We are fortunate to live in the digital age, where authoritative information on virtually any topic is easily retrieved by anyone with an Internet connection. This asset, combined with skyrocketing rates of smartphone usage over the past decade, may hold the key to improving health for a large percentage of the population.

Even with continued advances in the development of effective treatments and increased access to mental health care, a significant disparity still exists between need and actual delivery of mental health services. Internet-based applications, including mobile technology, could ostensibly increase access to treatment for those most in need [1].

Behavioral health providers tapping into this technology would be effectively reaching individuals through a device on which they already heavily depend. Data demonstrate that people with increased usage of smartphones include vulnerable populations who could benefit the most from interventions, including young adults, people with lower incomes and less educational attainment, and minorities.

Unsurprisingly, over the span of a year, more than half of Americans (62%) use their smartphones to access health-related information [2]. For people working with a healthcare provider, mobile apps may increase treatment engagement, facilitate provision of evidence-based care, and aid in continuation of mental health services following termination of treatment [3].

Additionally, mobile apps have the potential to address a wide variety of mental health concerns. Apps targeting depression, anxiety, and substance use have successfully improved user outcomes [4]. Most of these apps also included interaction with a mental health professional, suggesting that they could represent a beneficial component of a provider-monitored treatment plan.

Mobile apps demonstrate the ability to benefit both patients and treatment providers by increasing accuracy of reporting, increasing patient awareness and self-monitoring of symptoms, and providing a means of documenting symptoms between in-person office visits.

For example, patients were more likely to report suicidal ideation on a mobile app and most were able to follow through with daily reporting of symptoms [5]. Apps also improve access to treatment for individuals unlikely to seek face-to-face interaction with treatment providers, though not all mobile interventions are effective without additional assistance from trained professionals [6].

Mental health apps generally fall under one or more of three categories: a medium for delivering psychotherapy, a means of identifying and monitoring symptoms, and intervention delivery based on identified symptoms [7].

Delivery of Psychotherapy

Many research studies relating to the use of mobile apps in psychotherapy focus on the treatment of depression. Mobile delivery of CBT, with very minimal support from a mental health professional resulted in clinically significant reduction in depression, with gains maintained at a 3-month post-treatment assessment [8].

Types of therapies have also been compared, with behavioral activation demonstrating more benefit than mindfulness-based treatment [9]. Sophisticated apps have also been successfully utilized to monitor behavioral correlates of depression and deliver cognitive behavioral interventions as needed [10].

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Monitoring

Self-monitoring can enhance behavior change especially when utilized in conjunction with therapy. These “quantified self” apps allow individuals to track cognitions and behaviors as they occur and display results conveniently for therapists to review, as well as help patients to visualize their progress [11]. Some of these apps can be accessed at the Quantified Self website [12].

Research also exists on using monitoring in the context of treating specific disorders for which behavior tracking is especially salient. For example, an app providing monitoring and information to patients, along with serving as a platform for patient-provider communication is efficacious in decreasing risky alcohol use and may improve continued care for patients with alcohol use disorders [13].

Health Behavior Interventions

Chronic diseases, including heart disease, cancer, stroke, and diabetes are among the leading causes of death among adults 65+ [14]. Not only do these illnesses pose a pervasive and debilitating threat to the health of an aging population, but the chronic nature of these illnesses means they are likely to slowly develop throughout a person’s life and are influenced by the daily practice (or lack thereof) of health-promoting behaviors.

In light of these factors, strong research support for the ability to successfully prevent and manage these concerns through simple lifestyle interventions is certainly heartening. For example, exercise, low body mass index, and refraining from tobacco use demonstrated a fourfold reduction in rates of lifetime disability [15].

This is where mobile apps play an important role, demonstrating utility in improving the well-being of the population by placing health-focused behavioral interventions at the fingertips of consumers. In the context of integrated behavioral healthcare, mobile apps help address the problem of the limited time patients are allotted by primary care providers, assist patients with lifestyle management, and provide behavioral feedback and clinical education [16].

Apps have been found to increase tracking of health-promoting behaviors such as physical activity, and also to increase activity itself [17, 18]. Other applications have successfully addressed lifestyle factors related to common problems such as stress [19], attentive eating [20], and diabetes [21].

Psychologists working in primary care settings or providing health behavior coaching to patients interested in addressing psychological factors related to medical concerns would likely benefit significantly from incorporating mobile apps into treatment planning.

Mobile apps also facilitate collaboration and sharing of pertinent data on treatment progress between healthcare providers, further closing treatment gaps and ensuring that providers are on the same page.

Research

In terms of research support for their effectiveness, mobile apps show great promise. They have been used to remotely conduct randomized clinical trials (RCTs) of evidence-based interventions, demonstrating both the success of these interventions, as well as the utility of mobile apps, in significantly shortening the length of time typically required for RCTs [22, 23].

Apps also facilitate the comparison of different types of treatment for specific disorders, helping to identify the most effective treatment [24]. However, as of 2014, only five apps backed by RCTs were identified, and none were accessible to consumers [4]. While this does not mean that existing mental health apps are ineffective, and apps have been backed by other types of studies, it does point to a need for experimental validation of apps [25].

Selecting & Utilizing Mental Health Apps

Are you interested in incorporating mobile apps in your own work with patients and wondering where to start?

VA Mobile Health provides access to a number of free mental health apps for use in conjunction with psychotherapy. The apps include empirically-based approaches such as cognitive behavioral therapy, prolonged exposure, mindfulness, and acceptance and commitment therapy, geared towards concerns such as insomnia, substance use, and post-traumatic stress disorder [26]. Currently, apps are not regulated, and many utilize a limited number of intervention strategies or strategies of unknown efficacy.

Reading peer-reviewed literature, searching app clearinghouses such as Happtique for reviews, pilot testing apps, and obtaining feedback from patients are helpful in selecting appropriate apps and assessing quality [27].

Additionally, perusing research on the types of features desired in apps used for interventions may be helpful [28].

With these guidelines in mind, focus on finding what works best for your own practice. Much like other treatment strategies, using mobile apps as a component of individualized treatment is key in facilitating the delivery of effective healthcare.

References

[1] Moock, J. (2014). Support from the Internet for individuals with mental disorders: Advantages and disadvantages of e-mental health service delivery. Frontiers in Public Health, 2(65), 1-6.

[2] Smith, A. (2015). U. S. smartphone use in 2015. Pew Research Center: Internet, Science & Tech. Retrieved from http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/

[3] Price, M., Yuen, E. K., Goetter, E. M., Herbert, J. D., Forman, E. M., Acierno, R., & Ruggiero, K. J. (2014). mHealth: A mechanism to deliver more accessible, more effective mental health care. Clinical Psychology and Psychotherapy, 21(5), 427-436.

[4] Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M.R., & Christensen, H. (2013). Smartphones for smarter delivery of mental health programs: A systematic review. Journal of Medical Internet Research, 15(11), e247.

[5] Torous, J., Staples, P., Shanahan, M., Lin, C., Peck, P., Keshavan, M., & Onnela, J. P. (2015). Utilizing a personal smartphone custom app to assess the Patient Health Questionnaire-9 (PHQ-9) depressive symptoms in patients with Major Depressive Disorder. JMIR Mental Health, 2(1), e8.

[6] Birney, A. J., Gunn, R., Russell, J. K., & Ary, D. V. (2016). MoodHacker mobile web app with email for adults to self-manage mild-to-moderate depression: Randomized controlled trial. JMIR mHealth & Uhealth, 4(1), e8.

[7] Chan, S. R., Torous, J., Hinton, L., & Yellowlees, P. (2014). Mobile tele-mental health: Increasing applications and a move to hybrid models of care. Healthcare, 2(2), 220-233.

[8] Watts, S., Mackenzie, A., Thomas, C., Griskaitis, A., Mewton, L., Williams, A., & Andrews, G. (2013). CBT for depression: A pilot RCT comparing mobile phone vs. computer. BMC Psychiatry, 13(49), 2-9.

[9] Ly, K. H., Trüschel, A., Jarl, L., Magnusson, S., Windahl, T., Johansson, R., Carlbring, P., & Andersson, G. (2014). Behavioural activation versus mindfulness-based guided self-help treatment administered through a smartphone application: A randomised controlled trial. BMJ Open, 4(1), e003440.

[10] Wahle, F., Kowatsch, T., Fleisch, E., Rufer, M., & Weidt, S. (2016). Mobile sensing and support for people with depression: A pilot trial in the wild. JMIR mHealth & Uhealth, 4(3), e111.

[11] Aguilera, A., & Muench, F. (2012). There’s an app for that: Information technology applications for cognitive behavioral practitioners. The Behavior Therapist, 35(4), 65-73.

[12] Quantified Self Labs (2011). Quantified self: Guide to self-tracking tools. Retrieved from http://quantifiedself.com/guide/

[13] Gustafson, D. H., McTavish, F. M., Chih, M. Y., Atwood, A. K., Johnson, R. A., Boyle, M. G., Levy, M. S., Driscoll, H., Chisholm, S. M., Dillenburg, L., Isham, A., & Shah, D. (2014). A smartphone application to support recovery from alcoholism: A randomized clinical trial. JAMA Psychiatry, 71(5), 566-572.

[14] Centers for Disease Control and Prevention (2013). The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept. of Health and Human Services.

[15] Fries, J. F. (2003). Measuring and monitoring success in compressing morbidity. Annals of Internal Medicine, 139, 455-459.

[16] Quinn, C. C., Shardell, M. D., & Terrin, M. L. (2011). Cluster-randomized trial of a mobile phone personalized behavioral intervention for blood glucose control. Diabetes Care, 34(9), 1934-1942.

[17] Kirwan, M., Duncan, M. J., Vandelanotte, C., & Mummery, W. K. (2012). Using smartphone technology to monitor physical activity in the 10,000 Steps program: A matched case-control trial. Journal of Internet Medical Research, 14(2), e55.

[18] King, A. C., Hekler, E. B., Greico, L. A., Winter, S. J., Sheats, J. L., Burman, M. P, Banerjee, B., Robinson, T. N., & Cirimele, J. (2013). Harnessing different motivational frames via mobile phones to promote daily physical activity and reduce sedentary behavior in aging adults. PLoS One, 8(4), e62613.

[19] Ahtinen, A., Mattila, E., Välkkynen, P., Kaipinen, K., Vanhala, T., Ermes, M., Sairanen, E., Myllymäki, T., & Lappalainen, R. (2013). Mobile mental wellness training for stress management: Feasibility and design implications based on a one-month field study. JMIR mHealth & Uhealth,1(2), e11.

[20] Robinson, E., Higgs, S., Daley, A. J., Jolly, K., Lycett, D. Lewis, A., & Aveyard, P. (2013). Development and feasibility testing of a smart phone based attentive eating intervention. BMC Public Health, 13(639), 1-7.

[21] Goyal, S., & Cafazzo, J. A. (2013). Mobile phone health apps for diabetes management: Current evidence and future developments. Quarterly Journal of Medicine, 106(12), 1067-1069.

[22] Anguera, J. A., Jordan, J. T., Castaneda, D., Gazzaley, A., & Areán, P. A. (2016). Conducting a fully mobile and randomized clinical trail for depression: Access, engagement, and expense. BMJ Innovations, 2(1), 14-21.

[23] Arean, P. A., Hallgren, K. A., Jordan, J. T., Gazzaley, A., Atkins, D. C., Heagerty, P. J., & Anguera, J. A. (2016). The use and effectiveness of mobile apps for depression: Results from a fully remote clinical trial. Journal of Medical Internet Research, 18(12), 330.

[24] Dagöö, J., Asplund, R. P., Bsenko, H. A., Hjerling, S., Holmberg, A., Westh, S., Öberg, L., Ljótsson, B., Carlbring, P., Furmark, T., & Andersson, G. (2014). Cognitive behavior therapy versus interpersonal psychotherapy via smartphone and computer: A randomized controlled trial. Journal of Anxiety Disorders, 28(4), 410-417.

[25] Bakker, D., Kazantizis, N., Rickwood, D., & Rickard, N. (2016). Mental health smartphone apps: Review and evidence-based recommendations for future developments. JMIR Mental Health, 3(1), e7.

[26] VA App Store. (n.d.). Retrieved from https://mobile.va.gov/appstore?keys=&field_app_category_tid%5B3%5D=3

[27] Boudreaux, E. D., Waring, M. E., Hayes, R. B., Sadasivam, R. S., Mullen S., & Pagoto, S. (2014). Evaluating and selecting mobile health apps: Strategies for healthcare providers and healthcare organizations. Translational Behavioral Medicine, 4(4), 363-371.

[28] Rabin, C., & Bock, B. (2011). Desired features of smartphone applications promoting physical activity. Telemedicine Journal and e-Health, 17(10), 801-803.

Mei Slogar, M.A.

Mei Slogar, M.A.

Mei is a doctoral candidate in clinical psychology at Regent University. Her research and clinical interests focus on interactions between chronic physical and mental illness, as well as health-promoting behaviors and cognitive function. She has worked in crisis intervention, inpatient psychiatric, community mental health, and primary care settings, and has a passion for promoting mental health in the context of overall wellbeing. She is looking forward to beginning her predoctoral internship this summer at WellSpan Behavioral Health, a patient-centered medical home in York, PA. Outside of academia, Mei can be found exploring the mind-body connection through yoga and rock climbing all over the East Coast.
Mei Slogar, M.A.

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