By Associate Professor Leanne Hides MAPS, Australian Research Council Future Fellow, Institute of Health Biomedical Innovation, School of Psychology and Counselling, Queensland University of Technology

There are now more mobile phones than people in the world! Smartphone use accounts for the majority of the recent growth in global mobile devices. In Australia, smartphone ownership hit 60 per cent last year (ACMA, 2013). Almost 80 per cent of US smartphone users check their phone within 15 minutes of waking, and have their phone with them for all but two hours of their waking day (IDC, 2013).

This increased smartphone penetration has been a catalyst for the exponential growth in mobile applications, or ‘apps’. Apps are the software programs that enhance the functionality of smartphones, enabling them to be constant sources of information, entertainment and interactive communication. There are currently more than 2 billion apps available in the four leading app stores, and more than 13.4 billion apps were downloaded in the first quarter of 2013 (canalys, 2013). Sixty-eight per cent of Australian smartphone users downloaded a mobile app in the same quarter.

As the early adopters of technology, smartphone use has hit 89 per cent among young Australians. In the first quarter of 2013, 83 per cent of young people downloaded an app, a rate 30 per cent higher than older age groups (ACMA, 2013). The sheer penetration of smartphone use and apps provides an unprecedented opportunity to provide real-time standardised health information and treatment directly to young people in their natural environment. This not only has the potential to rapidly increase treatment access but may also result in population level improvements in young people’s mental health and wellbeing. Examples of the many uses of mental health apps in psychological practice are provided below.

Uses of mobile apps in psychological practice
  • Psychoeducation
  • Screening and feedback
  • Decision making, problem solving and goal setting
  • Self monitoring and tracking of treatment progress,
  • including medication adherence
  • Homework
  • Skills training
  • Self-management
  • Help seeking

Popularity of health and mental health apps

It is estimated that there are currently more than 100,000 health-related apps (free and paid) publicly available. Yet, a search of the U.S. iTunes store in June 2013 identified only 558 mental health apps, two thirds of which targeted autism, anxiety, depression and attention deficit hyperactivity disorder (Aitken & Gauntlett, 2013). A recent US consumer survey found only 19 per cent of adults and 24 per cent of young people had at least one health app (including mental health apps) on their phone (CHIC, 2011). While health apps targeting exercise, diet and weight management were popular, mental health apps were not. Of particular concern were findings that 26 per cent of health apps were only used once, and use of a further 74 per cent was discontinued prior to the tenth use. The main reasons for discontinued use were finding a better app, and the app not being engaging or user friendly enough. Clearly current health and mental health apps are not effective in engaging or meeting the needs of users.

As smartphone capability and functionality increases, so too does the engagement potential of apps. Users are able to personalise and track their phone content and online experiences and have potentially unlimited access to entertainment, information and resources. Smartphone apps, which leverage the interactive, adaptive, entertaining and socially connected nature of apps, are more likely to engage young people and encourage repeat use.

Quality and effectiveness of mental health apps

A growing number of studies have highlighted the poor quality of health and mental health apps in terms of engagement, usability and functionality. There is also typically little information available on app safety or effectiveness, beyond ‘star’ ratings and consumer reviews. Selecting apps on the basis of popularity yields little or no meaningful information on their quality or effectiveness (Fiordelli, Diviani & Schulz, 2013). The content of many apps is not based on psychological theories or evidence-based practice, and the evidence base for health and mental health apps themselves is poor at best. A recent systematic review of the impact of mobile phone and smartphones in health care identified only eight studies examining smartphone apps (Fiordelli, Diviani & Schulz, 2013).

While an increasing number of research groups are developing and testing health and mental health apps, there is a substantial time lag between development and publication. This is largely due to the time consuming nature of randomised controlled trial (RCTs). Delays in launching apps to enable efficacy testing can be costly in terms of market penetration and profit, as well as intellectual property theft. Technological advancements during testing may also supersede the app, including smartphone handset (screen size, button placement, new functionality) and operating system updates. Consumer smartphone and platform (e.g., iPads) preferences may also change during this time.

To begin redressing these issues, the Mobile App Rating Scale (MARS) has recently been developed as part of the Young and Well Cooperative Research Centre (Young and Well CRC) (Stoyanov et al., in sub). The 23-item MARS can be used by clinicians and researchers to classify and then rate an app on four quality dimensions (engagement, functionality, aesthetics and information quality) and four satisfaction dimensions (see below). The quality items are rated on a 5-point anchored rating scale (1-Inadequate, 2-Poor, 3-Acceptable, 4-Good, 5-Excellent). The MARS provides a total quality score and quality scores on engagement, functionality, aesthetics and information quality dimensions, ensuring the app has been assessed on all of the relevant criteria. The MARS has demonstrated excellent internal consistency and inter-rater reliability in relation to wellbeing apps. MARS training resources have been developed and will soon be available through the Young and Well CRC.

ReachOut.com has recently reviewed the quality of mental health and wellbeing apps using the MARs as part of the Young and Well CRC. Health professionals and young people have identified approximately 50 high quality apps for inclusion in a new web-based app portal for young people that will be available in 2015.

Mobile App Rating Scale – classification, quality and satisfaction dimensions

App classification – developer/affiliation, cost (initial, updates), platform, target group, confidentiality, security, registration, community, sharing, internet access required to function

App quality

  1. Engagement – entertainment, interest, customisation, interactivity, appropriateness for target group.
  2. Functionality – performance, ease of use, navigation, gestural design
  3. Aesthetics – layout, graphics, visual appeal
  4. Information – accuracy of app description, goals, quality and quantity of information, visual information, credibility, evidence base

App satisfaction – would recommend, number of times would use app, would pay for app, overall (star) rating

How to select a high quality mental health app

As well as utilising the MARS rating scale above, busy clinicians can use the following principles to assist with identifying high quality apps.

  • The app store description should first be reviewed. Look for apps with a simple, realistic and clear purpose developed by multidisciplinary teams of design, IT and health professionals with clear affiliations. Information on how the app was developed and tested should also be provided. A quick Google Scholar search using the app name should provide you with up-to-date information on the evidence base for the app. Use the app with caution if none of this information is available.
  • The app should then be trialed for at least 10 minutes to determine how easy it is to use, how well it functions and whether the app does what it purports to do. Clinical judgement should be used in evaluating the credibility, quality and quantity of the information contained in the app and how consistent the app is with evidence-based practice.
  • Apps that are visually appealing, have a high level of interactivity, can be customised to the user needs, and have a high level of fun/entertainment value are more likely to engage young people. ‘Gamified’ apps which utilise game mechanics to increase engagement are also likely to be popular.

Clinicians’ may also find the growing number of review articles describing the purpose, functionality, quality and effectiveness (where available) of mental health and wellbeing apps helpful. However, the methodological quality of these reviews is variable in terms of the search terms/procedures used, the retail stores/research databases searched and the criteria used to determine app quality.

Where to from here?

Mobile health apps are a nascent and growing field, and are fast becoming an essential component of global health care. Yet, the quality and efficacy of the majority of publicly available health and mental health apps is unknown. A more structured multidisciplinary approach to app development and testing is required to address these issues, perhaps using the MARS as a quality checklist. More rapid usability and efficacy testing could be achieved by building user feedback and evaluation into apps. Delayed RCTs comparing the short-term outcomes of users with immediate versus delayed access to apps may also expedite this process. More traditional RCTs could then be conducted comparing mental health apps in the same area.

Mental health apps have the potential to rapidly increase treatment access to large populations of smartphone users, including those in the developing world. They can provide simple and practical real world solutions to mental health problems, which, even if only small effects are found, could result in large population level changes. Mobile health experts were recently found to believe that 74 per cent of healthcare professionals and 67 per cent of consumers in the developed world will be using mobile health solutions by 2017 (research2guidance, 2012). We just need to ensure that apps are safe and effective in the real world first.

The author can be contacted at leanne.hides@qut.edu.au

For further information on the Young and Well Cooperative Research Centre see www.youngandwellcrc.org.au

References

InPsych June 2014