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How to choose a mental health app | Psyche

Photo by Mark Henley/Panos Pictures

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Guide

How to choose a mental health app

Of the thousands of apps, many are poor quality – but there are a few gems you can trust. Follow these steps to find them

by Margaret Emerson & John Torous + BIO

Photo by Mark Henley/Panos Pictures

Need to know

With the ease of access to healthcare via a smartphone, it is not surprising that more and more of us are turning to apps to get assistance with our mental health. Indeed, there are many more than 10,000 apps available to pick from today, from a variety of sources – including private companies and government agencies – and millions of people around the world are seeking to manage their mental health this way. Similar trends are only likely to increase with direct-to-consumer advertisements for the apps all over social media, television and even billboards.

The appeal of mental health apps is obvious: above all, it’s a matter of convenience – using an app is certainly easier than driving to and from an in-person appointment with a mental health professional in an office. With the stigma that still unfairly surrounds mental health issues, the privacy of receiving treatment in your own home is also highly appealing.

With a range of resources and creative approaches, apps promise to enable more people to better understand and manage their own mental health. Yet, as seemingly innocent as it can be to access mental health information from an app, for psychiatrists and researchers who specialise in this field, such as ourselves, there are several important factors you are advised to consider before rushing to download a mental health app on your phone.

Many apps are of questionable quality

Let us illustrate some of the pitfalls by sharing the de-identified story of one of our patients: let’s call him Mark. One of us (John Torous) met Mark in the emergency department after his anxiety symptoms began to worsen and the meditation-based app he was using to manage his care directed him to seek professional support. Mark explained that the app he had been using ‘kicked him off’ as his symptoms had grown more severe. He learned that the app was not actually offering mental healthcare, but rather ‘wellness services’ – this can be likened to the difference between patients with physical health problems being offered prescription medications versus herbal supplements.

To better understand the circumstances that led to Mark’s ER visit, he and I explored the app together. The app certainly gave the impression that it offered psychiatric services, together with claims that you could expect symptom improvement. There was even a section on the app’s scientific rigour. Unfortunately, when Mark had sought to use the app’s more intensive ‘psychiatric services’, he learned that these promoted features that were not actually available in the app. Similarly concerning, as we reviewed the app’s privacy policy, we quickly realised that Mark had also agreed to allow the app to access his contact list, location and voice, with no ability to delete this data and no clear indication of what the company was doing, or would do, with his personal data. Needless to say, this mental health app was not as advertised, and I was relieved to see Mark make the informed decision to quickly uninstall it from his phone.

Unfortunately, Mark’s story is not an isolated case – many patients in need are hoping to rely on app resources, only to find out that they are not as advertised. Moreover, looking beyond the marketing claims at the actual data reveals that the clinical evidence for the effectiveness of mental health apps is often lacking. Indeed, a meta-analysis of mental health apps in 2022 found that the overall support for their effectiveness was weak, and that most of the studies to date were of low scientific quality. This raises important questions about whether apps can actually deliver on their claims, such as to reduce depression, anxiety and more.

There are good apps available if you know how to find them

That being said, we don’t want to paint an unfairly negative picture or to put you off mental health apps entirely, as we are also still in the early stages of determining the full potential that apps have to offer. Useful apps certainly do exist, and not all will share your data. For example, the US Department of Veterans Affairs (VA) offers a suite of free mental health-focused apps that anyone in the world can use for free, even if you’re not a veteran. The VA works to research its apps and openly shares results that highlight how they can help augment care. For example, the VA’s COVID Coach app offers education, symptom-trackers and activities designed to help with self-care around pandemic stress. The app does not make unfounded claims and is likely a tool that many people may find helpful in augmenting their mental health.

But while there are quality apps out there, the problem is that finding the most suitable one, when you’re not informed about the risks associated with app use, can expose you to unintended consequences. Thanks to the simple laws of probability, if you pick an app without careful attention, the chances are that it will most likely be ineffective or unhelpful. Examples of problems we’ve seen include apps that list suicide crisis contact numbers that are disconnected or no longer accessible; or that provide misleading or potentially harmful psychoeducational information and tips that are not in line with best practices as assessed by clinical experts.

What’s more, searching for apps by seeing which have more downloads, stars or a higher page ranking – just as you might for other lifestyle apps, books, games or movies – is not a sound plan. Yes, it will let you know which are the more popular – yet popularity is not associated with effectiveness, nor does it tell you if the app will respect your privacy. Consider that when the magazine Consumer Reports looked at the privacy practices of highly ranked mental health apps in 2021, it found numerous concerns. You might also be tempted to rely on a third-party service that scores apps or presents app rankings. Keep in mind that many of these services base their ratings on factors – such as aesthetics and engagement – that are unique to each user and can’t be assumed to apply to all users. Worse, these app-rating websites are often out of date with their information, not able to keep up with the rapidly changing and updating world of apps. An analogy for these ratings services would be a website that attempted to tell you how you will feel about the weather (without knowing anything about your weather preferences) in different cities, based on climate data that is years out of date.

Our intention with this Guide is not to steer you away from using apps, but to empower you to better understand the factors to consider when you’re choosing an app to use. For years, we’ve worked with colleagues and the American Psychiatric Association (APA) to create a systematic framework for evaluating mental health apps – and from that we created a freely searchable database of apps. During this work we’ve gained input from patients, psychologists, nurses, social workers, students, administrators and other psychiatrists about what matters when it comes to choosing mental health apps. In the steps that follow, we’ve broken down the main factors to consider, and later on we’ll show you how to use the database we created.

What to do

It would be straightforward if we could simply provide you with a conclusive list of apps you should avoid, and ones that we recommend. Unfortunately, such an approach isn’t possible when it comes to mental health apps because it is a dynamic situation – apps come and go: some are constantly updated and improved, while others are left to languish – so what might have been safe once may no longer be so.

What’s more, no single app – however impressive – is going to meet all the unique needs of an intended end user, just as it would be impossible to find one video game that would be appealing to all gamers.

For this reason, our principal aim is to help you be more informed about what factors to take into consideration when searching for a mental health app. The most important thing of all is avoiding apps that could cause you harm. Then there’s the challenge of finding one that is actually likely to be beneficial. Based on our work with the APA, we suggest that you evaluate apps along four main criteria, in this order: 1) privacy/harm; 2) efficacy/benefit; 3) engagement/ease of use; and 4) clinical integration/utility. Let us walk you through each of these criteria in turn:

Check an app’s privacy policy and controls

First, just as you would in other medical and health contexts, you want to consider the matter of your personal privacy. Consider if the app is tracking your activity and – if it is sharing your information – who is it sharing it with? Secondly, how is the app protecting your information? Do you have control over this information? Can you delete it?

Answering these questions can take some practice. Admittedly it’s not until you really dig into conducting app evaluations that you begin to see what a reassuring mobile app privacy policy looks like, compared with a poor one.

What’s more, if an app has not been regularly maintained, this can pose problems. Imagine the last update for any bug fixes was over a year ago, which likely means it is not up to date with security measures needed to protect all the information you are placing in the app.

We strongly advise you not to share your data carelessly because, like all sensitive health data, you want to be in control of it and not allow users to use it for, or even against, you. Put it this way… if you would not want your medical records or information to be shared in the same capacity, then why would you want this data to be treated any differently?

In the United States, such privacy concerns around apps are mounting, with reviews consistently finding serious flaws, such as fewer than half of those apps for depression even offering a privacy policy. Even for apps that do offer a privacy policy, the reading level required to understand the policy is often college and higher. What’s more, when our team tested whether apps follow their privacy policies through a technical audit, we that found many simply do not, and that they send data to parties without telling users who those parties are.

Therefore, we recommend that the first and most important step is to learn about the privacy and security of an app or apps that you’re interested in. To do this, look into an app’s privacy policy or terms and conditions. If you cannot find one, that itself is a red flag. In these documents, look for key words or phrases, such as whether your personal data can be used or sold; whether you can delete your own data; and who your data may be shared with.

Check whether the app is likely to be of benefit

The second step is to consider whether the apps you’re looking at are supported by evidence and have sound clinical foundations. Not all apps need to be supported by specific research studies, as an app that recommends healthy tips or reasonable exercises is likely already based on sound research. Still, it is important to consider all claims made by an app that you’re interested in. If the claims sound overly impressive, look for impressive evidence to support that claim. Also, just because an app says it is backed by science or research does not in itself mean much. The quality and rigour of that supporting science is what’s important.

While evaluating the quality of science is challenging, some warning signs to look out for include:

  • the supporting science was done only by the company itself;
  • the supporting science supports trivial claims (eg, that people can use the app);
  • the science is not about the app at all (eg, it’s about the fact that therapy in general works); and
  • the supporting trial(s) did not involve a valid control group, such as another digital/app intervention.

Sometimes, looking at the source of the app and whether it was made by a trusted company or healthcare group can give you some insights. Better yet, step away from the app store and ask your friends if they have tried any they like and found beneficial. Your mental health clinician, if you have one, should be able to offer you suggestions too. Don’t be afraid to ask.

Assess how easy and enjoyable an app is to use

This third step is all about finding an app that you are likely to find enjoyable and engaging to use – thus increasing the chances that you stick with it. This is important because population data suggest that more than 95 per cent of people will stop using mental health apps within 15 days. To find an app that will avoid this pitfall, personalisation is key. That is, different people will find different engagement features most meaningful, and exploring what those are to you makes for the most impactful selection. Some people prefer apps with lots of animations and gamification, while others want a simple, minimalist experience. Others still want all content delivered via videos, and some prefer a combination of audio and text. Some apps today even offer cartoon characters to help guide you through the app, which some people appreciate and others find gimmicky.

Here are a couple of hypothetical scenarios to help you better understand how one app may differ from another in terms of its suitability for a person. Melissa, 32, is a mother of two who has been experiencing some anticipatory anxiety as her current pregnancy due date approaches. She is a busy mom on the go and tends to lose the handouts that the OB-GYN office provides her. She needs access to information and strategies to help reduce her anxiety when she begins to worry about things outside her control. An app likely to meet Melissa’s needs would involve sound educational material that applies to the busy working mom experiencing anxiety, in addition to incorporating anxiety-reducing strategies that can be done in a variety of environments.

In contrast, Sam, a 17-year-old male, is moderately overweight, struggling with sleep, and has a history of depression. He is experienced with technology and enjoys interacting in gaming environments. The ideal app for Sam would harness assistance with promoting healthy sleep hygiene habits, tips and motivation for behavioural activation, along with features that would allow Sam to track his mood and progress. Additionally, because Sam has a well-versed sense of technology, he may want to use an app that allows for more tracking features and artificial intelligence interaction.

So, spend some time playing around with a variety of apps that have the features you are looking for. Keep in mind that aesthetics, interactive features and the overall means of communicating with the end user are ultimately what will shape your willingness to continue use. For instance, if there is a feature that you immediately notice may be too time-consuming or frustrating, what is the likelihood that you’re going to go back and use that app? If you are inclined to say no, then try another.

Find out if an app can integrate with your other supports

The final step we recommend is to consider how well any app can integrate with any other forms of mental health support you are receiving. Also, if you have a specific mental health diagnosis, or you’re struggling with a specific problem, such as insomnia or social anxiety, you could consider searching for an app that is tailored to that specific issue. Our team’s own research found that some areas of the app marketplace are oversaturated (eg, mindfulness and mood tracking) and some are underdeveloped (eg, apps for serious psychiatric illnesses such as schizophrenia and bipolar disorder). There is strong evidence that apps can be helpful to people with illnesses such as severe depression, bipolar disorder and schizophrenia, it’s just that there are fewer apps currently available for these conditions on the commercial marketplace.

Therapists and mental health clinicians today will often have suggestions or recommendations too. If you have access to a mental health professional, it is important to let them know what app you may be interested in, or are using, as they may have ways to integrate the app into your treatment with them. Even if you are doing CBT with a therapist, practising outside of sessions with the right app could potentially make your treatment even more effective. In some cases, if an app offers contradictory advice from a therapist or psychiatrist, it is best to disregard the app. While some apps are now offering connection to a therapist, it is worth carefully considering the costs, as often these do not represent a large cost-saving versus traditional care.

As you begin your search, it’s worth remembering that there are thousands of apps available, so you can be demanding in finding the best match for you. Just because an app is popular does not mean it will be useful to you. Instead, consider giving several a test drive for a few days to see what you think. While a few days is often not enough time to see a clinical effect, it is enough to learn if the app feels user-friendly, engaging and helpful.

Key points – How to choose a mental health app

  • Many apps are of questionable quality. They have obvious appeal, but many do not work as advertised and have privacy problems and other issues.
  • There are good apps available if you know what to look for. There are quality offerings out there, but you probably won’t find them using review sites or ratings.
  • Check an app’s privacy policy and controls. The most important factor to check is whether an app will protect your personal data and give you control over it.
  • Check whether the app is likely to be of benefit. It’s not easy to assess the scientific backing of an app but there are red flags to look out for, such as grandiose claims.
  • Assess how easy and enjoyable an app is to use. Most people soon grow bored of an app, so it’s important to find one that will keep you engaged.
  • Find out if an app can integrate with your other supports. If you’re in therapy, it’s worth looking for an app that will be complementary – don’t be afraid to ask your therapist for advice.
  • Use the MIND database to simplify your search. This free, continually updated expert-led database (see below for more info) will help you narrow your search.

Learn more

Using the MIND database

Working with the APA, we developed a framework for evaluating mental health apps, and based on that framework we created the M-Health Index and Navigation Database (MIND) – an online tool, free to use, that allows you to search among more than 600 mental health apps based on the criteria we outlined above. To ensure data is timely, we designed MIND so it could be frequently updated by a network of staff and volunteers, to ensure each app is re-reviewed every six months or sooner.

When it comes to privacy, you can click the ‘privacy’ tab in MIND to select any of the 12 features related to privacy (such as: does it allow a user to delete data? Is data stored on or off the device? etc), and see which apps fulfil that requirement.

Based on your privacy selections, the database will present you with a narrowed-down list of available apps. The next step is to consider the remaining apps based on their supporting evidence and clinical foundations. You can click on this tab and look for apps with different levels of evidence ranging from relevant content to supporting studies. You’ll find that simply playing around with the different criteria and learning which apps appear and disappear is often informative.

The third step is to narrow down the remaining apps based on their user appeal and engagement level – to help you identify apps with features that make them easier to use and stick with. MIND breaks down engagement into questions, such as, does the app offer music, video, texting, graphs, social/chat features etc, and many other factors that people may want to drive engagement. Unlike review sites, MIND does not judge any app, but simply reports if the app offers such a feature or not.

Finally, there is a ‘supported conditions’ tab, to help you understand which apps may be aimed at specific mental health diagnoses. This will help you find apps that are tailored to your specific mental health problems, and that might mesh with any other mental health support you’re currently receiving.

There are many other options to explore in the database, such as cost and developer types (hospital, government, etc). MIND won’t ever recommend a certain app, but it will help you understand what features are available and if there is a combination of features that may match what is important to you.

Please bear in mind that, because most of the information that MIND uses to answer questions about the app is derived from what the app itself reports, you still need to actually check and verify that the app is offering what it claims. Also, while resources like MIND are designed to help you make more informed decisions about apps today, they are not perfect. Some of the most important data, such as how engaging an app will be and how much it may help someone feel better, are often not publicly available. Many companies simply do not share this information, likely because it is not favourable.

Here is a simple example of how you might use the MIND database. Imagine that you are seeking an app for post-traumatic stress disorder (PTSD). You want the app to be totally free, keep your data on the device (ie, not send it to the cloud), and for it to be backed up by at least some supporting studies.

Simply select ‘totally free’ under the cost filter, ‘PTSD’ under the supported conditions filter, ‘data stored on device’ under the privacy filter, and ‘supporting studies’ under the evidence and clinical foundations filter, and you’ll see that four potential apps emerge. You can visit our database to try this exercise for yourself. Your results may not be exactly the same as ours, because we regularly update the database, but see which apps you are able to find that match your criteria. MIND cannot tell you which app is best but, if you ask the right questions, there are many cases where only a single app will be returned.

Links & books

MindApps: updated every six months, this is the website we created with the American Psychiatric Association’s app evaluation framework in mind. It offers a free, searchable database of more than 600 mental health apps to empower you to make a more informed decision.

The APA’s App Advisor: this further online resource from the American Psychiatric Association offers many videos and tutorials on how to approach apps and learn the fundamentals of what questions to ask of an app.

Mental health apps in the workplace have their pros and cons, but you don’t need to be a business owner to consider the evidence. The article ‘Should Your Company Provide Mental Health Apps to Employees?’ (2021) by John Torous and Elena Rodrigues-Villa for the Harvard Business Review will help you learn whether they can be effective.

The FDA Digital Health Center of Excellence website: follow the latest news and updates as the FDA works on new regulatory pathways for these apps.

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6 July 2022