New Tool Helps Docs Assess Burgeoning Number of Mental Health Apps

Deborah Brauser

June 04, 2019

SAN FRANCISCO — The emergence of hundreds of thousands of mobile health apps can leave both patients and physicians overwhelmed, confused, and frustrated about which ones are best.

In a bid to help clinicians navigate what's best for individual patients, the American Psychiatric Association (APA) is planning to relaunch a new and improved app evaluation model.

Initially released last year, the tool employs a five-tiered system to assess individual apps that includes questions about privacy and security, clinical evidence of benefit, and ease of use.

The revised version updates the list of questions and lays out the entire process in an easy-to-understand pyramid design.

An article describing the tool's relaunch was published June 1 in Lancet Digital Health.

Dr John Torous

Coauthor John Torous, MD, led a work group on the evaluation of smartphone apps for the APA, which in turn led to the development of the evaluation tool. In addition to having a background in computer science and engineering, he was recently named chair of the APA's Health and Technology Committee.

"Instead of saying, 'Here's your fish,' we're teaching people how to fish for themselves. The goal of this is how you can take your clinical judgment, your informed decision making, all the skills that make you a great clinician, and then tweak them for the digital age," Torous told Medscape Medical News.

1.7 Billion Users

The US Food and Drug Administration (FDA) estimated that 1.7 billion individuals downloaded some type of mobile health app in 2018. There are currently more than 325,000 such apps to choose from.

In 2017, the FDA approved the first mobile app for treating substance use disorders (SUDs) involving alcohol, marijuana, cocaine, and stimulants. Since then, it has approved a variety of other medical apps and app-coordinated devices. Earlier this week it approved a smartphone-controlled wearable for migraine pain.

Torous, who is also director of the Division of Digital Psychiatry at Beth Israel Deaconess Medical Center, Boston, Massachusetts, noted that it's an especially confusing time because apps are constantly changing and being updated.

In response to those issues, the APA work group developed its evaluation tool in 2018.

Torous noted that the group didn't want to create "another Yelp," a program that lets consumers review restaurants. Because apps can quickly go through revisions or even go away, the work group didn't want a system focused on putting out reviews of specific apps.

"Even if you had a perfect score for an app, it's worthless, because by the time you publish the score, the app has changed, and you'd have to go back in and say what's different," he said.

"Just as no single best antidepressant or therapy exists, no single best app exists to treat all patients or mental illnesses," the authors write.

Tool Relaunched

A group of "international authors representing diverse stakeholders," including clinicians, researchers, patients, technology companies, and program officers from the National Institute of Mental Health, came together later in 2018 to create a consensus statement on mental health app standards similar to the APA's App Evaluation Framework, the authors report.

The new framework includes a list of 357 questions mapped onto five priority levels in a pyramid design.

The widest, bottom level of the pyramid (level 1) is about measuring an app's context and background information, such as its credibility, stability, and medical claims.

Moving up the pyramid, the other levels are as follows:

  • Privacy and security: assessing how data are collected, as well as privacy policies and security measures for potential harm

  • Clinical evidence: assessing clinical validity and impressions after use

  • Ease of use: assessing short- and long-term usability and adherence

  • Data integration: assessing meaningful data use and the potential to share data with the clinical team

"The pyramid shape is to remind users that they should begin at the bottom and do not need to proceed if any single level does not meet their needs," the authors write.

The accompanying questions "are intended to encourage and facilitate dialogue between patients and clinicians," they add. For example, one patient might want to stop using an app once he or she hears that geolocation data are being gathered, but another may be okay with that, especially if that person thinks the app is strongly beneficial.

"The APA App Evaluation Framework really just helps people apply their decision-making skills in the digital age. For some patients, an app could be a very useful and effective tool. But certainly for the wrong patient, it could be the opposite," said Torous.

"I wouldn't say we're at the point where we should be 'prescribing' an app. It's more like walking and exercise. It's at the stage where maybe we could recommend them, especially for augmenting treatment," he said.

He noted that the tool is not saying, "Use this app." Instead, it's asking how the app can boost or extend or augment what a clinician is already doing.

Even "Free Apps" May Have a Cost

A poster presented at the American Psychiatric Association (APA) 2019 annual meeting made the case that use of mental health mobile apps by patients can be beneficial — but cautioned that because there are also potential drawbacks, each should be evaluated carefully.

In addition to reviewing two recent studies that assessed apps for helping patients with nonopioid SUD or depression, the poster also included a recommendation for use of the APA App Evaluation Framework.

"The most important thing is to ask patients if they're using apps," lead author Hephsibah Loeb, MD, Department of Psychiatry, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, told Medscape Medical News.

"Then, the evaluation model [authors] recommend that clinicians familiarize themselves with the app using their questions in order to help a patient," Loeb said.

She noted that in a recent randomized controlled trial involving patients with SUD, for those who used the Therapeutic Education System (TES) mobile software and who received guidance from a clinician or coach, treatment dropout rates were lower and abstinence rates were greater than those of nonusers after 12 weeks.

In a second study, patients who used a coach or clinician plus PRIME-D, a mobile-based treatment for depression, showed improved self-reported symptoms of both depression and disability.

Loeb noted that increased access to care, lower cost, and the potential to reduce stigma are all benefits of self-help apps. On the other hand, privacy concerns, possible misinformation, and their inadequacy in emergency situations are issues that should also be considered.

Other research was presented during oral sessions and at almost every poster session at the APA meeting discussing specific apps. Loeb said this proliferation is why the APA evaluation tool is important for clinicians.

"There are so many other apps out there that are interesting and educational, and people want help with certain things. So it's important for clinicians to educate themselves about what patients are using," she said.

"The recommendation is to not just look at the number of stars in the Apple store and assume that because it has more stars than another app, it's a good one for patients to use. Instead, make sure that it's safe, accurate, and careful with privacy," she said.

"Even with a so-called free app, the actual cost could be your data," she said.

The current app evaluation model is available on the APA's website, including an example of how to use the process. The updated version of the model with the new pyramid design will be available soon, Torous reported.

Lancet Digital Health. 2019;1:52-54. Full article

American Psychiatric Association (APA) 2019: Poster abstract P2-131. Presented May 18, 2019.

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