Dramatic growth in mental health apps has created a risky industry

                                                                 The Economist, Dec 11 2021

Apps are not always treatment substitutes: costs can add up quickly, especially if they’re not covered by insurance, and more traditional professional intervention might be your key to recovery

                                                                                                                        Prevention, Christine Forbes, 2021

There is very little industry regulation and very little information on app effectiveness

                                                                                                                                                National Institute of Mental Health

…the global mental health app market is expected to reach $3.7 billion by 2027. Apps like Calm and Headspace help users to cultivate positive thinking and relax and relieve stress..

                                                                                                                                                Acumen Research & Consulting

There are at least twenty thousand smartphone apps targeting mental health; information and communication technology (ICT) advances mean a myriad of apps that incorporate proven techniques such as Cognitive Behavioural Therapy (CBT) and Acceptance Commitment Therapy (ACT), and address everything from depression to eating disorder recovery, anxiety, PTSD, obsessive-compulsive disorder, and more, can be downloaded in seconds. Unfortunately, star ratings and other metrics correlate poorly with app efficacy, risks, safety and usefulness.

This article is the first of a series which aims to inform client decision-making around adoption and utilisation of popular mental Health apps. To this end various evaluation frameworks^(1.-3.) have been incorporated to tabulate issues of app data sharing, engagement, benefit/efficacy, risk/privacy, and safety.

Whilst every effort has been made to ensure sound analysis, this Centre does not endorse nor take responsibility for the information contained herein.

Why they are used?

In a nutshell: (1) ease of habit, (2) low effort expectancy, and (3) high hedonic motivation.^(4.,5.)

• Immediacy/anonymity/safety/non-stigmatising/non-judgementalistic: it is contact-less and not location/time contingent.
• Treatment aids: apps can be useful for data recording and self-monitoring (subjective, biometric, and VR-based) which is used to expedite therapeutic goals.
• Therapeutic motivation and engagement: a simple user interface including games, quizzes, and other resources can add novelty and reward, real-time reminders/prompts promote re-engagement, and cognitive load can be tailored to specific conditions/impairments.

What might they lack?

• Try before you buy: some apps require purchase before use and are often platform-specific.
• Functionality: information may be difficult to export and access to carers absent in critical situations.
• Evidence-based approaches: whilst purporting to use sound psychological theory (many apps utilise ‘online-adapted’ modalities eg they substitute (evidence-based) Cognitive Behavioural Therapy (CBT) with Internet-based Cognitive Behavioural Therapy (ICBT)- where research data is scant and lacking in scientific rigor).
• Easy to access to understandable Privacy Policy.
• Personal data including clinical information may be stored remotely on the app’s provider’s servers- here there is increased risk that data is used/sold for purposes not known, including social profiling and insurability.
• Control of Chatbot technology (questionable or scant safety or efficacy evaluation).
• Advertisement-free environment.
• Intra-operability (compatibility with other apps and data export to aid independent professional treatment plan).
• Trans-diagnosis: apps are generally disorder-specific and omit co-morbid factors.
• Legitimate and supportive websites: the same cyber-security risks plaguing all interactive websites including insecure URLs, unsafe payment methods, or absent/ambiguous physical address, contact/support, terms and conditions, reviews, and security seals/certifications.  
• Use of the application does not fit into busy lifestyles or routines.

What types are there at the moment?

Apps may be categorised according to what they offer as follows:

• Tools, activities/exercises, information/link resources, and self-monitoring logs, which may include real-time prompts and reminders, gamification, AI, music & images, VR, and bio-feedback interfaces (including Passive Symptom Tracking- Smartphone sensors -movement, patterns, social interactions (number of SMSs and phone calls), vocal tone and speed, and more).
• The above plus contact with peers, mental health professionals or chatbots- this category is outside the scope of this survey.
• Consumer group targeting- pre-natal, LGBTQ+, ethnic minorities, women’s issues, adolescents & children, families, and traumatic brain injury or domestic violence sufferers,

or what they are primarily used for:

• Self-help and therapeutic interventions including Cognitive Behavioural Therapy (CBT), Acceptance & Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT), Positive Psychology, psychoeducation, mood, symptom, and habit tracking, mindfulness, meditation, yoga, and breathing & muscle relaxation exercises.
• Clinical disorder apps including schizophrenia, Autism Spectrum Disorder, Borderline Personality Disorder, Obsessive Compulsive Disorder, psychosis, stuttering, Traumatic Brain Injury, ADHD, depression, anxiety, Post Traumatic Stress, phobias, suicidal ideation, eating disorders, and addiction disorder.
• Family/parenting/relationships apps.
• Group therapy apps- this category is outside the scope of this survey.

What do Clinicians think?

Whilst many mental health professionals recommend apps to their clients, some question the effectiveness of mental health apps when used in isolation, recommending them as an adjunct to therapy rather than an alternative or replacement for traditional treatment, and are wary of them diverting focus from achieving the interpretations, insights, breakthroughs and resolutions that only a sound therapeutic alliance with a highly trained and experienced professional can foster.

Survey Method

The following information was collated from over 30 online lists of recommended apps and 10 clinicians’ choices, and utilises several assessment tools including the Mobile Application Rating Scale (MARS)^(11.):

Waking Up with Sam Harris Android | iOS

Sam Harris is a respected neuroscientist, philosopher, and writer on meditation. His approach to meditation aims to achieve measurable benefits for anxiety, stress, and sleep. His view regarding the purpose of meditation is self-understanding and the realisation that ‘you are not your thoughts’.

This American app provides extensive coverage of meditation theory, interviews/conversations with eminent practitioners, and guided short and long exercises. It explores mindfulness, Zen, Dzogchen, Advaita, and other practices, and purports to teach how neuroscience and psychedelics can illuminate the path of meditation.

Although the app is expensive (it does offer a seven-day free trial however), it does donate 10% of profits to charity, and rates favourably when compared to Calm (see below).

Score: 29/40 (Assessment & Background, Privacy & Security, Clinical Foundation, Therapeutic Goals). The app is not customisable, uses tracking, and data not exportable.

Smiling Mind Android | iOS

Smiling Mind is a free (not for profit) 10 minute per day Australian meditation app for children and adults. There are grounding body scans, breathing meditations, and sensory exercises such as listening to music or tasting foods. The meditations for younger children appear to be parent-child focused, as many of them speak directly to the parent and include activities that are parent-child appropriate. There are also lesson plans for teachers that can be paired with the student meditations provided.

Smiling Mind includes programs for children in different age groups, a workplace program, and a sport program. Users are offered short meditations or longer versions with less guidance. Smiling Mind also has a six-year “Mindfulness Curriculum” for educators to use with their students with complementary student versions. Offline use occurs via meditation downloads.

Smiling Mind includes an indigenous languages component and recognises first nation owners.

Score: 35/40 (Assessment & Background, Privacy & Security, Clinical Foundation, Therapeutic Goals). This app has excellent privacy and security.

Yogibirth Android | iOS

Created by a Midwife, YogiBirth is a pregnancy wellbeing programme to support the mental, physical and emotional health of pregnant women; both at home and at work. It offers midwife-led yoga classes, guided meditations & relaxations, breathing exercises, education, and advice for partners.

It claims to use evidence-based techniques and has a monthly subscription rate (but does support charity) with a seven-day free trial. A Privacy Policy and company ownership details are not clear.

Score: 34/40 (Assessment & Background, Privacy & Security, Clinical Foundation, Therapeutic Goals). This app includes excellent resources but does not clearly enumerate some technical details.

Calm Android | iOS

This American mood-lifting and meditation app offers various programs that range from 7 to 21 days for all ages. A custom 10-minute Daily Calm program also helps provide a moment of relaxation at the start or the end of the day. There is a free trial version, with the premium subscription including weekly updates and new content, masterclasses, music and nature sounds.

On top of these programs, Calm has guided meditation sessions for different needs, including finding forgiveness, breaking habits and increasing self-esteem. The app also has guided stress management, breathing exercises, and over 100 adult bedtime stories to help facilitate restful sleep.

Score: 31/40 (Assessment & Background, Privacy & Security, Clinical Foundation, Therapeutic Goals). Mindfulness-Based Stress Reduction (MBSR) is borderline evidence-based.

Headspace Android | iOS

Yet another California-based app, Headspace recognises that mindfulness-based interventions and meditation are increasingly being utilized for psychological disorders (i.e., addiction, eating disorders, anxiety, depression, insomnia) and stress reduction. Significant evidence exists to support the efficacy of mindfulness interventions^(9.) Headspace has been shown to be beneficial in randomized controlled trials to enhance well-being and compassion^(7-8).Itscored the highest in all categories on MARS.

Some evidence-based treatments such as Acceptance and Commitment Therapy (ACT) and Dialectical Behaviour Therapy (DBT) are used, while others such Mindfulness-based Cognitive Therapy (MBCT) for depression and Mindfulness-Based Relapse Prevention (MBRP) for addiction are less scientifically validated. Mindfulness meditation resembles exposure therapy through its acceptance of internal responses as a way to extinguish conditioned fear. Neuroimaging studies have begun to identify the brain areas and circuits associated with the positive effects of mindfulness meditation, however, the underlying neural mechanisms are not well understood^(9.). Emerging research indicates that mindfulness meditation may produce neuroplastic changes in the structural and functional brain regions implicated in attentional control, emotion regulation and self-awareness^(10.).

Some Headspace packages offer physical and mental health psychoeducation topics such as depression, anxiety, sleep and self-esteem. A technique called “noting” is included which supposedly helps the individual come back to the object of focus without labelling or attachment. There is also an SOS button that leads the user through an abbreviated 3-minute session for dealing with stressful circumstances.

Score: 36/40 (Assessment & Background, Privacy & Security, Clinical Foundation, Therapeutic Goals).

CBT Thought Diary iOS

CBT Thought Diary is an Australian app that uses tools from evidence-based Cognitive Behavioural Therapy (CBT) and Positive Psychology to help users track and improve their moods and to analyse and reframe their thinking. The app guides users through identifying and addressing their cognitive distortions. Other features include insights and a discover page that has different issues that users might be struggling with (e.g., social relationships, sleep). The app allows charting of several indices including mood and positive experiences so that users can see ‘big picture’ changes. The developers claim this provides perspective, promoting recall and appreciation as well as gratitude.

The basic app is free but requires subscription for pro. features such as more journals, assessments, guides, insights, customised emotions, extra notifications, export, data sync, passcode protection, and ‘discover’ features.

Score: 34/40 (Assessment & Background, Privacy & Security, Clinical Foundation, Therapeutic Goals).

The Resilience Project Android | iOS

The Resilience Project app is an Australian based daily well-being journal which uses practical, evidence-based mental health strategies to build resilience and happiness. Each day users are prompted to identify their emotions, record moments of gratitude and practice mindfulness. The aim is for users to develop emotional literacy, engage with the positive things in life and be actively present. Social connection and physical health education and activities are also incorporated as essential building blocks.

It was developed by Hugh van Cuylenburg after his experiences volunteering in north India, where he observed that despite poverty, poor shelter and the absence of running water & electricity, locals maintained extremely high levels of happiness.  His subsequent academic research attributed practicing gratitude, empathy and Mindfulness to this phenomenon and lead him to develop a program adapted to Australian conditions.

There is a small one-time cost (around $5) with a seven-day free trial offered.

Score: 34/40 (Assessment & Background, Privacy & Security, Clinical Foundation, Therapeutic Goals).

Grateful Android | iOS

Grateful is a free Indian-based app that aims to be an avenue for those suffering from anxiety and depression. It claims to help users improve their mental health and change their perception of life and teach them ‘how to love and care for themselves through the power of gratefulness’.

Stemming from Positive Psychology research, the practice of ‘gratitude’ (involving recognition, acknowledgement, and appreciation) is strongly and consistently associated with greater happiness. Gratitude helps people feel more positive emotions, relish good experiences, improve their health, deal with adversity, and build strong relationships.

Studies have demonstrated that at the neural level, moral judgments involving feelings of gratefulness are evoked (involving serotonin, dopamine and stress hormones) in the right anterior temporal cortex, with subjects exhibiting unusually high expression/feelings of gratitude found to have a higher volume of grey matter in the right inferior temporal gyrus ^(12.). Brain scans of people assigned a task that stimulates expression of gratitude show lasting changes in the prefrontal cortex that heighten sensitivity to future experiences of gratitude^(13.).

This journaling app features daily journaling, a ‘vision board’, quotes and affirmations, challenges, exemplars, photo attachments, and daily reminders.

Score: 33/40 (Assessment & Background, Privacy & Security, Clinical Foundation, Therapeutic Goals).

Findings

While ideally these new digital tools would be used as a supplementary treatment to traditional therapy, for those who aren’t able to access the support of a mental health practitioner, mental health apps offer valuable support and guidance.

Our research recommends choosing a mental health app in consultation with a registered psychologist, and, when searching, using a reputable registry such as the website Beacon (an online portal developed by the Australian National University).

Jan 2022

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