Mental health apps: A new field in community mental health care

Digital revolution and smartphone explosion have created several new opportunities in the field of health care, and “mobile health” (mHealth) is one such application that has empowered users. Most mHealth applications (called as “Apps” henceforth) address self-management skills and also assist in augmenting clinical treatment processes in a convenient environment. These apps are easily downloadable, easy to navigate, inexpensive in cost, and convenient to use from anywhere anytime. The apps have the potential to reach large populations in the community in the shortest possible time frame. It is estimated that as many as 259,000 mHealth apps[1] exist; mental health apps comprised about one-third of disease-specific apps.[2] There are apps for suicide prevention, general mental health care, anxiety, depression, insomnia, addiction, eating disorders, bipolar disorder, obsessive–compulsive disorder, schizophrenia, posttraumatic stress disorder, stress, and so on. Many of these apps are free or reasonably priced, making the proposed therapy easily accessible, portable, and cost-effective. Considering the recent popularity and promise of digital mental health care in bridging the treatment gap,[3] mental health apps have come to occupy an important niche area in screening, prevention, care, and research. Nearly 10,000 mental health apps are currently available for immediate download from Apple iTunes or Google Android Play.[4] In addition, there are websites, blogs, videos, and e-resources that offer advice, therapy, and self-help tools in dealing with distress. It is clear that mental health apps will be accessed by those who would not otherwise come to seek treatment for any number of reasons. Furthermore, the stigma of seeking mental health care is an important reason for people to opt for app-based help. Apps provide the comfort of anonymity, confidentiality, and a potential safe space for people to share their mental health concerns from the privacy of their own homes-cum-environment. However, apps can supplement care only in a very broad and generic manner, but they cannot substitute for individualized therapy sessions needing interpretation and insight. For those who cannot go for traditional therapy, apps can be an option to get some support and guidance. Apps can be categorized as (a) Self-help apps-these assist in the self-management of mental health problems and are considered unsupported apps; (b) apps in conjunction with a therapist or coach and are considered supported apps; and (c) digital adjuncts to improve efficacy or efficiency of care called as blended care.[5] Although there is a lot of enthusiasm among users about these apps, it is not easy to know about their quality, efficacy and usefulness. It has become a big industry with tall claims that need to be ascertained in an objective and scientific manner. It is necessary to have clear guidance to access and choose from the available apps that support mental health care. Although several apps are available for specific mental disorders, there is very little evidence base about their efficacy which is built around the use of weak control groups such as wait-listed patients or no treatment designs. Thus, there is a situation of “high market availability with low evidence base”[6] and users are exposed to unregulated and unsubstantiated claims in lieu of mental health care. Several mental health apps have also come up in India in the last 4–5 years. For example, a mental health app, Mental Health and Normalcy Augmentation System, was launched in 2021 and has been implemented by NIMHANS, Bengaluru, AFMC, Pune, and C-DAC, Bengaluru, based on life skills and core psychological processes for all age groups. This app also integrates the health and wellness efforts of mental health professionals and various ministries in the government. There are others such as “YourDost,” “Amaha,” and “Evolve,” to name a few. They provide online chat sessions, audio–video consultations, personalized sessions with the expert of one’s choice, and chatbots. Services provided include sharing of emotions and thoughts, self-help guidance, relaxation advice, mood tracker, counseling, and self-test. “Wysa” is an artificial intelligence (AI) chatbot that uses cognitive behavioral therapy techniques to provide personalized guidance on physical activity and relaxation. The apps are accessed from app marketplaces such as the Apple iTunes or Google Play Store. Most people go by their popularity rating, or by word of mouth, or listing as “top” mental health apps. The American Psychiatric Association has proposed a five-stage app rating model that includes (1) gathering background information; (2) determining risk, privacy, and security; (3) evaluating evidence; (4) assessing ease of use; and (5) considering interoperability.[5] Another widely used rating system for mobile apps is the Mobile App Rating Scale that provides a multidimensional objective rating of app quality and usability[7] on engagement, functionality, esthetics, and information. There is also a need to assess user engagement experience on the parameters of “usability,” “satisfaction,” “acceptability,” and “feasibility.” Ultimately, app use experience is personal and there are variations in digital literacy contributing to the levels of satisfaction or otherwise. There is a serious need to develop framework and guidelines for the evaluation of mental health apps. At present, the clinical utility and efficacy of mHealth care apps are largely unregulated. Lack of regulation of medical and mental health apps is a growing international problem.[8] In the US, very few medical apps and wearables, including those for mental health, require Food and Drug Administration review. Regulation is limited primarily to software that is an accessory to a regulated medical device or that will transform a mobile platform into a regulated medical device.[9,10] While the potential of mental health apps is not much in doubt, the worrying fact is that of little clinically validated evidence of their efficacy. How do we test the effectiveness of these applications in a timely, robust, and cost-effective manner remains a major challenge? Are clinical trials necessary? Answering these questions is critical and will require innovative approaches in methodology. There are many ethical issues associated with mental health apps. Mental health apps may promote unsafe and misleading messages ranging from trivialization to universalization to an alarmist concern about mental health issues. There are also concerns about the commercialization of personal data collected on apps and the violation of privacy. In the US, most apps fall outside of HIPAA protections. Most apps provide protection through the privacy policy and most people just agree without reading the privacy policy which is written in complicated legal language without adequate safeguards against data sharing. Data security breaches and cyberattacks are another major area of concern for there are no robust safeguards. IT companies spend much less on the security of health-care data as compared to financial services data. Security concerns impact the disclosure of information and app use in many instances. In US National Surveys, about half the people had concerns about the privacy and security of medical records,[11] and 25% of those offered a patient portal they would not use due to privacy concerns.[12] Most publicly available mental health apps have no direct scientific support. User ratings are an indication of app popularity but not clinical usefulness. Consumers and clinicians need additional ways to determine what “good” apps are.[5] It is evident that app development requires a multidisciplinary approach with expertise in medical, legal, consumer, and technical areas. Physicians and patients should be majorly involved in all phases, and large-scale testing in clinical settings is a must. In India, organizations such as the Indian Council for Medical Research or the National Medical Commission or the Government of India led bodies must engage in this field to oversee, certify, and regulate the mushrooming of the entire field of mental health-care apps, protecting the public from unethical or unscrupulous practices. There is no denying the fact that apps are a useful tool in the self-management of mental health and well-being that supports mental health education and care in the community. Mental health-care scenario in India and the world is only expected to improve with greater involvement of digital technology and the provision of high-quality service for the convenience of people from the precincts of their homes in an anonymous and confidential manner. With the greater use of AI and voice commands; enhancement of digital literacy and access among masses; use of robust tools governing privacy and security; and incorporation of scientifically tested and validated interventions, apps are likely to occupy a major space and thrust area in digital mental health care in India and the world in times to come. It is expected that the community mental health-care delivery systems will come in the form of a new “digital avatar” in future and may rely on this powerful tool to help bridge the mental health gap.