Smartphone Apps for Serious Mental Illness: A Step-by-Step Tutorial to Help You Support Your Patients

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Today thousands of mental health apps are available for immediate download. Many patients are interested in these apps, and some are already using them.

At the 2019 American Psychiatric Association Annual Meeting, we will be presenting on how to support patients around app use and will help you select safe apps while avoiding misleading and even dangerous ones. The goal of the session is to show that you don’t need to be a tech wizard to help patients and offer guidance on digital mental health tools. With just a few pointers and new skills, you can bring your clinical expertise and judgment to bear toward a wide range of digital tools. Below are some highlights and resources from the session.

True or false? If you give patients instruction on how to download a mental health app, they will be set and have no trouble accessing it.

Answer: False. While some patients will have no problems downloading apps, we have found that some do need extra help. Not all patients have access to the app stores; for example, some do not have Apple and Google accounts that may be necessary to download an app. Others may own phones that have not been updated recently and thus are not compatible with the app they want to download. Others may not have enough memory on their phone to install the app.

Thus, the first step in considering the use of any app in care may be to help patients check whether they can actually get an app on their phone. You can find tips for helping people set up apps at our division’s clinical skills website page: https://www.digitalpsych.org/digital-skills-training.html

True or false? As with medications, apps can only make claims that are backed up with clinical evidence.

Answer: False. The vast majority of apps are not evidence based, although many still make bold claims about their effectiveness. This is possible because most mental health apps fall outside of medical regulation and thus are not subject to rules about marketing and transparency that, for example, medications are. One recent study suggested that while over 50% of apps make claims about their effectiveness, fewer than 2% have been assessed. This stark dichotomy makes it all the more important that you help patients determine whether the app they want to use is actually going to be helpful. You can read more about app claims versus evidence in this free paper: https://www.nature.com/articles/s41746-019-0093-1

True or false? Using the number of stars or number of ratings for an app is a good way to find better apps.

Answer: False. Research has shown that the number of stars or ratings for health apps does not correlate with either app utility or quality. You may want to be very skeptical of any rating or point system for apps because these scoring systems have several critical flaws. The simplest flaw is that apps constantly update and change, but these scores do not. Thus, anything they recommend is out of date, and you may be offering your patients incorrect information.

A second flaw is that many features around app use-such as how usable an app is and whether it will fit into the treatment plan-are impossible to capture via a single number or score. What is easy for one person to use is not the same for another. There is a reason we don’t rate therapies with stars-and that same reason applies to apps as well. In picking an app, don’t worry about stars and instead focus on the risks and benefits for the patient at hand, just as you would do for any clinical decision. Dive deeper into the troubles of health app star ratings with this paper (paywall): https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.0578

True or false? The American Psychiatric Association App Evaluation Framework can help me make more informed decisions about picking better apps.

Answer: True. While the decision to use-or not use-any app is between you and the patient, the APA App Evaluation Framework can offer you help in making that decision. Consider this evaluation model to be like a roadmap. You don’t need to use all parts of it all the time; but, like a roadmap, it is a good reference to find the right direction when you need help. The framework is divided into hieratical levels. If an app does not satisfy your need at one level, then you do not need to consider higher levels as that app is likely not ideal for the case at hand. The levels, in order, include: background information, privacy and safety, evidence, ease of use and engagement, and clinical integration. You can read more about the five levels and access the full framework here: https://www.psychiatry.org/psychiatrists/practice/mental-health-apps/app-evaluation-model

True or false? Only younger patients are interested in and want to use apps as part of care.

Answer: False. While younger generations are often considered to be “tech-savvy” and “digital natives,” that does not mean they all want to use apps and other digital technologies as part of care. Likewise, many older adults who may have less experience using apps are actually very interested and willing to try them. Based on our clinical experience and results from research data, we have found that older adults may often be the ones who benefit most from using technology as part of care. For example, one study using a fitness app in people with serious mental illness found that only those over age 50 benefited.¹ It is important not to make assumptions about technology use and approach each patient with an open mind. Read more about mobile technology and its uses in older adults in this free article: https://aging.jmir.org/2019/1/e10019/

Dr Torous is Director of the Digital Psychiatry Division, Department of Psychiatry at Beth Israel Deaconess Medical Center, Boston; Editor in Chief of JMIR Mental Health; Web Editor of JAMA Psychiatry; and Digital Psychiatry Editor for Psychiatric Times. Twitter: @JohnTorousMD. Ms Hoffman is the Clinical Director of the Digital Psychiatry Division, Department of Psychiatry at Beth Israel Deaconess Medical Center, Boston. Twitter: @LHoffmanLICSW.

Disclosures:

The authors report no conflicts of interest concerning the subject matter of this article.

References:

1. Macias C, Panch T, Hicks YM, et al. Using smartphone apps to promote psychiatric and physical well-being. Psychiatr Q. 2015;86:505-519. doi: 10.1007/s11126-015-9337-7.