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Do mental health apps really work?
Mental health apps are booming. Ranging from platforms for improving well-being, to those focused on specific mental illnesses, the last few years have seen a proliferation of digital self-help tools. With many of us using our phones to log our fitness, it's no surprise that we're downloading apps for mind as well as body.
While research in this field is fairly limited, some studies do suggest that mental health apps can be effective. At a time when NHS resources are stretched thin (mental health receives just 13% of the NHS budget), digital self-help strategies are emerging as a way to fill the gaps.
At one end of the spectrum, services like TalkSpace (which you have to pay for) can pair you up with licensed therapists. This can be a useful resource if you're waiting for your next therapy appointment, and need someone to talk to in the meantime. Then there are free apps, which give you access to online support communities and teach the kind of techniques you might glean from therapy. Many of these are rooted in cognitive behavioural therapy (CBT).
Peter Yellowlees, professor of psychiatry at UC Davis, has written a book on digital psychiatry with a chapter on mental health apps. He says he uses apps commonly with patients, and finds that they have essentially replaced the pen and paper approaches he once used to monitor their symptoms.
"Some of the apps are very sophisticated, and include not just information, but the capacity to self-monitor and even a series of useful treatment strategies," he says. "There are also a number of good mindfulness and relaxation apps that are like having a therapist in your pocket. I think they are best used as an adjunct to professional treatment, although some of the CBT apps are now being designed as standalone tools."
Trying out the apps
Since I'm personally prone to stress and anxiety, I was interested to see whether an app might help me. I scroll down this list of suggestions, compiled by Mind in Brighton and Hove, and pick two that I think could be useful.
First I download Happier, a free app that claims to help you 'stay more present and positive throughout the day'. At first it strikes me as a more saccharine version of Instagram - I'm invited to log in via Facebook, and subsequently to 'invite friends'. My feed displays photos of blossom, seashores and kittens, each accompanied by the app's version of a 'like' button - 'Smile'. You can record your own happy moments, either displaying them to the public or keeping them private.
As someone who prefers silly memes to inspirational quotes, I find the photo feed a little sugary. However, as I delve further, I definitely come to respect the premise. Created by 'happiness expert' Nataly Kogan, the app hinges on the power of gratitude. It offers bite-sized courses (some of which are free) and enables you to connect with other users.
"More than 11,000 scientific studies show that developing a gratitude habit helps you feel more optimistic, sleep better, and be more creative, productive and less stressed," claims the website. This is accompanied by glowing user testimonies, many saying the app has helped them through difficult times.
While I don't think this app is for me, it's hard to begrudge what it's trying to achieve. Who doesn't benefit from stopping every so often to admire the small things? When your mind is whirring at a thousand miles an hour, apps like Happier may serve as a useful prompt.
More clinical looking is WellMind, a free mental health and well-being app developed by the NHS. It enables you to track your moods over time; get advice on stress, anxiety and depression; access help in a crisis and unwind with relaxation audio tracks. It also features the game Snake (beloved to anyone who once owned a Nokia flip phone), helping users distract themselves when stressed or anxious.
I was never very good at Snake - in fact, playing it makes me significantly more anxious - so I skip the game and look instead at the well-being calendar. Each day, you're invited to 'choose the face that best describes your mood' (happy, so-so or sad), as well as listing what you're looking forward to, what you're grateful for, or what you've achieved. The idea is that, through looking back at trends over time, you'll gain a better understanding of your true emotional state and maybe the underlying factors. It's similar in this regard to journalling.
This app certainly seems like it might be useful, but the information it contains is fairly basic. Personally, I don't think the 'advice on anxiety' section would help me much - it simply recommends learning relaxation techniques, eating healthily and exercising regularly (none of which are novel suggestions). And I doubt many clinically depressed people would take well to hearing 'go for a walk or take time out to relax'.
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That said, the app does clarify that anyone with a suspected mental health problem should see their GP. It is just a starting point, and doesn't pretend to be a substitute for professional advice.
Stephen Buckley, head of information at the mental health charity Mind, says this is one of the important functions of mental health apps - pointing people towards services.
"Many people with mental health problems tell us that they find apps useful when it comes to managing their mental health," he says. "They're especially valuable for people who - for whatever reason - are less able to engage with face-to-face services."
The caveat here is that not all apps are equally fit for purpose. As Buckley explains, it's imperative that apps are properly maintained, managed and (where appropriate) moderated, to ensure they're safe.
"We also want to see app builders engaging with people with mental health problems and taking their experiences on board when designing or redeveloping apps," he says. "The user community has the best handle on what will be of benefit to them and the expertise to say what works and what doesn't."
Yellowlees recommends avoiding apps that don't have much information about who built them.
"Go for apps built by reliable sources, or validated by such sources and recommended by them. Ideally use them in conjunction with your doctor or therapist," he says.
An unregulated marketplace
Steve Flatt, director of the Psychological Therapies Unit in Liverpool, is more sceptical about the rise of mental health apps.
"The real issue for me is the speed at which the apps market has developed," he says. "Most people have not bothered to stop and test or gather evidence for their applications, and I'm afraid to say that with the current level of research into apps for mental health there are very few that would meet the criteria. There are 303,000 apps in the marketplace at current time. Of these, 49 are in the NHS library, seven are approved by the Federal drug agency, and two are approved by NICE."
He likens the current state of the market to the Wild West of the 1860s, in which unscrupulous salesmen got rich by selling snake oil.
"There are so many possibilities of using apps for the benefit of health, including in mental health, but there are people who are prepared to make significant sums of money out of the misery of others without providing anything of value," he says. "As the market becomes more regulated by organisations like ORCHA, the wheat will be sorted from the chaff."
The NHS has a mental health apps library. Some of the apps (such as SilverCloud) require NHS referral and are intended as a supplement for therapy. Others can be downloaded and accessed by anyone with a smartphone.
While conceding that the better apps can offer benefits, Flatt feels that users generally should err on the side of caution.
"Psychological interventions in the NHS are known to cause about 5% deterioration rate but these are generally picked up by other employees within the service, such as GPs. There is no such safety net for mental health apps," he says.
Dr Sarah Jarvis, clinical director of Patient.info, agrees that while online tools can be extremely useful, it's important to know what you're looking for.
"I have recommended online tools such as Living Life to the Full (free) and MoodGym (previously free, now $39Aus per year) to patients for years. That doesn't mean they're the only ones out there, but my patients have seen consistently positive results. GPs don't keep up to date with all the latest apps, but apps produced or recommended by mental health charities are usually safe and effective.
I like the idea that Mind has produced a wider range of apps which it vouches for and it's really gratifying to see a wider range of mental health conditions covered. For instance, Calm Harm, developed for teenage mental health charity stem4 by a clinical psychologist, has proved invaluable to some of my patients who self-harm."
How people can benefit
Clearly, if you're suffering with a serious mental health condition, the best app in the world is only going to get you so far - seeking out proper treatment is essential. However, self-management has always played a role in mental health care, and that's what an app can facilitate.
"I recommend them widely to most of my patients, along with specific books or reading materials for patient education," says Peterlees. "For instance, I routinely have all my depressed patients keep depression scores and behavioural activation measures on their phones and show them to me at each appointment."
He believes that mental health apps are the 'way of the future', adding that their real strength so far lies in collecting data for monitoring symptoms. On top of that, they can provide on-demand strategies for alleviating stress and anxiety.
"I have several patients who used to be terrified of flying, for instance, who now get on a plane with their ear buds in listening to relaxation programmes and who have much reduced symptoms," he says.
Personally, I plan to download a few more apps, and see if I can find one that works for me. Through my brief exploration, I don't think they're any kind of substitute for therapy, but they may well be a useful supplement. And I wouldn't be surprised if the apps continued to improve in line with user demand. As mental health is talked about more openly, more of us will be seeking strategies to manage our symptoms proactively.
The important thing really is to find the right one - and that will differ greatly from person to person. Tracking symptoms may be more important to one person, community support to another.
Buckley, at Mind, points out that three quarters of people who experience mental health problems don't access any formal support, meaning apps can serve a vital purpose.
"We welcome the fact that apps can increase the options available and mean that more people get help," he says. "If you’re thinking of using a new app, we'd always suggest doing some research first and perhaps getting a recommendation from a registered counsellor or another mental health professional."