Mental Health Apps Research Articles

A conceptual model of feedback mechanisms in adjusted affordances – Insights from usage of a mental mobile health application

Affordance theory provides one of the most prominent lenses through which the socio-technical aspects of a system’s use can be investigated and understood. In this context, the literature has proposed that perceived and actualized affordances may be adjusted over time. Yet, how the adjustment of affordances occurs has not been explained in detail. Thus, in this article, we develop a conceptual model of feedback mechanisms that includes a more explicit description of how affordances are perceived by users, whether actualized and adjusted. With the model, we introduce the central concept of a generative base, out of which affordance perceptions emerge and which can be updated through affordance actualizations. With this base, we integrate mental model (MM) theory to explain better the differing perceptions before and after actor–artifact interactions. Our conceptual model is illustrated and specified using an empirical case of the mental mobile health (mHealth) app “Between The Lines” in Germany. In this study, we conducted 40 interviews in two rounds with 20 teenage app users. Our results show that the users’ perceptions of mHealth affordances become adjusted and hence change over time due to experiencing the actualization process, which may lead to an update of the generative base, including the user’s MM.

Artificial intelligence-informed mobile mental health apps for young people: a mixed-methods approach on users’ and stakeholders’ perspectives

BackgroundNovel approaches in mobile mental health (mHealth) apps that make use of Artificial Intelligence (AI), Ecological Momentary Assessments, and Ecological Momentary Interventions have the potential to support young people in the achievement of mental health and wellbeing goals. However, little is known on the perspectives of young people and mental health experts on this rapidly advancing technology. This study aims to investigate the subjective needs, attitudes, and preferences of key stakeholders towards an AI–informed mHealth app, including young people and experts on mHealth promotion and prevention in youth.MethodsWe used a convergent parallel mixed–method study design. Two semi–structured online focus groups (n = 8) and expert interviews (n = 5) to explore users and stakeholders perspectives were conducted. Furthermore a representative online survey was completed by young people (n = 666) to investigate attitudes, current use and preferences towards apps for mental health promotion and prevention.ResultsSurvey results show that more than two-thirds of young people have experience with mHealth apps, and 60% make regular use of 1–2 apps. A minority (17%) reported to feel negative about the application of AI in general, and 19% were negative about the embedding of AI in mHealth apps. This is in line with qualitative findings, where young people displayed rather positive attitudes towards AI and its integration into mHealth apps. Participants reported pragmatic attitudes towards data sharing and safety practices, implying openness to share data if it adds value for users and if the data request is not too intimate, however demanded transparency of data usage and control over personalization. Experts perceived AI-informed mHealth apps as a complementary solution to on–site delivered interventions in future health promotion among young people. Experts emphasized opportunities in regard with low-threshold access through the use of smartphones, and the chance to reach young people in risk situations.ConclusionsThe findings of this exploratory study highlight the importance of further participatory development of training components prior to implementation of a digital mHealth training in routine practice of mental health promotion and prevention. Our results may help to guide developments based on stakeholders’ first recommendations for an AI-informed mHealth app.

On the privacy of mental health apps

An increasing number of mental health services are now offered through mobile health (mHealth) systems, such as in mobile applications (apps). Although there is an unprecedented growth in the adoption of mental health services, partly due to the COVID-19 pandemic, concerns about data privacy risks due to security breaches are also increasing. Whilst some studies have analyzed mHealth apps from different angles, including security, there is relatively little evidence for data privacy issues that may exist in mHealth apps used for mental health services, whose recipients can be particularly vulnerable. This paper reports an empirical study aimed at systematically identifying and understanding data privacy incorporated in mental health apps. We analyzed 27 top-ranked mental health apps from Google Play Store. Our methodology enabled us to perform an in-depth privacy analysis of the apps, covering static and dynamic analysis, data sharing behaviour, server-side tests, privacy impact assessment requests, and privacy policy evaluation. Furthermore, we mapped the findings to the LINDDUN threat taxonomy, describing how threats manifest on the studied apps. The findings reveal important data privacy issues such as unnecessary permissions, insecure cryptography implementations, and leaks of personal data and credentials in logs and web requests. There is also a high risk of user profiling as the apps’ development do not provide foolproof mechanisms against linkability, detectability and identifiability. Data sharing among 3rd-parties and advertisers in the current apps’ ecosystem aggravates this situation. Based on the empirical findings of this study, we provide recommendations to be considered by different stakeholders of mHealth apps in general and apps developers in particular. We conclude that while developers ought to be more knowledgeable in considering and addressing privacy issues, users and health professionals can also play a role by demanding privacy-friendly apps.

"Money Doesn't Buy You Happiness": Negative Consequences of Using the Freemium Model for Mental Health Apps

As global rates of anxiety and depression increase, we observe millions of downloads of mobile apps addressing mental health that adopt 'freemium' charging models offering complex combinations of free and paid features. We explore potentially negative outcomes of deploying such freemium designs to vulnerable MH populations. We assess outcomes for 41 frequently downloaded mental health apps, by combining thematic analysis of 41K user reviews with audits to validate app descriptions and reviews. We propose a new analytic framework identifying three types of negative outcomes for freemium deployments: first vulnerable users currently experiencing crises may feel pressure to download unhelpful or costly apps. Second unintuitive descriptions of complex apps can lead to inappropriate treatments and expensive subscriptions. Third, limited duration offers may result in incomplete treatments or unexpected charges. We discuss ethical considerations and broader HCI consequences. We describe implications for mental health app design, including the need for greater transparency around free versus paid features, and propose new approaches to provide vulnerable users with validated information about these commonly downloaded apps.

"For an App Supposed to Make Its Users Feel Better, It Sure is a Joke" - An Analysis of User Reviews of Mobile Mental Health Applications

Mobile mental health applications are seen as a promising way to fulfill the growing need for mental health care. Although there are more than ten thousand mental health apps available on app marketplaces, such as Google Play and Apple App Store, many of them are not evidence-based, or have been minimally evaluated or regulated. The real-life experience and concerns of the app users are largely unknown. To address this knowledge gap, we analyzed 2159 user reviews from 117 Android apps and 2764 user reviews from 76 iOS apps. Our findings include the critiques around inconsistent moderation standards and lack of transparency. App-embedded social features and chatbots were criticized for providing little support during crises. We provide research and design implications for future mental health app developers, discuss the necessity of developing a comprehensive and centralized app development guideline, and the opportunities of incorporating existing AI technology in mental health chatbots.

Mental health mobile application self-help for adolescents exhibiting psychological distress: A single case experimental design.

The present demand for child and adolescent mental health services exceeds the capacity for service provision. Greater research is required to understand the utility of accessible self-help interventions, such as mobile apps. This study sought to investigate whether use of a mental health app, underpinned by CBT, led to changes in psychological distress amongst adolescents. Mechanisms of change were examined, specifically whether changes are attributable to cognitive strategies. This study utilised a multiple-baseline single-case experimental design, tracking variables across baseline and intervention phases. Surveys assessing participant experience were also administered. Five participants with moderate-to-severe levels of psychological distress engaged with a CBT-based app over five weeks. Participants were recruited from both a well-being service and the general population. Supplementary weekly calls to participants offered clarification of app content. A small overall effect of the intervention of psychological distress was evident; however, outcomes were dependent on the analysis conducted. The intervention appeared to promote an increase in use of adaptive cognitive strategies but not negative thinking styles. The CBT app did not promote changes in participant well-being. Participant feedback highlighted practical challenges of utilising the app. The clinical benefits of app-based CBT were small, and a range of barriers to engagement were recognised. While further research is required, caution should be exercised in the interpretation of studies reporting on app effectiveness.

The feasibility of using Apple's ResearchKit for recruitment and data collection: Considerations for mental health research.

In 2015, Apple launched an open-source software framework called ResearchKit. ResearchKit provides an infrastructure for conducting remote, smartphone-based research trials through the means of Apple's App Store. Such trials may have several advantages over conventional trial methods including the removal of geographic barriers, frequent assessments of participants in real-life settings, and increased inclusion of seldom-heard communities. The aim of the current study was to explore the feasibility of participant recruitment and the potential for data collection in the non-clinical population in a smartphone-based trial using ResearchKit. As a case example, an app called eMovit, a behavioural activation (BA) app with the aim of helping users to build healthy habits was used. The study was conducted over a 9-month period. Any iPhone user with access to the App Stores of The Netherlands, Belgium, and Germany could download the app and participate in the study. During the study period, the eMovit app was disseminated amongst potential users via social media posts (Twitter, Facebook, LinkedIn), paid social media advertisements (Facebook), digital newsletters and newspaper articles, blogposts and other websites. In total, 1,788 individuals visited the eMovit landing page. A total of 144 visitors subsequently entered Apple's App Store through that landing page. The eMovit product page was viewed 10,327 times on the App Store. With 79 installs, eMovit showed a conversion rate of 0.76% from product view to install of the app. Of those 79 installs, 53 users indicated that they were interested to participate in the research study and 36 subsequently consented and completed the demographics and the participants quiz. Fifteen participants completed the first PHQ-8 assessment and one participant completed the second PHQ-8 assessment. We conclude that from a technological point of view, the means provided by ResearchKit are well suited to be integrated into the app process and thus facilitate conducting smartphone-based studies. However, this study shows that although participant recruitment is technically straightforward, only low recruitment rates were achieved with the dissemination strategies applied. We argue that smartphone-based trials (using ResearchKit) require a well-designed app dissemination process to attain a sufficient sample size. Guidelines for smartphone-based trial designs and recommendations on how to work with challenges of mHealth research will ensure the quality of these trials, facilitate researchers to do more testing of mental health apps and with that enlarge the evidence-base for mHealth.

4.F. Skills building seminar: How can we achieve effective interdisciplinarity in digital public health practice?

Abstract Digital technology, which is driven by technical opportunities rather than by demands, can fail to realise the critical objectives of evidence-based public health and pose novel ethical, legal, sociocultural, and equity-related challenges. While individual health already needs various disciplines to be adequately addressed, even more fields gain importance when it comes to population health. Public health requires collaboration across all domains: Those that tackle an individual's health but also those that set the framework for health practices (e.g., law, medicine, psychology, ethics, or sociology), measure health outcomes on a population-level (e.g., epidemiology), or that develop interventions to improve the populations’ health (e.g., health promotion, health management, implementation science). During the last years, health has become more and more digitalised. Adding the digital level to public health also brings more and increasingly important players on the stage (e.g., human-computer-interaction, computer science, or engineering), who are needed to develop and improve evidence-based digital technologies and innovations on a population level. Having various disciplines collaborating with each other can offer new opportunities but also create new challenges if there is no mutual understanding of digital public health. This skill-building workshop aims to foster awareness of interdisciplinary approaches in public health research and practice. Two short introductory presentations (10 minutes each) will form the frame for the workshop. The first talk will introduce participants to the idea of interdisciplinarity in research and practice and highlight the prerequisites for effective and sustainable interdisciplinary collaborations. The second talk will build on this understanding and present a holistic (digital) public health model that displays how different disciplines contribute to the field and how an interdisciplinary approach can be used to overcome individual challenges. Based on the talks, participants will be invited to work on a case study regarding mobile mental health apps as a digital public health intervention. We will apply the world coffee method, in which each table will display one individual discipline (epidemiology, health economics, psychology, law, ethics, and computer science). An expert in the field will support each table to assist the participants if needed. Every participant will be able to discuss their ideas at three tables (10 min. each). The goal will be to work out how one could best integrate the individual disciplines when developing, implementing, and evaluating mental health apps in the digital public health environment. We discuss what each discipline can contribute to the topic and for which aspects it needs support from other scientific fields. The final results will be collected and summarised as a chapter in a digital public health handbook published by the Leibniz ScienceCampus Digital Public Health. Key messages • Considering different disciplines when developing and implementing digital public health interventions improves the interventions’ outcomes and long-term acceptability in user groups. • Interdisciplinarity in digital public health requires a mindset from researchers that is characterised by empathy/curiosity towards other disciplines and a common understanding of the intervention.

Understanding Mental Health Apps for Youth: Focus Group Study With Latinx Youth.

An increasing number of mental health apps (MHapps) are being developed for youth. In addition, youth are high users of both technologies and MHapps. However, little is known about their perspectives on MHapps. MHapps might be particularly well suited to reach the youth underserved by traditional mental health resources, and incorporating their perspectives is especially critical to ensure such tools are useful to them. The goal of this study was to develop and pilot a process for eliciting youth perspectives on MHapps in a structured and collaborative way. We also sought to generate learnings on the perspectives of Latinx youth on MHapps and their use in ways that might facilitate discovery, activation, or engagement in MHapps, especially in Latinx populations. We created a series of focus groups consisting of 5 sessions. The groups introduced different categories of MHapps (cognitive behavioral therapy apps, mindfulness apps, and miscellaneous apps). Within each category, we selected 4 MHapps that participants chose to use for a week and provided feedback through both between-session and in-session activities. We recruited 5 youths ranging in age from 15 to 21 (mean 18, SD 2.2) years. All the participants identified as Hispanic or Latinx. After completing all 5 focus groups, the participants completed a brief questionnaire to gather their impressions of the apps they had used. Our focus group methodology collected detailed and diverse information about youth perspectives on MHapps. However, we did identify some aspects of our methods that were less successful at engaging the youth, such as our between-session activities. The Latinx youth in our study wanted apps that were accessible, relatable, youth centric, and simple and could be integrated with their offline lives. We also found that the mindfulness apps were viewed most favorably but that the miscellaneous and cognitive behavioral therapy apps were viewed as more impactful. Eliciting youth feedback on MHapps is critical if these apps are going to serve a role in supporting their mental health and well-being. We refined a process for collecting feedback from the youth and identified factors that were important to a set of Latinx youth. Future work could be broader, that is, recruit larger samples of more diverse youth, or deeper, that is, collect more information from each youth around interests, needs, barriers, or facilitators or better understand the various impacts of MHapps by using qualitative and quantitative measures. Nevertheless, this study advances the formative understanding of how the youth, particularly Latinx youth, might be viewing these tools.

Mental Health Mobile Apps in the French App Store: Assessment Study of Functionality and Quality.

BackgroundApproximately 800 million people, representing 11% of the world’s population, are affected by mental health problems. The COVID-19 pandemic exacerbated problems and triggered a decline in well-being, with drastic increase in the incidence of conditions such as anxiety, depression, and stress. Approximately 20,000 mental health apps are listed in mobile app stores. However, no significant evaluation of mental health apps in French, spoken by approximately 300 million people, has been identified in the literature yet.ObjectiveThis study aims to review the mental health mobile apps currently available on the French Apple App Store and Google Play Store and to evaluate their quality using Mobile App Rating Scale–French (MARS-F).MethodsScreening of mental health apps was conducted from June 10, 2022, to June 17, 2022, on the French Apple App Store and Google Play Store. A shortlist of 12 apps was identified using the criteria of selection and assessed using MARS-F by 9 mental health professionals. Intraclass correlation was used to evaluate interrater agreement. Mean (SD) scores and their distributions for each section and item were calculated.ResultsThe highest scores for MARS-F quality were obtained by Soutien psy avec Mon Sherpa (mean 3.85, SD 0.48), Evoluno (mean 3.54, SD 0.72), and Teale (mean 3.53, SD 0.87). Mean engagement scores (section A) ranged from 2.33 (SD 0.69) for Reflexe reussite to 3.80 (SD 0.61) for Soutien psy avec Mon Sherpa. Mean aesthetics scores (section C) ranged from 2.52 (SD 0.62) for Mental Booster to 3.89 (SD 0.69) for Soutien psy avec Mon Sherpa. Mean information scores (section D) ranged from 2.00 (SD 0.75) for Mental Booster to 3.46 (SD 0.77) for Soutien psy avec Mon Sherpa. Mean Mobile App Rating Scale subjective quality (section E) score varied from 1.22 (SD 0.26) for VOS – journal de l’humeur to 2.69 (SD 0.84) for Soutien psy avec Mon Sherpa. Mean app specificity (section F) score varied from 1.56 (SD 0.97) for Mental Booster to 3.31 (SD 1.22) for Evoluno. For all the mental health apps studied, except Soutien psy avec Mon Sherpa (11/12, 92%), the subjective quality score was always lower than the app specificity score, which was always lower than the MARS-F quality score, and that was lower than the rating score from the iPhone Operating System or Android app stores.ConclusionsMental health professionals assessed that, despite the lack of scientific evidence, the mental health mobile apps available on the French Apple App Store and Google Play Store were of good quality. However, they are reluctant to use them in their professional practice. Additional investigations are needed to assess their compliance with recommendations and their long-term impact on users.

Development of a Mental Health Application: A Formative Evaluation

Although numerous mental health applications (apps) are available to the public, the process behind their development is unclear. Many researchers doubt the validity of the mental health content in existing apps and have criticized the lack of evidence-based content regarding the targeted mental health issues, such as trauma, anxiety, and depression. The purpose of this study is to systematically describe the entire process of designing, developing, and evaluating a mental health app in South Korea. Using an instructional systems model, we describe the entire mental health app design and development process through five phases: analysis, design, development, implementation, and evaluation (ADDIE). Using those phases, we conducted expert reviews and usability tests and examined whether the mental health app helped to improve the emotional and psychological issues of users. Overall, participants were highly satisfied with the mental health app, specifically for low- and medium-risk conditions. Our mental health app demonstrated its potential to cultivate mental health literacy and reach a large Korean audience. Further implications are discussed.

Mental Health Weekly would like to know your thoughts on mental health apps

In recent years we have seen tremendous growth in the availability of mental health apps and other virtual tools for patient treatment and support. Are you finding any of these useful for clients in your organization? Send us your comments via email to garyenos5@gmail.com; we will plan to include some of your thoughts in our coverage of this topic in our Innovations Issue in October.

Online mental health treatment use among college students at-risk for suicide

Mental health apps (MHAs) and online interventions have considerable potential for addressing the unmet mental health needs of college students at-risk for suicide. We examined attitudes about MHAs and reported use of online treatment (online interventions and MHAs) among at-risk college students using a diverse sample of 827 students. About 65% of students were inclined to use MHAs, with over a third preferring MHAs to in-person treatment. Despite positive attitudes, actual use of online treatment was low. The full potential of online treatment on college campuses has not been fully realized due to low student awareness and uptake.

Developing a smartphone App based on the Unified Protocol for the transdiagnostic treatment of emotional disorders: A qualitative analysis of users and professionals' perspectives

Emotional Disorders have become the most prevalent mental disorders in the world. In relation to their high prevalence, mental health care from public health services faces major challenges. Consequently, finding solutions to deliver cost-effective evidence-based treatments has become a main goal of today's clinical psychology. Smartphone apps for mental health have emerged as a potential tool to deal with it. However, despite their effectiveness and advantages, several studies suggest the need to involve patients and professionals in the design of these apps from the first stage of the development process. Thus, this study aimed to identify, from both a group of users and professionals, the needs, opinions, expectations and design aspects of a future smartphone app based in the Unified Protocol (UP), that will allow to develop the subsequent technical work of the app engineers. Two focus groups were conducted, one with 7 professionals and the other with 9 users, both groups familiar with the UP. A thematic content analysis based in grounded theory was performed in order to define emergent categories of analysis derived from the interview data. The results revealed 8 common topics in both focus groups and 5 specific key topics were identified in the professionals' focus group. Of the total proposals, 93 % of the professionals' and 78 % of the users' are implemented in the preliminary version of the app.

Systematic assessment of the quality and integrity of popular mental health smartphone apps using the American Psychiatric Association's app evaluation model.

Mobile phones are playing an increasingly important role in supporting mental health, by providing confidential, accessible and scalable support for individuals who may not seek or have means of accessing professional help. There are concerns, however, that many apps claiming to support mental health do not meet professional, ethical or evidence-based standards. App store search algorithms favour popularity (reviews and downloads) and commercial factors (in-app purchases), with what appears to be low prioritisation of safety or effectiveness features. In this paper, the most visible 100 apps for “depression”, “anxiety” and/or “mood” on the Google Play and Apple App stores were selected for assessment using the American Psychiatric Association App Evaluation model. This model systematically assesses apps across five broad steps: accessibility, integrity, clinical and research evidence base, user engagement and interoperability. Assessment is hierarchical, with the most fundamental requirements of apps assessed first, with apps excluded at each step if they do not meet the criteria. The relationship between app quality and app store visibility was first analysed. App quality was also compared across four different app function types: mental health promotion or psychoeducation; monitoring or tracking; assessment or prevention; and intervention or treatment. Of the 92 apps assessed (after eight failed to meet inclusion criteria), half failed to meet the first criterion step of accessibility, and a further 20% of the remaining apps failed to meet the second criterion step of security and privacy. Only three of the 10 apps most visible on app stores met the criteria for research/clinical base and engagement/ease of use, and only one app fulfilled all five criterion steps of the evaluation model. Quality did not differ significantly across app function type. There was no significant correlation between app quality and app store visibility, which presents a potential risk to vulnerable consumers. The findings of this review highlight the need for greater accountability of app developers to meet, and report, at least minimum quality and integrity standards for their apps. Recommendations are also provided to assist users and clinicians to make informed choices in their selection of reputable and effective mental health apps.

Comparing Professional and Consumer Ratings of Mental Health Apps: Mixed Methods Study.

BackgroundAs the number of mental health apps has grown, increasing efforts have been focused on establishing quality tailored reviews. These reviews prioritize clinician and academic views rather than the views of those who use them, particularly those with lived experiences of mental health problems. Given that the COVID-19 pandemic has increased reliance on web-based and mobile mental health support, understanding the views of those with mental health conditions is of increasing importance.ObjectiveThis study aimed to understand the opinions of people with mental health problems on mental health apps and how they differ from established ratings by professionals.MethodsA mixed methods study was conducted using a web-based survey administered between December 2020 and April 2021, assessing 11 mental health apps. We recruited individuals who had experienced mental health problems to download and use 3 apps for 3 days and complete a survey. The survey consisted of the One Mind PsyberGuide Consumer Review Questionnaire and 2 items from the Mobile App Rating Scale (star and recommendation ratings from 1 to 5). The consumer review questionnaire contained a series of open-ended questions, which were thematically analyzed and using a predefined protocol, converted into binary (positive or negative) ratings, and compared with app ratings by professionals and star ratings from app stores.ResultsWe found low agreement between the participants’ and professionals’ ratings. More than half of the app ratings showed disagreement between participants and professionals (198/372, 53.2%). Compared with participants, professionals gave the apps higher star ratings (3.58 vs 4.56) and were more likely to recommend the apps to others (3.44 vs 4.39). Participants’ star ratings were weakly positively correlated with app store ratings (r=0.32, P=.01). Thematic analysis found 11 themes, including issues of user experience, ease of use and interactivity, privacy concerns, customization, and integration with daily life. Participants particularly valued certain aspects of mental health apps, which appear to be overlooked by professional reviewers. These included functions such as the ability to track and measure mental health and providing general mental health education. The cost of apps was among the most important factors for participants. Although this is already considered by professionals, this information is not always easily accessible.ConclusionsAs reviews on app stores and by professionals differ from those by people with lived experiences of mental health problems, these alone are not sufficient to provide people with mental health problems with the information they desire when choosing a mental health app. App rating measures must include the perspectives of mental health service users to ensure ratings represent their priorities. Additional work should be done to incorporate the features most important to mental health service users into mental health apps.

The Effectiveness of Mobile Apps for Monitoring and Management of Suicide Crisis: A Systematic Review of the Literature.

Suicide risk is a multifaceted phenomenon, and many risk factors are involved in its complexity. In the last few decades, mental health apps have spread, providing economic and affordable strategies to prevent suicide. Therefore, the aim of this review is to identify original studies on mobile apps that target suicidal crises. The review follows PRISMA guidelines, searching through four major electronic databases (PubMed/MEDLINE, Scopus, PsycInfo and Web of Science) for relevant titles/abstracts published from January 2010 to May 2022. It includes original studies that explicitly analyze mobile apps for suicide prevention. A total of 32 studies met the inclusion criteria. Sixteen studies assessed the feasibility and acceptability of mobile apps, ten studies assessed the efficacy of mobile apps in preventing suicide, and six studies described randomized control trial protocols not yet implemented. Generally, the apps were judged by participants to be acceptable and helpful, and several improvements to enhance the functionality of apps were suggested. The efficacy of mobile apps, although limited and assessed with very heterogenous methods, was confirmed by most of the studies. Mobile apps could represent a helpful supplement to traditional prevention tactics, providing real-time monitoring of at-risk persons, personalized tools to cope with suicidal crises, and immediate access to specific support.

Mental Health Weekly would like to know your thoughts on mental health apps

In recent years we have seen tremendous growth in the availability of mental health apps and other virtual tools for patient treatment and support. Are you finding any of these useful for clients in your organization? Send us your comments via email to garyenos5@gmail.com; we will plan to include some of your thoughts in our coverage of this topic in our Innovations Issue in October.

Efficacy and Conflicts of Interest in Randomized Controlled Trials Evaluating Headspace and Calm Apps: Systematic Review.

BackgroundAlthough there are thousands of mental health apps, 2 apps, Headspace and Calm, claim a large percentage of the marketplace. These two mindfulness and meditation apps have reached tens of millions of active users. To guide consumers, clinicians, and researchers, we performed a systematic review of randomized controlled trials (RCTs) of Headspace and Calm.ObjectiveOur study aimed to evaluate intervention efficacy, risk of bias, and conflicts of interest (COIs) in the evidence base for Headspace and Calm, the two most popular mental health apps at the time of our search.MethodsTo identify studies, we searched academic databases (Google Scholar, MEDLINE, and PsycINFO) and the websites of Headspace and Calm in May 2021 for RCTs of Headspace and Calm testing efficacy via original data collection, published in English in peer-reviewed journals. For each study, we coded (1) study characteristics (eg, participants, sample size, and outcome measures), (2) intervention characteristics (eg, free vs paid version of the app and intended frequency of app usage), (3) all study outcomes, (4) Cochrane risk of bias variables, and (5) COI variables (eg, presence or absence of a preregistration and the presence or absence of a COI statement involving the company).ResultsWe identified 14 RCTs of Headspace and 1 RCT of Calm. Overall, 93% (13/14) of RCTs of Headspace and 100% (1/1) of RCTs of Calm recruited participants from a nonclinical population. Studies commonly measured mindfulness, well-being, stress, depressive symptoms, and anxiety symptoms. Headspace use improved depression in 75% of studies that evaluated it as an outcome. Findings were mixed for mindfulness, well-being, stress, and anxiety, but at least 40% of studies showed improvement for each of these outcomes. Studies were generally underpowered to detect “small” or “medium” effect sizes. Furthermore, 50% (7/14) of RCTs of Headspace and 0% (0/1) of RCTs of Calm reported a COI that involved Headspace or Calm (the companies). The most common COI was the app company providing premium app access for free for participants, and notably, 14% (2/14) of RCTs of Headspace reported Headspace employee involvement in study design, execution, and data analysis. Only 36% (5/14) of RCTs of Headspace were preregistered, and the 1 RCT of Calm was not preregistered.ConclusionsThe empirical research on Headspace appears promising, whereas there is an absence of randomized trials on Calm. Limitations of this study include an inability to compare Headspace and Calm owing to the dearth of RCTs studying Calm and the reliance on author reports to evaluate COIs. When determining whether or not mental health apps are of high quality, identification of high-quality apps and evaluation of their effectiveness and investigators’ COIs should be ensured.

Evaluation of chatbot-delivered interventions for self-management of depression: Content analysis

BackgroundConversational agents (CAs) or chatbots are increasingly used for depression, anxiety, and wellbeing management. CAs are considered acceptable and helpful. However, little is known about the adequacy of CA responses. This study assessed the structure, content, and user-customization of mental health CA dialogues with users with depression or at risk of suicide. MethodsWe used content analysis to examine the dialogues of CAs previously included in three assessments of mental health apps (depression education, self-guided cognitive behavioural therapy, and suicide prevention) performed between 2019 and 2020. Two standardized user personas with depression were developed to interact with the CA. All conversations were saved as screenshots, transcribed verbatim, and coded inductively. ResultsNine CAs were included. Seven CAs (78%) had Android and iOS versions; five CAs (56%) had at least 500,000 downloads. The analysis generated eight categories: self-introduction, personalization, appropriateness of CA responses, conveying empathy, guiding users through mood-boosting activities, mood monitoring, suicide risk management, and others. CAs could engage in empathic, non-judgemental conversations with users, offer support, and guide psychotherapeutic exercises. LimitationsCA evaluations were performed using standardized personas, not real-world users. CAs were included for evaluation only if retrieved in the search strategies associated with the previous assessment studies. ConclusionAssessed CAs offered anonymous, empathic, non-judgemental interactions that align with evidence for face-to-face psychotherapy. CAs from app stores are not suited to provide comprehensive suicide risk management. Further research should evaluate the effectiveness of CA-led interventions in mental health care and in enhancing suicide risk management strategies.