Mental illness is among the most widespread ailments in the United States; 43.8 million U.S. adults experience mental illness each year. With innovative surges in mobile health care (mHealth), people are turning to their smartphone, tablets and other mobile gadgets for self-treatment and supplemental treatment for others. But the efficacy of these applications and devices is closely scrutinized among academics and health care experts, and many of them question how much people should be relying on mHealth apps.
There are more than 165,000 mobile health care applications in the iTunes and Google Play stores, and the largest category is for people with mental-health disorders. These apps claim to manage everything from addiction to depression and schizophrenia.
Alongside the average mHealth user, who self-treats using these mental-health apps, are caregivers—nurses, family members or friends who look after the day-to-day care of an individual. Caregiver duties and responsibilities vary widely depending on the relationship between the caregiver and their patient, but those who use mHealth apps depend on these claims of accuracy and reliability for best treatment practices.
There are more than 40 million caregivers in the United States, and like self-treatment users, caregivers monitor how their dependents mental health shifts daily. For people who can’t oversee their own independent mental health care, caregivers play a crucial role in tracking treatment success and providing information to psychiatric professionals.
And although these apps are in wide use among caregivers and individuals alike, the efficacy of most of these programs has not undergone rigorous scientific review, Peter Yellowlees, a UC Davis professor of psychiatry and expert in using technology in clinical settings, said in a press release.
“While patients have access to an exponentially increasing number of apps, the research literature has not kept pace,” Yellowlees said in the release. “But this lack of data has not held back the high level of industry and consumer interest.”
There is increasingly-large gap between clinically tested apps and what help they’ve been proven to provide, and untested apps where the treatment claims are limited to the app description and customer reviews.
Out of thousands of options, only 14 apps for bipolar or major depressive disorder were examined in a recent literature review, the UC Davis release states. And only seven apps had been reviewed for people with psychosis. Those studies found that there was little efficacy, safety or clinical outcome data in the published literature, which makes using an untested app for caregiving or self-care a gamble.
But this unreliability and lack of clinical evidence has not dampened consumer demand for mental-health treatment apps.
The American Psychiatric Association is considering how to provide guidance to psychiatric providers on how to use or recommend mHealth treatment options, but the U.S. Food and Drug Administration has stated that it will not approach the monumental task for non-physical devices.
A commentary published in the Journal of Clinical Psychiatry identifies that patients are already bringing mHealth apps, sleep-tracking devices and activity-monitoring devices to psychiatrists, physicians and caregivers to ask for a professional opinion on their use. The commentary states people are approaching mHealth options in the same way that many patients rely on internet resources and Google searches when they feel sick, and then bring those findings to physicians for second opinions.
The commentary recommends a framework that psychiatrists should consider when evaluating all “ASPECTS” of an app: whether the app is Actionable, Secure, Professional, Evidence-Based, Customizable and TranSparent.
“The framework presented here is important, as it offers a flexible tool that clinicians and patients can use together to make more informed decisions about whether to use or not use a smartphone app or other mobile health technology,” said John Torous, commentary first author and clinical fellow in psychiatry at Beth Israel Deaconess Medical Center and the Harvard Medical School.
“While both patients and clinicians know the right questions to ask about a new medication or pill, sometimes they may not be aware of all the best questions to ask about an app. With this framework we hope to guide them towards a more informed discussion,” said Torous, who also chairs the American Psychiatry Association Workgroup on Smartphone App Evaluation.
Here are ASPECTS and their exact phrasing:
Actionable — To be actionable, an app should collect data, but it must be data that can be valuable and clinically useful. A psychiatrist should consider how app data will be incorporated into clinical decision-making and how the data will inform care. He noted that in the future, it will be increasingly valuable for some categories of apps to seamlessly integrate with electronic health records and complement clinical practices.
Secure — Laws mandate that health information be secure, among them the Health Insurance Portability and Accountability Act (HIPAA). Psychiatrists should examine whether apps are password protected or biometrically authenticated. Patient data should be encrypted in case the mobile device is stolen or hacked.
Professional — Apps should be in line with professional standards for clinical use, including legal and ethical standar1ds. HIPAA is a federal law and in part requires strict protection and confidential handling of protected health information, and severe penalties for violation. Other laws protecting privacy may vary state to state.
Evidence-Based — Apps with little or limited data may be risky to use. There are already documented cases in which apps designed for reduction in alcohol intake led to increased alcohol use.Caveat emptor — let the buyer beware.
Customizable — One size does not fit all where apps are concerned. When considering an app for clinical use, psychiatrists should look for those that offer more customizable and flexible features. Patients and clinicians are more likely to be invested in and adhere to something they created together.
TranSparent — Apps should openly report how data is collected, stored, analyzed, used and shared. This is critical in selecting an app for clinical care. If there is uncertainty about how an app is using a patient’s health care data, then there is uncertainty in any conclusions or recommendation that app may offer.
People are going to continue using mobile health care devices to treat themselves and others. It’s important for health care workers and experts to understand app complexity, reliability and usefulness in order to best treat their patients.