Smartphone Applications for Depression and Anxiety: Are They Ready for Widespread Use?

There are more than 10,000 digital applications for mental health. Direct-to-consumer smartphone apps are available to teach mindfulness, alleviate depression and anxiety, simulate psychotherapy sessions, and help individuals with ADHD get organized. Apps aimed at mental health professionals promise to streamline psychiatric diagnoses, symptom assessment, data collection, medication adherence, and physician-patient communication.

How to Advise Patients on Mental Health Apps

Selecting from the available mental health apps to use in clinical practice or advising patients who want to use a mental health app on their own can be daunting for even tech-savvy clinicians, as very few mental health apps have been clinically tested.

“Although several groups have started to tackle the issue, clinicians do not yet have a reliable way to determine the apps that have good data regarding their effectiveness,” Seth Feuerstein, MD, JD, told Psychiatry Advisor. Dr Feuerstein is Chief Innovation Officer at Magellan Health and Executive Director of the Yale Center for Digital Health, Innovation, and Excellence.

Joseph Firth, PhD, a research fellow at Western Sydney University, told Psychiatry Advisor that clinicians could narrow the field by selecting from apps shown to be effective in randomized clinical trials (RCTs).

Dr Firth was the primary investigator in 2 recent meta-analyses that examined RCTs of mental health interventions for anxiety or depression delivered by smartphone.^1,2 Analysis of 9 eligible RCTs examining the effect of smartphone interventions for symptoms of anxiety resulting from subclinical or diagnosed anxiety disorders¹ and of 18 eligible RCTs of 22 smartphone apps for depressive symptoms² showed that symptoms were reduced significantly more by smartphone apps than by control conditions.

Testing Apps’ Efficacy in Real-Life Settings

A recent pilot project undertaken in New York’s Montefiore Health system is among the latest to demonstrate the value of digital apps for patients with depression and anxiety.

Montefiore partnered with digital technology provider Valera Health to roll out an application for patients receiving collaborative medical and behavioral health care at 5 Montefiore primary care sites in the Bronx, New York. The pilot was funded by a grant Montefiore received from the Center for Medicare and Medicaid Innovation (CMMI) of the Centers for Medicare and Medicaid Services (CMS) to implement a collaborative care model (CoCM), in which behavioral health care is integrated into primary care.  

“The program was designed to increase access to vital behavioral health services for low-income, ethnic minority populations in primary care settings and improve overall healthcare quality through the implementation of the evidence-based collaborative care model, with an eye toward sustaining the program beyond the 3-year grant period,” Michelle Blackmore, PhD, Project Director of the Bronx Behavioral Health Integration Program at Montefiore Care Management Organization told Psychiatry Advisor.

“Despite the model’s strong evidence base of quality improvement, it is hard to sustain and scale. The app enables monitoring for depression and anxiety between visits, timely follow up, support for patient activation strategies, access to health education materials, a secure chat function for patient support, as well as appointment reminders and support for medication adherence. Patients can also opt to provide passive data collection to help inform individualized coaching — step counts for exercise, for example — and alert the healthcare team if a patient does not leave their home after 2 to 3 days, a sign that the individual’s symptoms may be worsening.”

Data from the pilot study presented at the American Psychiatric Association annual meeting in 2017 indicated that Montefiore patients using the Valera platform showed significant improvement in depression and anxiety scores and remission rates. Additionally, Montefiore’s care managers were able to interact with patients 3 times more than usual and manage caseloads of up to 120 people. Montefiore is now expanding the use of the technology to additional primary care settings, departments, and specialty clinics.

Concerns About Integrating Apps Into Practice

Dr Blackmore advised that mental health clinicians interested in integrating digital apps into their practices should spend time researching and vetting existing apps that will best meet their needs and the needs of their patients. 

“Once you’ve narrowed down the options, connect with the vendors to see what flexibility is offered in terms of app customizations and expected delivery timelines. Also, check on what training and implementation support the vendor will provide. On-the-ground vendor support can be vital.”

Will the digital revolution in psychiatry lessen the importance of the interpersonal relationship between patient and clinician? Dr Feuerstein told Psychiatry Advisor that to the contrary, digital apps have the potential to make the therapeutic alliance even more central and powerful for the patient and the provider.

“We have seen in other fields the power of technology to enhance connections between people. There is a risk, of course, of it interfering as well,” he noted. “On the positive side, there are many ways this potential strengthening of the therapeutic relationship can occur. For instance, I may have a patient in therapy for depression in a traditional office setting. If the patient has trouble sleeping, I can offer them a well-studied app for insomnia and continue to focus on the depression. This allows me to offer a well-validated program to address a condition [affecting] the patient, and should help build the connection and value I bring as a clinician in an area that may not be my expertise. It may also reduce the cost to the patient and the system and may provide more data to support the live sessions. Or I may decide to offer a texting platform to some of my patients, as this is the way they prefer to communicate most often. I may see them less often in person but text with them more regularly.”

Dr Firth commented that patients may indeed miss out on the benefits of the patient-clinician alliance if they look to apps to replace standard face-to-face care. “Instead, I would recommend apps only be used as an add-on to standard treatment, or to fulfil entirely different roles, like reaching people not typically reached by psychiatric services,” he said.

References

1. Firth J, Torous J, Nicholas J, Carney R, Rosenbaum S, Sarris J. Can smartphone mental health interventions reduce symptoms of anxiety? A meta-analysis of randomized controlled trials. J Affect Disord. 2017;218:15-22.
2. Firth J, Torous J, Nicholas J, et al. The efficacy of smartphone-based mental health interventions for depressive symptoms: a meta-analysis of randomized controlled trials. World Psychiatry. 2017;16:287-298.