Therapy App “Innovation” – Research into Mental Health Apps, Part I

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HERE IS HOW

Therapy apps have grown in popularity in recent years as a method for consumers to get inexpensive mental health support from the comfort of their own homes. However, according to a recent study by researchers Camacho, Cohen, and Torous, published in JAMA Network Open, many therapy apps provide nothing more than the basic functions of psychoeducation, goal monitoring, or mindfulness. Despite the growing number of companies making promises that their product is the best or one of the “best mental health apps,” few offer innovative solutions for those struggling with mental health conditions. 

Researchers assessed the quality and safety of treatment apps across six categories: app origin and accessibility, privacy and security, clinical foundation, features and engagement, inputs and outputs, and interoperability. For evaluation, apps were entered into the American Psychiatric Association’s app rating system called the M-Health Index and Navigation Database (MIND). The raters examined these criteria: the existence of a privacy policy, disclosing security measures in place, declaring data usage and purpose, permitting data deletion, and allowing users to opt out of data gathering. The researchers trained 10 raters who were college students, medical students, and research assistants. Raters underwent a 4-hour interrater reliability training and entered their answers to the 105 MIND questions for each app.

Understanding the Features of Therapy Apps

The study’s results give insight into the present status of some of the best therapy apps. These are the discrete functions identified:

• 41% psychoeducation
• 38% goal setting/habit 
• 38% mindfulness 
• 2% Acceptance and Commitment Therapy (ACT) and Dialectical Behavioral Therapy (DBT)
• 1% biofeedback and sensor data 

Common App Inputs

• Surveys (45%)
• Diary entries (34%)
• Microphones (21%)

Common App Outputs

• Notifications (68%)
• Data summaries (61%)
• References and information (50%)

Other findings of this study included the following:

• Twenty-two unique features related to therapeutics were identified among the apps.
• Additionally, only 30% of apps allowed users to email or export their data, and only 2% offered integration with an electronic medical record.
• The study also found that apps designed for higher-acuity conditions, such as schizophrenia, were less common.
• These apps’ most common features were psychoeducation, goal setting, habit forming, and mindfulness.
• Only a few apps provided specialized treatment approaches such as Acceptance and Commitment Therapy, Dialectical Behavioral Therapy, and biofeedback.

Evidence-Base of Therapy Apps

Although most clinicians in the United States are mandated by state law to deliver evidence-based care, many professionals have already begun using apps that are far from evidence-based. Researchers Camacho, Cohen, and Torous in this study did not assess the quality of the apps they reviewed, but they did note that eighty-five apps (15%) offered either a feasibility or efficacy study. Feasibility studies are used to establish the first level of an evidence base to assess an approach’s viability to determine if it will be effective. Feasibility studies then must be replicated with different populations to determine validity. Similarly, efficacy determines whether an intervention produces the expected result under ideal circumstances. Even if an app were to have a feasibility or efficacy study documented, neither is adequate to establish an evidence base for the app. App developers may also try to camouflage their lack of an evidence base for an unproven app by describing it as a “CBT” app, for example. While the underlying theory in such a case, cognitive behavior therapy, is evidence-based, the app may be using that theory, but it remains unproven. Evidence-based apps must have substantial research to legitimately identify themselves as evidence-based.

It is also important to note that while therapy apps can be a convenient and accessible way to access mental health care, as per state law, licensed professionals are expected to use evidence-based tools that meet specific safety standards. Clinicians are by no means limited to using evidence-based apps in a marketplace where few exist, but they may want to be mindful of these issues when making their choices and documenting those choices accordingly.

Mental Health Apps Research Summary

Researchers concluded that current app marketplaces offer basic features but emphasize the need for more inventive solutions to address people’s complex mental health needs.

Many of the apps in the study cannot qualify for even the most basic of criteria needed for evidence-based. Clinicians relying on reviews left in app stores for the best mental health apps must be more informed than the general public, which is often duped by reviews that are notorious for being created by vendors simply to increase sales. As with telehealth platforms claiming HIPAA compliance, claims are often suspect.

• When an app requests permission for the user to share data to help the programmer “with bugs,” toggling on that permission allows the app vendor to track every stroke entered by the user. Clinicians are encouraged to educate their clients and patients about the proper installation of apps and install the app in session to avoid such privacy concerns.

Clinicians may be asking themselves about the lack of innovation despite the 10,000-20,000 apps in the marketplace after decades of being available. These considerations may be helpful:

• Psychotherapy is a challenging field that is not easily put into a simple-to-use app architecture.
• While some apps have specialized in simple therapy components, such as relaxation, or tracking behaviors, delving into deeper aspects of human behavior requires research and clinical input, both of which are difficult to package into a free or low-cost app.
• Given that most apps considered worthy of investigation by the researchers do not meet the basic criteria for being evidence-based, it may be safe to assume that recommending therapy apps is not for the inexperienced or untrained.
• Therapists using apps with clients or patients may want to document their time reading about the topic or take professional development training to augment their research. Documenting that training is also suggested.
• It would behoove the world for more mental health clinicians to work with researchers to focus on studying and creating safe, clinically useful therapy apps. Given the current plethora of mental health apps flooding the marketplace, waiting for app developers to produce evidence-based apps has not been successful.

To summarize, when working with clients or patients with apps, cautious clinicians may want to do the following:

• Choose apps that are evidence-based when available. When not available, clearly outline one’s research to find an evidence-based app is suggested. 
• Choose apps based on clinical relevance in a written treatment plan. Specific benefits of using a particular app may also be helpful when explaining the function of an app to a client or patient.
• Carefully discuss the introduction and demonstration of the app in the clinical session, focusing on the safety and clinical appropriateness of the app for the intended purpose of the treatment plan.
• Provide written instructions to the client or patient will also provide the opportunity to document whether the app is evidence-based or not and provide appropriate written cautions when needed.

Part II of this series examines privacy, accessibility, and the limitations of this important contribution made by researchers Camacho, Cohen, and Torous and published in JAMA Network Open. It can be found below, along with other app-related blog posts published by Telehealth.org.

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