What Can Tooth Brushing Teach Us About Behavior Change in the Era of Digital Health?

by John Torous

John Torous MD is a board certified psychiatrist who has a background in computer science.  He co-directs the Beth Israel Deaconess Medical Center’s digital psychiatry program, www.psych.digital, where he also serves as a staff psychiatrist and a clinical informatics fellow. He also serves as the Editor-in-Chief of JMIR Mental Health. You can                                                                        follow him on Twitter @JohnTorousMD


All health apps, including mental health apps, experience a serious engagement problem. A large observational study of an asthma-monitoring app [1], real world users of an app for post traumatic stress disorder, PTSD Coach [2], and even the popular gamified physical activity app Pokémon GO [3] all show the same pattern. Many users download the app, most use it a few times, but few persist after a few weeks. In short, despite people’s strong interest in using health apps, few people stick with them.

It is useful to check our assumptions about ideal engagement against other healthy behavioral patterns. Take tooth brushing for example. This is healthy habit that seems routine and ubiquitous. The American Dental Association recommends that people brush their teeth twice a twice. What can tooth brushing teach us about helping people stick with health apps?

A first step is to check the data.  Apparently only 69% of Americans brush their teeth twice per day [4]. That means nearly one third are not able to stick with this simple healthy habit! If nothing else, this shows how challenging behavior change is, there are no ‘easy wins.’ But looking at the bright side, 69% is large amount of the population. What can these people teach us about success? What helps them stick with twice-daily tooth brushing? While there are of course many factors, one of the most common is that it is fast and part of their daily routine.

Mental health apps can learn from this. Brushing your teeth takes about two minute – but how long does it take to use most mental health apps. Many apps offer lessons drawn from traditional face-to-face therapies that take users hours to read! Others create entire digital ecosystems that take hours to master and significant time to navigate. What if mental health apps could be simpler and faster to use? A recent study by Dr. David Mohr and the IntelliCare team, including Stephen Schueller, PsyberGuide’s Executive Director, explored if a suite of mental health apps called IntelliCare designed for ultra brief use sessions would be engaging and effective. [5]. Findings showed that usage of the apps followed from this design consideration. App sessions averaged 1.1 minutes and people used the apps an average of 3.5 times per day. Furthermore, people experienced significant reductions in depression and anxiety with over three-fourths of people either in full remission or recovery after 8 weeks. The results of the study suggest that these ultra brief  apps were indeed both effective and engaging – highlighting a new paradigm for mental health apps – and perhaps all health apps.

Apps have much to offer mental health, but there is still much that apps must improve on to be more effective mental health tools. The IntelliCare study offers an encouraging solution to engagement. You can learn more about IntelliCare and find where to download here.

Trivia: What percent brush their teeth while driving: 0.2%. What percent of teen have used their smartphone while driving: 80%.

  1. Chan YF, Wang P, Rogers L, Tignor N, Zweig M, Hershman SG, Genes N, Scott ER, Krock E, Badgeley M, Edgar R. The Asthma Mobile Health Study, a large-scale clinical observational study using ResearchKit. Nature Biotechnology. 2017 Apr 1;35(4):354-62.
  2. Owen JE, Jaworski BK, Kuhn E, Makin-Byrd KN, Ramsey KM, Hoffman JE. mHealth in the wild: using novel data to examine the reach, use, and impact of PTSD coach. JMIR mental health. 2015;2(1):e7.
  3. https://medium.com/achievemint/can-augmented-reality-alter-reality-quantifying-the-pok%C3%A9mon-go-effect-561bf996d4b9
  4. https://www.deltadental.com/Public/NewsMedia/NewsReleaseDentalSurveyFindsShortcomings_201409.jsp
  5. Mohr DC, Tomasino KN, Lattie EG, Palac HL, Kwasny MJ, Weingardt K, Karr CJ, Kaiser SM, Rossom RC, Bardsley LR, Caccamo L. IntelliCare: An Eclectic, Skills-Based App Suite for the Treatment of Depression and Anxiety. Journal of Medical Internet Research. 2017;19(1):e10.

 

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