A proliferation of mental health apps in recent years means that for the first time, digital health and treatment tools are readily available on our smartphones. But while interest and development of these digital treatments is to be applauded, as a whole they are yet to be tested for efficacy. In this article, we examine the evidence supporting the use of mental health apps, as well as the concerns that mental health professionals have in relation to their use.
Global mental health crisis
With the World Health Organisation predicting that one in four people in the world will be affected by mental illness at some point in their lives and around 450 million people currently suffering, mental disorders are among the leading causes of ill health and disability worldwide.
The need is so great it is no surprise the number of therapy apps seems to be increasing exponentially. Research is now imperative to scrutinise their potential, both robustly and scientifically. Clinicians need to know if apps can ever be more effective than more traditional therapies and whether patients will use mobile health or therapy apps once the novelty has worn off.
Thrive’s Behaviour Change Consultant, Dr Felix Naughton, points out that "apps are primarily a commercial enterprise, usually developed by people often thinking in business terms such as profit or return on investment. This is one complication, and that's why there are so many apps available. Often they are developed by people without mental health expertise, which presents another challenge."
Nevertheless, Felix maintains that "there are some people who will respond better to a well-developed and clinically tested app, rather than face-to-face therapy. The challenge with apps as things stand is that they tend not to be as tailored as the treatment you would receive in a face to face consultation. However, it is also the case that a generic face to face intervention may be no more, or perhaps less, effective than a well-developed app."
Mental health apps - the evidence
In terms of overall efficacy the jury is still out on the use of mobile applications in mental health treatment. In a randomised control trial in the US, a chatbot called Woebot was compared to a control group who had access to an ebook on mental health. The clinical trial found that the programme delivered measurable improvements on psychometric screening tools, the nine-item Patient Health Questionnaire, the seven-item Generalised Anxiety Disorder scale and the Positive and Negative Affect Scale among college students. However, these students had not been officially diagnosed with depression or anxiety. Woebot, meanwhile, states 75% of users reported feeling better after using the tool for the first time and a 98.9% accuracy rate in detecting crisis language - essential for intervention purposes.
In a report for Nature Digital Medicine, researchers analysed the claims on 73 mental health apps related to depression, self-harm, substance use, anxiety and schizophrenia. Of the mental health apps, 64% claimed effectiveness at diagnosing a mental health condition or improving symptoms or self-management. Yet none of the apps referenced certification or accreditation processes and just two apps offered "low-quality, primary evidence" from a study using that particular app. Only one app included a citation to published literature.
The researchers noted that while there are plenty of reviews attesting to consumer mobile health apps’ success in helping individuals, the majority are simply not evidence-based and can, in fact, "contain harmful content."
UK-based studies are also looking into the extent to which CBT apps, apps for depression and other therapy apps - both paid for and free - could help support the National Health Service.
Indeed, Dr Felix Naughton, suggests that apps may have a vital role to play in supporting traditional methods of therapy, "providing people with the option to use both face-to-face and app based therapy, rather than one or the other. Blended approaches that integrate one-to-one with digital currently show the best evidence of effectiveness for improving mental health disorders but we need more research in this area. In an ideal world, the choice should rest with the person, to choose which form of therapy they want to use, providing they are given enough information to make an informed decision."
Technological advancements may also pave the way for mental health apps to provide insights that are beyond on the scope of traditional mental health therapy. Dr Felix explains that:
"There is real potential that well developed apps, using tech that is available in smartphones at the moment but has yet to be harnessed sufficiently, could actually provide a level of insight and service that discussion based therapy is unable to. For lots of reasons the perspective provided by the individual to the therapist may not always best represent the reality of their mental health in that moment, whereas a mobile health app could be better placed to gather data on indicators which may provide more objective insights into the individual’s mental state at the moment.
"For example, there is important work being done in how location relates to people's mental health, where patterns of movement are analysed to gain an insight into their mental health, such as how much time they are spending away from their home, as research has found that when people are depressed they tend to spend more time closer to home, rather than going out and about. Those patterns might be quite a useful way of highlighting when that individual is at risk of entering or is in a low mood state, alongside other indicators."
For the time being, however, usage of mental health apps remains at a relatively low level - despite the almost universal adoption of smartphones - with a study from JMIR Mental Health suggesting that as few as 10% of mental health patients have actually downloaded a mental health app, while the number who reported regular app use is fewer still.
However, in the post Covid-19 world, apps will surely play an ever-increasing role in how mental health care is administered to support people suffering with anxiety or depressive symptoms. But while apps are helpful, currently they should not be considered as a solution in themselves. Mobile apps built by reliable app developers and/or recommended by recognised mental health service providers, such as the NHS, should currently be considered as an adjunct to clinical advice and professional care, not an alternative.
The NHS Apps Library
With the overwhelming choice of mobile phone apps available on the Apple App Store and Google Play, it can be difficult for individuals to make an informed judgement on which app is safe to download. In recognition of this, the NHS Apps Library helps people to find trusted mental health related digital tools, which have 'been assessed by the NHS as clinically safe and secure to use'.
Read on below to discover some of the mHealth apps assessed as clinically safe and secure to use by the NHS:
Be Mindful uses Mindfulness-Based Cognitive Therapy (MBCT) to help people to reduce their levels of stress, anxiety and depression and to enhance their mental health and wellbeing.
BlueIce is an evidence based app designed to help young people manage their emotions and reduce urges to self-harm. Developed by Paul Stallard from Oxford Health NHS Foundation Trust, the app was co–produced by young people who have lived experience of self-harm.
Calm Harm is an award-winning app developed for teenage mental health charity stem4, using the basic principles of Dialectical Behavioural Therapy (DBT), an evidence-based therapy.
MeeTwo is a self-help group which provides anonymous advice to teenagers wanting to discuss issues affecting their lives such as mental health, self-harming, relationships and friendships.
My Possible Self
My Possible Self is a clinically proven mental health app which enables users to take control of their thoughts, feelings and behaviours through learning modules and mood tracking.
WorryTree is an app designed to help people to record, manage and problem solve their worries using Cognitive Behavioural Therapy (CBT) techniques.
If you are searching for mental health support, please refer to the NHS’s online mental health services resource or contact your local GP.
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