Medical Marvels 

Could mental health apps offer a much-needed lifeline during the Covid-19 pandemic? 

Covid-19 has affected almost every aspect of everyday life, including the toll it has taken on people’s mental health. Could technology offer much-needed support? Ellen Daniel investigates whether mental health apps are the answer.

Mental health apps have surged in popularity during the pandemic. Searches for mindfulness apps jumped by 2,500% in March 2020, according to a recent study by the Organisation for the Review of Care and Health Apps (ORCHA). The researchers believed developers behind these solutions could help provide “safe, trusted and evidence-based technologies” just as the coronavirus crisis raised the demand for these solutions. The question is whether they really can. 

“Without a doubt the pandemic has had a drastic impact on the mental health crisis,” says Sabine Bahn, co-founder and chief medical officer at mental health tech startup Psyomics. As well as underlying anxieties that inevitably come with living through a global pandemic, the coronavirus crisis has cut off many people from routines, friends and family, often whilst they also face increased financial insecurity. 

“The impact of isolation, particularly on those that were already vulnerable, is worrying,” says Bahn. “We have heard reports of patients avoiding seeking help for mental health conditions, possibly because they don’t want to ‘burden’ an already stretched health service. Others may be unaware that mental health services were still operating during this time.”

Among UK adults, 19.2% experienced some form of depression during the coronavirus pandemic in June 2020; almost double the 9.7% who said the same between July 2019 and March 2020, according to research by the Office of National Statistics.

Tech sector workers are seemingly suffering particularly badly, with 38% of them having considered therapy for the first time this year, according to recent research by Spill and Censuswide.

Without a doubt the pandemic has had a drastic impact on the mental health crisis

An appetite for apps

For those working remotely, lockdown measures have resulted in workers spending increasing amounts of time at home and with fewer opportunities for social interaction. At the same time, technology has created an “always on” mentality among some workers feeling like they must be contactable at all times, adding to the stress.

All these things together have amplified the need for psychological help. However, not everyone is able to get it. Even though the stigma surrounding mental wellbeing has lessened in recent years, those seeking support are often met with long waiting lists and financial barriers to treatment. 

Ironically, given it has exacerbated the problem, some believe that technology may also be a valuable lifeline during uncertain times. For some, this comes in the form of mental health apps. 

The last few years have seen a proliferation of digital self-help tools, with many people turning to mobile health resources in times of need. 

Mental health technology

Facilitated by the prevalence of smartphones and wearable devices, a growing number of startups backed by investors have emerged in this area.

Global investment in mental health technology reached $580m in 2019, but it is still a relatively small portion of the healthtech market as a whole, according to Octopus Ventures. Nevertheless, there are now over 10,000 mental health apps available to download from app stores, according to Bupa. Some have gained a loyal following, with stress reduction app Calm reaching over 100 million downloads and announcing a £22m funding round in July 2019.

These tools are ubiquitous and cater to many different mental health aspects. Apps such as Headspace offer guided meditations for those dealing with stress or loneliness. Elsewhere, apps such as PTSD Coach and RR: Eating Disorder Management provide support for those navigating more acute mental health conditions. Services like TalkSpace pair and connect users with licensed therapists. Mental health chatbots like Wysa enable individuals to talk about their feelings through a series of automated questions. Other apps provide tools to track the user’s mood or offer games designed to distract users from feeling anxious.

“Like having a therapist in your pocket”

But do they really help? Well, to some extent, yes. In an interview with medical instruction site MedCram, Peter Yellowlees, professor of psychiatry at UC Davis and telemedicine expert, explained that smartphone apps can be effective in supporting patients in-between contact with a trained therapist or medical professional, or for those facing lengthy waiting lists when seeking support. 

“From a mental health point of view, there are an increasing number of apps on [smartphones] that are essentially like having a therapist in your pocket,” he said. “I regularly use several apps with patients, particularly those who are anxious in their homes during Covid and can have them put their earbuds in and sign into an app and go through a series of either meditation or breathing or other relaxation-style exercises just as if they had a therapist with them when they get anxious. So I think there’s a lot of good things about phones and I strongly encourage people to use them.”

Spill is an example of one such service. The message-based therapy app launched an integration for workplace communication app Slack in January 2020. The partnership means employees of companies that sign up to Spill's services can access mental health resources, as well as making it easy for individuals to book video appointments with registered therapists, all without leaving Slack. 

I regularly use several apps with patients, particularly those who are anxious in their homes during Covid

Such resources have proven particularly relevant over the past 12 months, with remote working presenting new challenges for organisations looking to support employees’ wellbeing.

“Technology’s scalability empowers employers to give entire workforces access to proactive support at a relatively low cost,” says Nick Taylor, clinical psychologist, co-founder and CEO of Unmind, a workplace mental health platform. “This lowering of the barrier to accessing mental health services enables anyone in possession of a phone, computer or tablet to proactively manage, measure and improve their mental wellbeing, anywhere at any time.”

And the demand for this type of solutions is only set to grow. The percentage of full-time remote workers globally is expected to increase from 16.4% before the coronavirus outbreak to 34.4% in 2021, according to an Enterprise Technology Research study.

“Covid-19 has shone a light on the need for businesses to place employee wellbeing front and centre,” says Taylor. “Business leaders are directly seeing the impact of poor mental health on engagement, productivity and happiness. In the last few years, investment in mental health or traditional employee assistance programmes were nice-to-haves. But as we enter a new era of work, businesses need to take a more proactive approach to nurturing their staff’s mental wellbeing, beyond the crisis.

“Mental health platforms, and strong support networks for employees, will become an expected benefit as employers see the importance of supporting mental wellness. Employers will have a greater appreciation of wellbeing and be willing to invest in preventive and supportive tools will continue with greater momentum.”

“It is imperative that this care has continued with as little disruption as possible”

As well as providing support to individuals, these solutions can also be valuable tools for mental health professionals who may have less face-to-face contact with patients amidst the pandemic. Platforms such as Censeo from healthtech company Psyomics use algorithms to better understand a patient’s mental health. 

“Many psychiatrists manage the care of patients with complex needs, so it is imperative that this care has continued with as little disruption as possible,” says Bahn. “Most psychiatrists have moved to conducting assessments remotely via phone or video call. However, it is not just the delivery of assessment that needs to be adjusted, but also the content. Most standard mental health measures do not take into account global disruptions or disasters, which obviously can and do impact the individuals and their symptoms. The benefit of using digital assessment is that questions can be easily added or removed to tailor the assessment to make sure it is relevant to the time and experiences that people are going through.” 

Most psychiatrists have moved to conducting assessments remotely via phone or video call.

A comprehensive review of the current evidence for the benefit of chatbots in the field of psychiatry, published in the Canadian Journal of Psychiatry, concluded that the potential for conversational agents in psychiatric use is “high”. The researchers particularly noted that “conversational agents showed potential for benefit in psychoeducation and self-adherence”, adding that "satisfaction rating of chatbots was high across all studies, suggesting that they would be an effective and enjoyable tool in psychiatric treatment”.

A lack of evidence

While anecdotal evidence suggests that digital self-help tools can offer a valuable lifeline to those experiencing a range of mental health issues, research into the benefits of these apps is currently scarce. 

“The problem with all of the apps is they’ve had very little real research performed on them and so while they seem to be nice and have some good immediate validity, we really don’t know scientifically yet how effective some of them are,” warned Yellowlees.

Mental health charity Mind has highlighted that users should ensure that an app is genuine and secure before sharing personal health information. 

According to ORCHA, while there is evidence to show that digital therapies can achieve “comparable outcomes to face-to-face therapy”, of the 600 mental health apps it reviewed, only 29.6% met quality thresholds in terms of clinical assurance, data privacy and user experience. 

A recent IBM report on how technology and data can improve access to mental health resources highlighted that “people downloading an app don’t always know what they’re getting, including whose ‘expertise’ is the source of the content” and it expects that the “sophistication and the scrutiny” of mental health technology will improve over time.

People downloading an app don’t always know what they’re getting

This is echoed by a 2015 report published in the Evidence-Based Mental Health journal, which applauded mental health apps’ ability to circumvent financial barriers to treatment, a shortage of available trained professionals and long waiting lists. However, the report also repeated the warning of the lack of underlying evidence and stated that apps can also come with “issues including an over-reliance on apps, equity in access and increased anxiety resulting from self-diagnosis”. 

In short, tech solutions are by no means a replacement for other forms of support. They should instead be viewed as a tool to be used alongside guidance from a qualified practitioner. Like any form of support, digital mental health tools may prove more useful to some people than others, and individuals who find it difficult to talk about their wellbeing in-person may respond positively to an app. 

“What we want is for people to use the technologies well, but not excessively to a stage where they start losing out on the real-world relationships,” said Yellowlees.

The importance of regulation

The National Institute of Mental Health said there has been a “burst of app development” in the sector, but warned that very little industry regulation exists. The organisation has a point. 

When it comes to health apps, the regulatory landscape can be complex and, in some cases, non-existent. It is especially so given that these solutions operate across different regions and have to comply to the laws of that area. In the US, for instance, health and mental health apps do not fall under the Health Insurance Portability and Accountability Act, meaning they are not legally required to protect users’ health data. 

In the UK, while some health apps are subject to medical device regulation Care Quality Commission registration, others are not. 

In the absence of concrete regulation, some organisations have stepped in to offer patients guidance in this area. The American Psychiatric Association acknowledges a “growing patient, clinical, government, and payer interest in the potential of mobile health technologies for psychiatric clinical care”. In response it has developed an App Advisor, designed to help psychiatrists, mental health professionals and patients choose an app that best fits their needs. 

Furthermore, if mental health apps become more commonplace, greater regulation may follow. The FDA, for instance, recently launched its Digital Health Innovation Action Plan, outlining plans for a precertification programme for digital health technologies. 

The NHS has put together a library of over 20 approved mental health apps and has developed the Digital Technology Assessment Criteria for digital health tools, which sets out standards for clinical safety, data protection, technical security, interoperability and usability and accessibility. 

Personalised wellbeing support

IBM’s report predicts that digital health tools like apps could play a key role in the future of personalised mental health management, with data collected from multiple sources being used to create customised treatments for patients. As this happens, experts may start setting standards to ensure that digital tools meet certain quality requirements, with the report speculating that tools endorsed by government agencies, non-profit organisations or psychiatric associations could soon emerge. 

Only through empathetic conversation with a trusted health professional, can the full picture of needs and solutions be assessed

For this growing field to truly benefit those who need it most, the involvement of qualified mental health professionals and robust evidence during the development of new apps is key, as is the role of Google and Apple in ensuring that apps that appear in their app stores are reviewed carefully. 

“Only through empathetic conversation with a trusted health professional, can the full picture of needs and solutions be assessed,” says Christine Husbands, managing director at personal nurse adviser service RedArc. “There is definitely no ‘one-size, fits all’: two patients with exactly the same diagnosis can have very different concerns, circumstances and physical, practical and social needs but without professional insight it is difficult to assess the most appropriate support for each individual and the best way to deliver it.”