When mental health care goes home
If you find yourself looking at screens a bit more these days due to COVID-19, then you are in good company. Reading this at the time of publication in May 2020, it might be hard to believe that only two months ago the BBC was recommending that we all cut down on screen time by installing an app to make everything on our screen look grey. In fact, this was ranked number 2 on ‘Eight simple things you can do to live better’1. Despite the longstanding enthusiasm for discussing links between screen time and wellbeing by the media, the science surrounding whether or not screen time is actually relevant to our mental wellbeing is not entirely supportive of a link. For example, researchers from the University of Oxford demonstrated (with some rigorous statistics) that it’s likely using screens is as strongly linked to mental wellbeing as eating potatoes2. Or in other words, not incredibly relevant.
Due to this, local researchers, such as Dr. Holly Scott at the University of Glasgow3, are now focussing on what people actually do when they are online and how this may impact upon wellbeing, rather than simply how long they actually spend looking at screens. Demand for digital mental health interventions has increased since the start of the pandemic4 suggesting that many of us are using our screen time to try and take care of our mental health.
A recent summary on the impact of quarantine reports that we can expect an increase in anxiety and even post-traumatic stress disorder (PTSD) due to social distancing measures being used to flatten the curve of COVID-195 (and that isn’t even considering the impact of the virus itself, such as death of a loved one). However, it’s clear that many people were struggling with mental health problems long before any of this happened6. As it seems like “every country in the world” has more demand for mental health care than the ability to provide it7, digital solutions such as mental health apps have been mooted as a means to upscale provision and provide support. Therefore, a burgeoning science of mental health apps exists. A lot of evidence on the efficacy of measures such as social distancing comes from pre-COVID-19 pandemics and has informed the design of government response8.
So, if an aspiring entrepreneur is inspired by the current pandemic to design and test an evidence-based app to support people with their mental wellbeing, what does the existing evidence suggest they should consider?
Once our app developer has decided which issue they would like to address (anxiety? Depression? Psychosis?) it’s important to find out what people who experience these problems would actually want from an app. Mental health app scientists don’t get to decide whether or not an app is user friendly, their users do. Looking to the evidence, conducting usability evaluations9 (exploring how easy an app is to use) would be a key step. Usability evaluations can be conducted at a very early stage of research (designing an app together with people who experience mental health problems) or at later stages, such as by giving people prototypes and then making changes based on feedback.
At all stages, it’s important to discover the motivations, values and emotions that people experience when engaging with an app as these can inform usage. And if it seems no one wants to use an app? Well, that’s OK too. Some key journals, where researchers may disseminate findings from their work, have policies encouraging user involvement. For example, the British Medical Journal (BMJ) now requires a ‘Patient and Public Involvement Statement’10 within the methods section of any submitted work, describing how the authors involved patients and the public within their research.
Sadly, the existing evidence suggests there are a lot of problems with data security regarding mental health apps. For example, a number of apps supporting people with problems such as depression and smoking have been found to be selling private data to Google11. Concerningly, this study found that nearly a third of apps did not have any sort of security policy in place. Of those that did, it was still difficult to figure out who had access to the private mental health data of end users and what this was being used for. This, combined with the fallout of digital security scandals such as Cambridge Analytica fresh in the minds of many, means our app developer should seriously consider a strong data security policy. For example by following best practices for app developers12 and not forgetting GDPR13.
It’s normal for any intervention to have both positive and negative effects. While an app might not actually do anything to improve your mental health, it is important to know whether or not it could actually be harming you. Apps could inadvertently make your mental health worse. Researchers at the University of Glasgow discovered (that at least in the case of apps for schizophrenia) that app creators weren’t routinely asking people using the app about any negative impacts upon their wellbeing that occurred during app usage14. Therefore, any would-be app developer should seriously consider voluntarily adopting enhanced adverse event monitoring procedures to ensure that their app is safe to use.
While it might seem obvious to point out, the ability to use an app depends on well… having a mobile phone in the first place. Digital exclusion still persists in Scotland15, with older people and those living in more rural and/or deprived areas being less likely to have access to the internet at all. Our app developer might want to think about providing access to a smart phone with data (and support on how to use it) to maximise who can take part in their research.
It’s typical for many people who download a mental health app to log in a few times and then never use it again. What could our prospective app creator do to try and encourage people to stay involved? A study exploring predictors of longer-term usage for Android apps downloaded from Google Play discovered that one of the best predictors for long-term app use was the provision of peer support16 – the ability to interact with another person accessing the app for the same issues as you. Looking at this evidence, our app developer may not want to create an app which sits on its own but to consider including some aspect of human contact.
Building an Evidence Base
While it’s understandable to want to help people who are struggling to access support for their mental wellbeing, such as by building an app, people should only be using interventions that are known to actually work for mental health problems. Once they’ve reached the stage of testing their app, our creator should consider employing rigorous testing.
Currently, many apps that are available to download on the app store do not have any evidence that they work17. By the time they’ve developed an app, our entrepreneur has likely invested a lot of time into their work but it’s important they do their best to make sure the app does what they claim it will. Despite many apps not actually having much evidence behind them, organisations such as the NHS compile libraries of evidence-based apps. Currently, staff in NHS England now have free access to many different evidence-based mental health apps18. However, even ‘apps with evidence’ may only present cherry-picked evidence that indicates they are effective. For example, the website for Headspace (a popular meditation app) at the time of writing only includes positive studies19 and does not link to publications (such as the one described here20) which suggest sham meditation may be equally as beneficial as the Headspace product.
Digital app development is a fast-moving field and there is considerable debate about how best to evaluate interventions. They might even consider looking at what qualifications local universities in Glasgow are offering in order to learn how to do this better21 22.
People needing support for mental health problems have a right to access evidence-based treatment and many people were not getting adequate support before the pandemic. Designing any sort of mental health app is challenging and any app developer wanting to assist during COVID-19 (and beyond) will need to think about so much more than these six topics and keep on top of a complex and rapidly changing global situation. However, learning from all the work done by digital mental health app scientists might just get them started.
This article was specialist edited by Alison Hughes and copy-edited by Katrina Wesencraft.