TheCurrentStateofmHealthApplicationsfortheTreatmentofDepression

ByChristopherd’Autremont

Advisedby:KarenEden,PhD

OregonHealth&ScienceUniversitySchoolofMedicine

DepartmentofMedicalInformatics&ClinicalEpidemiology

2

SchoolofMedicine

OregonHealth&ScienceUniversity

CERTIFICATE OF APPROVAL

This is to certify that the Master’s Capstone Project of

Christopher A. d’Autremont

“The Current State of mHealth Applications for the Treatment of Depression”

Has been approved

_________________________________________KarenEden,Ph.D.

3

Introduction

Smartphonesandothermobiledeviceshaverevolutionizedsociety.Around

theglobe,wearebetterabletocommunicate,accessandshareinformation,

whereverwetravel.Thedevelopmentofapplicationsforthesedeviceshasallowed

ustoperformbankingandmonetarytransactions,tocallaride,andtointeractwith

ourfriends,families,andacquaintances,amongmanyotheractivities,evenwhenwe

areonthemove.

Inhealthcare,mobilehealthtechnologies(mHealth)haveemergedtoallow

patientstocommunicatewithphysiciansandothercaregiverstocheckinand

monitorconditionsandprogressremotely.WhilemHealthpracticesbeganwell

beforetheeraofthesmartphone,thefieldhastrulytakenoffsince.Publicinterest

intheuseofmobiledevicesforhealthcare,whetherintermsofinterventions,

monitoring,medicationreminders,orself-management,hasblossomed,witha

broadmajorityofrespondentstosurveysindicatingthattheywouldlikemobile

devicestobeincorporatedintocare.1

AlthoughanumberofmHealthapplicationshavebeendesigned,tested,and

implementedintomedicalpractice,anybodycandesign,develop,andpublishan

apptoanonlinemarketplaceandcallitahealth-relatedapp.2Thevastmajorityof

applicationsbilledashealthappsarenotdesignedbymedicalprofessionalsand

providelittletonoevidencethattheyarebasedinclinicaltheoryandresearch.1As

such,itisdifficulttoassesstheefficacyofanapporitsbasisintheclinicalliterature

fromthedescriptionlistedinthemarketplace.

4

Thisisespeciallytrueofappspurportingtoassistinmentalhealth.Thereare

amultitudeofappsthatclaimtoassistinthemanagementandmonitoringof

anxiousanddepressivesymptomsinparticular.3,4Theseconditionsareparticularly

popularforappdeveloperstofocuson,asamajorityofpeopleexperiencesome

symptomsoftheseconditionsatvaryingpointsintheirlivesatsomedegreeof

intensity.2Assuch,applicationstoaddresstheseconditionsareverycommonand

canbeaneasysellonthemarketplacesduetotheirtopicalityandwidespread

appeal.

Thepurposeofthisreviewistoassesstheoverallstateofpubliclyavailable

mHealthappsthatclaimtotreatdepression.Thiswillbedonebyreviewing

systematicreviewspublishedafterDecemberof2015,infollow-uptoasystematic

reviewpublishedbyHuguetetal.(2016).3Theappsdiscussedinthisreviewwere

chosenasexamplesofnoteworthyapps,andanapplication’sinclusioninthisstudy

isnotanendorsementoftheapplication,butratheraresultofitsreviewbya

previousstudy.Byreviewingprevioussystematicreviews,thisstudywillhighlight

researchgapsintheliteratureandidentifymethodsbywhichtheoverallefficacy,

usability,andsustaineduseofpubliclyavailableapplicationsforthetreatmentof

depressioncouldbeimproved.

Methods

Forthepurposeofthisreview,onlysystematicreviewsassessingoneor

moremobileapplicationspertainingtothetreatmentormonitoringofdepression

andwhichwerepublishedinpeer-reviewedjournalsafterDecemberof2015were

included.Farfewerreviewsexistforsmartphone-basedtreatmentofdepression

5

thanforweb-basedmHealththerapies,soapp-basedinterventionswerethefocusof

thisreview.

Thefollowingdatabaseswerereviewedforpeer-reviewedsystematicreview

studiesofapp-basedinterventionsfordepression:PubMed,MEDLINE,PsycInfo,

Scopus,TheCochraneControlledRegisterofTrials,andGoogleScholar.These

sourceswerereviewedforcombinationsofthefollowingsearchterms:“depression”

“mHealth”“application”“mobilehealth”“mentalhealthapp”“systematicreview”

“MajorDepressiveDisorder”“marketplace”“iTunes”and“GooglePlay”.

Ofthearticlesfoundinthesesearches,atitleandcitationsearchwas

performedtoscreenoutnon-reviewarticles,articlesthatwerenotpublishedin

peer-reviewedjournals,articlesthatwerenotavailableinEnglish,articlesforwhich

fulltextcouldnotbeobtained,andarticlesthatwerepublishedpriortoorduring

Decemberof2015.Followingthis,16abstractsandthetextoftheremaining

articleswerereviewed,and10articlesthatdidnotincorporateapp-based

interventionsfordepressionintheiranalyseswereexcluded.Theremaining6

systematicreviewarticleswerereviewedanddescribed.

RiskofbiaswasassessedaccordingtotheCochraneCollaboration’stoolfor

assessingriskofbias,5aswellasbyreviewingtheexaminedarticles’own

assessmentsofriskofbiasandtheirmethodologies.

Results

Thesixstudiesreviewedweresystematicreviewsfocusingonthetreatment

ofdepressionviamHealthapps.Theapplicationsincludedinthetablewere

includedbecausetheyserveasarepresentative,butnotexhaustive,samplingof

6

applicationspubliclyavailableandwhichpertaintothetreatmentormanagement

ofdepression.

ThesixsystematicreviewsarepresentedonTable1(seeappendix),andare

discussedbelow:

VanAmeringen,Turna,Khalesi,Pullia,&Patterson(2017)

VanAmeringenetal.(2017)conductedacomprehensivereviewofmHealth

literatureforanxiety,mood,andrelateddisorders,includingdepression.Theirwork

reviewed5studiesofappsthatwererelevanttodepression,includingatotalof5

applicationsthathelppatientstoself-managetheirdepressivesymptoms.2The

authorsfoundthatonlyoneofthereviewedstudieshadevaluatedtheeffectiveness

ofmHealthinterventionsascomparedtootherinterventions.Theappinquestion,

Project:EVO,identifiespersonalstylesandprovidesapersonalizedplannerfor

promotingactivitiestocounterdepressivesymptoms.Thestudyauthorsfoundthat

thisapphadonlybeensignificantlymoreeffectivethanthecontroltherapyin

reducingthesymptomsofmilddepression.2

Ingeneral,theauthors’reviewindicatesthatmHealthapplicationsshow

promisingresultsforrelievinganddocumentingdepressivesymptoms.Theauthors

reportedthatmonitoringappsfordepression,whichallowuserstoreport

symptomstotheirdeviceand/orusedanalgorithmandthedevice’sbuilt-insensors

topredictdepressivesymptoms,demonstratedutilityinchartinghighlevelsof

PHQ-9scoresinthepatientreportmodelandwereabletopredictdepressive

symptomswith65-86%accuracy.2However,theauthorsalsoreportthatthese

applicationmodalitiesarebestusedinconjunctionwithothertherapies,aspoor

7

adherencewasreportedintheabsenceofincentivesorreinforcement.2Theauthors

reportthatalackofusedataamongthemajorityofmHealthapplicationslimitsthe

reliabilityofuserreportsandpassiveoutcomereporting.Togetherwithpoor

adherence,thisreflectstheprimarylimitationofthisstudy’ssourcematerial.

Theauthorsofthisstudydidnotperformariskofbiasassessment.2

Firth,Torous,Nicholas,Carney,Pratap,Rosenbaum,&Sarris(2017)

Firthetal.(2017)assessed18studiesand22appsconcerningthetreatment

ofdepression.Thestudiesassessedhaddurationsof4to24weeks,includedawide

rangeofparticipants,andutilizedarangeofoutcomemeasures,includingPHQ-9

assessments.Theauthorsreportedthatappeffectivenessreportingwasmore

reliablewhenbaseduponin-appfeedback,suchassummarystatisticsandprogress

scores,thanwhenbasedonuserreporting.6Theauthorsfoundthatcognitive

training(CT)applicationsproducedsmallereffectsizeswhenusedforthetreatment

ofdepressionthanforotherconditions,suchasanxiety,andthatCognitive

BehavioralTherapy-basedandmood-managementappsdidnotgeneratelarger

effectsizesthantraditional,in-persontreatmentmethods.Overall,theyassessthat

smartphoneinterventionshaveamoderatelypositiveeffectondepressive

symptoms.6

Theauthorsidentifiedtheprimaryriskofbiasforsmartphoneinterventions

asinadequateblindingofparticipants,withonly5of18studiesusingintervention-

matchedcomparatorstopreventparticipantsfromidentifyingtreatmentorcontrol

statusorofpredictedoutcomes.6Theyalsoassessedtheirriskofpublicationbias,

andidentifiednopresentrisk.6Althoughtheauthorsidentifiedthedatabasesthey

8

searchedandthenumberofstudiesfound,excluded,andincluded,theydonot

providethetermsusedintheirsearch.

Fleming,Bavin,Lucassen,Stasiak,Hopkins,&Merry(2018)

Flemingetal.(2018)evaluatedunguidedself-helpdigitalinterventionsfor

depression,anxiety,andmoodenhancement,includingelevenstudiesandtwoapps

relatedtothetreatmentofdepression.Theirprimaryfindingsindicatethatthereis

alackofevidentiarysupportfortheefficacyofmHealthapplicationsfordepression

inreal-worldsettings,intheabsenceofclinicalguidanceorothertherapy.4The

authorscitedgenerallypooradherencetousingtheapps,reportinguserscompleted

aminimalnumberofexerciseswhencomparedtoexercisecompletionintrial

settings.Theyhighlighttheextremevarianceininitialuseasmeasuredbydownload

ratesandtheindicatorsofongoinguseasevidencesupportingtheneedforbetter

usagereportingmeasuresinapps.4

Theauthorsindicatethatthegreatestriskofbiastheyencounteredwasof

publicationbias,asinterventionstudiesthatobtainedpoorresultswerelesslikely

tobepublished.4Theauthorsdescribetheirsearchstrategiesingreatdetail,

includingdatabasesqueried,searchtermsused,andinclusion/exclusioncriteria.

Huguet,Rao,McGrath,Wozney,Wheaton,Conroy,&Rozario(2016)

Huguetetal.(2016)identifiedandassessedappsbasedonstrongevidence

forefficacyinthetreatmentofdepression.Theyreviewed53studiesand117apps,

12ofwhichutilizedCognitiveBehavioralTherapy(CBT)orBehavioralAdjustment

(BA).Theyfoundthatthedegreeofadherencetothesetherapieswasgenerallypoor

andseldomincludedcorecomponentsofthesetherapies,butthatalackof

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adherencedidnotcorrelatetousersatisfactionwiththeapp,tothenumberof

downloads,ortothenumberofreviewsmadeonthemarketplace.3Theauthorsalso

foundlittleprimaryresearchintotheeffectivenessofBA-andCBT-basedapps,and

concludedthatduetopooradherencewhatevidencethathasbeenpublished

requiresfurtherstudyandreplication.3

TheauthorsofthisstudylefttheevaluationofBAandCBTadherencetoa

singleexpert,ratherthanusinganexpertpanel.Thisraisestheriskofdetection

bias,asonlyonepersonperformedtheassessmentandmayhavemisseddetails

thatagroupofexpertsmayhavecaught.Theauthorsclearlydescribedtheirsearch

ofthescientificliteratureandofappmarketplaces,includinginclusion/exclusion

criteria,reviewpoliciesofpotentialstudiestoinclude,andexamplesearchterms.3

Stawarz,Preist,Tallon,Wiles,&Coyle(2018)

Stawarzetal.(2018)analyzedthefunctionalityanduseropinionsofCBT-

basedmobileappsforthetreatmentofdepression.Theyfoundthatofthe31apps

reviewed,themajoritydemonstratedpooradherencetoCBT,andthatCBT

adherencedidnotcorrelatetoexpertinvolvementduringappdevelopmentorto

marketplaceappratings.7Theirfindingssuggestthatalthoughappshavebeen

showntoprovidebenefitswhenusedinconjunctionwithtraditionaltherapies,

thereislittleclinicalevidencethatthecomponentsofCBTthatareincludedhave

beenbeneficialinandofthemselves,suchthatfurtherresearchisrequired.7The

studyalsoassesseduserfeedbacktotheselectedapps,identifyingcommonthemes

inuserreportingofapplications,andassessinguserfavorabilitytowardsspecific

therapeuticandpresentationcomponentsoftheapps.Thiscomponentofthestudy

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foundthatusersappreciateboththeCBT-basedcomponentsaswellasother,non-

CBTfeatures.7

TheauthorsreviewedappspurportingtobebasedinCBTdirectly,anddid

notreviewstudiesoftheseapps,justifyingthisapproachasallowingthemtobetter

studythewayusersfindanduseappsfortreatingdepressionandtobetterreviewa

broadselectionofapps.7TheysearchedforpubliclyavailableappsontheUnited

KingdomversionsoftheAppleAppStoreandGooglePlay.Theauthorsclearly

definedtheirsearchtermsandtheirinclusionandexclusioncriteria.Theprimary

riskofbiasidentifiedbytheauthorswasselectionbias,asappswithextreme

ratingsandpositivereviewscouldhaveahigherlikelihoodofinclusion.Theysought

tominimizethisriskthroughanexhaustiveselectionandreviewprocesspriorto

beginningtheiranalysis.7

Zhao,Lustria,&Hendrickse(2017)

Zhaoetal.(2017)analyzedtheinformationandcommunicativetechnology

(ICT)featuresofpsychoeducationalinterventionsfordepressiondeliveredvia

smartphoneappsandtheinternet.Ofthe55studiesreviewed,only2pertainedto

mobileapplications.Theother53studiesfocusedexclusivelyonweb-based

interventions.Theresultsofthetwoapp-basedstudies,eachevaluatingasingleapp,

indicatedthatmobileappversionsofweb-basedtherapieswereaseffectiveasthe

webversionsandresultedinequivalentreductionsinsymptoms.Bothappsutilized

aninteractivecomicstripaspartoftheeducationalcomponentandincorporated

remindertelephonecallsoremailsfromacliniciantoencouragecontinued

adherencetotheapplication.8Oneofthestudies,utilizingtheGetHappyProgram

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app,foundthatsymptomreductionremainedconsistentfollowingthree-month

followup.8Intheirreview,theauthorsindicatedthattheuseofappsthat

incorporatemultimediaandnovelactivitiesimprovedadherencetotherapyand

usersatisfaction.

Theauthorsreviewed55studies,twoofwhichevaluatedapp-based

psychoeducationalinterventionsforreducingdepressivesymptoms.Theauthors

clearlydefinethedatabasesreviewedandsearchtermsused,aswellastheir

inclusionandinclusioncriteria.Theauthorshighlightedthedifficultyinassessing

theefficacyofthevariousprogramsdescribedduetolackingdocumentationof

someprograms,butbothapp-basedstudiesreviewedbytheauthorsdescribeclear

reductioninsymptomsfortheexperimental(app-basedtherapy)groupsandreflect

effectivestudydesign.8

AssessmentofBias

AllofthereviewedstudiesotherthanVanAmeringenetal(2017)report

somedegreeoflimitation.However,onlyonereportedglaringlimitationsorbiases

thatcouldseriouslyunderminetheirfindingsatasystemiclevel.Severalstudies

reportedpotentiallimitationsduetoattrition,butthestudiesthemselvesalso

reportedmeasurestakentoreducethelikelihoodthatsuchbiasessignificantly

influencedtheirfindings.

Ofthereviewedarticles,onlyFirthetal.(2017)explicitlyaddressesthe

biasesofthereviewedstudies,reviewingthemaccordingtotheCochrane

Collection’sRiskofBiasTool.5,6Theauthorshighlightariskofpublicationbias,

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wherebythelikelihoodthatonlysignificantresultswerepublishedandsowere

usedasthebasisfortheauthors’conclusionscouldbeelevated.

SelectionbiasisapotentialriskforStawarzetal.(2018),astheir

methodologyinvolveddirectlyevaluatingpubliclyavailableappsfrom

marketplaces,assessingtheappsforadherencetoCBTandforuserfavorability

accordingtouserreviews,ratherthanevaluatingtheapps’effectivenessin

improvingdepressivesymptoms.7Theriskofselectionbiasisthereforesomewhat

elevatedduetothepossibilityofincludingappsthatreceivedpositivereviewsand

extremeratings.However,theauthors’practiceofindependentlyreviewingappsto

potentiallyincludeandthendiscussingdisagreementstheapps’suitabilityunder

theinclusioncriteriabetweenthemselvesuntilaconsensuswasreachedprovides

somecontroloverthisrisk.7

PerformancebiasisapotentialriskforFirthetal.(2017),whichidentified

inadequateblindinginamajorityoftheirreviewedstudies,althoughitisuncertain

whetherthisinfluencedtheoutcomesofthosestudiesandhowsignificantlyifso,

duetotheirrigorousstatisticalcontrols.6Detectionbiasishighlightedaspotential

issuebyHuguetetal.(2016),astheyreliedontheopinionofasingleexpert,rather

thanapanelofexperts,toassessappadherencetoCBTandBAprotocols.3

Attritionbiasrepresentsapotentialriskfortwoofthereviewedstudies.Van

Ameringenetal.(2017)reportedthatalackofusedataforapplicationsand

generallypooradherencetoappuseweretheprimarylimitationsintheirsource

material.2Theriskofincompletedataforuseintheirreviewrepresentsthe

possibilityofattritionbiasaffectingtheresults;however,theauthorsdonotreport

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pooradherenceforthedepression-relatedstudies.Zhaoetal.(2017)reportalack

ofdocumentationforthecomputer-basedinterventionprogramsassessedbythe

studiestheyreviewed,aswellasproblemswithadherence;however,thislimitation

wasreportedforthedepression-treatingprogramsingeneral,notforthetwoapp-

basedinterventions.8Giventhatadherencewasencouragedbyongoingtelephone

and/oremailcontactstoparticipantsbyclinicians,8attritionbiasappearslesslikely

tohaveaffectedthereviewsoftheapp-basedinterventionsfordepression.Assuch,

theriskofbiasisunclear.

ReportingbiasisapotentialissueforStawarzetal.(2018),astheirreviewof

userfeedbackcouldpotentiallybeaffectedbyusers’tendenciestowritereviewsfor

anapponlywhenthatappisparticularlygoodorbad;however,thealgorithmic

samplingofreviewsandexclusiveevaluationofuserreviewsthatwereinreference

tooneormorespecificCBT-basedfeatureoftheappwouldhelptocontrolfor

polarizationofuserreviews.7Duetothisproceduralcontrol,theriskofreporting

biasisunclear,ratherthanhigh.

Flemingetal.(2018)facesahighriskofpublicationbias,identifiedintheir

reviewastheirprimarypotentialsourceofbias,whichtheydefineastheresultof

interventionswithpoorresultsnotbeingreported.4Theauthorsacknowledgethata

meta-analysiscouldpotentiallyhaveaddressedthissourceofbias;however,this

analysiswasnotconductedduetotherebeingfewpublishedsourcesand

heterogeneousdata,althoughtheynotethatsuchananalysiswouldbeavaluable

additiontotheliterature,andthattheirfindingscouldbeofuseasabasisforfuture

research.4

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Zhaoetal.(2017)maybelimitedforthepurposesofthisevaluationbysmall

samplesize.8Ofthereviewedstudies,onlytwoexaminedmobileapp-based

interventionsfordepression;theremaining53interventionswereweb-based.

Giventhatbothappsweremobileversionsofweb-basedinterventionsreviewedin

thesamesystematicreviewandthatbothappsproducedsimilaroutcomestotheir

web-basedcounterparts,itisdifficulttoassesshoweffectiveapp-based

interventionsarewhencomparedtoweb-basedversions.

ASampleofAppsforDepressionIntervention

Thefollowingisareviewofappsreviewedbypreviousstudies,assessing

theirpurpose,features,trustworthiness,anddemonstratedhealthoutcomes.These

appswereidentifiedfromthereviewedarticlesasbeingworthyofdiscussionas

caseexamplesinthecontextofdepressioninterventions.Withoneexception,all

demonstratedefficacyintreatmentfordepressionorforthemonitoringof

depressivesymptoms.

Table2.NoteworthyAppsforDepressionInterventionName Platform Cost Purpose Outcomes Features TrustworthinessDepressionMonitor2(NowpartofPacificaapp)

iPhone Free Assessseverityofdepressivesymptoms

Assessedseverityofdepressivesymptoms

MobilePHQ-9test,tracksseverityofsymptomsovertime

ValidatedagainstpaperversionofPHQ-9test

GetHappyProgram2

iPhone Free Toincreasepersonalhappinessandwellbeingviaactivityandlessons

Ledtosignificantdecreaseindepressivesymptomswithnosignificantdifferencebetweenappandcomputerversions.

BasedinCBT,deliverslessonsondealingwithdepressionviainteractivecomicbook.

An8-weekclinicaltrialresultedinsignificantlyreduceddepressivesymptoms,whichremainedstableafter3months(P<.001)

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Happify4

Android&iPhone

Free(paidversionhasextrafeatures)

Assessuserhappinessandpromptactivitiestoimprovemood

Demonstratedhighrateofuptakeandcomparativelyhighrateofongoinguse.

IncludeselementsofCBT&positivepsychology,includinggamingelements

Noclinicalevidencefromprevioustrialstosupportuseintreatingdepression;significantlyhighrateofshort-termusage(withintwoweeksofregistration)

IntellicareAppSuite2,4(includesBoostMeandWorryKnotapps)

Android Free Reversedropinmoodviaactivity

SignificantlyreducedPHQ-9scoresintrialconditions.

Promptsavarietyofpositiveactivitiestailoredtotheuserwhenadropinmoodisreported

An8-weekclinicaltrialresultedinsignificantlyreducedPHQ-9scores(P<.001)

MindfulMoods2

iPhone Free Assessseverityofdepressivesymptoms

EffectivelyseverityofdepressivesymptomsusingtruncatedversionofPHQ-9test.

ProvidesrandomsampleofthreequestionsfromPHQ-9testonadailybasis

Studymonitoredsymptomsoverperiodof1month.ResultsshowedastrongcorrelationofeffectivenessbetweenappandpaperversionofPHQ-9test(r=0.84).

Mobilyze2

Notavailable

N/A Assessusermoodandpromptactivity

Viamonitoring,appeffectivelyreduceddepressivesymptomsviapromptedlessons,activities,andcoaching.

Moodmonitoringviabuilt-insensors,featuredwebsitesupportandcoaching

8-weektrial(n=7)showedsignificantdecreaseindepressivesymptoms(P<.001).

PurpleRobot2

Android Free Predictdepressivesymptomsviaactivitymonitoring

Successfullyidentifiedamajorityofdepressivestatesinparticipantofpilotstudy

Moodmonitoringviabuilt-insensors.Doesnotinterpretmoodstates

Predicteddepressivestateswith65-86%accuracy(n=28),verifiedbyPHQ-9testing

TheDepressionMonitorappadministersthePatientHealthQuestionnaire-9

(PHQ-9)test,whichprovidesscorestoassessthestrengthofdepressivesymptoms

atthetimeofthetest.Thisappispurelyforassessmentpurposes,andhasbeen

verifiedtobeaseffectiveasthepaperversionofthetest.2Anotherappthatemploys

thePHQ-9testisMindfulMoods,whichprovidestheuserwiththreerandomly-

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selectedquestionsfromthetesteachday,andwhichtrackstheuser’sPHQ-9scores

overtime,providingongoingmonitoringthatacliniciancouldusewhenproviding

treatmentorwhichausercoulduseforself-care.

TheefficacyoftheIntellicareAppSuiteintreatingdepressionwasvalidated

viaPHQ-9scores,2,4aswasthePurpleRobotapp’sabilitytomonitorandpredict

depressivesymptomsbasedonpersonalactivities,asmonitoredbythe

smartphone’sbuilt-insensors.2

Discussion

Mobileapplicationsintendedtoserveasinterventionsfordepressionhave

becomemorecommonlyavailableoverthelastseveralyears.However,thepaceof

developmenthasfarexceededthatofthescientificliteratureconcerningthe

efficacy,usability,androleoftheseapps.Anybodycandesignandpublishanappto

amarketplaceandadvertiseitashealth-related.Asaresult,theoverwhelming

majorityofappsavailableonthemajormarketplacesthatclaimtoberelevantfor

thetreatmentand/ormanagementofdepressionhavelittletonobasisinthe

clinicalliterature.2Thislackofliterarybacking,andthegenerallackofcorrelation

betweentheoverallratingofappsandadherencetoestablishedmethodsof

treatmenthavecreatedanenvironmentwhereitcanbeverydifficulttotrust

whetheranappthatpurportstotreatoraidinthetreatmentofdepressionactually

doesso.Thischallengeiscompoundedbytheextremelylimitedanalysesof

potentialbiasesinthereviewedarticles.Withoutamuchmorerigorousanalysis

anddiscussionofpotentialbiases,itisdifficulttoconfidentlyassesstheoverallstate

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ofresearchintotheeffectivenessofmobileappsinthetreatmentandmonitoring

depression.

Sofar,studiesofapp-basedinterventionsfordepressionhaveyieldedmixed

results.Somereviewshaveindicatedthatapp-basedinterventionsarebestusedto

augmentotherformsoftherapy.7,8Otherstudiesreportthatsomeappscanelicit

improvementinsymptomsindependentlyofothertreatmentmodalities.2,

Thesebestinclassappsarebasedinclinicalresearchandtheory,andhave

demonstratedtheirvaliditywhenproperlyused.TheIntellicareAppSuite,

Mobilyze!,andtheGetHappyProgramwereshowntodecreasedepressive

symptomsin1-monthtrials.2TheMobilyze!appandtheIntellicareSuiteprompt

activitieswhenadropinmoodisreported,whereastheGetHappyProgramusesan

interactivecomicstriptoteachuserslessonsonhowtomanagetheirsymptoms.

Theseapps,andthemethodstheyemploy,canbedirectlyusedtohelppatients

managedepressivesymptoms.

DepressionMonitor,theIntellicareapps,MindfulMoods,andPurpleRobot

werevalidatedagainstpaperversionsofthePHQ-9test.2,4Theseapps,andfuture

developmentsuponthem,couldbeeffectivelyusedinthemonitoringofdepressive

symptoms.

Mobilyze!,andtheGetHappyProgramengageuserswithtailoredactivities,

includinggames,toencourageuserstocontinuetoparticipateintreatment.Models

ofengagementlikethesehavebeenwelldocumentedfortheirabilitytoattractand

helpuserstoadheretotheinterventionprovidedbytheapplication.8Unfortunately,

appsthatusethesemodelsforengagementcaneasilyprovemoreattractivetousers

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thanappsthatmorecloselyadheretoclinicalguidelines.Theextremelypopular

Happifyapp,forexample,incorporatesgamingelements,positivepsychology,and

elementsofCBT,buthasnoclinicalevidencetosupportitsuseintreating

depression.4

TheHappifyappexemplifiesaprobleminappdesignfordepression

interventions:thatengagingandfunapplicationscanbemarketedashealth

applicationswhenthereisnoclinicalbiasfortheiruse.AcommonprobleminCBT-

basedappsisthatonlyafewcomponentsoftheactualtherapymightbe

incorporatedintotheappinquestion.7Asaresult,appsbasedinCBTandother

therapiescommonlyhaveextremelypooradherencetosaidtherapies,whilestill

beinglabeledaccordingtothosetherapies.3

Thetrustworthinessofpubliclyavailableapp-basedinterventionsfor

depressionisthereforegenerallysuspect.Thus,itisessentialthatresearchbe

conductedtoimprovetheadherenceoftheseapp-basedinterventionstotheir

clinicalunderpinningsandtoincorporatetheengagingmultimediaapproachthat

encouragesusers’continueduse.

Conclusion

Asresearchintotheroleandefficacyofapp-basedinterventionsforthe

treatmentofdepressioncontinues,itwillbeimportanttoestablishameansof

makingwell-designed,highlyusable,andefficaciousappsavailableandvisibleto

smartphoneownersseekingsuchanapp.Theseappswillneedtobeeasily

identifiabletoprospectiveusersashavingevidencetosupporttheirrolein

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treatment,andtoprovideprospectiveuserswithacleardescriptionofhowtoappis

tobeused.

Onepotentialsolutionwouldbetheestablishmentofacuratedcollectionof

applicationsofferedonthemarketplaces.Suchacollectioncouldrequireoneor

moreclinicianstoreviewandevaluatewhethertheapphasenoughsupportinthe

clinicalliteraturetowarrantinclusion.Thissolutioncouldallowpatientstobe

confidentthattheapptheyuseprovidesdocumentedbenefitsinthemanagement

andtreatmentofdepressivesymptoms.

Ultimately,theprimaryresearchneedsinthisfieldaretoexpandthebodyof

evidenceforwhatapp-basedinterventionsdemonstratesignificantbenefits;to

studyappsthatsustainhighlevelsofuserengagement;andtoassesstheroleof

app-baseddepressioninterventionsbothintherapysettingsandasself-help.Itwill

beextremelyimportanttodevelopareliablemeansofcommunicatingto

smartphoneuserswhichappshavehighefficacyandtoincorporatefeaturesthat

fosteruserengagementandadherencetotherapy.

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21

7. StawarzK,PreistC,TallonD,WilesN,CoyleD.UserExperienceofCognitive

BehavioralTherapyAppsforDepression:AnAnalysisofAppFunctionality

andUserReviews.JournalofmedicalInternetresearch.2018;20(6):e10120.

8. ZhaoD,LustriaML,HendrickseJ.Systematicreviewoftheinformationand

communicationtechnologyfeaturesofweb-andmobile-based

psychoeducationalinterventionsfordepression.Patienteducationand

counseling.2017Jun1;100(6):1049-72.

Chrisd’Autremont

Table1.StudiesReviewedReviewYear

Aim SearchStrategy No.StudiesIncluded

TotalNo.ofApps

SummaryofFindings

SummaryofHealthOutcomes

VanAmeringen,Turna,Khalesi,Pullia,&Patterson22017

ToprovideacomprehensivereviewofmHealthappliteratureforanxiety,mood,andrelateddisorders.

UsedPubMed,MEDLINE,PsycINFO,andGoogleScholarSearchtermsprovidedAppleiTunesandGooglePlaystoresreviewedforpopularapps.

5studiesonappstotreatMajorDepressiveDisorder

5specifictoMajorDepressiveDisorder

OnlyonestudyreviewedevaluatedeffectivenessofmHealthinterventionsfordepressivesymptoms.Thereisalackofresearchonmentalhealthapplicationeffectiveness.SeventypercentofmentalhealthprofessionalsdonotutilizemHealthapplicationsintreatment.Applicationuseislessacceptedamongpatientsasanalternativetoface-to-facetreatment.

Manyapplicationspurporttotreatmentalhealthconditions,includingdepression.TwoapplicationsdescribedimprovedrecoveryratesforMajorDepressiveDisorder,butonlyoneeffectivelyreducedsymptoms.Withoutincentivestousetheapps,studiesfoundpooradherencetomHealthinterventions.

Firth,Torous,Nicholas,Carney,Pratap,Rosenbaum,&Sarris62017

Toassesstheefficacyofdeliveringmentalhealthinterventionsviasmartphonestoreducedepressivesymptoms

UsedCochraneRegisterofControlledTrials,HealthTechnologyAssessmentDatabase,AMED,HMIC,MODLINE,Embase,PsycINFO,andGoogleScholar(throughMay1,2017)SearchtermsnotprovidedLimitedtoEnglish-languagestudies

18 22 In-personreportingonmHealtheffectivenessintreatingdepressionunreliable,whilethosethatdidnotrelyonhumanreportinggeneratedmoresignificantfindings.In-appfeedback,suchasprogressscoresand

Cognitivetrainingappsproducedsmallereffectsizesfordepressiontreatmentthanformentalhealthconditionsasawhole.Useofmood-monitoringsoftwareandCBT-basedapplicationsdidnotelicitlargereffectsizesthan

summarystatisticswerebettermeasuresofeffectiveness.

traditionaltreatmentmethods.Smartphoneinterventionshadamoderatelypositiveeffectondepressivesymptoms.

Fleming,Bavin,Lucassen,Stasiak,Hopkins,&Merry42018

Toassessusagedataofunguidedself-helpdigitalinterventionsfordepression,anxiety,andmoodenhancement.

UsedScopus,Embase,MEDLINE,andPsycINFO(throughMarch8,2017)Searchtermsprovided.LimitedtoEnglish-languagestudies.

11 2appsrelatedtodepression(1foranxiety&depression,and1foranxiety,mood,&depression)

Smartphoneinterventionsseelimitedadherenceinreal-worldsettingsasopposedtointrialsettings.Theauthorsfoundthattherewaslimitedreporteddataonuptake,ongoinguse,andeffectsizesinreal-worldsettings.

Withgenerallypooradherencereporting,mentalhealthoutcomesfromrealworldapp-basedtreatmentsaredifficulttoassesscomparedtotrial-basedreporting.

Huguet,Rao,McGrath,Wozney,Wheaton,Conroy,&Rozario32016

Toidentifycurrentlyavailableappsthatarebasedonstrongandrecommendedevidencemodelsfordepression.AssessedappsaccordingtoCBTandBAmodels.

IEEE,ACMDigitalLibrary,Embase,PubMed(Ledline),PsycINFO,andWebofScience(throughNovember2015).Searchtermsprovidedinappendix.UtilizedCanadianAppleAppStoreandAndroidMarket.

53 117(36iOSexclusive,74Androidexclusive,7availableacrossplatforms)12of117appsdeliveredCBTorBA

Usabilityratingsofappsarehighlyvariableandreflectbarrierstoadoptionandimplementation.UsabilityratingsandadherencetoCBTorBAmodelsdonotcorrelatetowhetherusersliketheapp,tothenumberofdownloads,ortothenumberofreviews.TherewaspoormedianadherencetoCBTandBAmodels.

ThereisalackofprimaryresearchstudiesassessingtheeffectivenessofBA-andCBT-basedapps.Assuch,thehealthoutcomesofmobileappsbasedonthesetherapeuticmodelsisunclearandrequiresfurtherstudy.

Stawarz,Preist,Tallon,Wiles,&Coyle7

Toanalyzethefunctionalityanduseropinionsof

UKversionofGooglePlayandAppleAppStore(throughJanuary2017)

n/a 31 Thereviewedapplicationsgenerallydemonstratedpoor

Appuserreportssuggestthatappusageimprovespatients’

2018

mobileappsthatuseCBTtoaddressdepression.

Searchtermsprovided.

adherencetoCBTmodel,oftenincludingthreeorfeweritems.CBTadherencedidnotcorrelatetoexpertinvolvementandappratings.

experiencewithtraditionaltherapywhenusedalongsideit.PooradherencetocorecomponentsofCBTrendersreportsofdirectbenefitstohealthoutcomessuspect.

Zhao,Lustria,&Hendrickse82017

ToexamineICTfeaturesofpsychoeducationalinterventionsdeliveredviatheinternetorviamobiletechnology

CINAHL,CochraneLibraryofSystematicReviews,EBSCO,EssentialEvidencePlus,Evidence-BasedMedicineReviews,HealthReferenceCenter,PsycINFO,andPubMed.(through2014).Searchtermsprovided.

55 2apps,53web-exclusivemajordepressivedisorderinterventions

Higherlevelsofcompliancecorrelatetogreaterclinicianinvolvementinuse.Mobileapplicationsandweb-basedinterventionsareeffectiveinincreasingadherencetotherapy.Multimediaandinteractivefeaturesofappsandwebsitesimprovedcorrelatedtoimprovedadherencetotherapyandusersatisfaction.

Acombinationofanappandawebsiteinconjunctionwithtraditionaltherapysignificantlyreduceddepressivesymptomswhilemaintaininghighusersatisfaction.Oneappusinganinteractivecomicstripdemonstratedconsistentsymptomimprovementafter3-monthfollowup.