Is Depression Treatable with a Mobile Phone App?

Screen Shot 2015-09-22 at 3.12.21 PM SEPTEMBER 22, 2015

Thousands of new mobile phone apps have popped up to treat symptoms of depression and anxiety. Though many claim to employ clinically sound methods, critics say that human interaction is key to mental health care.

Is it safe or effective to use apps to treat anxiety or depression?

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Digital Mental Health Therapies Work, But Must Be Refined

David C. Mohr

David C. Mohr, a professor of preventive and behavioral medicine, is the director of Northwestern University’s Center for Behavioral Intervention TechnologiesSEPTEMBER 22, 2015

A large body of clinical research shows that web-based and phone applications can treat depression and anxiety. These applications — called behavioral intervention technologies (B.I.T.s) — differ in style from traditional face-to-face forms of therapy, but the aim is the same: to help people understand their difficulties, and take steps to reduce symptoms.

To do this, most B.I.T.s include straightforward steps for improved wellbeing, as well as interactive features, which build cognitive and behavioral skills that identify and challenge negative thinking patterns.

To be effective, B.I.T.s require repeated use over a number of weeks — an obstacle because many people with depression or anxiety have trouble staying engaged long enough to make substantial improvements. But even a small amount of support from a coach or therapist via phone calls or messaging, can lead to improvements similar to that of face-to-face psychological treatments.

Screen Shot 2015-09-22 at 3.18.01 PMTherapist or coach-supported B.I.T.s have been so successful that many countries have integrated such apps into their health care systems, including Australia, the Netherlands and Britain.

The question, then, is no longer whether apps are effective, but, rather how best to design them.

At Northwestern University’s Center for Behavioral Intervention Technologies, psychologists, physicians and software engineers create products that help people manage their mental health. For example, our Daily Feats app provides checklists with successive goals to activate people who are depressed. Another app, Aspire, helps people identify personal strengths and values, and prompts them to begin acting with a greater sense of meaning and purpose. The Thought Challenger app uses cognitive behavioral techniques to challenge negative thinking.

Of course, B.I.T.s are still an emerging field, and they are not a panacea. But as nearly 80 percent of Americans with mental health disorders receive no mental health care whatsoever, apps could provide cost-effective services more broadly.

The big challenge in the U.S. will be how to provide people with coverage, since our health care system pays on a fee-for-service basis, and preventive care is often not covered by insurance.

Another complication is that consumers don’t have reliable information about the quality of the thousands of apps. Countries that are implementing B.I.T.s provide guidelines for only some of what is available in today’s marketplace. What’s more, certification requirements for B.I.T. coaches have not been defined.

When implemented correctly, though, B.I.T.s can significantly broaden the availability of mental health care. The technology, however, should not be greeted as a replacement for more traditional treatments, which are severely under-funded but still necessary for many.

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Mental Health Apps Are Not an Adequate Substitute for Human Interaction

Galit Atlas

Galit Atlas, a faculty member in New York University’s postdoctoral program in psychotherapy and psychoanalysis, is the author of the forthcoming book, The Enigma of Desire: Sex, Longing, and Belonging in PsychoanalysisSEPTEMBER 22, 2015

Mental health apps promise to fix us with no human touch. But much research shows that therapeutic progress depends on the quality of a relationship with a therapist. The therapy process — which invites another human being to know and to hold the most intimate parts of one’s self — requires two minds that can feel, think and love. But relationships can be painful and quick fixes, tempting.

Screen Shot 2015-09-22 at 3.20.33 PMPsychological pain, including depression and anxiety, emerges largely in response to problematic human relations and traumatic history, and it is healed through a human relationship. It is often the body that expresses psychological symptoms (for example, sweat in a state of panic, fatigue when depressed, insomnia from distress), and as therapists, we work with each patient’s somatic experience. We examine the way they breathe and learn their body language to understand the experience of their pain so non-verbal language and communication are often integral parts of treatment and healing.

Our culture increasingly demands instant gratification and immediate relief, but the therapeutic process doesn’t provide quick answers. The psychoanalytic tradition values depth, reflection and intimacy — all of which are necessary for a person to take the risk of letting another in.

Initially, most people are afraid of long-term therapy and the dependence on their therapists. Apps allow these individuals to imagine that everything is under control, that no attachment to a live human being is necessary to untangle mental illness. Like pornography — interestingly, usually viewed on the very same devices — mental health apps substitute a two-dimensional image for a real in-depth relationship, and support an illusion of omnipotent control. The defensive move of avoiding therapists might even intensify a person’s symptoms: Underneath a defense mechanism there is always pain and fear that need to be addressed.

This is the greatest danger of seeking help through an app: It could prevent a patient from getting the actual help they need. Insurance companies will jump at the chance to cut costs, reduce spending and limit mental health benefits. As a result, people may find themselves alone, without human contact when it’s needed most. And there is no adequate substitute for human interaction dedicated to the very real task of healing psychological suffering.

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Even Those with Severe Mental Illnesses Benefit from Therapy Apps

Dror Ben-Zeev

Dror Ben-Zeev, an assistant professor of psychiatry, leads a research group that studies the effects of mobile phone applications on mental health at Dartmouth College. SEPTEMBER 22, 2015

In researching an array of mobile phone apps for people with severe mental illnesses, including schizophrenia, my research group has found that some interventions can definitely benefit those who use them.

We test computerized treatments, two-way mobile phone texting with live therapists, and smartphone apps that use sensors such as accelerometers, G.P.S. and microphones to monitor functioning. We explore whether day-to-day behavior can reveal symptoms of severe mental illness.

Screen Shot 2015-09-22 at 3.22.08 PMAcross studies, my colleagues and I find that most people we offer treatment apps to are open to using them. In doing so, they overcome the first major barrier to treatment. Many people with severe mental illness may be apprehensive about treatments that take place in a clinic or hospital, or live hundreds of miles away, so their acceptance of these apps is promising.

Used successfully, mobile health apps enable these individuals to receive support outside of brick-and-mortar clinics and in their real-world environments. They are no longer constrained by office hours, location or therapist availability.

For example, when individuals with schizophrenia used a treatment app we developed called Focus, the majority had fewer symptoms of psychosis and depression. The app sends questions to individuals about their clinical status daily, and based on their responses, offers support and guidance on everything from mood problems and medication use to coping with hallucinations. Many individuals who integrated Focus into their daily routine reported that it felt like they had another caring support person in their lives.

The key is to offer mental health apps that are based on sound research. Those that are the product of trial-and-error and close consideration of the intended user group’s needs and preferences, are often better than those marketed in the commercial app world. The public should know that most apps are made available with little to no research examining their effectiveness or safety. Glossy looks and inflated claims of potency are typically marketing strategies, not indicators of demonstrated effectiveness.

Of course, even the best apps are not magic bullets. Some patients respond well to a particular app, while others get disengaged or bored — opting for a different, more useful app or no digital treatments at all. But at the very least, to date, our research on mental health apps has not found them to be harmful.

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The Use of Apps for Mental Health Has Outpaced the Scientific Evidence

Matthew Hertenstein

Matthew Hertenstein, an associate professor of psychology and director of the Touch and Emotion Lab at DePauw University, is the author of The Tell: The Little Clues That Reveal Big Truths About Who We Are. SEPTEMBER 22, 2015

One of every five Americans will experience major depression or anxiety every year. Unfortunately, most who suffer go untreated.

To meet the need, a cottage industry has developed: Well-intentioned and enterprising individuals have designed over 3,000 apps dedicated to mental health, only some of which are free. The apps vary in function but most fall in line with the current zeitgeist of Track Thyself (whether it be calories, weight, steps or depression). The good news is that these kinds of apps increase access to health support and that access is portable. But their use should be supplemental, rather than a primary therapeutic avenue.

Screen Shot 2015-09-22 at 3.24.26 PMOne of the most significant problems with apps is the high attrition rate: People begin using them butoften tire of the required dedication quickly. More important, using an app doesn’t allow individuals to deeply connect to other humans – be they therapist or friend. In-person interaction is something we’ve benefited from for thousands of years as a species. Regulating our emotional lives via an app is a lot to ask of our stone age minds that perceive others’ emotions based on facial expression, voice, body language and touch. Some people need humans more than they think.

In addition, tracking one’s caloric intake, weight or steps over the course of days and weeks is child’s play compared to faithfully recording, let alone understanding, one’s emotions. As a scientist who studies emotion, I believe it’s possible to study one’s emotional life systematically, but most apps fall woefully short of helping individuals truly assess themselves.

When considering the use of apps as therapy, one has to ask the most important question: Does it work? There are some promising studies showing positive effects of some apps, but to date, there have been few randomized clinical trials with adequate people and diversity to say anything definitive. “Further evidence about efficacy is needed,” wrote the authors of one recent review of the scientific literature.

The proliferation of apps and their use has outpaced the scientific evidence. Ultimately, people would be well served to go beyond Internet apps to help alleviate the depressive and anxious episodes they experience.