mHealth for Mental Health

Last revised November 3, 2013, 4:50 AM EDT

An App for That? What Counselors Need to Know about the Latest Research
on mHealth for Mental Health

Anne H. Giles, M.A., M.S.

Virginia Counselors Association Annual Convention
The Homestead, Hot Springs, Virginia, November 8, 2013

Overview:

• Why we think mobile health (mHealth) should work for mental illness
• Why we hope (and need) mobile mental health technology to work
• Why counselors have reservations about mobile mental health apps
• Why determining the evidence-base for mobile mental health services is challenging
• What we’ve learned so far about mobile health for mental health
• Ways counselors might embrace the use of mobile technologies to support and enhance their life’s work

Why we think mobile mHealth should work for mental illness:

• Support. Isolation is anathema to mental health. Mobile phones, increasingly ubiquitous, can be experienced as “company,” whether as a personal support device or through a social network.
• Treatment vs. no treatment. Those who experience therapeutic treatment interventions do better than those without, in general. Any (good) mental health app on a mobile phone is better than none.
• Awareness of the interplay between feelings, thoughts and behaviors is a cornerstone of therapy for many mental illnesses. An individual’s use of a mobile mental health app is an act of consciousness in and of itself.

Why we hope (and need) mobile mental health technology to work:

• Reach and access. While meeting all needs all of the time is the ideal, populations needing mental health services are vastly underserved due to an undersupply of mental health professionals; lack of funding for personnel, programs, facilities; physical limitations of clients, transportation and daycare; rural and hard-to-reach geography and other factors.
• Affordable care mandates. While one-on-one counseling sessions are the ideal, they are dollar- and resource-intensive. Limited resources result in service to the few. Mental health apps offer the possibility and affordability of serving the many with at least some care rather than with no care. Patient self-management and self-monitoring are increasingly required to receive reimbursement from health insurance providers.

Why counselors have reservations about mobile mental health apps:

• One-on-one is best for clients and counselors. “It’s the relationship that heals,” Irvin Yalom tells us. Therapeutically, from education, training, experience, theory and counseling philosophy, counselors know that individual sessions with counselors and clients are the optimum way to serve them. Financially, counselors also know clients who use apps instead of a counselor can’t be billed for services.
• Evidence-based treatments. Counselors are professionally, ethically and morally required to offer treatments that work. Are mobile mental health apps evidence-based? If so, which ones for what?
• Clients without mobile devices. As of September 2013, according to the U.S. Census Bureau as reported by CNSNews.com, 80.9% of households below the poverty level had cell phones. Please see more stats about mobile device access for those using mental health services.
• One more intrusion of, and violation by, technology. Mandated Electronic Health Records (EHRs) are only the most recent technology forced upon counselors without their consultation or consent, and without adequate time or funding for notice, training, practice, or tech support. At present, mobile health is optional and in the over-worked and under-staffed counseling field, opting out is the preferred option.

Why determining the evidence-base for mobile mental health services is challenging:

• Research expense, time, and time lag. The health research process – proposal writing, grant application writing, grant receipt, Institutional Review Board application writing and approval, doing the research itself, writing a report on the results (assuming results are conclusion-worthy), seeking and finding a publisher, seeing the research online or in print – is snail-like compared to the warp speed of development in the mobile industry. While research is being conducted on one variable for one app, better and better mousetraps are being developed and released. As of early 2013, users could access 97,000 mobile health apps in 62 app stores, 700 of them for mental health. In contrast to tens of thousands of available health apps, an estimated 100 have been reviewed by the Food and Drug Administration (FDA).
• App or treatment? On September 23, 2013, the FDA issued long-awaited guidelines on whether, or which, mobile health apps needed FDA approval, determining it would be “reviewing only the mobile apps that have the potential to harm consumers if they do not function properly.” Further clarifications  were issued October 22, 2013. Questions remain. For example, how does one determine if a Cognitive Behavior Therapy (CBT) app has “the potential to harm consumers”?

What we’ve learned so far about mobile health for mental health:

• Mental illness in general: “Although limited, the evidence to date points to mHealth programs being acceptable and assisting individuals to effectively monitor and manage their mental health, leading to improved outcomes.” Judith Proudfoot, The future is in our hands: The role of mobile phones in the prevention and management of mental disorders, 2013
• Depression: “A random-effects analysis [of web-based interventions for treating depressed adults] yielded a medium effect of web-based interventions compared to controls, with a significant reduction in depression and improvement in well-being.” Louise Cowpertwait and Dave Clarke, Effectiveness of web-based psychological interventions for depression: A meta-analysis, 2013 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0058751/
• Anxiety: “Because CP [computer-aided psychotherapy for anxiety] as a whole was as effective as face‐to‐face psychotherapy, certain forms of CP deserve to be integrated into routine practice.” Pim Cuijers et al., Computer‐Aided Psychotherapy for Anxiety Disorders: A Meta‐Analytic Review, 2009
• Schizophrenia: “Through a comprehensive development process, we produced an mHealth illness self-management intervention that is likely to be used successfully, and is ready for deployment and systemic evaluation in real-world conditions.” Dror Ben-Zeev et al., Development and Usability Testing of FOCUS: A Smartphone System for Self-Management of Schizophrenia, September 9, 2013.
• Addictions: “Computer-based interventions for drug use disorders show initial evidence of efficacy during treatment and some evidence effects continue after treatment.” Note: This review found “most studies to date have reported delivering the intervention via a computer on-site rather than via the Internet, telephone, or mobile access.” Brent A. Moore, et al. Computer-based interventions for drug use disorders: A systematic review, 2011
• Cognitive Behavior Therapy (CBT): “Computerized CBT for anxiety and depressive disorders, especially via the internet, has the capacity to provide effective acceptable and practical health care for those who might otherwise remain untreated.” Gerhard Andersson and Pim Cuijpers, Computer Therapy for the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health Care: A Meta-Analysis, 2010
• Safety concerns. “Issues were resolved with prescribed safety procedures.” Safety of telemental healthcare delivered to clinically unsupervised settings: a systematic review, David Luxton et al., 2010
• Privacy concerns. “Semistructured interviews were conducted with 27 key informants from across the health and mHealth sectors in the United States. Interviewees were approached directly following an environmental scan of mHealth in the United States or recommendation by those working in mHealth. Results: The most common issues were privacy and data security, funding, a lack of good examples of the efficacy and cost effectiveness of mHealth in practice, and the need for more high-quality research.” Robyn Whittaker, Issues in mHealth: Findings from key informant interviews, 2012
• What the app does matters. “Assistive and monitoring apps are shown to be frequently used, whereas informative and educational apps are only occasionally used.” From a study of mobile apps for the eight most prevalent health conditions identified by the World Health Organization, one of which is “unipolar depressive disorders” (vs. bipolar with depressive and manic phases). Borja Martínez-Pérez et al., Mobile Health Applications for the Most Prevalent Conditions by the World Health Organization: Review and Analysis, 2013.
• It’s about the client. “Potential benefits to the quality of care received were seen in terms of assisting clinicians, faster and more efficient data exchange, and aiding patient-clinician communication. However, patients often failed to see the relevance of the systems to their personal situations, and emphasised the threat to the person centred element of their care.” Jasper E. Palmier-Claus et al., Integrating mobile-phone based assessment for psychosis into people’s everyday lives and clinical care: A qualitative study, 2013
• Studies of individual apps are promising. “Preliminary analyses found that participants’ symptoms of stress, anxiety, depression and overall psychological distress were significantly reduced after using myCompass. Improvements were also found in functional impairment and self-efficacy.” Virginia Harrison, Judith Proudfoot, et al., Mobile mental health: review of the emerging field and proof of concept study, 2011.
• Practitioners will need to be mobile-savvy. “Future widespread use of smartphone technology in the behavioral health field can be expected. Our increasingly mobile, tech-savvy, and health conscious society will demand care delivery solutions that expand beyond traditional office-based requirements to better fit diverse needs and lifestyles. Smartphone technology has the potential to make behavioral health care more accessible, efficient, and interactive for patients and can improve the delivery of evidence-based treatments.” David Luxton et al., mHealth for Mental Health: Integrating Smartphone Technology in Behavioral Healthcare,.2011. “Whether psychologists embrace or resist aspects of technology, they should recognize how advanced technologies are changing the way we communicate and process information, anticipate needed growth, and prepare to meet ensuing challenges to professional psychology… Key technologies that presage future trends include video teleconferencing, ‘smart’ mobile devices, cloud computing, virtual worlds, virtual reality, and electronic games.” Marlene M. Maheu et al., Future of telepsychology, telehealth, and various technologies in psychological research and practice, 2012
• Clients will want mobile mental health services in the future. From a survey of 1,592 individuals with serious mental illness, 72% owning a mobile device, both “mobile device users and nonusers expressed interest in future mobile services.” Dror Ben-Zeev, et al., Mobile Technologies Among People with Serious Mental Illness: Opportunities for Future Services, 2013

Ways counselors might embrace the use of mobile technologies to support and enhance their life’s work:

• Let clients lead the way. In accord with a person-centered approach, add questions to intake interviews about mobile phone and smart phone access and use. Do clients text and phone only, or use email and search? Ask what apps clients use and find useful. This will conduct “market research” and help you determine the “market need” for apps within the population you serve.
• Pay a kid. Pay a young person for 3 hours of work at a mutually agreeable rate to Google around a bit for well-reviewed mental health apps. Ask them to download and demo 3 to 5 of them for you, plus those most recommended by clients. You’ll avoid the research and learning curve time and get oriented to what’s on the market by an expert user. (Quixey, a search engine for apps, may prove of value.)
• Check Google Scholar. Every 3 months or so, try this search phrase – “mhealth for _________” – and fill in the blank with the condition or subject of interest to you. Click “Since 2013” in the left-hand navigation. Because the field is so new, these very latest results may include general articles like this one about the promise of mHealth for mental health. Keep scrolling. The app that can help you help your clients might not only have been invented, but be tested and evidence-based and ready for your clients to try.

Session introduction, synopsis and abstract: https://www.annegiles.com/2013/10/13/what-counselors-need-to-know-about-the-latest-research-on-mhealth-for-mental-health/

This handout online: https://www.annegiles.com/mhealth-for-mental-health/

Anne Giles, M.A., M.S., has a master’s degree in mental health counseling. Read more about Anne and please feel free to contact her.

Conflict of interest disclosure: Anne Giles (formerly Anne Giles Clelland) is a co-founder of behavioral and mental health mobile app Cognichoice(R) www.cognichoice.com.