Yusuf’s phone is ringing. His GPS shows he’s nearing a suicide hotspot, so his therapist has received an automated notification and is calling him to check in.
Trinity is feeling overwhelmed when she gets an automated message on her cellphone: “You set the goal of talking to Travis about childcare support today. Here are some tips on how to have difficult conversations. And here’s a number you can call for additional support.”
While these examples are hypothetical, mental health e-therapies are very much here, with the app described in the first scenario currently being tested and apps similar to the second example in widespread use around the world.
Some of the apps attempt to enhance the care that patients receive through the health system, as with the first example. Most, however, are standalone apps that are downloaded by the user (for free or for a nominal fee) and aren’t connected to health care providers.
The need for such solutions is great. A worldwide study involving more than 55,000 people who have contemplated suicide showed that only 56% of those in high-income countries sought mental health treatment in the previous year. Those who do attempt to seek care can be stymied by long wait times, little in the way of 24/7 support, and the requirement to pay out of pocket when publicly funded pharmaceuticals or psychotherapy aren’t available.
The use of e-therapies in mental health is “absolutely the way of the future,” says Ray Lam, a professor of psychiatry at the University of British Columbia who launched a mood-tracking app in 2014. It remains to be seen, however, if e-therapies will live up to the hopes being placed on them.
Current e-therapies and how they work
The most common e-therapies are interactive websites and smartphone apps. These tools may teach the basics of cognitive behavior therapy or mindfulness, include standardized questionnaires and automated advice, provide chat forums or offer simple tools like goal-setting trackers. Some of the most popular and evidence-backed apps include Big White Wall, Sleepio and Moodscope.
While apps that aren’t connected to the health system dominate the market, increasingly, clinicians are developing apps with hopes of amplifying the effectiveness of existing health care. Simon Hatcher, vice-chair of research for the Department of Psychiatry at the University of Ottawa, is about to launch a pilot study of an app he helped create. The app will be offered to men who have been admitted to hospital after a suicide attempt. (According to Statistics Canada, nearly 3,000 men ended their own lives in 2012, while the number was just under 1,000 for women.) The app allows a user to check in daily with a therapist or coach, prompting him to indicate his mood on a standard scale. Depending on how the man responds, automated messages of encouragement will appear, but if the results over a few days indicate he seems to be sliding into depression, the program will notify a therapist.
In a feature that uses phone GPS technology, men can program the app to send warnings when they’re heading toward a location that isn’t good for their mental health. So if a father who is trying to quit drinking goes near his local bar, a photo of his daughter could appear as motivation to stay away. “There are potential places that are often quite difficult for people, like places where people go to drink or the location of ex-partners,” explains Hatcher.
In the initial pilot, 10 people will use the app so that Hatcher’s team can get feedback on how to improve it. Hatcher’s research is being backed by a $1.75 million award from the Ontario Strategy for Patient-Oriented Research (SPOR) Support Network.
Hatcher’s interest in suicide prevention and e-health technologies grew out of the work he did previously as a professor in New Zealand, which is more advanced than Canada in mental health e-therapies. There, he was involved with the development of two e-therapies funded by the Ministry of Health’s National Depression Initiative: The Lowdown for youth, and The Journal for adults.
For people with relatively mild symptoms, the apps can provide advice, interactive e-therapy courses and evidence-backed self-assessment tools, explains Anil Thapliyal, the eMental Health Lead at the Auckland University of Technology and someone who was instrumental in developing the two e-therapies. In 2015, 371,000 people signed up for The Journal. Approximately 88,000 youth access The Lowdown website each year, with around 14,000 completing a self-test to gauge whether they had depression, and the level of their depression.
Around half of all users access the tools from their mobile phones, according to Thapliyal. “People are glued to their mobile phones all the time,” he says. “You have to go to the place where the consumer is.”
For those dealing with moderate to severe mental health issues, both The Lowdown and The Journal also have 24/7 in-person support available – predominantly through text for The Lowdown and through a phone line for The Journal. And staff monitor the site’s chat forums for “risk words,” Thapliyal explains. If a person has said they are going to harm themselves or others, staff can contact the person (if they’ve opted into sharing their information) or they can locate a person using their IP address and involve emergency authorities.
The evidence behind mental health apps
Unfortunately, “there isn’t much evidence behind e-therapies,” says Hatcher. The majority of the thousand-plus available mental health apps don’t have any evidence behind them. In many cases, that’s because apps have been designed by private developers, explains Simon Leigh, a consultant with the health economics agency Lifecode Solutions in England and the author of a review of mental health apps published last year in the Evidence-Based Mental Health journal. “If I was an app developer, I’d probably sooner spend my money on advertising than evidence generation,” he says.
For those apps that have been evaluated, the studies aren’t ideal. As Hatcher explains in a recent review, e-therapy studies often follow people who sign up online, and who haven’t been assessed by a therapist. (That means participants may not be clinically depressed or may be suffering the kind of crisis the particular app isn’t designed to address.)
Still, there’s some emerging evidence behind a small number of mental health apps. A recent review of five computerized cognitive therapy apps found three to be as effective as in-person cognitive therapy. That said, the conclusion was based on “only a small number of randomized controlled trials,” some of which were funded by the companies.
England’s National Health Services has approved seven mental health apps, based on evidence of their clinical effectiveness. Depending on where a person lives in the country, the cost of the apps may be covered (sometimes only with a referral from a health provider).
Another systematic review found that overall, the e-therapies that have been studied have been “moderately” effective, but that not all e-therapies are created equal. Those linked with therapist support, the review found, tended to be effective, while those that provided no provider support had only slight impacts.
The Journal and The Lowdown, meanwhile, are currently being evaluated, with results expected in January, according to Thapliyal. Have the online programs reduced the suicide rate? No, says Thapliyal, but that could be because the health care system and online therapies are “doing a lot, but not enough” or because the rate would have otherwise gone up.
In other words, says Hatcher, “it’s not as simple as giving people an app and then everything will be okay.”
Risks of e-therapies in mental health
Research hasn’t revealed any direct harms from mental health apps themselves, though that could be because harms simply haven’t been rigorously investigated.
There are hypothetical risks. “There’s always the risk that people measure their symptoms, they’re not improving, and it makes them feel worse,” says Leigh. (If a person was taking the same standardized tests with a therapist’s guidance, the provider could provide hope and perspective.)
The bigger concern is the potential risk of the “opportunity cost” associated with spending time on an ineffective e-therapy versus an evidence-based app or conventional treatment, says Leigh. Unhelpful apps are also a waste of money.
E-therapies might also incorrectly diagnose people. Joanna Henderson, head of research with the child, youth and family program of the Centre for Addiction and Mental Health, worries that key information can be missed in online, standardized questionnaires. With teens, she points out, “we know that you get the best clinical results when you combine in-person interview information and observational information from parents together with information gathered from standardized measures.”
Privacy is another serious issue. As Henderson points out, parents or spouses could potentially access someone’s mental health app, and the health provider sending the message can’t be certain who they’re talking to. “How do you know the person on the other end of the text is the person you think it is?” she asks.
Given that most apps are developed by private companies, what worries Wiplove Lamba, an addiction physician at St. Michael’s hospital, is that “the company often has full rights in terms of the content on it. If these apps are bought up by another company, that information is everywhere.” As Leigh notes, few people read or reflect on the terms and conditions when downloading an app.
In a recent review or mental health apps and privacy legislation in Europe and the UK, authors noted that health privacy legislation in place are “too open and too old” to respond to the implications of health apps, and most health apps on the market do not have adequate security and informed consent mechanisms in place. For his part, Hatcher says the app he’s developed is HIPAA and PHIPA compliant, which means that data is encrypted and on secure servers.
Of course, several of the concerns around e-therapies are based on the premise that those accessing e-therapies could otherwise access more proven therapies. That may be true in some cases, but in many cases, users wouldn’t otherwise feel comfortable opening up to a health provider or have the time and money to access care. “I think the people who will benefit the most from apps are those who are quite excluded from traditional health care, such as the mother with three kids who can’t get out of the house,” explains Leigh.
Future direction of e-health therapies
With the evidence suggesting that apps that are integrated with health care are more effective, it is likely we’ll see more health system-backed apps in the future. E-therapies could potentially be used both to draw hesitant people into care, or to support already-enrolled patients in their day to day life. “It’s easy to design pretty apps. The tricky part, going forward, will be to integrate e-therapy with existing therapies,” says Hatcher.
A website and mobile app Lam developed called moodfx.ca integrates the two by letting people track their appointments, and record their scores on various evidence-based depression, anxiety and functioning scales over time. This is important, Lam says, because many treatments for depression don’t work, and doctors tend not to follow up with patients to see how a person is doing on treatment. Meanwhile, depressed people have low motivation and are likely to blame themselves if something isn’t working. That’s why the app sends patients motivational messages to remind them to speak to their doctor when the evidence-based scales suggest a treatment isn’t working. Lam says he’s planning a randomized controlled trial to look at the effectiveness of the app.
Mental health apps might also see more success by targeting certain populations. For example, military personnel tend to access mental health services in lower numbers because of the stigma associated with mental disorders. For this reason, the U.S. Veteran’s Affairs has launched an app designed to help veterans suffering from PTSD, and the app has recently been adapted for use in Canada. The app can provide more anonymity than a busy health clinic and it also uses language that resonates with soldiers.
And there’s a research advantage e-therapies have over conventional therapy: the possibility of data generation on a massive scale. This is the area of e-therapies that excites Henderson. “You can get much more robust understanding of what’s going on for people who are experiencing crisis,” she says. For instance, the US Crisis Centre, which has received almost 16 million texts since 2013, has anonymized the text data for researchers. Scientists can make queries, pulling geographic information and time and dates of texts to find out when people are most likely to feel suicidal and in which jurisdictions people need the most support. The Crisis Trends website points out that among the myriad queries the data could shed light on include “the relationship between weather and depression” or – since researchers can analyze the content of messages – “how are bullying and depression related?”
While big data analysis and GPS tracking are indeed here, it is important to keep in mind that, for the most part, mental health care remains decidedly low-tech. Many still can’t email their mental health provider, for instance. And as Thapliyal says, most e-therapies are relying on messaging, automated reminders and online surveying technology that’s far from cutting edge. “These are simple tools to reach consumers in the ways they want to be reached. This is not innovation,” he says.