Paving the Way for Apps in Mental Health Care



by Kayt Sukel

July 12, 2016

BRIEFING PAPER

Soon after Carolyn Miller[i] relocated across the country for a new job, she began to experience feelings of sadness and problems with sleep. Miller was successfully treated for a debilitating episode of depression years earlier—and she worried she might be relapsing. But when she tried to make an appointment with a therapist in her new city, she discovered she was looking at a wait of at least three weeks for an appointment.

“I honestly wasn’t sure if I was depressed or just having trouble adjusting to a new place and new job,” she says. “I really just wanted to talk to someone, a professional, and get an outside perspective to better understand if I should be worried or not. But even with insurance, and a referral, I was surprised at how difficult it was to get an appointment.”

Miller’s story is not uncommon. Lack of access to mental health care is a serious issue in this country. The National Alliance on Mental Illness (NAMI) says that one in four Americans will experience a mental health issue in any given year, and the World Health Organization estimates that 55 percent of individuals in developed countries like the U.S. are not getting the treatment they require. That translates to millions of people in need, with conditions ranging from depression to post-traumatic stress disorder to schizophrenia, who may have difficulty getting assistance due to a lack of mental health resources. Many psychiatrists and technology professionals believe that mobile applications, or apps, may be a tool to help to meet this overwhelming need.

 MentalHealthApps
Credit: Shutterstock

Thomas Insel, former director of the National Institutes of Mental Health (NIMH) and a Dana Alliance member, announced last year that he was leaving the agency to take a new position at Google Life Sciences, now renamed Verily. In September 2015, he discussed the reasons for his move with Fortune and the Dana Foundation blog.

“What will it take to make a big difference for people with schizophrenia, autism, depression, Alzheimer’s, and other mental health disorders?” he said. “We haven’t been able to bend the curve, so far, with the kind of research we’ve historically done. So it became clear to me that we’re going to have to do something very different to make that difference.”

That something very different, he suggested, was the use of mobile technologies and analytics to help better inform the diagnosis and prognosis of mental health conditions. Deborah Estrin, a computer science professor at Cornell University and a founder of Open mHealth, a non-profit start-up that uses mobile technologies to inform clinical decisions, agrees that the right mobile technologies could be a boon to mental health management.

“When I first started thinking about mHealth, I thought that mental health was the perfect place to start. There are no blood tests currently that monitor the patients’ behavioral conditions,” she says. “Clinicians help patients manage their conditions with a really small amount of data. And it’s a testament to those clinicians at how well they do with self-reported information in a limited clinical setting. Relevant data could be reported to them with an app. But creating such apps is easier said than done.”

Separating the Wheat from the Chaff

Roni Frank, co-founder and Head of Clinical Services for Talkspace, says the lack of mental health services in the U.S., is what inspired her and her husband to create the app, a popular download for smart phones and tablets that allows individuals to connect with licensed therapists in real-time by phone or text.

“You have millions of people who are going untreated, due to lack of resources or stigma, and we wanted to help solve that problem. We felt that technology could help bridge this gap,” she says. “Not only is it hard to get [an appointment] for traditional therapy, but it’s also really expensive. A face-to-face 50 minute session in the U.S. averages about $120. That’s a price point that most people can’t afford. Many people don’t have insurance that covers mental health. And we thought technology could help reduce that price point, too.”

She’s far from the only one who sees the opportunity in mobile technologies and mental health. Head to the Apple or Android App stores, and you’ll see thousands of mental health apps on offer—apps that say they can help diagnose, monitor, and manage mental health conditions ranging from depression to road rage. But the problem, says Peter Yellowlees, a psychiatrist at the University of California at Davis and clinical technology expert, is that most of these apps have not been scientifically tested and proven to be effective.

“There’s a very large number of apps now—an overwhelming number, really—and it’s difficult to work out which of them are likely to be clinically valid. In general, there has been effectively no research on these apps,” he says. “Many were developed by people who see a need, have a great ideas, and a desire to do good. But because they haven’t been rigorously tested, we don’t know if they are really measuring what they say they are measuring or doing what they are meant to do. And that’s a problem.”

That said, Yellowlees, like Insel, Estrin, and Frank, believes that mobile applications have amazing promise. And it’s time to start supporting that promise with an evidence-based, real-world approach to development and release.

“People are using these apps. They want to use these apps. They are actually bringing in these apps to appointments with their doctors to share information. We can’t put the genie back in the bottle and start over. And these apps are opening up a whole series of new approaches to mental health care that we haven’t had in the past. But there’s no doubt that the majority of the apps that you can find in the app store today will not be around in a year’s time,” says Yellowlees. “So we need a framework we can use to evaluate these apps and understand what they are really offering our patients.”

To that end, Yellowlees and colleagues have proposed such a framework in a commentary  published in the Journal of Clinical Psychiatry earlier this year. They argue that apps need to be Actionable, Secure, Professional, Evidence-Based, Customizable, and Transparent (ASPECTS).

“We really need to put the focus on researching these apps—and understanding which ones are safe and useful,” he says. “The other area of research we need to do is take the data we collect from these apps, because they are already gathering an astonishing amount of data, particularly about lifestyle things, and apply machine algorithms to see what more we can learn about these conditions. We may, as Dr. Insel has suggested, be able to see when someone is about to enter a psychotic episode or relapsing into depression. There’s a big opportunity here and we may be able to combine these large amounts of data and see what extra value we may be able to get from it to help us better help our patients in the future.”

Paving a Way Forward

While there is consensus that there is a large need—and an active market—for mental health apps, it’s unclear how many people are actually using them because it’s so easy to download and then discard these programs –the majority of apps in the App store have fewer than 5,000 downloads each.  But experts expect that as the quality rises, with the adoption of a more robust research and development framework, so will use. 

The question, however, is who would enforce such a research and development framework. The Food and Drug Administration (FDA) has punted authority, stating that they will only regulate apps that “are intended to be used as an accessory to a regulated medical device, or transform a mobile platform into a regulated medical device.”  And Estrin says that NIMH, NIH, and big healthcare and insurance companies aren’t stepping up to the plate either.

“It’s refreshing to see clinicians saying it’s time to get systematic and proactive,” she says. “To do that effectively, we need more effective ways of rapid creation of evidence for these apps, especially as new technologies and approaches emerge. That will require increased funding and commitment to community progress on mental health.”

Tanzeem Choudhury is the co-founder and Chief Technology Officer of HealthRhythms, a company that designs apps to manage conditions like depression, bipolar disorder, and schizophrenia. The apps are currently part of clinical trials. Choudhury says that thorough evaluation of mental health apps require both the mental health and technology communities working together to make sure apps truly are safe and effective.

“A key for us has been to bring all the stakeholders, from the clinical and the technology side, to the table to help design our application to sense changes in social rhythms. We brought in patients to test the app as we went through iterations of the design so we could make sure they were connecting and would be willing to use it. And now we are testing it with Dartmouth-Hitchcock Hospital,” she says. “But I still see a disconnect between the technical and clinical sides of the house in many cases—and how to define guidelines leading design when it comes to mental health apps. We need to co-evolve in order to move forward and really figure this out.”

Miller, while waiting for her appointment with a new psychiatrist, decided to try an app to help tide her over until she could be seen by a mental health professional. She says she was a bit overwhelmed by the sheer number of depression-related apps in the App store—and was surprised to learn that so many had little to no evidence backing their efficacy.

“I eventually found an app that I liked and I used it a little. It was nice to have in my back pocket when I needed it,” she says. “But I’m hoping that my new doctor might have some suggestions for better apps once I get in to see her—things that will help me keep better track of my mood and what I can do to help keep my depression in check.”

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[i]Not her real name