My month with Headspace: Martha Neary

Martha Neary is the Project Coordinator of PsyberGuide. She is based at Northwestern University as a member of Northwestern’s Center for Behavioral Intervention Technologies. She has a strong interest and background in child mental health. Her research interests also include reducing healthcare disparities among minority populations and integrating technology into mental health interventions.

I am not a meditator. I would like to be. I like the idea of meditation, but have little personal experience of regular meditation. My parents, however, are avid meditators; my mother meditates at least 30 minutes nearly every day, so I have decided that this makes me Zen by association (it definitely doesn’t). My month with Headspace was the first time I meditated consistently. Through this practice, I meditated for 4 hours over 30 sessions. There were a lot of things I liked about the app, and some things I didn’t.

From an aesthetic point of view, I love how the app looks. It has nice colors and animations, it was fun to use and easy to navigate through. I liked the voice on the meditation tracks (Andy Puddicombe, Headspace co-founder). I found it soothing, more casual and informal than other guided meditations I’ve heard, and unlike Stephen, I enjoyed the British accent (this may, however, be because I’m Irish, and reluctantly admit that the British accent made me feel at least a little closer to home).

As a beginner meditator, I appreciated how the app eased me into meditating. The first 10 sessions were 3, 5, or 10 minutes. Longer meditations, even 15 or 20 minutes, have seemed somewhat intimidating in the past, so these were a more manageable starting point. After the first sessions, the meditations did get longer (10-20 minutes). But by the time this happened, my Headspace honeymoon period had fizzled. I found the longer meditations repetitive. I couldn’t push myself through the 3 beginner packs the app recommends starting with, so I completed 2 basic packs and moved onto the Happiness pack.

In my limited meditation experience, I always felt that I was doing meditation ‘wrong’ by being distracted by other thoughts. Headspace assured me that was ok (and even normal)! One of the core mantras of the app is that it’s not possible for us to block all thoughts. Instead when our minds wander, we can gently bring them back to focus. This is illustrated by a clever exercise (accompanied by the cute animation below); “Imagine yourself sitting by a busy highway. Cars continue to pass by. You can choose to sit there and notice the cars without focusing on any of them, or you can follow a car down the road.” This non-judgmental approach was perfect for a beginner meditator (and self-confessed perfectionist) like me.

Admittedly, I enjoyed being a little part of the Headspace craze. I discovered that many of my friends were also using the app, which was motivating.  The Headspace ‘buddy’ network is not necessarily something I tapped into though; I didn’t discover this feature until near the end of my month, which brings me to what I didn’t like about the app. After a month of using Headspace, I still don’t think I have explored all of the features. The quantity of content is extremely impressive: there are packs for health, happiness, work and performance, sport, as well as single meditations for rough days, anxious moments, travel. However, at times I felt overwhelmed by so much content.  I avoided exploring new tracks as I didn’t want to sift through the options, and didn’t have enough information to choose the most relevant one.  Maybe that’s because I wasn’t being as savvy a user as I should have been, and it’s certainly a good complaint to have, but I would have liked a more guidance to work through the app and discover the features most relevant for me. In an ideal world, this app would ask me ‘How are you feeling today?’ and based on my response, guide me to the appropriate tracks.

Being a very evidence-focused person, I would have also liked some feature to track my progress. After a month of meditating, do I actually feel calmer, less stressed, happier? It’s hard to tell. My final qualm with the app is that I think it’s expensive. After the 10-day free trial, subscription is $12.95 per month or $95.88 per year (USD). I’m a huge advocate for investing in your mental health, I’m just not convinced that this is a worthwhile investment for me personally. I take time to destress and take care of my mental health by taking walks, spending time outside, or reading. I find these more enjoyable, more effective, and they’re free. Maybe Headspace is just not for me, or maybe I just didn’t reap all of the potential benefits due to issues around navigation and content overload.

Meditation is a very personal thing. This is a great app, it’s beautifully designed and has an abundance of content, but I struggled to turn my daily meditations into a routine. Once the novelty of the first 10 days of meditating wore off, I found the meditations repetitive and struggled to complete them. I don’t know that any other app would have led to a different outcome. There is a myriad of meditation apps out there which I’m interested to explore (many reviewed on PsyberGuide, like Calm, Potential Project, Smiling Mind, to name a few). I’m not yet convinced that Headspace is the best one, although it is the best marketed and widely used. Sure, it was nice to take 10 minutes each day to sit quietly, without my phone or computer or other distractions, and that’s something I’ll try continue to do. I just don’t know if I necessarily need Headspace, or a paid monthly subscription, to do that.

My month with Headspace

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.

Headspace is arguably the most popular and widely used mental health app. Headspace’s website reports having over 15 million users. Andy Puddicombe’s, one of Headspace’s founders, TEDTalk has nearly 8 million views. On our PsyberGuide site, the information about Headspace is one of the most visited pages (behind just our home page and product guide). Because of this, we’ve decided to take a deeper dive into Headspace, using it as an example to learn more about digital mental health tools, and providing more content for those of you using Headspace or wanting to learn more.

First, though, I have a small confession. Of course, I’ve heard of Headspace, I’ve downloaded Headspace, I’ve looked at Headspace, but admittedly, I had never really used Headspace. That is to say, I’ve poked around the free content. Listening to the basics, watching the videos, playing around with the reminders. But, I never committed to practicing Headspace on a consistent basis. So, for the past month I’ve used Headspace. I logged 3 hours of practice through 28 sessions (sorry, I didn’t make it to 1 session each day, some days I really struggled to find the time and motivation, although it appears I’m not alone in this1). Through this month, I learned a few things and I wanted to share those thoughts with the PsyberGuide community.

Content. Headspace is one of the deepest mental health apps I’ve seen in terms of quantity of content. The audio tracks address diverse targets. This includes health issues covering all aspects of life, from pregnancy and cancer to stress and depression. Our professional lives and hobbies are noted in tracks on work & performance and sports. Headspace Pro provides content for those who want to take it to the next level (I definitely did not see myself as a “pro”). Headspace kids for ages grouped 5 and under, 6-8, and 9-12 (sadly I couldn’t get my 2-year-olds to sit through any of these so no opinions here). Content is meant to fit the structure of your schedule, your attention span, and your skill with tracks ranging from 1 to 10 minutes. I really liked the shorter meditations and my average duration ended up being 7 minutes. I would have loved a couple without that British accent though, no offense to the British, it just didn’t work for me.

Making it a practice. Here’s one place I would have liked more help. Headspace has a lot of features to make the app more “sticky.” Notifications, streaks, a play button prominently displayed when you start up the app. But I really struggled with transforming my use of the app into a true practice. And this is definitely a skill I have other places in my life. I’m a runner and put in about 2,000 miles each year. I’ve run 9 marathons and one 50k. Doing this has required me to train my body and my mind to tolerate runs that last a long time and long distances. However, my early days of running were short distances, alternating periods of running and walking, and I still have to boost my weekly mileage by about 40% to gear up for a race. As I began my month with Headspace, the 10 minute meditations really challenged me. I slogged through the Basic pack before I started to utilize the minis. This isn’t just a feature of Headspace, starting the practice of meditation is challenging no matter how you come to it. If I hadn’t committed to try this for 30 days, then I probably wouldn’t have been able to do even as much as I did. I would have loved to have someone or something help me better figure out ways to better use the tools to slowly build me up. Alternate minis, packs, and singles.

Focusing on why I’m doing it. Maybe I missed a feature, but I felt the metrics Headspace reflected back to me (e.g., number of minutes, number of sessions, streaks), were more about what Headspace wanted me to do (continue to use the app) rather than what I wanted to get out of Headspace. My goals are to improve my focus, reduce procrastination, feel more relaxed, along with all the things I set out to accomplish in my life. I would love to track progress on the things I care about or connect to what I hoped to get out of Headspace.

So for 30 days Headspace simplified the practice of meditation. It put it in my pocket and allowed me to take it with me wherever I went. To my office, on trips. It’s hard to say if I’m more mindful, more productive, or happier as a result of it. But I also think I realized early on that Headspace was not for me. I stuck with it because I wanted to see where it would go. It has a lot to offer and given its popularity it’s obviously doing a lot right. We’ll have another take on Headspace in a few weeks here and we’ll put up some more material regarding the app on PsyberGuide. I hope you find it useful and as always, feel free to post your own thoughts and experiences in the comments below or on our social media.

  1. Laurie, J., & Blandford, A. (2016). Making time for mindfulness. International journal of medical informatics96, 38-50. http://dx.doi.org/10.1016/j.ijmedinf.2016.02.010

 

 

 

 

Bringing apps into the therapy room

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.

Many people get excited about the potential of mobile apps to transform mental health care because not enough current treatment resources exist. Long waiting lists, limited availability in rural areas contribute to difficulties in receiving care. Therefore, a lot of apps, app-based services, and app research studies are intended to be used instead of traditional face-to-face services. However, this overlooks the fact that for many people, having a professional relationship with a licensed mental health provider might be necessary to deal with their mental health issues. Furthermore, licensed providers might be able to guide people to effective apps and help them steer clear of bad ones. Thus, mobile apps can play a role in the context of face-to-face practices. As adjuncts to traditional care they can increase people’s engagement with their treatment and hopefully make such treatments more effective and efficient.

Providers then need guidance as to what apps are effective, what features they offer, and how they might be able to be used in their practice. A recent review of mobile apps for mental health attempted to address some of these issues with questions such as what are the common features of apps that are effective? And what are the implications of such findings for practitioners? Joyce Lui, David Marcus, and Christopher Barry from Washington State University combed the research literature and identified 21 studies evaluating 18 different apps.1 These apps targeted anxiety disorders, mood disorders, post traumatic stress disorder, schizophrenia, and substance use disorders. Eight of those apps, or roughly half, were designed specifically as adjuncts to traditional therapy, including things such as DBT Coach for or The Stress Manager. We’ve identified several other apps on PsyberGuide that are intended for use with providers like the eCBT of the VA’s PE Coach.

Most apps have some form of symptom monitoring and a menu of therapeutic skills. Common skills included cognitive restructuring, relaxation techniques, drink refusal skills, and scheduling pleasurable activities. If you are a provider and these are skills you cover in your practice then there are several apps that can help support your clients practice these skills outside of sessions. If you are a client receiving therapy, apps that help monitor symptoms might provide you the tools necessary to bring objective data into the therapy room when you’re asked “So, how was your week?”

Very few apps offer testimonials from individuals who have recovered from the same disorder or used that app. This is unfortunate because learning how other people used the same app to overcome similar difficulties could be useful for both clients and providers in determining how that app might be useful for them. Social features within the apps often use people’s own contacts within the phone or can share progress on social media. I would strongly encourage clients and providers to be wary of the use of social media within mental health apps. Few apps provide details about how user’s information is gathered or returned to the software developers. Information may be shared to a user’s social media account inadvertently, without the user’s knowledge, or a user may later come to regret information that was shared intentionally. It would be great if more apps had safe and secure ways of connecting users to other people, but currently this does not seem to exist in most mental health apps.

In the end, it appears as though apps that could be brought into the therapy room face many of the same issues that mental health apps do generally. Too many apps with too little research evidence makes it hard to separate the good from the bad. Therefore, I would really encourage clients and providers to consult guides, like PsyberGuide, to engage with their professional communities (e.g., local and national organizations), and if you are using apps in your practice to share what you’re learning. We’re always happy to hear from people at PsyberGuide and will be working to develop more resources to help providers interested in using apps in their practice.

  1. Lui, J. H., Marcus, D. K., & Barry, C. T. (2017). Evidence-based apps? A review of mental health mobile applications in a psychotherapy context. Professional Psychology: Research and Practice48(3), 199-210. http://psycnet.apa.org/psycinfo/2017-07848-001/

 

 

 

 

“How do you use this thing?” Apps and Usability

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.


Although many researchers and academics have decried the lack of scientific evidence for many mobile apps available on the public app stores, fewer have brought up the glaring usability issues of such resources. Usability refers to how easy an app is to use. In order for a mobile health app to be useful, it must first be usable. Usability testing, that is the analysis of how well users can learn and use a product to achieve their goals and how satisfied users are with that process, has a long history in the development and evaluation of technologies. Engineers, computer scientists, and human-computer interaction specialists usually consider usability guidelines in their designs and evaluate usability as a first step in the evaluation of novel technologies. Usability testing is less frequently used in by clinical psychologists or behavioral scientists conducting research on mobile mental health apps, who often jump to evaluations of whether apps lead to intended changes in clinical outcomes (e.g., less depressed or anxious, increased well-being). Therefore, we often learn whether or not an app can be effective, without knowing how easy it is for people to use it on their own. Usability is captured in “Functionality” score on the Mobile App Rating Scale (MARS) that PsyberGuide uses to rate products listed on our site. Functionality on the MARS refers to the functioning, ease of use, navigation, flow logic, and gestural design of the app.

A recent study explored the usability of 4 mental health apps (Depression CBT, Mood Tools, Optimism, and T2 MoodTracker).1 Twenty-six patients were invited into the laboratory to complete a series of tasks on these apps and researchers watched, videotaped, and questioned participants to learn more about the usability of these apps. These tasks included data entry tasks such as entering one’s mood or taking a depression test and data retrieval tasks such as viewing a graph or watching a video. Only 51% of the time were participants able to complete the data entry tasks without assistance. Data retrieval tasks were even more challenging at 43%. Participants reported that their experiences with these apps were frustrating and instilled a lack of confidence that such tools could then be helpful for them. Not an extremely positive review of the usability of these apps.

I bring up these results as a word of warning both to those developing mobile health apps and those using mobile health apps. Developers, we can and should do better. Mobile health apps should be easy to use for a wide range of the people. The authors of this paper offered the following advice: (1) explain why each task is helpful, (2) use simple language and graphics, (3) reduce the number of screens, and (4) reduce manual entry as much as possible. And for those who want to use mobile health apps, this is one reason we provide multiple ratings of mental health apps on our website. PsyberGuide ratings address the credibility of a product. MARS ratings combine several aspects of an app, including its functionality. Lastly, expert reviews provide detailed information about why and how an app might be beneficial for you. An app might have a lot of research support, and thus a high PsyberGuide rating, but low scores for engagement, functionality, and aesthetics and thus a low MARS score. Usability and functionality might be a more important aspect for particular people. For designers, we need to better understand the capacities of the people we’re designing for. For users, it’s helpful to have a sense of your own capabilities with mobile technology and to select an app that best fits with those capabilities. If you’re having trouble using a mobile app, you’re not alone and it might be useful to run it by someone you trust – a doctor, family member, friend, to see if they can help you figure it out. And remember that for you to benefit from a mobile app, you need to use it, and one of our tasks at PsyberGuide is to help you find which apps are most usable.

  1. Sarkar, U., Gourley, G. I., Lyles, C. R., Tieu, L., Clarity, C., Newmark, L., … & Bates, D. W. (2016). Usability of commercially available mobile applications for diverse patients. Journal of general internal medicine31(12), 1417-1426. https://www.ncbi.nlm.nih.gov/pubmed/27418347

 

 

 

 

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.

 

Can apps reduce anxiety?

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.


A recent meta-analysis by Joseph Firth and colleagues [1] explored whether the scientific evidence supports that smartphone apps can reduce symptoms of anxiety. Meta-analyses are often considered one of the most useful forms of scientific information because they combine the results of several studies to produce a more powerful investigation than any single study could provide. The findings of Firth and colleagues meta-analysis suggest that smartphone apps were an effective form of treatment for anxiety, although the size of the impact is what researchers would call small-to-moderate. That means, that we can reliably say that smartphone apps designed to decrease anxiety can do so, but that the impact would be less than one would expect with the gold standard face-to-face treatments or medications. This is not surprising, the dose of “treatment” from these smartphone apps was much shorter than what one would typically receive in terms of face-to-face treatment or medications, ranging from 4 to 10 weeks with an average of 6.1 weeks.

It is useful to dig into this meta-analysis a little more deeply as it tells us what we know (and don’t know) about the effectiveness of smartphone apps for anxiety and some of the limitations of the current research. First, the authors identified only 9 eligible studies that collectively represented 1837 total participants. There are many more than 9 apps targeting anxiety available in the Google Play and Apple iTunes store, which again shows that most of the apps available have no direct scientific evidence confirming their effectiveness. Conversely though, only 4 of the apps are currently available in those app marketplaces (Flowy, myCompass, SuperBetter, and components of the LivingSMART intervention which consisted of non-mental health apps such as Google Calendar, Evernote, Stayfocusd or SimplyNoise with instructions on how they could be applicable for mental health issues). We currently only have SuperBetter listed on PsyberGuide, along with an expert review, but will work to get these other resources listed in the near future. The 1837 people included in this meta-analysis likely represents a small portion of the total number of people with anxiety who have downloaded a mental health app. It is impossible to know how well these 1837 people represent people who download apps for anxiety more generally. These people tended to be adults, average age of 36.1 years, women (65.2%), and no study used a diagnosed anxiety disorder as a criterion for inclusion. Therefore, it’s hard to say how well apps would work for adolescents or older adults, men, or people with more severe anxiety.

The most impactful apps were those that were included along with some other treatment either face-to-face or Internet-based therapy programs. This is an important caution that for many people, apps alone are unlikely to be a sufficient treatment. If you’re not currently receiving treatment, an app can be a good way to introduce you to important treatment skills like deep breathing, exposure, goal setting, or self-monitoring. If you’re in treatment, apps can help support the work you are currently doing, although it might be useful to discuss with your provider for suggestions or which skills or apps might be the most useful. And lastly, if you’ve received treatment in the past, apps can help reinforce the work you’ve done or to keep up with some of the skills you’ve learned. If you use an app and don’t feel like you’re getting better that doesn’t mean you’re beyond help, it might be that you haven’t found the right app or that it would work better for you in combination with something else.

Thus, although this meta-analysis is a useful summary of the current research evidence, it illustrates the need for additional information: evidence produced by researchers on the efficacy of such apps, evidence gained from consumers on the effectiveness of such apps, and evidence from experts, like that provided in PsyberGuide, to better guide decisions regarding the usefulness of smartphone apps for anxiety. The findings provide enthusiasm that smartphone apps can work but more information is needed about which ones, for whom, and how people can get the most benefits out of such resources.

1. Joseph Firth, John Torous, Jennifer Nicholas, Rebekah Carney, Simon Rosenbaum, and Jerome Sarris. Can smartphone mental health interventions reduce symptoms of anxiety? A
meta-analysis of randomized controlled trials. Journal of Affective Disorders, 218, 15-22.

http://www.sciencedirect.com/science/article/pii/S0165032717300150

 

 

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; http://i4health.paloaltou.edu/) and Distinguished Professor of Clinical Psychology at Palo Alto University (https://www.paloaltou.edu/).  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.