We Know There's an App For That (Part I)--But Often Research Lags Behind Mobile Mental Health App Claims

“It’s a nascent field, and few health apps have been rigorously evaluated. A lot of the apps you see out now have a disclaimer, or should have a disclaimer, that they have not been validated through rigorous research. It comes down to the individuals’ perceptions that the app works for them.” ~ Alain B. Labrique, director of the Hopkins Global mHealth initiative

Sample app for self-regulation via CBT

I don’t know how I existed before my iPhone.

It can tell me the weather, inform me of the latest bad news in the market, check the answer to my husband’s crossword puzzle via Google so that I sound like a trivia genius, keep me abreast of all my social media accounts, take pictures of my perfect grandchildren, make sure I get every SPAM e-mail at any moment, allow me to identify birds when I’m on one of my birding outings where I get so excited upon hearing a call, only to determine it’s once again a robin–and I’m really scratching the surface.

To be honest, most of my multitude of apps belong to the grandkids–all about birds with anger problems and making already squeaky voices squeakier. I don’t know what to make of them–and since the kids know how to download better than I do,they cover the face of a multitude of screens.

But clearly people like myself who mainly check e-mail and Twitter and then take more shots of the grandkids, are missing the boat, for nowadays apps for mental health are making serious inroads. Sometimes I think  I’ll just have to keep a step ahead of them to keep myself in a job–although I do have a personality that’s a bit hard to computerize.

Although I’m from the old-fashioned world where interaction with a therapist is optimal, the apps may address certain mental health issues. This is particularly true in the area of self-regulation.

Great. I’m all for progress.

But due to the quick movement of mobile technology, I start to wonder if we haven’t gotten ahead of ourselves. The apps sound good, and I’ve given some practice tries and found them promising.

But, a researcher at heart, I can’t help but notice a lack of, well, research on the effectiveness of the treatments.  Note how many times the research articles say their studies suggest effectiveness, or are only preliminary, or might mean that patients will improve, or recommend further research–you get the drill.

I’m not for holding out on using an app until I’ve got a randomized controlled trial proving its effectiveness in my hand–but I’d like a little more than I’ve got.

See what you think.

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SELF-REGULATION

We all have days when it’s tempting to throw what I would call, for lack of a ‘grown-up’ term for it, a temper tantrum.

Days when you’re tempted to flick your pens and pencils, one by one, at the boss’s back–and then graduate to tape dispensers and glue sticks, and, if you’ve really had it, dream about hurling that stapler.

Days when, if your husband comes home and complains that you’ve overcooked his steak [which, in truth, you have], you’d be only too pleased to dump the steak in his lap–and follow it up with a long pour of A-1 sauce.

Days when, if the computer refuses to connect to the Internet just one more time, you’re ready to rip out all the wires from that thing with all the flashing lights that your teenage son assures you is your access point, open a window, and see how if you can throw the darned thing as far as your neighbor’s window, since, come to think of it, you’re sick of their teenage son playing loud music right as you are about to enter REM sleep.

Really, we’ve all been there–and it’s so so tempting.

Unfortunately, it appears that it’s bad for us. I’m sorry to be the one to break the news.

Evidence–drat those studies!–just piles up to assure us that self-regulation [the trendy psychological term for self-control] is a prerequisite for emotional health.

In terms of behavior, to reduce it to the lowest common denominator, self-regulation means not throwing a temper tantrum when the mood strikes. Taking it up a notch, self-regulation is the ability to alter behaviors in accordance with your standards and beliefs [fundamentally we don't believe that throwing modems into neighbors' windows is a way to live, and we really do hold ourselves to higher standards, which is why it hasn't happened--yet.] (Baumeister & Vohs 2007).

In terms of emotion, self-regulation is the capacity to soothe yourself when you’re upset and lift your spirits when you’re down.

All-told, self-regulation’s a good thing, across the board. The National Institute of Health writes:

Effective self-regulation leads to adaptive interpersonal interactions, development of a positive self-identity, engagement in positive health behaviors, receptiveness to information (including threatening information), cognitive flexibility, and impulse control. Lapses in self-regulation can be highly consequential, promoting addictive behavior, and undermining critical long term pursuits such as educational attainment, social integration, and health promotion.

There’s basically no getting around it. So to the apps we go.

There are a remarkable number of mobile apps that deal with mood, behavioral and emotional regulation. Yet, interestingly, when I searched the scholarly databases for publications on their proven usefulness–nada. Publications are not keeping apace of app creation–understandable, given the pace of app-creation, but leaving us with very little solid ground to stand on in asserting the effectiveness of these mobile health applications.

My gut instinct tells me that simple Cognitive Behavioral Therapy (or CBT) apps–where you list your unhelpful or unproductive thought and then go through ways to combat that thought–would be as useful as the standard homework sheets given by a CBT therapist, since that is what they mimic. Therefore I provide a list of them below at the bottom. Most of the them state that they are taken out of CBT workbooks.*

But what of mobile technology meant to help you regulate actual behavior?

Well,  let’s take a moment to look at the literature that there is, and what it indicates about the mental health regulation apps.

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“Smartphone apps may be promising for helping people improve their health. However, research on apps for these and other health promotion purposes has not kept pace with technological innovations, and their efficacy is yet to be determined”. ~ ER Breton, health and technology researcher

In 2011, Michael Susick Jr. wrote a thesis paper, “Applications of Smartphone Technology in Management of Treatment of Mental Illnesses” that was illuminating, and pointed out some positives of smartphones.

One of the largest pluses of doing CBT homework (a crucial component of the therapy) on the phone as opposed to with pen-and-paper was not anything inherent in the app’s creativity; rather it was simple compliance, which went up significantly if adolescents had to monitor moods between sessions.

The program “Mobile Mood Chart” was installed on . . .adolescents’ personal phones and they were asked to fill out the mood questionnaire for 2 weeks. This group’s completion rate was compared to a group of adolescents who were given paper and pen diaries to keep track of their mood. The authors reported that they only retrieved 18 paper diaries (35% of the paper and pen group) compared with an 81% completion of diaries in the mobile phone group.

Simply having the phone with you helps on compliance with homework; that seems sensible. But what about effectiveness?

Susik found that, overall, CBT modules helped patients using smartphone technology more than patients in a control group–but the effect was significantly less than in-person CBT sessions.

That doesn’t say much to me. It tells me kids like playing with their phones more than they like doing pencil and paper work, and it tells me that if the teens did enter the requisite data, they did better than if they had done.. . .nothing. It’s not a total rave review.

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The ultimate validation of one’s product is to submit it to the rigors of a clinical trial to see if the product actually provides the intended clinical benefit.. . . .This type of clinically based patient feedback is critical to the product development process and cannot be achieved via traditional qualitative or quantitative methods. ~ Demir Bingol, vice president of commercial marketing and commercial development at WellDoc, whose flagship app is the FDA-approved DiabetesManager

The MD Andersen Center notes that mobile health apps ‘don’t get the job done’ the same way many other, more helpful apps,  do. Their explanation? Well, says Alexander V. Prokhorov, M.D., Ph.D., director of MD Anderson’s e-Health Technology Program and professor in the Department of Behavioral Science,

Many companies are in such a hurry to sell their app that they don’t conduct a study to see if users will adopt real, lasting change. . .And, app stores don’t have medical reviewers who make sure health apps are medically sound.

It’s somewhat concerning, giving what we come to rely upon them for.

In the paper, “Mobile Therapy: Case Study Evaluations of a Cell Phone Application for Emotional Self-Awareness,” the authors  analyzed a mobile app that combined ‘experience sampling’ of mood, which would help gather information that would give insight to users over time, with cognitive behavioral exercises, which were to be used as ‘on-the-spot- interventions.

It was a small, case study paper , analyzing 8 users, their self-regulation insights, and whether there was growth in regulation over time as a result of the cognitive behavioral exercises.

Although the study was too small to be definitively conclusive, the authors found that

Interview narratives suggest that study participants applied the mood scales and therapeutic content in ways that helped them initiate meaningful personal change. . . .[O]bservations suggest a readiness to use mobile therapies when experiencing intense emotions.

And that’s all good and well, although ‘suggestion’ of ‘a readiness to use mobile therapies’ doesn’t sound like a ringing endorsement of their effectiveness.

So, to be academically honest, researchers really couldn’t end there. A qualitative study of 8 people does not a proof make, as they forthrightly state

This was a preliminary study with limitations that should be addressed in future studies. The first limitation concerns the small sample size used for this initial, qualitative exploration of how people adopt mobile therapies. . . To evaluate the efficacy of such a system, a large controlled study would be required. . . .. Ideally the study should continue for a longer period of time to allow accommodation to the mood scales. Finally, evaluating this type of intervention is complicated because it combines therapy and assessment and because people’s use of the tool changes over time. [emphasis mine]

Complicated to evaluate, huh? I like that.

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One whole market of self-regulatory apps that research concludes does not work is in controlling drinking. According a study published in  the December issue of the journal Alcoholism: Clinical and Experimental Research, few apps exist on the iPhone to help you cut back on alcohol, and what exists had not been shown to work.

In a review piece entitled “No Proof That Smartphone Apps Help Drinkers Reduce Alcohol Use,” author Amy Sutton quoted lead author of the study, Amy Cohen, that

we really didn’t find any empirically based apps to help people quit drinking.

90% percent of the apps that tried a form of intervention utilized some empirically based principles of alcoholism treatment, such as, for our purposes, self-control training, or self-monitoring and feedback,” but  there was no evidence that any of the apps underwent testing for effectiveness.

In short, says Cohn, what’s missing is. . . .the research.

That seems to be what happens when you don’t have clinical trials, and don’t really test for effectiveness.

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Under the principle that anyone, researcher or no (competent or no), can make an app and market it, let’s take a look at an iPhone app called Appetite Manager, supposedly for those with eating issues. The app–and these are its own words

controls your appetites. . . [I]t’s better diet than calorie counting [sic].

So now we’ve got an app that controls our appetites, if we believe everything we app-read. Where have you been all my Reese’s-Peanutbutter-Cup-filled life?

So here you get points for eating behavior:

Only ‘diet food’ all day?  +10 for you.
Ate ‘some kind of junk food’–only once (is this for real?)?:  +5.
A binge?? Lose 60 points.

And what do you do with these points? This is a for-real quote from the app ad:

When you get `100` points, you can eat your favorite food. . . . It makes your stress decrease.

I don’t have to be a rocket scientist to know this app didn’t pass any clinical trials–and doesn’t pass muster–since it actually contradicts existing research on eating issues. It’s a given in treating eating disorders (and really in creating a healthy approach toward food for all) that you don’t think of yourself as better (or worth more points, as here) if you ‘eat right,” and you most certainly don’t reward yourself with food for good behavior.

So, yes, there’s an app for eating disorders–but lack of any recourse to the most basic of the research causes it it to make the situation worse than leaving it up there to gather dust on the app shelf.

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In a study published as “Weight loss—there is an app for that! But does it adhere to evidence-informed practices?,” the authors analyzed 204 apps downloadable from iTunes directly related to weight loss and management.

By the time their study began, in late 2009, the researchers noted that

To date, we are not aware of any efficacy studies of commercially available smartphone [weight-loss] apps.

They also found, almost shockingly, that not one weight-loss cessation app adhered to all 13 of the ‘evidence-informed practice for weight loss programs’ recommended by government agencies. These recommendations are common among the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Food and Drug Administration (FDA), and the US Department of Agriculture (USDA). Only 15% of the apps had 5 or more.

Overall, the authors did not believe the apps to be helpful in controlling weight-loss long-term–and they clearly believe research into the apps and their efficacy could have made a significant difference in this situation, and they conclude about health apps in general that

Continued research is needed that sheds light on the accuracy of smartphone apps for health behavior change in the public domain, and research is also needed that seeks to develop, improve, and evaluate these apps. [emphasis mine]

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Smoking-cessation apps fared not a whole lot better when assessed for adherence to evidence-based practice guidelines, and for evaluation by research for their efficacy.

The ‘gold standard’ in smoking treatment is the U.S. Public Health Service’s 2008 Clinical Practice Guideline for Treating Tobacco Use and Dependence.

“iPhone Apps for Smoking Cessation: A Content Analysis” found that “currently available smoking cessation apps have low-level of adherence,” and the most popular apps were not the most adherent.

On average, the antismoking apps scored 7.8 out of a possible 60 points, the researchers reported in March in the American Journal of Preventive Medicine.

In short, the research that we know to be helpful in quitting smoking is not being incorporated into the smoking-cessation apps–even the most popular ones–and then there’s no research into how the apps will assist in the quitting process. The one piece of research we have in hand is into the efficacy of the  apps themselves, post-fact–and it’s not highly flattering.

Suggests author Lorien Abroms from the Department of Prevention & Community Health at the GW School of Public Health and Health Services:

Although this content analysis reveals that currently available apps have low levels of adherence to key guidelines from the US Public Health Service’s 2008 Clinical Practice Guidelines, future apps may nonetheless serve as powerful tools in smoking cessation. It is therefore recommended that new apps be developed and existing apps be revised around evidence-based principles, and that these apps undergo rigorous evaluations. [emphasis mine]

The refrain is clear—these apps could help/might help–if they only followed known principles for treatment, were tested in advance, and were ‘rigorously evaluated’ for the contribution they do, in fact, make, to smoking cessation.

[Clearly a woman not just to gripe and moan, Abroms created her own smoking-cessation mobile program in the end of 2011, this one based on evidence-based best practice. Not exactly an app, but based on mobile technology, it became available to individuals just a few weeks ago--and after clinical trials (published in The Lancet no less, indicated) indicated positive success rates. Apparently top research can be done and implemented into the best of mobile health programs, after all. (Free, et al)]

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[The]  majority of the literature [on technological interventions in mental health] consisted of either pilot or feasibility studies which had a low number of participants, limiting the generalizability of the reported results. These studies also generally reported on preliminary findings and/or focused on case studies in lieu of quantitative analysis of health outcomes. ~ Michael Susick Jr.

 Thus concluded Susick in 2011. I would say, a year later that:

App-wise, we’re in a different world.

Research-wise, we have not come a long way, baby.

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*Note on CBT-based apps for reduction in negative thinking:

A quick perusal of my iPhone found 6 CBT-related apps with a single focus on CBT–meaning not CBT-based apps that focus on depression or drinking or migraines or panic or trauma or sleeping, all of which are out there.

It’s a sure thing that each one doesn’t come with its own published research, but I looked at them, and overall found them useful, especially to a person who isn’t seeing a therapist, or isn’t too familiar with CBT philosophy.

If you’re in the market for regulating negative thoughts. . .

Check out:

• eCBT (with a brief overview of cognitive behavioral therapy, the app then prepares you to keep a feelings and thoughts log, and has an ‘automatic thought identification tool’ to help challenge negative beliefs)
• ICBT (geared ,as  would be expected, at combatting troubling and negative thoughts; has a list of common emotions and distortions)
•  CBTReferee  (recommended for those with depressive-tendencies; user records thoughts, then does the CBT drill, identifying errors in thinking and challenges negative patterns of thinking)
• i Can Do It (claiming it can help you “transform inertia and procrastination into immediate action by quickly dealing with the thoughts and feelings blocking you from the task,” it helps you identify your blocking thoughts or feelings and rephrase them in a more motivating way)
• iCouch CBT (like some of the others,  you start out by filling out a ‘what happened’ screen, describe your negative thoughts, and add your emotions. Then you select your cognitive distortions and create a better thought.)
• Moodkit (one of the ‘big-buck’ apps at $4.95, this one works through the CBT process using 4 components. The Activities section provides over 150 ‘mood-lifting activities,’ while Thought Checker does the standard identifying a feeling and its thought distortions. Mood Tracker lets you rate your daily mood from 1-10 and integrates that with the MoodKit Journal which leaves space for written notes.)

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REFERENCES

Abroms LC, Padmanabhan N, Thaweethai L, Phillips T. iPhone apps for smoking cessation: a content analysis. American Journal of Preventive Medicine 2011; 40(3):279-85.

Anger in the Age of Entitlement

Baumeister RF, Vohs KD . Self-Regulation, Ego Depletion, and Motivation. Social and Personality Psychology Compass 2007; 1:1-14.

Breton ER, Fuemmeler BF, Abroms LC. Weight loss—there is an app for that! But does it adhere to evidence-informed practices? Translational Behavioral Medicine 2011; 1: 523-529.

Free C, Knight R, Robertson S, et al. Smoking cessation support delivered via mobile phone text messaging (txt2stop): a single-blind, randomized trial. Lancet 2011; 378(9785):49-55.

Luxton D, et al. mHealth for mental health: Integrating smartphone technology in behavioral healthcare. Professional Psychology: Research and Practice 2011; 42(6):505-512.

Morris ME, Kathawala Q, Leen TK, Gorenstein EE, Guilak F, Labhard M, Deleeuw W. Mobile Therapy: Case Study Evaluations of a Cell Phone Application for Emotional Self-Awareness. Journal of Medical Internetet Research 2010; 12(2):e10.

Susick M. Applications of Smartphone Technology in Management of Treatment of Mental Illnesses. Thesis presented to Graduate Faculty of Public Health, Pittsburg University, 2011.

Related articles

• Cognitive Therapy (allaboutcounseling.com)
• Emotional Regulation: Getting Your Emotions Out of the Driver’s Seat (letlifeinpractices.com)
• Cognitive Behavioral Therapy, delivered as a Videogame, Can Help Lower Anxiety and Depression (sharpbrains.com)
• CBT effective for mental problems (arabnews.com)

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Tagged: CBT, CBT apps, cognitive behavioral therapy, mental health apps, mobile apps and mental health, self-regulation

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