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Who will use it? How to get digital mental health apps into the hands of patients

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In our last article, we discussed how to navigate the minefield of mental health apps. Now, how do you get them used by patients?

One of the hardest challenges in digital psychiatry is deciding the optimal workflow to integrate apps into clinical practice. A survey found that 77% of clinicians refer patients to informative websites, but only 19% tend to suggest usage of mobile applications to patients to improve clinical information. 1

For widespread adoption by clinicians, apps need to be optimized to address technology competency, resource availability, reimbursement and regulatory issues and organizational infrastructure. For mental health apps to attain clinical relevance, information systems need to make it easy for overburdened clinicians to collect patient data, interpret new forms of data, and address roadblocks. These roadblocks to app adoption include hesitance about billable time, therapeutic boundaries, and privacy and liability. 2

In addition to these roadblocks, there are other reasons for hesitancy for clinical apps.

Setting expectations of apps — what they can and cannot do

Live, person-to-person communications are the gold standard. But among patients, typical mental health apps might not necessarily be seen as a replacement for live support. There has been evidence that mental health apps tend to be more effective when coupled with live support, but apps cannot replace traditional face-to-face psychotherapy.

What about collateral information? There is a recent clinical trial that investigated the feasibility of use of collateral information sources, such as social media through digital communication with  providers. This trial will report whether getting this collateral information leads to superior patient outcomes when compared to clinical settings without collateral information. 3 Collateral information has proven to be beneficial in clinical care 4, and apps that might help streamline the process will certainly be welcome.

Finally, where do these data live? A major roadblock is that integrating apps with clinical electronic health record (EHR) systems is difficult. We need clinical data to appear within records for easy access and tracking by clinicians. Having the right data appear at the right moment can streamline the process.

How will we know if apps are effective and being used?

General smartphone apps face low user retention rates, with 25% of users abandoning them after one use 5. In a review of 10 digital mental health self-help apps and programs — online or computerized — for depression and anxiety, which involved 8 to 40,000 downloads or registrations a month — 21-88% of users were using at least once, and 0.5-28.6% continuing after 6 weeks. 6

Despite the potential benefit these mental health apps may have for the end-user, all consumer technologies tend to have selective use and low retention rates. A high interest in these apps will not automatically translate into high usage. 7 There are some practices that might lead to higher mental health app retention. Usage of the app in clinical settings and provision of smartphones with data plans may lead to higher usability. 8 One of the biggest hurdles that exists in mental health smartphone apps and wearables is the lack of research on their efficacy. Many papers tout the potential of mental health apps, but there is little clinical validated evidence. In a review of 100 studies using a mental health app for different conditions, only 14 had clinically validated evidence of their efficacy.9

Since there is a relatively low cost and few hurdles to developing and deploying apps — compared to the heavily-regulated pharmaceutical industry — most mental health app makers do not perform clinical trials for establishing efficacy. Thus, measuring the effectiveness of these apps becomes a great challenge. Clinician and research leadership can drive independant and replication studies, thus boosting research and helping to establish their legitimacy.10

In order to study their effectiveness more closely and monitor usability, more clinicians need to be in both the development and app-prescription process. Clinicians need continuous feedback from the patients regarding their needs and whether they are being met, with consistent iterations until the digital tools become standard clinical care, as they have demonstrated promise to do so.

About the Authors:

Last month was Mental Health Awareness Month. In case you missed our last article, How To Navigate Quality Issues with Mental Health Apps, please see it here. This is our 2nd article in our guest writer series on digital mental health.

Burhan Ahmed Khan, MD, Research Collaborator at McLean Hospital, in the Developmental Biopsychiatry Research Program & Functional Neuroimaging & Bioinformatics Lab.

Steven Chan MD MBA, Director of Digital Health, Addiction Consultation & Treatment at VA Palo Alto Healthcare System and Clinical Assistant Professor (Affiliated) at Stanford University School of Medicine.
1.     Schueller SM, Washburn JJ, Price M. Exploring mental health providers’ interest in using web and mobile-based tools in their practices. Internet Interv. 2016;4:145-151. doi:10.1016/j.invent.2016.06.004 Link: https://www.sciencedirect.com/science/article/pii/S2214782916300197
2.     Lazar MA, Pan Z, Ragguett R-M, et al. Digital revolution in depression: A technology update for clinicians. Pers Med Psychiatry. 2017;4-6:1-6. doi:10.1016/j.pmip.2017.09.001Link: https://www.sciencedirect.com/science/article/pii/S2468171717300352
3.     Vahia I. Feasibility of Collateral Information Review and Its Impact on Clinical Decision-Making. Published March 2020. Link: https://clinicaltrials.gov/ct2/show/NCT04635748
4.     Hobbs KW, Monette PJ, Owoyemi P, et al. Incorporating Information From Electronic and Social Media Into Psychiatric and Psychotherapeutic Patient Care: Survey Among Clinicians. J Med Internet Res. 2019;21(7):e13218-e13218. doi:10.2196/13218. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6659389/
5.     Localytics. 25% of Users Abandon Apps After One Use. Link: https://uplandsoftware.com/localytics/resources/blog/25-of-users-abandon-apps-after-one-use/
6.     Fleming T, Bavin L, Lucassen M, Stasiak K, Hopkins S, Merry S. Beyond the Trial: Systematic Review of Real-World Uptake and Engagement With Digital Self-Help Interventions for Depression, Low Mood, or Anxiety. J Med Internet Res. 2018;20(6):e199. doi:10.2196/jmir.9275. Link: https://pubmed.ncbi.nlm.nih.gov/29875089/
7.     Torous J, Wisniewski H, Liu G, Keshavan M. Mental Health Mobile Phone App Usage, Concerns, and Benefits Among Psychiatric Outpatients: Comparative Survey Study. JMIR Ment Health. 2018;5(4):e11715. doi:10.2196/11715. Link: https://pubmed.ncbi.nlm.nih.gov/30446484/
8.     Achtyes ED, Ben-Zeev D, Luo Z, et al. Off-hours use of a smartphone intervention to extend support for individuals with schizophrenia spectrum disorders recently discharged from a psychiatric hospital. Schizophr Res. 2019;206:200-208. doi:10.1016/j.schres.2018.11.026. Link: https://pubmed.ncbi.nlm.nih.gov/30551981/
9.     Wang K, Varma DS, Prosperi M. A systematic review of the effectiveness of mobile apps for monitoring and management of mental health symptoms or disorders. J Psychiatr Res. 2018;107:73-78. doi:10.1016/j.jpsychires.2018.10.006. Link: https://pubmed.ncbi.nlm.nih.gov/30347316/
10.     Marshall JM, Dunstan DA, Bartik W. Clinical or gimmickal: The use and effectiveness of mobile mental health apps for treating anxiety and depression. Aust N Z J Psychiatry. 2020;54(1):20-28. doi:10.1177/0004867419876700. Link: https://journals.sagepub.com/doi/full/10.1177/0004867419876700

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