Welcome to PsyberGuide, a pioneering Digital Apothecary!

by Ricardo F. Muñoz

Dr. Muñoz is the Founding Director of the Institute for International Internet Interventions for Health (i4Health) and Distinguished Professor of Clinical Psychology at Palo Alto University.  He is also Professor Emeritus at the University of California, San Francisco and Adjunct Clinical Professor at Stanford University.


“Is this a good time to talk?”

It’s the year 2025.  Your digital assistant has just pinged you.  For a few days now, you have been feeling a lack of energy that is different from the usual fatigue when you have been working hard, or the boredom that you have felt from time to time. You just finished talking to one of your friends on your latest mobile device, and, as soon as the conversation ended, your digital assistant inquired if you are available to chat.

It informs you that, according to the health app you activated when you set up your device, your voice tone during the few conversations you’ve had over the last week indicates that your mood level has been unusually low for you. Does that ring true?  And, if so, would you like to do something about it now?

You say “Yeah, what have you got?”  And your digital assistant immediately connects you to the pages in PsyberGuide that list the apps on depression prevention.  There are several depression prevention apps. In addition to the PsyberGuide research rating, the Mobile App Rating Scale, and the expert review, you can also click on a button that says “Drill down.”   You click on the button. 

The apps are then grouped into three categories:  Adjuncts, Guided apps, and Automated apps. Adjuncts are intended to be used as add-ons to regular treatment with a licensed psychotherapist or pharmacotherapist.  Guided apps provide live lay assistance via phone, chat, email, or text messaging, to help the user stay with the program (most users have a hard time completing totally self-help programs).  And Automated apps are intended to be used without any human support. 

You also notice a “Box Score” for many of the apps.  It turns out that some of the apps provide effectiveness data on the fly.  The Box Score shows the proportion of users whose mood levels have decreased significantly after using the app for a week and for a month.  And the data is updated daily.  Clicking on the Box Score provides more data:  The number of people who downloaded the app, who used the app more than once, their ratings, and their outcomes.  You can also drill down and check out outcomes by gender, age, race, ethnicity, education, income, religion, language, and so on, so you can pick the app that has worked best for people like you.

You decide you’d like help from a live therapist.  But your digital assistant informs you that your small town does not have mental health providers.  The nearest one is two hours away.  You decide you’ll try one of the guided apps.  But, you see that most of the best-rated apps involve a fee.  So, you decide to begin with the best-rated free automated app.  And you get started…

Welcome to the future.   PsyberGuide is one of the first Digital Apothecaries and thus has the potential to become the premier one going forward.  It already takes into account expert ratings and is starting to obtain consumer ratings.  Perhaps it will eventually add some of the features that I describe in my time travel fantasy.

We tend to think of the future as a modification of the present.  But this constrains us unnecessarily.  Our health care practices were developed at a time when in-person care was the only option, when people sought help only when they were hurting, when most health care required payment.  Minor modifications to this individually-focused practice will not reduce the burden of disease at the population level.  We need to redesign our health care systems with global health in mind.

There is now research evidence that we can prevent half of the new episodes of major depression in persons at risk.  Why wait until people are clinically depressed to teach them the mood management skills that will avert a full-blown episode?  There is research evidence that we can provide these preventive interventions online.  And there are proof-of-concept projects that show that it is feasible to provide interventions for such issues as depression and smoking to people all over the world at no charge to them.  This can be done by using digital tools that have been developed and tested with research grants and, after the grant ends, making them accessible to anyone in the world who wants to use them.  We have called these “Massive Open Online Interventions” (MOOIs, pronounced MOO-ees), inspired by MOOCs (Massive Open Online Courses).

We need to develop business models that will allow for sustainability of MOOIs that are free and open to all.  For example, we could create links from MOOIs to companies that provide guided help for a fee.  Those companies could then pay a referral fee to the group hosting the MOOI.  This revenue stream would help pay for ongoing hosting expenses and, ideally, for continuing development and testing of the MOOI, so that outcomes for the fully automated version continue to improve.

I wish PsyberGuide a long, successful, and influential life.  May it contribute to the dream of making health care a human right.

 

 

Finding an App That’ll Work for You: Building the PsyberGuide Community

Dr. Schueller is the Executive Director of PsyberGuide and an Assistant Professor at Northwestern University’s Feinberg School of Medicine. He is a faculty member of Northwestern’s Center for Behavioral Intervention Technologies (CBITs) and his work focuses on increasing the accessibility and availability of mental health resources through technology.


It is with great pleasure that I write the first Director’s Blog for PsyberGuide. PsyberGuide aims to be the leading source of unbiased information regarding technologies intended to address mental disorders – e.g., depression, anxiety, bipolar, and schizophrenia – and to promote mental health. This is hardly an easy task. The number of mHealth apps exceeds 165,000 with estimates that roughly 12,000 of those are targeted towards mental health and wellness. Very few of these apps have been subjected to rigorous scientific evaluation, and those that have don’t often persist in the app stores. As a consumer sorting through these apps and separating the good from the bad is a nearly impossible task. As such, resources like PsyberGuide have an important role to play in ensuring that people can find the apps that might be the most beneficial for them and understanding what role those apps can play on each person’s own road to recovery. An important goal of mine with PsyberGuide is to continue to grow the number of products and reviews listed on this website. I encourage you to keep coming back to PsyberGuide to see what new apps we’ve identified and the ratings and expert reviews associated with those apps. If there’s an app you’ve found that’s been particularly useful, please let us know which app it is and why and how you’ve found it useful.

This relates to another critical point. It is unlikely that there is one app to rule them all, or said differently that any app will work for all people. The struggles that people encounter with mental health can often be deeply personal. And although our destinations might be the same – finding happiness, meaning, and purpose; building positive relationships; and achieving our goals and dreams – the roads we take to reach those destinations might differ. To better understand these differences, however, we need to hear from the people using these apps in their lives, we need to hear from you. Another goal for PsyberGuide is to connect the communities of interest – consumers, professionals, researchers. In the past, we’ve done this by providing experts ratings and reviews of available mental health apps. We’d also like to learn from your expertise and experience with these tools. We’d love to have more information from people who use mental health apps about which ones are useful and why. Currently in the product guide you can provide some of this information: how likely you would be to recommend the app to others, how effective the app was in helping with problems, how easy to use and engaging the app is. We’d like to make more use of this information to help point us towards the most popular, useful, and engaging apps. We’d also like to expand this information, to better design PsyberGuide to collect the information needed to not just provide scores of products, but to start to make recommendations to guide you towards what might be useful apps for you.

None of this can happen without you. I am excited to lead PsyberGuide because I truly believe that technology and digital resources have a critical, yet unrealized, role to play in mental healthcare. I believe that technology and digital resources have the potential to ensure that all people who need mental health resources will have access to them and that those who might prefer technology or digital resources for a variety of different resources will be empowered to find ones that are high-quality and effective. These Director’s Blogs will give me one avenue to communicate with the PsyberGuide community. But we’ll also find other ways to connect. For example, through emails, newsletters, social media, and events. We’ll also engage the community of experts using guest blogs which will alternate with the blogs I write myself. Again, PsyberGuide will be a resource where multiple voices come together to identify the state-of-the-art advances in mental health and technology. This is an exciting partnership, and I’m extremely curious to see where we go together.

 

 

REEACT cCBT Trial

Comment on: “Computerized cognitive behavior therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomized controlled trial”, Gilbody S et al, British Medical Journal BMJ 2015;351:h5627

This is an important study that sought to evaluate cCBT for the treatment of depression in primary care settings. The study was conducted in the United Kingdom, where cCBT has been promoted and reimbursed by the National Health Service since 2006. Depression is a common illness and most patients are treated by primary care physicians rather than specialists. Antidepressants are frequently offered to patients, but access to psychotherapy and other forms of treatment for depression is often quite limited.

Previous studies of cCBT tend to support the efficacy of this intervention, however these studies have been criticized for having small sample sizes, highly selected participants (in that they may be from academic settings and screened for complicating factors that are common in the “real world”), and for lack of bias (in that they are often supported by companies with a commercial interest in the outcome).

The REEACT study was a “real world” study conducted at large primary care practices in various parts of the United Kingdom.  Patients with depression were randomized to receive: usual care from primary care physicians, usual care supplemented by a commercial cCBT (Beating the Blues) or usual care supplemented by a “free to use” cCBT (MoodGYM). Incidentally, both Beating the Blues and MoodGYM have been reviewed favorably by PsyberGuide. Follow-up data were collected at 4, 12 and 24 months after randomization. Patients assigned to cCBT received weekly support phone calls from trained technicians.

After entering the study, follow-up data were obtained for 76% at 4 months, 70% at 12 months, and 67% at 24 months. Thus, almost one quarter of the subjects had dropped out by 4 months. At four months, 50% of people using Beating the Blues, 49% of people using MoodGYM and 44% receiving usual care were still depressed. Therefore, the authors concluded that there was no demonstrable benefit for any of the three treatment arms. There also did not appear to be differences at 12 and 24 months. Most interestingly, the median number of sessions completed for Beating the Blues was 2, and for MoodGYM was 1. Only 18% of patients completed all 8 sessions of Beating the Blues and only 16% completed all 6 sessions of MoodGYM.

The authors conclude that cCBT programs appear to be effective when they are led by developers but do not appear to be effective in an independent study in a standard primary care setting. They believe that the main reasons for the negative study were low adherence and engagement rather than lack of efficacy.

This study raises several questions for me:

  1. Can depression be treated reliably in primary care settings? I think “high contact” specialty care will be necessary for most patients with significant depression.
  2. Can we develop computer programs that are engaging enough to overcome the inertia and lack of motivation that are part of depressive illnesses?
  3. If “high contact” care is needed for patients with major depression, can therapies delivered on-line (such as tele-psychiatry or on-line social networks of support) solve our access to care issues and be more effective than cCBT?

Wellocracy – Tracking for Health

As researchers and developers increasingly tout the potential benefits of health-related apps and wearables, the large number of options available to consumers can make the job of choosing between them nearly impossible. While PsyberGuide surveys the field of products that address mental health concerns, a group of scientists at Brigham and Women’s Hospital and Massachusetts General Hospital have created Wellocracy, a consumer-oriented website reviewing tracking apps and devices that focus on physical health and wellness.

When it comes to apps and wearables, “tracking” relates to the collection and analysis of data about daily health-related activities such as exercise or diet. The idea is that this information can be used to give feedback to the user or to medical providers and researchers in order to improve physical health at both individual and community levels. Wellocracy focuses on nine categories of products that provide this service:

  • Wearable Devices
  • Running Apps
  • Pedometer Apps
  • Sleep Apps and Devices
  • Mood Apps
  • Food and Calorie Apps
  • Heart Health Apps and Devices
  • Connected Scales
  • Healthy Habit Apps

An excellent feature of Wellocracy is that products in each category are compared side-by-side to make it easy to determine which fits best into the user’s lifestyle. To help with this decision-making process, the site includes a useful questionnaire of potential health/wellness goals and problem areas in order to generate individually-tailored suggestions. In addition, Wellocracy provides basic information about tracking and how making it a regular part of a daily schedule can lead to a better life.

Wellocracy holds a lot of promise in the growing field of tracking apps and wearables. As scientists at renowned research hospitals, the group behind Wellocracy is in a unique position to study the current crop of products and offer reliable data about which can be most helpful. We at PsyberGuide think that anyone who is interested in tracking for health should make a visit to Wellocracy the starting point in their search.

Why making good apps is hard: Part 1

At PsyberGuide, our goal is to evaluate apps from all perspectives. It is critical that an app has a sound science-based approach toward improving mental health, but it is also critical that an app is not frustrating to use – it is fast, responsive, doesn’t crash, and avoids all of the other common frustrations for users.

Over the next few weeks, we’ll write about some of the difficulties facing app manufacturers in trying to make and maintain apps that perform well. The first difficulty we are going to look at is the constant need for updating an app.

There are several reasons why apps need to be updated:

  • Adding new features
    Products need to frequently add new features, to keep up with competitors and to keep the interest of users
  • Expanding capacities
    Such as adding support for other languages, or extending the app for new smartwatches
  • Responding to updates in the platform
    IOS, Android, and Windows platforms are frequently updated. Apps need to perform well in the updated environment and take advantage of the new features of that environment. They also need to still work well on older versions of the platforms, since many users do not update to the current versions of the platform.
  • Fixing bugs
    Bugs inevitably occur in the products, especially given the quick timeframe in which new versions of the app are produced

Let’s look at two very popular apps – Lumosity and Headspace. Both of these products are considered mature apps – they have been around for several years and are feature-rich and well-tested. And yet this doesn’t mean that they don’t have to keep continuously updating. Recent updates include:

Lumosity: 18 new IOS versions in 2015
Headspace: 8 new IOS versions in 2015

This is just for the Apple IOS platform and just for 2015. Most apps are also frequently updating an Android version and a web version of the product, multiplying the amount of work.

The need for constant updates means that apps have to have access to significant funding.   Some of the apps on PsyberGuide have institutional financing, and many other apps rely on equity funding and growing a large user base. Lumosity and Headspace both use the popular model of offering a limited version of the product for free, and then charging subscription fees for more content. It is likely that they have a large enough user base that they can afford to keep constantly updating their apps in the future. Many other apps may have more difficulty finding the money for updates.

Brain Futures conference

BrainFutures 2015: Exploring New Frontiers to Improve Brain Health & Optimize the Mind’s Potential is an upcoming conference that will cover many of the new developments in brain technologies and neuroscience. There is also a BrainFutures Expo with hands-on access to new technologies.

Hosted by the Mental Health Association of Maryland, the conference is  November 4-5, 2015 in Annapolis, Maryland.  Information and registration for the conference.

Dr. Michael Knable of PsyberGuide is one of the speakers at the conference.  In a recent program on Maryland’s NPR affiliate station previewing the conference, Dr. Knable talks about reviewing mental health software and the issues around the customer benefits and patient safety.  Henry Harbin and Jay Lombard, two of the other speakers at the conference, are also interviewed.  Audio of the presentation is here.

 

The state of bi-polar apps

I recently came across a very interesting paper that I think points out the timely need for PsyberGuide and its mission to objectively review apps for mental illness. The paper is entitled: “Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality,” published in the Journal of Medical Internet Research.

The study was conducted by Jennifer Nicholas and her colleagues in Sydney Australia. They attempted to identify all English apps for bipolar disorder and to check on various aspects of their content. They found 517 apps, 82 of which met their very simple criteria for further review. Of these apps, only 22% had a stated privacy policy, only 36% of the apps that claimed to provide psychoeducation contained the accepted “core principles” of this technique, and only 15% of apps that claimed to provide psychoeducation followed best practice guidelines. None of the apps had been evaluated in a research study and only 31% cited a source for the information they contained. In addition, neither the comprehensiveness of the psychoeducation content, nor the adherence to best practice guidelines, was correlated to user ratings. Finally, many of the symptom monitoring apps failed to measure critical data elements such as medication adherence or sleep patterns.

This article points how easily it might be for users to buy an app that differs widely from accepted standards of care, and which therefore, could potentially lead to harm.

Electronic Case Management Techniques

A lot has been written in recent years about “access to care” problems for people with mental illnesses. For example, we know that a large sector of the United States lacks professionals who can treat mental disorders  and according to a recent report by Merritt Hawkins, psychiatry as a medical specialty has one of the highest numbers of vacant positions. Not only is access to care difficult for patients who live in rural or underserved urban areas, but communication between the various provider organizations (hospitals, residential programs, partial hospitalization programs, and outpatient clinics) that serve patients with mental illness tends to be poorly coordinated, which further complicates patients’ search for long-term stability. For these reasons, we at PsyberGuide are very interested to learn if digital technologies can close these access to care and communication gaps. To that end, we have been following several companies that are working in the “electronic case management” area.

Wellframe

Wellframe is a private, venture-backed company based in Boston whose purported customers are health insurance plans, provider organizations and pharmaceutical companies. They have developed the “Intelligent Care Management Platform” that uses a smart-phone app health checklist combined with HIPAA compliant Clinical Dashboard to track patient progress in many different health conditions, including psychiatry. They claim that their system allows care managers to meaningfully interact with more patients and reduce the number of costly phone and in-person sessions. They also claim that the system leads to better treatment adherence and consumer self-management. The company has sponsored one pilot studying looking at the use of their platform to improve the physical health of psychiatric patients (http://www.ncbi.nlm.nih.gov/pubmed/25636496). They have also recently concluded agreements with large behavioral health organizations to study their platform in young adults with mental illnesses in Boston, and in a population of veterans in Chicago.

 Mindoula

Mindoula  is a private company based in Maryland. They claim to provide around the clock connectivity between case managers (“Mindoulas”) and psychiatric patients using traditional methods (phone or in-person meetings) or a HIPAA-compliant digital platform that includes a smart phone app. The website is directed at consumers themselves, but the company claims that they can also serve individual and group medical practices, therapists, residential programs, hospitals, college counseling services and geriatric care groups. It is not clear from their website whether they have concluded contracts with larger organizations or are focused mainly on individual patients at this point.

ThriveStreams

ThriveStreams  is a venture backed company based in Brooklyn, NY. They have developed ThriveTracker, which is a smartphone app designed to improve the management of mood disorders by tracking mood ratings, sleep patterns and therapy sessions. Recently, the company has also developed ThriveSync, a platform similar to the two mentioned above, that combines a provider dashboard with a smart phone app to allow for active monitoring of patients with mood disorders, and hopefully for the development of more individualized and timely interventions. It is not clear from their website that any major contracts have yet been awarded.

We are quite sure that there will be many more such companies and technologies hitting the market soon and we will be tracking them closely. If you are a provider or a consumer and have had any experience with these systems we would be happy to have your input and comments.

 

The Promise of Technology: Efficient Systems, Better Care, and Improved Outcomes

I participated in this panel at the Kennedy Forum National Conference on June 9 in Boston. I gave an overview of PsyberGuide and our efforts to provide unbiased information on the usefulness and quality of digital applications for mental health. I described our most recent summary of the PsyberGuide internal rating system, the availability of expert reviews, and the difficulties we have had in collecting consumer input directly on our site. I received very positive feedback from many in the audience about the usefulness of our data.

Other members of the panel included: Lisa Marsch, Ph.D. is the Director of the Center for Technology and Behavioral Health at Dartmouth College. This center has received funding from NIDA and other sources to better incorporate digital technologies into clinical practice. Anne Altman is the General Manager of US Federal Government and Industries for IBM Corporation. Anne spoke about the efforts of her company to improve data analytic capabilities for government agencies that provide or evaluate healthcare. Bill Crouse, M.D. is Senior Director, Worldwide Health for Microsoft Corporation. Bill is an internist who is responsible for implementing technologic solutions in the healthcare industry. Stephen Kennedy Smith is Co-Founder and Executive Vice President of Pear Therapeutics, a company that is trying to develop and market linked prescriptions of pharmaceuticals with digital applications that may enhance efficacy.

The discussion was lively and thought provoking and I continue to be very impressed with the overall efforts of the Kennedy Forum to improve mental health care in this country.

App Curation and Prescription Services for Providers

While PsyberGuide is intended to be a service that gives information about apps and software marketed directly to consumers, there is a growing trend in the industry to develop “curation services” for providers or health care systems. In these systems, apps are evaluated or rated and providers that sign up for the service can e-prescibe products to their patients. Two of these services are:

AppScript

AppScript was developed by IMS Health, which is a very large (15,000 employees), publicly traded, healthcare consulting company based in Danbury Connecticut. AppScript claims to have evaluated more than 40,000 health care apps with a proprietary evaluation procedure. AppScript allows providers to register for their platform, and after reviewing products, prescribe them to patients by e-mail. The site contains apps for a variety of medical conditions. There is a specific category for Depression, which contains 8 rated apps, and a category called Mental Health and Behavioral Disorders, which contains 12 rated apps. Of the 8 apps for Depression, 6 have also been evaluated on PsyberGuide, and there appears to be general agreement between the two sites’ ratings. The remaining 2 apps in the Depression section are rating scales based on the Geriatric Depression Scale and the Beck Depression Inventory, and these are therefore are not self-directed treatment apps. Of the 12 apps in the Mental Health and Behavioral Disorders Category, only 1 of the products has also been evaluated on PsyberGuide. The AppScript site gives a detailed description of the apps including information on the manufacturer and cost. There does not yet appear to be significant data published on the site from patient and peer ratings. I found the site clever, attractive and easy to use and no fee was required for me to sign up.

SocialWellth

SocialWellth is a private company based in Las Vegas, Nevada. One of SocialWellth’s main investors is Cigna Corporation, the large health insurance company. In December 2014, SocialWellth acquired Happtique, which was started by the Greater New York Hospital Association, and which provided the basis for their healthcare app evaluation platform called mWellth. Apps are screened for functionality, consumer appeal and usability. Apps are then further evaluated for privacy and security issues, such as malware and encryption problems. Finally, an in-depth certification review is performed which includes assessments of research foundation, usability, and self-management capability. About 500 apps have been evaluated in this way. When providers use mWellth, they are able to log in, select a patient from an electronic database, and add a prescription for an app. The patient then receives an SMS message with a link to the app, and after using it, further data regarding patient use of the app are shared with the prescriber. As of this writing, I was not able to determine how to set up an account with SocialWellth, to examine the number of apps that might be relevant for mental illness, or if there was a fee associated with the service.