Treating Depression and Preventing Suicide: The Impact of mHealth Apps

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In a 2016 review, there were more than 165,000 mHealth apps available to patients on the market.¹ A review published just 3 years later noted the availability of 259,000 mHealth apps worldwide.² Of the rapidly evolving app market, mHealth apps are among the fastest-growing groups, with an annual estimated growth rate of 32.5%.² mHealth apps focused on mental health are one of the most prominent categories.¹ These apps can be obtained for numerous device types and through the Apple iTunes/App Store or Android Google Play App Store.¹

There is currently no standardized review process to evaluate mHealth apps for quality or accuracy of information.¹ There are also no centralized repositories for app reviews and ratings, and no type of standard app rating process or procedure.¹ Current rating systems are based solely on app user ratings, which often are focused on design, interface, and usability. The evidence base of the information contained in these apps is not externally reviewed or verified as part of a requirement of implementing an app and getting it on the market.¹ Relatively few apps have been through the rigor of a clinical trial.³

The United States Food and Drug Administration (FDA) does not offer guidance for mHealth apps, and the FDA has indicated no plans to begin to regulate apps, especially as the FDA has deemed many to be low risk.¹ Between the FDA and European regulatory bodies, only 8 mental health apps have been approved.³ The FDA provides minimal guidance related to the post-market management of medical devices, which include mHealth apps, to consider risk management and utilize necessary steps to secure patient information.⁴ However, there is a lack of ongoing guidance and regulation in this area for app developers to utilize. There is also a lack of clear, consistent privacy policies and transparency with app users about how their information may be used and transmitted to third parties.⁴

mHealth Apps for Depression

The number of mHealth apps addressing depression continues to increase. There have been several approaches and foci for these apps. Some of the existing mHealth apps on the market related to depression include a focus on preventing depression, screening for depression, and supporting treatments with depression; there is even a suicide risk assessment app.^4,5 Currently there is no guidance, position statement, or even clear guidelines related to mHealth apps addressing psychiatric conditions from major national professional organizations such as the American Psychological Association and the American Psychiatric Association.²

The mHealth apps are not consistently included in the same categories of the app store; some are listed in “Health and Fitness” categories, whereas others are indicated to be within the “Medical” category.³ Studies reviewing health app quality have found that apps are not consistently utilizing evidence-based clinical information or verified decision support tools.³ The inconsistent categorization of these apps further demonstrates the impact of the business and marketing perspectives on this area. The app development world is often approached from a strategic standpoint of business and marketing, which can pose a challenge when apps are potentially looking to address serious medical issues.³

Some mHealth apps focused on depression address those currently diagnosed with the medical condition, and a randomized controlled trial by Deady et al⁵ evaluated the efficacy of a new app to reduce and even prevent depressive symptoms within a working population in Australia. The results were statistically significant in the app’s efficacy during the period of the trial, which included follow-up until 12 months post-baseline assessment.

The reported focus and aims of some of the mHealth apps addressing depression are either to complement traditional psychotherapy or to replace traditional therapy.⁶ A review and analysis conducted by Stawarz et al⁶ specifically reviewed apps that indicate a basis on cognitive behavioral therapy (CBT), which is an evidence-based treatment for depression along with other mental health conditions. However, within the review, there was significant variability in the context and intentions of the apps, along with inconsistent utilization of the evidence-based elements of CBT. As noted by other app reviews, there is an identified glaring gap regarding how chatbots and other technologies can engage with patients who may be experiencing complex conditions.

mHealth Apps for Suicide Prevention

Given the numerous barriers to accessing care, especially timely care, there has been some research focused on the potential for apps to be utilized as a suicide prevention and screening tool.³ A team of researchers conducted a comprehensive assessment of available suicide prevention apps on Google Play and the Apple App Store, and evaluated the suicide prevention content contained within depression management apps.³ Martinengo et al completed a systemic review utilizing descriptive statistics, evaluating the function and reliability of the apps.³ The initial pool of apps screened for use was over 2500 prior to deduplication; after 2 rounds of screening and subsequent systematic assessment, 69 apps were selected to be analyzed in the study.

Within these apps, some used validated, evidence-based tools such as the Patient Health Questionnaire-9 (PHQ-9), and some utilized chatbots to analyze suicidal behavior.³ Some of the apps that address depression symptoms may incorporate suicide screening or prevention content. Both providers and patients are interested in the potential to effectively utilize these tools to support mHealth apps assisting in managing depression.

Patient Empowerment

In the ever-evolving digital world, interest in utilizing mHealth apps is occurring in patients along with health care providers. If health care providers have their patients ask for an opinion about a particular supplement. For example, if patients ask about a particular supplement, their providers will give an overview of the supplement including the lack of FDA regulation compared to other pharmaceutical medications to inform their shared decision-making. Currently, and for the foreseeable future, patients will ask their health care providers about some of these mHealth apps. As health care providers are busy in an increasingly complex health care environment, chances are providers do not have the time or bandwidth to thoroughly investigate what is available. With the sheer thousands of apps available, it would be impossible to remain current and provide our patients with an informed overview or answer. Providers must be cautious about recommending or endorsing these apps as well, as it can potentiate legal, ethical, or professional risk if the recommendation is in appropriate due to possible negative patient outcomes.¹

Patients struggling with their mental health, whether they are formally in psychiatric treatment or not, may find that the ability to access help in the palm of their hand is quite appealing. However, the plethora of available apps is likely overwhelming for someone dealing with major depression, as one of the prevalent symptoms can be difficulty concentrating and making decisions.⁷ Often, when faced with so many choices without a prior recommendation, the app user will likely decide which app to utilize based on user review ratings. The user reviews do not take into consideration the validity or reliability of the app content, or whether it is evidence-based. Ratings and reviews are often based on app cost, visually appealing properties, reliability, minimal freezing or crashing of the app, and ease of signup, amongst other factors. There is no requirement or consideration for the scientific validity of the content and interventions within the app. As such, a highly rated app with many downloads may be enticing for someone interested in trial use, regardless of the fact that the app may not be evidence-based and may lack external validity to support its use. The current system of app ratings and oversight lacks transparency from experts to convey this information to consumers.

Sara Robinson is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire area, and a clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham. Dr Kallmerten is a Clinical Associate Professor and Director for the Direct Entry Master’s in Nursing, Evidence-Based Nursing and Clinical Nurse Leader programs at the University of New Hampshire, Durham. Her research interests include the use of Health Information Technology such as mHealth in support of health equity initiatives.

References

1. Powell A, Torous J, Chan S, et al. Interrater reliability of mHealth app rating measures: analysis of top depression and smoking cessation apps.JMIR Mhealth Uhealth. 2016;4(1):e15.

2. Munoz Ramos R, Ferrer Cheng PG, Jonas SM. Validation of an mHealth app for depression screening and monitoring (psychologist in a pocket): correlational study and concurrence analysis. JMIR Mhealth Uhealth. 2019;7(9):e12051.

3. Martinengo L, Van Galen L, Lum E, et al. Suicide prevention and depression apps’ suicide risk assessment and management: a systematic assessment of adherence to clinical guidelines. BMC Med. 2019;17(1):231.

4. Tangari G, Ikram M, Ijaz K, et al. Mobile health and privacy: cross sectional study. BMJ. 2021;373:n1248.

5. Deady M, Glozier N, Calvo R, et al. Preventing depression using a smartphone app: a randomized controlled trial. Psychol Med. 2020;1-10.

6. Stawarz K, Preist C, Tallon D, et al. User experience of cognitive behavioral therapy apps for depression: an analysis of app functionality and user reviews. J Med Internet Res. 2018;20(6):e10120.

7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed). 2013.