We Can’t Rely On Mental Health Apps…Yet
There’s a real need for easy-to-access treatment options, but for now, experts are skeptical
Last summer, Chanel Omari, 34, couldn’t fit therapy in her schedule. She was frequently out of town for work, while also working on a podcast, and it was seemingly impossible to make time for regular check-ins. But she was diagnosed with mild depression and anxiety and needed help managing her mental health, so she downloaded two apps: one called Calm, which would teach her meditation, and another called 7 Cups, which would connect her with mental health professionals or trained “listeners” (volunteers who are not necessarily certified therapists) who could offer support over text messages.
“At first I felt better,” she says. “It was the beginning of a new journey and it seemed like a new approach. Most importantly it was convenient and cost-effective. Therapy was costing me an arm and a leg.”
But soon the app approach would leave her confused. Omari downloaded an app to track her daily emotions, and it suggested she had a mood disorder after she used it for a week. “I was like, okay, if that’s what it is, I am going to embrace it and work on it,” she says. But when she shared her new “diagnosis” with a psychiatrist and therapist, they both found it to be untrue after independently evaluating her.
“I think what’s most concerning is that at first glance these apps appear okay, and then you read what they’re telling you to do, or the recommendations they are giving, and you realize that they’re incorrect.”
Pick a mental health condition and there’s most likely a corresponding app, including guides for managing depression, anxiety, PTSD, and schizophrenia. Some claim to give users mental health assessments, while others help in smaller ways, like offering tips for combatting negative thoughts. An app for anxiety might teach deep breathing, while one for bipolar disorder may ask the user to track moods throughout the day.
These digital tools are marketed as a viable alternative to seeing someone in person, and a convenient solution for people who can’t access care. A 2018 report from The Substance Abuse and Mental Health Services Administration found that around 57% of people 18 years or older in the United States who have a mental illness say they don’t receive any treatment, and 90% of people with a mental health condition and a substance use disorder said the same. It’s no surprise, then, that accessible interventions are needed. Mental health apps may offer an opportunity to fill the void, but medical experts say that, at least right now, too many of them are making empty promises.
“I think what’s most concerning is that at first glance these apps appear okay, and then you read what they’re telling you to do, or the recommendations they are giving, and you realize that they’re incorrect,” says Dr. John Torous, a leading mobile mental health researcher and the director of the digital psychiatry division in the department of psychiatry at Beth Israel Deaconess Medical Center in Boston.
Earlier this year, Torous and colleagues published a study in the journal Nature that found that out of 73 mental health apps surveyed, 33% referred to scientific techniques for which no evidence could be found, and only one app included a citation to published literature; other researchers in a 2015 study analyzed more than 200 depression apps and came to the conclusion that many lack sufficient science to back up their effectiveness. “Such false information impedes consumers and clinicians from making informed decisions about apps,” says Torous. “But apps have overpromotionalized some of their claims in part because they know no one is checking on them.”
Apps are not required to undergo clinical trials to show that they work. If developers do study them, Torous says the research is often low-quality. “Companies will say ‘my app makes you feel 30% better.’ I always ask, compared to what? A group that had therapy? A group that was locked in a basement? App studies [we’ve reviewed] don’t really have a good control group, among other things like not being randomized, and that makes it hard to know how effective they really are,” he says.
Most mobile mental health apps also fall outside the purview of the U.S. Food and Drug Administration (FDA) — the agency that oversees the safety and efficacy of drugs and medical devices — since it only currently regulates apps that connect to and control medical devices or that transform mobile platforms into a regulated device, like a glucose strip monitor that plugs into a phone to become a glucose meter.
“A lot of these apps are very careful about what they promise in terms of disclaimers or advertisements to avoid regulation by the FDA,” says Stephen Schueller, PhD, an assistant professor of psychological science at the University of California-Irvine. “But then when you get into the app, there’s a lot of content that makes more promises or suggestions than what it has promised at a broad level. For example, you might have an app that says, ‘this is not a treatment for depression.’ And then when you open the app, it starts to say, ‘now, this is how we’re going to help you work on your depression.’”
Mental health apps may also market themselves in a problematic way, experts say. Australian researchers pored over the promotional material of 61 mental health apps, publishing the results in the journal Annals of Family Medicine last year. “We found that apps don’t talk about the fact that it’s normal to have ups and downs in your daily life,” says Lisa Parker, PhD, a postdoctoral research associate at the University of Sydney and author of the study. “I’m troubled that the apps seemed to suggest that if you experience anything like sadness or worry, then you had a mental health condition.”
Parker and her team also reported that apps pushed self-management of mental health conditions. “Apps were insinuating that individuals were responsible for their own mental health, and that really worried me,” she says. “Many people with serious mental health conditions need and benefit from a huge amount of support. These apps imply that you can make changes yourself, and it’s your responsibility to do so.”
Medical experts say people should do their research before making a mental health app a part of their daily care. Schueller currently heads up PsyberGuide, an online tool that has expert ratings of many mobile mental health apps that he hopes can help users and clinicians make more educated decisions. Both Torous and Scheuller say there are some apps, like the free app PTSD Coach from the U.S. Department of Veterans Affairs, that have good quality evidence behind them. A randomized controlled study from the VA and Stanford University found that people who used PTSD Coach for three months saw a reduction in post-traumatic stress disorder symptoms.
Schueller was also part of a team that developed and tested Intellicare, a platform of 12 “mini-apps,” each focusing on a different skill or strategy that’s been effective for treating anxiety and depression, like an app that helps users restructure negative thoughts and another that tracks accomplishments, even ones as simple as getting out of bed. “We’ve seen promising results from our recent trial, which found that people who used the apps had significant reductions in depression and anxiety symptoms,” he says. “That’s giving us hope that a mobile app strategy can be successful and help.”
In Boston, Torous is working to fill in some holes in app research in order to help create ones that work in the way they claim. With permission, Torous and his team are gathering data from the phones of people with schizophrenia — like their step count and psychological symptoms from a mood tracking app — to see if there are times they would benefit from a digital intervention.
“Perhaps a phone can help us predict when someone might be having a tough time, maybe after not getting enough sleep or steps in the day, and then send notifications or reminders to engage with an app or healthful activity,” he says. “We hope to learn about people’s real time experience so we can pair them with the right intervention at the right time.”
But the science still has to catch up to the innovation. “In first wave of translating pencil and paper psychology into the digital space, apps were created but they weren’t well-studied, which gave us poor quality evidence and we weren’t able to build up a good knowledge base of what makes a good app,” says Torous. “Now we’re entering the next phase, where people are specializing, targeting certain patients or conditions. I think that will give us a much better understanding of what apps can really do.”
These days, Omari says she doesn’t really use apps to manage her mental health, except in what she calls “an emergency.” Recently she was vacationing in Delaware with a few friends and having a hard time with her anxiety. “I did a few breathing exercises on Calm, which helped me relax for about an hour,” she says. “What I try to do now is see my therapist once a week. The apps can help, but they can only take you so far.”