could fill some of these gaps as they could offer affordable, confidential, and convenient tools to manage depression.
What is CBT?
Cognitive behavioural therapy (CBT) is a talking therapy recommended by the NHS to treat depression. The NICE guidelines for treating depression recommend self-guided or computer-based CBT as the preferred treatment for people with persistent subclinical depression or those with mild to moderate depression. Antidepressants should be used only in people who do not improve with psychological treatment, or if the individual presents with moderate to severe depression.
CBT supports individuals in developing more adaptive ways of thinking and behaving by challenging and modifying dysfunctional thoughts and behaviours. However, such treatment, delivered by a trained professional in a clinic, can be time-consuming (requiring 45 min to 1 hour weekly or bi-weekly meetings with the therapist for at least 3 months, and costly for some individuals. This is where using apps to help manage symptoms of depression comes to the rescue. However, how do we know which apps would be best suited to help?
Evidence behind mental health apps
The COVID-19 pandemic and accompanying social distancing measures are associated with an increase in the rate of anxiety and depression in the population, which stresses the need to improve mental health care. Digital technologies are particularly well placed to make this happen. Apps, with their immense reach and scalability due to the extensive use of smartphones, are increasingly being used to bridge these gaps. But despite their ubiquity, many of these apps are developed by individuals without healthcare training and only a few apps are tested in clinical trials before being offered to the public. As such, little is known about the concordance of mental health apps content with the best clinical evidence.
With more people downloading apps to help monitor their health conditions, it becomes ever more important to evaluate the quality of health apps offered by the app stores.
Our researchers, comprising physicians, psychologists, and digital health experts conducted a study recently, looking at existing mental health apps offering CBT-based interventions that people with depression could use without the assistance of a healthcare provider. The focus of our evaluation was whether the information and exercises offered by the apps followed well-established norms set by research and well-recognized practice manuals. To do this, we focused on three aspects:
1. Basic information about the apps,
2. Information about the CBT strategies included in the apps,
3. Technical aspects, such as how easy it is to use the app if it includes information about the users’ privacy, and composition of the app development team (does it include mental healthcare providers, academic institutions, or relevant non-governmental organizations (NGOs)?)
To develop a CBT-related evaluation checklist, we consulted a recognized CBT manual, used to train healthcare providers and a list of skills CBT therapists should be familiar with. We looked for six important evidence-based techniques: education about depression and CBT; behavioural activation techniques to encourage the user to engage in different activities; cognitive restructuring, to monitor negative thoughts, and try to come up with a different, more positive explanation for these thoughts; problem-solving techniques, relaxation exercises such as mindfulness and meditation; and exposure techniques commonly used for people who also have anxiety. We also checked if the apps monitored the users’ mood and risk of suicide, gave access to crises helplines for individuals at risk, provided homework in-between sessions, and encouraged users to continue the programme. As this evaluation was done after the start of the COVID-19 pandemic we also checked if the apps included information about the virus and how it affected mental health.
We searched Apple’s App Store and Google Play for self-guided CBT apps that complied with predetermined characteristics. We found 1955 apps, of which we included 98 apps. We grouped them into three distinct categories: wellbeing apps (20 apps) aimed to improve the general wellbeing of otherwise healthy users; mental health apps (65 apps) included CBT exercises to manage two or more common mental health disorders, including depression; and depression apps (13 apps) aimed exclusively to people with depression.
What did we find?
Wellbeing apps offered up to three evidence-based techniques, mainly cognitive restructuring, and relaxation. They also frequently checked the users’ mood, but only 2 (10%) of the apps checked the risk of suicide or included crisis information. Mental health apps commonly offered up to five evidence-based techniques, although there was great variety in the number of techniques offered by each app. Most apps offered cognitive restructuring and CBT education, and less often behavioural activation and relaxation exercises. Two-thirds of the apps monitored users’ mood, but only 35% evaluated suicide risk or offered crisis information. Finally, depression apps commonly offered four evidence-based techniques including cognitive restructuring, behavioural activation and CBT and depression education, with about half of the apps offering relaxation techniques and mood monitoring. Suicide risk management was included in two-thirds of depression apps.
Are these apps trustworthy?
In our assessment, we found that the apps published in commercial app stores differ from each other in terms of standards and make-up. For example, only half of the apps we evaluated were developed in teams including psychiatrists, psychologists, or institutions with mental health expertise, and only about 60% included references to the information they provided; only 17 apps were backed up by research published in scientific journals.
In summary, our research showed that few apps in the app stores offer comprehensive CBT programs, and most do not address suicide risk by offering emergency contact information such as crisis helpline phone numbers. Also, we found that privacy policies are not always clear on sharing user data, with little oversight from regulatory agencies.
Given a large number of apps, and the fluidity of the app market with apps constantly being published and removed, it is not easy for the general public to find the one “right app” for their mental health needs. However, there are promising apps that provide evidence-based content and privacy settings but you will need to review them with a critical eye before downloading. Here are some tips on what to look for before downloading a mental health app:
1- Who developed the app? Is it a well-known healthcare institution? If not, are mental healthcare professionals part of the development team?
2- Does the app include links or references to reputable books, journals, or websites?
3- Does the app include a disclaimer saying that the app does not replace the provider’s advice?
4- Does the app include emergency information if the user is at risk of suicide?
6- Are the app settings modifiable to fit users’ needs, including the option of setting up passwords if needed?
7- Are the techniques and exercises offered by the app based on best evidence?
Mental health apps could play an important role in helping people with depression or other mental health problems, particularly for people in low- and middle-income countries. Although many apps found in the app stores present several shortcomings, our main message would not be to avoid such apps completely, but to approach them with a ‘buyer beware’ mindset and do the research before deciding to commit to one.