Effectiveness of Using Mental Health Mobile Apps as Digital Antidepressants for Reducing Anxiety and Depression: Protocol for a Multiple Baseline Across-Individuals Design

Background The use of mental health mobile apps to treat anxiety and depression is widespread and growing. Several reviews have found that most of these apps do not have published evidence for their effectiveness, and existing research has primarily been undertaken by individuals and institutions that have an association with the app being tested. Another reason for the lack of research is that the execution of the traditional randomized controlled trial is time prohibitive in this profit-driven industry. Consequently, there have been calls for different methodologies to be considered. One such methodology is the single-case design, of which, to the best of our knowledge, no peer-reviewed published example with mental health apps for anxiety and/or depression could be located. Objective The aim of this study is to examine the effectiveness of 5 apps (Destressify, MoodMission, Smiling Mind, MindShift, and SuperBetter) in reducing symptoms of anxiety and/or depression. These apps were selected because they are publicly available, free to download, and have published evidence of efficacy. Methods A multiple baseline across-individuals design will be employed. A total of 50 participants will be recruited (10 for each app) who will provide baseline data for 20 days. The sequential introduction of an intervention phase will commence once baseline readings have indicated stability in the measures of participants’ mental health and will proceed for 10 weeks. Postintervention measurements will continue for a further 20 days. Participants will be required to provide daily subjective units of distress (SUDS) ratings via SMS text messages and will complete other measures at 5 different time points, including at 6-month follow-up. SUDS data will be examined via a time series analysis across the experimental phases. Individual analyses of outcome measures will be conducted to detect clinically significant changes in symptoms using the statistical approach proposed by Jacobson and Truax. Participants will rate their app on several domains at the end of the intervention. Results Participant recruitment commenced in January 2020. The postintervention phase will be completed by June 2020. Data analysis will commence after this. A write-up for publication is expected to be completed after the follow-up phase is finalized in January 2021. Conclusions If the apps prove to be effective as hypothesized, this will provide collateral evidence of their efficacy. It could also provide the benefits of (1) improved access to mental health services for people in rural areas, lower socioeconomic groups, and children and adolescents and (2) improved capacity to enhance face-to-face therapy through digital homework tasks that can be shared instantly with a therapist. It is also anticipated that this methodology could be used for other mental health apps to bolster the independent evidence base for this mode of treatment. International Registered Report Identifier (IRRID) PRR1-10.2196/17159

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Effectiveness of Using Mental Health Mobile Apps as Digital Antidepressants for Reducing Anxiety and Depression: Protocol for a Multiple Baseline Across-Individuals Design (Preprint)

10.2196/preprints.17159 ◽

2019 ◽

Author(s):

Jamie M Marshall ◽

Debra A Dunstan ◽

Warren Bartik

Keyword(s):

Mental Health ◽

Rural Areas ◽

Mobile Apps ◽

Text Messages ◽

Multiple Baseline ◽

Anxiety And Depression ◽

Independent Evidence ◽

Health Apps ◽

Published Evidence

BACKGROUND The use of mental health mobile apps to treat anxiety and depression is widespread and growing. Several reviews have found that most of these apps do not have published evidence for their effectiveness, and existing research has primarily been undertaken by individuals and institutions that have an association with the app being tested. Another reason for the lack of research is that the execution of the traditional randomized controlled trial is time prohibitive in this profit-driven industry. Consequently, there have been calls for different methodologies to be considered. One such methodology is the single-case design, of which, to the best of our knowledge, no peer-reviewed published example with mental health apps for anxiety and/or depression could be located. OBJECTIVE The aim of this study is to examine the effectiveness of 5 apps (<i>Destressify, MoodMission, Smiling Mind, MindShift,</i> and <i>SuperBetter</i>) in reducing symptoms of anxiety and/or depression. These apps were selected because they are publicly available, free to download, and have published evidence of efficacy. METHODS A multiple baseline across-individuals design will be employed. A total of 50 participants will be recruited (10 for each app) who will provide baseline data for 20 days. The sequential introduction of an intervention phase will commence once baseline readings have indicated stability in the measures of participants’ mental health and will proceed for 10 weeks. Postintervention measurements will continue for a further 20 days. Participants will be required to provide daily subjective units of distress (SUDS) ratings via SMS text messages and will complete other measures at 5 different time points, including at 6-month follow-up. SUDS data will be examined via a time series analysis across the experimental phases. Individual analyses of outcome measures will be conducted to detect clinically significant changes in symptoms using the statistical approach proposed by Jacobson and Truax. Participants will rate their app on several domains at the end of the intervention. RESULTS Participant recruitment commenced in January 2020. The postintervention phase will be completed by June 2020. Data analysis will commence after this. A write-up for publication is expected to be completed after the follow-up phase is finalized in January 2021. CONCLUSIONS If the apps prove to be effective as hypothesized, this will provide collateral evidence of their efficacy. It could also provide the benefits of (1) improved access to mental health services for people in rural areas, lower socioeconomic groups, and children and adolescents and (2) improved capacity to enhance face-to-face therapy through digital homework tasks that can be shared instantly with a therapist. It is also anticipated that this methodology could be used for other mental health apps to bolster the independent evidence base for this mode of treatment. CLINICALTRIAL Australian and New Zealand Clinical Trials Registry ACTRN12619001302145p, http://www.ANZCTR.org.au/ACTRN12619001302145p.aspx INTERNATIONAL REGISTERED REPORT PRR1-10.2196/17159

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The effects of mobile apps on stress, anxiety, and depression: overview of systematic reviews

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462320002093 ◽

2020 ◽

pp. 1-11

Author(s):

Fatemeh Khademian ◽

Azam Aslani ◽

Peivand Bastani

Keyword(s):

Mental Health ◽

Systematic Reviews ◽

Behavioral Activation ◽

Behavioral Therapy ◽

Mobile Apps ◽

Conclusive Evidence ◽

Anxiety And Depression ◽

Health Apps ◽

Acceptance And Commitment ◽

Overview Of Systematic Reviews

Abstract Objectives Despite a large number of mobile apps in the field of mental health, it is difficult to find a useful and reliable one, mainly due to the fact that the effectiveness of many apps has not been assessed scientifically. The present study aimed to assess the effects of mental health apps on managing the symptoms of stress, anxiety, and depression. Methods A comprehensive literature search was conducted in PubMed, Scopus, EMBASE, Cochrane, and Web of Science databases for the papers published from 2000 to 2019. Studies were included if they reviewed articles or mobile apps for their effectiveness in stress, anxiety, and depression. The reviews that had considered mobile apps or web-based mobile applications as an intervention or part of intervention were included, as well. Results A total of 4,999 peer-reviewed articles were identified, out of which nine systematic reviews met the inclusion criteria. Seven systematic reviews measured depression outcomes, three measured stress, and five systematic reviews measured anxiety symptoms. The applications that used behavior change strategies, such as Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, and Behavioral Activation, reported significant effects on depression, anxiety, and stress. Conclusion It seems that mental health apps can be promising media for reducing depressive symptoms. This field is an emerging area of mobile health, and further research should be done in future in order to reach conclusive evidence.

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Apps With Maps—Anxiety and Depression Mobile Apps With Evidence-Based Frameworks: Systematic Search of Major App Stores (Preprint)

10.2196/preprints.16525 ◽

2019 ◽

Author(s):

Jamie M Marshall ◽

Debra A Dunstan ◽

Warren Bartik

Keyword(s):

Mental Health ◽

Dialectical Behavior Therapy ◽

Behavioral Therapy ◽

Therapeutic Interventions ◽

Anxiety And Depression ◽

Future Research ◽

Evidence Based ◽

Health Apps ◽

App Store ◽

Published Evidence

BACKGROUND Mobile mental health apps have become ubiquitous tools to assist people in managing symptoms of anxiety and depression. However, due to the lack of research and expert input that has accompanied the development of most apps, concerns have been raised by clinicians, researchers, and government authorities about their efficacy. OBJECTIVE This review aimed to estimate the proportion of mental health apps offering comprehensive therapeutic treatments for anxiety and/or depression available in the app stores that have been developed using evidence-based frameworks. It also aimed to estimate the proportions of specific frameworks being used in an effort to understand which frameworks are having the most influence on app developers in this area. METHODS A systematic review of the Apple App Store and Google Play store was performed to identify apps offering comprehensive therapeutic interventions that targeted anxiety and/or depression. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was adapted to guide this approach. RESULTS Of the 293 apps shortlisted as offering a therapeutic treatment for anxiety and/or depression, 162 (55.3%) mentioned an evidence-based framework in their app store descriptions. Of the 293 apps, 88 (30.0%) claimed to use cognitive behavioral therapy techniques, 46 (15.7%) claimed to use mindfulness, 27 (9.2%) claimed to use positive psychology, 10 (3.4%) claimed to use dialectical behavior therapy, 5 (1.7%) claimed to use acceptance and commitment therapy, and 20 (6.8%) claimed to use other techniques. Of the 162 apps that claimed to use a theoretical framework, only 10 (6.2%) had published evidence for their efficacy. CONCLUSIONS The current proportion of apps developed using evidence-based frameworks is unacceptably low, and those without tested frameworks may be ineffective, or worse, pose a risk of harm to users. Future research should establish what other factors work in conjunction with evidence-based frameworks to produce efficacious mental health apps.

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Apps With Maps—Anxiety and Depression Mobile Apps With Evidence-Based Frameworks: Systematic Search of Major App Stores

JMIR Mental Health ◽

10.2196/16525 ◽

2020 ◽

Vol 7 (6) ◽

pp. e16525 ◽

Cited By ~ 2

Author(s):

Jamie M Marshall ◽

Debra A Dunstan ◽

Warren Bartik

Keyword(s):

Mental Health ◽

Dialectical Behavior Therapy ◽

Behavioral Therapy ◽

Therapeutic Interventions ◽

Anxiety And Depression ◽

Future Research ◽

Evidence Based ◽

Health Apps ◽

App Store ◽

Published Evidence

Background Mobile mental health apps have become ubiquitous tools to assist people in managing symptoms of anxiety and depression. However, due to the lack of research and expert input that has accompanied the development of most apps, concerns have been raised by clinicians, researchers, and government authorities about their efficacy. Objective This review aimed to estimate the proportion of mental health apps offering comprehensive therapeutic treatments for anxiety and/or depression available in the app stores that have been developed using evidence-based frameworks. It also aimed to estimate the proportions of specific frameworks being used in an effort to understand which frameworks are having the most influence on app developers in this area. Methods A systematic review of the Apple App Store and Google Play store was performed to identify apps offering comprehensive therapeutic interventions that targeted anxiety and/or depression. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was adapted to guide this approach. Results Of the 293 apps shortlisted as offering a therapeutic treatment for anxiety and/or depression, 162 (55.3%) mentioned an evidence-based framework in their app store descriptions. Of the 293 apps, 88 (30.0%) claimed to use cognitive behavioral therapy techniques, 46 (15.7%) claimed to use mindfulness, 27 (9.2%) claimed to use positive psychology, 10 (3.4%) claimed to use dialectical behavior therapy, 5 (1.7%) claimed to use acceptance and commitment therapy, and 20 (6.8%) claimed to use other techniques. Of the 162 apps that claimed to use a theoretical framework, only 10 (6.2%) had published evidence for their efficacy. Conclusions The current proportion of apps developed using evidence-based frameworks is unacceptably low, and those without tested frameworks may be ineffective, or worse, pose a risk of harm to users. Future research should establish what other factors work in conjunction with evidence-based frameworks to produce efficacious mental health apps.

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Interdisciplinary Development of a Transdiagnostic Mobile App to Enhance Children’s Emotion Regulation: Sharing Insights and Lessons Learned (Preprint)

10.2196/preprints.28300 ◽

2021 ◽

Author(s):

Bettina Moltrecht ◽

Praveetha Patalay ◽

Holly Alice Bear ◽

Jessica Deighton ◽

Julian Edbrooke-Childs

Keyword(s):

Mental Health ◽

Emotion Regulation ◽

Young People ◽

Design Process ◽

Public Engagement ◽

Mobile Apps ◽

High Tech ◽

Classroom Observations ◽

Health Apps ◽

Interdisciplinary Framework

BACKGROUND Digital interventions, including mobile apps represent promising means to provide effective mental health support to young people. Despite the increased availability of mental health apps, there is a significant gap for this age group, especially for younger children. Research investigating the effectiveness and development process of child mental health apps is limited, and the field faces persistent issues in relation to low user up-take and engagement, which is assumed to be a result of lacking interdisciplinary approaches. OBJECTIVE We present the development and design process of a new mental health app for children that targets their emotion regulation abilities. We describe the creation of a new interdisciplinary development framework, to guide the design process, and explain how each activity informed different app features. METHODS The first two stages of the framework employed a variety of methods, including: 1) classroom observations, 2) public-engagement events with the target group (N=21), 3) synthesis of the existing evidence as part of a meta-analysis, 4) a series of co-design and participatory workshops with young users (N=33), clinicians (N=7), researchers (N=12), app developers (N=1) , designers (N=2), and lastly 5) testing of the first high-tech prototype (N=15). RESULTS For the interdisciplinary framework we drew on methods derived from the medical research council framework for complex interventions, the patient-clinician-framework and Druin’s cooperative inquiry. The classroom observations, public-engagement events, and synthesis of the existing evidence informed the first key pillars of the app and wireframes. Subsequently, a series of workshops shaped and reshaped the content and app features, including games, psychoeducational films, and practice modules. Based on the prototype testing sessions we made further adjustments to improve the app. CONCLUSIONS Although mobile apps could be highly suitable to support young people’s mental health on a wider scale, there is little guidance on how these interventions could be designed. The involvement of the different methods and especially the young users was very valuable. We hope that the interdisciplinary framework and multiple methods that we applied will be helpful to others who are also aiming to develop suitable apps for young people.

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An Online Intervention to Support Student-Athlete Mental Health: Implementation, Evaluation, and Critical Reflection

Case Studies in Sport and Exercise Psychology ◽

10.1123/cssep.2019-0048 ◽

2020 ◽

Vol 4 (S1) ◽

pp. S1-54-S1-61

Author(s):

Ben Laslett ◽

Mark Uphill

Keyword(s):

Mental Health ◽

Student Athletes ◽

Well Being ◽

Multiple Baseline ◽

Probe Design ◽

Single Subject ◽

Single Subject Design ◽

Subject Design ◽

Mental Well Being

This study examined the influence of two interventions (therapeutic letter to self; values targeting) on student-athletes’ mental health using two variants of a single-subject design: a multiple-baseline single-subject design and a probe design. Four high-ability student-athletes (two males and two females) who competed in various sports (e.g., soccer and cycling) completed two preintervention measures (Mental Health Continuum Short Form; Clinical Outcomes Routine Evaluation 10) at baseline. These measures were then readministered after Intervention 1, Intervention 2, and at a 2-week follow-up using a probe design. Mental well-being (Short Warwick-Edinburgh Mental Well-Being Scale) was assessed every 2 days from start to finish using a multiple-baseline across-participants design. Data were analyzed via visual inspection methods, specifically, immediacy of effect, mean change, effect sizes, and percentage of overlapping data. Results indicated that two participants who completed the study (Nina and Tim) showed an increase in total mental health and a decrease in psychological distress from baseline to follow-up. Findings are discussed with respect to prior research and study limitations.

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Psychology and Surveillance Capitalism: The Risk of Pushing Mental Health Apps During the COVID-19 Pandemic

Journal of Humanistic Psychology ◽

10.1177/0022167820937498 ◽

2020 ◽

Vol 60 (5) ◽

pp. 611-625

Author(s):

Lisa Cosgrove ◽

Justin M. Karter ◽

Zenobia Morrill ◽

Mallaigh McGinley

Keyword(s):

Mental Health ◽

Mobile Apps ◽

Negative Mood ◽

Unintended Consequences ◽

Humanistic Psychology ◽

The Public ◽

Health Apps ◽

Digital Phenotyping ◽

The Rich

During the COVID-19 pandemic, telehealth technologies and mental health apps have been promoted to manage distress in the public and to augment existing mental health services. From a humanistic perspective, the promotion and use of mobile apps raises ethical concerns regarding the autonomy of the person using the app. However, there are other dangers that arise when technological fixes are embraced at a time of crisis. Naomi Klein and Shoshanna Zuboff have recently warned about disaster and surveillance capitalism—using crises to pass legislation that will benefit the rich and deepen inequality, and using anonymized behavioral data for commercial purposes. This analysis reveals that mental health apps may take individuals at their most vulnerable and make them part of a hidden supply chain for the marketplace. We provide a case study of a mental health app that uses digital phenotyping to predict negative mood states. We describe the logic of digital phenotyping and assess the efficacy data on which claims of its validity are based. Drawing from the frameworks of disaster and surveillance capitalism, we also use a humanistic psychology lens to identify the ethical entanglements and the unintended consequences of promoting and using this technology during the COVID-19 pandemic.

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Mobile Mental Health Apps in China: Systematic App Store Search (Preprint)

10.2196/preprints.14915 ◽

2019 ◽

Author(s):

Huifang Yin ◽

Klaas J Wardenaar ◽

Yuhao Wang ◽

Nan Wang ◽

Wenjin Chen ◽

...

Keyword(s):

Mental Health ◽

Health Care ◽

Mental Health Problems ◽

Mobile Apps ◽

Psychiatric Patients ◽

Evidence Based ◽

Health Apps ◽

Main Technique ◽

Stress Relieving ◽

Mobile Mental Health

BACKGROUND Smartphones have become ubiquitous in China, offering a promising way to deliver mental health interventions; however, little is known about the current use and characteristics of smartphone apps for mental health. OBJECTIVE The purpose of this study was to gain insight into mobile mental health apps available in China as of December 2018. METHODS A systematic search was conducted to identify and evaluate the most downloaded apps from iOS and Android platforms. Apps were categorized according to their main purpose and downloaded to evaluate their content. Each app’s affiliation, cost, target users, information security, and evidence-based nature were evaluated. RESULTS Of the 172 unique apps that were identified, there were 37 apps (21.5%) for psychological counseling, 50 apps (29.1%) for assessment, 12 apps (7.0%) to relieve stress, 24 apps (14.0%) for psychoeducation, and 49 (28.4%) multipurpose apps (ie, a combination of counseling and assessment). Most apps were developed for adults in the general population (166/172, 96.5%), rather than for psychiatric patients. App-based counseling was mostly provided by psychologists, and of the assessed apps, only 40% (70/172) used evidence-based scales to assess mental health problems such as anxiety or depressed mood. Guided meditation was used as the main technique in stress-relieving apps. CONCLUSIONS Many apps contained useful and evidence-based elements, such as good quality information, validated measurements, and useful meditation methods; however, for mobile apps to contribute significantly to mental health care in China, considerable challenges remain, including the need for more patient-focused apps that can actually take on the role of a health care provider. In addition, efficacy studies are needed.

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Mental Health Apps in Psychiatric Treatment: A Patient Perspective on Real World Technology Usage (Preprint)

10.2196/preprints.12292 ◽

2018 ◽

Author(s):

Emil Chiauzzi ◽

Amy Newell

Keyword(s):

Mental Health ◽

Lived Experience ◽

Patient Perspective ◽

Psychiatric Treatment ◽

Mobile Apps ◽

Psychiatric Patients ◽

Primary Objective ◽

Health Apps ◽

The Difference ◽

Mobile Mental Health

UNSTRUCTURED For many people who use mobile apps, the primary motivations are entertainment, news, gaming, social connections, or productivity. For those experiencing health problems, particularly those with chronic conditions such as psychiatric disorders, the stakes are much higher. The digital tools that they select may be the difference between improvement and decompensation or even life and death. Although there has been a wide expansion of mental health apps with promise as well as hype, the current means of researching, evaluating, and deploying effective tools have been problematic. As a means of gaining a perspective that moves beyond usability testing, surveys, and app ratings, the primary objective of this patient perspective is to question the killer app and condition-specific mentality of current mental health app development. We do this by reviewing the current mobile mental health app literature, identifying ways in which psychiatric patients use apps in their lives, and then exploring how these issues are experienced by a software engineer who has struggled with her bipolar disorder for many years. Her lived experience combined with a technology perspective offers potential avenues for using technology productively in psychiatric treatment. We believe that this responds to JMIR Publications’ call for patient perspective papers and provides encouragement for patients to share their views on mental health and technology.

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StayWell at Home: A Text Messaging Intervention to Counteract Depression and Anxiety during COVID-19 Social Distancing (Preprint)

10.2196/preprints.25298 ◽

2021 ◽

Author(s):

Adrian Aguilera ◽

Rosa Hernandez-Ramos ◽

Alein Yaritza Haro ◽

Claire Elizabeth Boone ◽

Tiffany Luo ◽

...

Keyword(s):

Mental Health ◽

Text Messaging ◽

The United States ◽

Text Messages ◽

Anxiety Symptoms ◽

Anxiety And Depression ◽

Depression And Anxiety ◽

Negative Consequences ◽

Social Distancing ◽

At Home

BACKGROUND Social distancing and stay-at-home orders are critical interventions to slow down person-to-person transmission of COVID-19. While these societal changes help to contain the pandemic, they also have unintended negative consequences, including anxiety and depression. We developed StayWell, a daily skills-based SMS text messaging program, to mitigate COVID-19 related depression and anxiety symptoms among people who speak English and Spanish in the United States. OBJECTIVE This paper describes the changes in the anxiety and depression levels of participants in the StayWell program after 60 days of exposure to skills-based SMS text messages. METHODS We used self-administered, empirically supported web-based questionnaires to assess the demographic and clinical characteristics of StayWell participants. Anxiety and depression were measured using the 2-item Generalized Anxiety Disorder (GAD-2) scale and the 8-item Patient Health Quesstionanire-8 (PHQ-8) scale at baseline and 60-day timepoints. We used paired t-tests to detect the change in PHQ-8 and GAD-2 scores from baseline to follow-up measured 60 days later. RESULTS The analytic sample includes 193 participants who completed both the baseline and 60-day exit questionnaires. At the 60-day time point, there were statistically significant reductions in both PHQ-8 and GAD-2 scores from baseline. We found an average reduction of -1.72 (95% CI: -2.35, -1.09) in PHQ-8 scores and -0.48 (95% CI: -0.71, -0.25) in GAD-2 scores. This translated to an 18.5% and 17.2% reduction in mean PHQ-8 scores and GAD-2, respectively. CONCLUSIONS StayWell is a low-intensity, cost-effective, and accessible population-level mental health intervention. Participation in StayWell focused on COVID-19 mental health coping skills and was related to improved depression and anxiety symptoms. In addition to improvements in outcomes, we found high levels of engagement during the 60-day intervention period. Text messaging interventions could serve as an important public health tool for disseminating strategies to manage mental health. CLINICALTRIAL ClinicalTrials.gov Identifier: NCT04473599 INTERNATIONAL REGISTERED REPORT RR2-10.2196/23592

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