Smartphone applications (apps) can assist with the self-management of mental health conditions, including behaviour and symptom tracking, psychoeducation and mindfulness exercises (Torous and Roberts 2017; Torous et al., 2018a).

Whilst having increasing dedicated research funding, and attracting attention from consumers and investors, the potential of mental health apps is unclear (Connolly, Hogan, Shimda & Miller, 2020). Low attrition rates, small real-world treatment effects and ‘digital placebo effects’ (where MH apps are not much more effective than any app) are all important issues that need addressing (Arean et al., 2016; Firth et al., 2017a, 2017b; Torous et al., 2019). There is therefore a potential disconnect between the enthusiasm, effort and invested funding of MH apps comparative to the understanding of their effectiveness and factors that sustain use (Connolly et al., 2020).

Implementation science involves “The study of methods to promote the systematic uptake of research findings and other evidence-based practices” (Bauer at al., 2015; Eccles and Mittman 2016). This multi-disciplinary field of research has the potential to explore issues identified with MH apps, but is currently being under-utilised in digital health research (Buis, 2019).

The current study by Connolly et al., (2020) therefore aimed to use the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to characterise mental health app use and produce recommendations to support implementation.

Methods

The authors conducted a narrative review of multiple sources to identify eligible content between 2015 and 2020. They focused on depression and anxiety apps and included a variety of sources including: peer-reviewed papers, newspaper articles and press releases. Twitter feeds were also reviewed due to the increasing popularity of the platform to disseminate and discuss research.

The narrative review involved sources that has information relevant to app implementation as defined by the i-PARIHS framework domains, which includes, facilitation, innovation, recipients and context.

Results

Of the 88 sources included in the review, 28 were original primary research papers, 23 were meta-analyses or reviews, 24 were conceptual/opinion pieces and 13 were other non-peer reviewed sources. The results were organised by the framework domains with the additional heading of ‘successful implementation’:

Innovation

• Apps must demonstrate additional value over pre-existing care options.
• Consideration should be given to the complexity of the app in relation to its desired outcome, and whether a simpler strategy is possible.
• Strategies for successful usability should be considered when developing apps including; simple and clean designs, dynamic and tailored responses, and gamification.

Recipients

• Opinions of users must be considered during design and delivery as negative attitudes can be a barrier to uptake.
• Transparency and education may help with concerns around the credibility and privacy of apps.
• Smartphone and access to Wi-Fi/data must both be considered when assessing the feasibility of app use.
• Education, training and support is needed for providers and users.
• App libraries which are curated and frequently updated, could be helpful.

Context

• App stores are largely unregulated and are ranked on user rating rather than credibility, so caution should be taken when selecting apps.
• Long-term commitment of time and funding and leadership support is needed to incorporate apps into healthcare systems and to ensure sustainability.

Facilitation

• There is limited research on facilitation of mental health apps.
• Training has shown some positive effects of increasing provider use.
• For fully user-guided MH apps, engagement could be improved by advertisement, education or tailored coaching messages.

Successful implementation

• Metrics of measuring successful implementation include:
  • the degree of integration into provider workflows and healthcare system budgets
  • having undergone multiple versions/updates
  • number of downloads
  • user interactions.
• Implementation has not been a core focus of MH app research to date.
• Funding mechanisms must adapt to prioritise this research, so that strategies can ensure uptake and long-term sustainability can be identified and improved’.

Conclusions

The main conclusion from this narrative review is that for apps to be successful they must be advantageous relative to other provisions, easy to navigate and be aligned with users’ needs, skills and resources. For facilitation strategies to be refined, significantly more attention must be paid to the complex contexts where implementation of mental health apps is occurring.

Strengths and limitations

This was a good narrative review which presented important findings, but also offered practical recommendations to support the implementation of mental health apps. By choosing this less systematic approach they were able to include important sources that may not have been included if a systematic method was used. By drawing attention to actions that could help improve uptake and engagement with MH apps, it provides practical considerations for developers and providers. As well as effectiveness, understanding what is needed for acceptability and usability of MH apps is important to consider so that they can be implemented successfully.

The main limitation of the study was by not exploring the influence of metrics or outcomes using meta-analysis it is not possible to know which factors are potentially the most important in influencing implementation for this type of app. This might have helped future developers prioritise and focus upon specific areas to aid successful implementation.

Additionally, this study only focussed on mental health apps relating to depression and anxiety. Although these may be more prevalent, this limits the focus and there may be important differences in uptake between apps for these and other apps that have not been addressed.

Implications for practice

• There is currently a large amount of effort and funding invested in the development of mental health apps. Factors for successful implementation need to be prioritised to ensure user uptake.
• The importance of including users in the design and development of MH apps has been highlighted and should be acknowledged by funders, stakeholders and industry.
• Considering the current lack of regulation around MH apps, having curated libraries which are frequently updated and appraised with more than just rating reviews by users may be important for the integration of MH apps in healthcare systems.

Statement of interests

I have no conflicting interests for this post/study.

Links

Primary paper

Connolly, S. L., Hogan, T. P., Shimada, S. L., & Miller, C. J. (2020). Leveraging Implementation Science to Understand Factors Influencing Sustained Use of Mental Health Apps: a Narrative Review. Journal of Technology in Behavioral Science, 1-13.

Other references

Arean, P. A., Hallgren, K. A., Jordan, J. T., Gazzaley, A., Atkins, D. C., Heagerty, P. J., & Anguera, J. A. (2016). The use and effectiveness of mobile apps for depression: results from a fully remote clinical trial. Journal of Medical Internet Research, 18(12), e330.

Buis, L. (2019). Implementation: the next giant hurdle to clinical transformation with digital health. Journal of Medical Internet Research, 21(11), e16259.

Firth, J., Torous, J., Nicholas, J., Carney, R., Pratap, A., Rosenbaum, S., & Sarris, J. (2017a). The efficacy of smartphone-based mental health interventions for depressive symptoms: a meta-analysis of randomized controlled trials. World Psychiatry, 16(3), 287–298.

Firth, J., Torous, J., Nicholas, J., Carney, R., Rosenbaum, S., & Sarris, J. (2017b). Can smartphone mental health interventions reduce symptoms of anxiety? A meta-analysis of randomized controlled trials. Journal of Affective Disorders, 218, 15–22.

Torous, J., & Roberts, L. W. (2017). Needed innovation in digital health and smartphone applications for mental health: transparency and trust. JAMA Psychiatry, 74(5), 437–438.

Torous, J., Wisniewski, H., Liu, G., & Keshavan, M. (2018a). Mental health mobile phone app usage, concerns, and benefits among psychiatric outpatients: comparative survey study. JMIR Mental Health, 5(4), e11715.

Torous, J., Lipschitz, J., Ng, M., & Firth, J. (2019). Dropout rates in clinical trials of smartphone apps for depressive symptoms: a systematic review and meta-analysis. Journal of Affective Disorders, 263, 413–419.

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