What makes a mental health app work?

Engagement over the longer term is a big issue with digital mental health tools. According to the authors of a recent meta-analysis looking at studies of apps for depression and anxiety, the 15-day retention rate for mental health apps is just 3.9%!

Keeping it simple

In my practice I find that the most successful apps are the ones that don’t try to do too much. They focus on a single symptom set or a single mental health strategy. Smiling Mind and other mindfulness apps seem to be successful for that reason. Beyond Now Suicide Safety Planning app does just one thing and does it very well. Virtual Hope Box focuses clearly on managing trauma-related symptoms. These are the sorts of apps that in my experience people tend to find most useful and that keep them engaged.

Two ways of looking at app design:

The study I referred to above, published in NPJ Digital (a partner journal of the better-known journal Nature) used information about duration of use and completion rates to assess the level of engagement users had with apps. They were able to look at the apps they examined through the lens of Persuasive System Design (PSD) and Behavioural Economics to compare the features of those frameworks which appeared in the apps with adherence and completion rates across twenty-five different studies.

1. Persuasive System Design

Described with a broad-brush, PSD includes features which “facilitate the purpose of the app, promote user-app interactions, leverage social interactions and increase app credibility.” PSD techniques are based on psychological principles coming out of the original work of Stanford University’s  B.J Fogg, whose best known work is probably  “Persuasive Technology: Using Computers to change what we think and do,” (a title I find fairly frightening!).

Examples of persuasive technology-based features include:

• alarms to remind you to carry out a task (eg. the reminder in the Reach Out Breathe app),
• online communities that allow people to share their experiences (as in the Hello Sunday Morning “Daybreak” app for people wanting to change their relationship with alcohol)

The investigators in this paper found that there was an unexpected negative association between PSD features and engagement, but still stated that PSD features show promise in augmenting app efficacy through engagement. I don’t know about you but I’m a little confused. Maybe they are talking about the fact that things like reminders and online communities seem like a good idea in theory. What I do know, is that my dentist told me that all the reminders in a particular well-known (and expensive) weight loss app he had signed up to, and that I had mentioned because it had been successful for me too, had made him so mad that he dropped out within two weeks of signing up. “I wasn’t going to let an app control my life and I certainly didn’t have time to spend reading all that material every day” was his comment.

2. Behavioural Economics (?!)

If you are like me your eyes just glazed over and your brain was enveloped in a thick fog at the sight of these two words sitting together. However, I’ve applied myself and learnt that “behavioural economics” is about understanding the way human decision making differs from what would be expected in a rational world based on economic principles.

Remember Daniel Kahneman the Israeli psychologist who wrote Thinking, Fast and Slow? He, along with economist Vernon Smith jointly won the Nobel Prize in Economic Science in 2002 for “integrating insights from psychological research into economic science, especially concerning human judgement and decision making under uncertainty”. He and others have helped establish behavioural economics as a field of study.

Within the behavioural economics framework fall strategies used in digital tools, that you might think of as games. Examples include requiring “commitment to action” and “lotteries”, awarding of points and badges. If you would like to know more there’s an interesting article about gamification in mental health apps co-authored by Prof Ian Hickie and published in 2019 in JMIR.

I wonder how my dentist would feel about gamification? That dieting app contains rewards and “levels” that are features of gamification. I’d be willing to bet he ‘d say he was “too old for star charts”!

Finding the right app

I’ve seen estimates that claim there were 10,000 to 20,000 mental health apps existing in 2021. As clinicians, we can only really be aware of a tiny fraction of the apps that are out there. What we can do though is introduce people to the idea of trying an app for support, and perhaps even help them in their quest to find one that suits them. Head to Health is not a bad place to start looking for reliable and effective apps. There’s also the Tools and Apps page of the Reach Out website . One of the best ways I’ve learnt about apps is by asking my patients what they are already using. It can be both helpful and surprising. 

So, what happened to my dentist, did I hear you ask? He’s a tech-friendly kind of guy so he continued his search for something that might help him. He decided to eschew weight loss apps altogether and took up regular mindfulness exercises, using Smiling Mind. He found that he felt calmer overall and more able to control his stress related eating. He was also happier that he was being guided rather than being “told what to do” and “treated like a child”.

The bottom line

It seems to me that the bottom line when it comes to apps (and digital tools generally) is that they don’t suit everyone, and within the group of those who are keen for digital support and solutions, it’s very much a case of finding the right one for that person.

So, what’s our job here as mental health professionals? We need to keep encouraging people to find something that helps and when they find it, file the information away to use with the next person who comes along, for whom using an app might be beneficial. Maybe we can then effectively use digital tools to augment therapy.

References and resources in chronological order

Smiling Mind website - https://www.smilingmind.com.au/smiling-mind-app

Beyond Now, Suicide Safety Planning website - https://www.beyondblue.org.au/get-support/beyondnow-suicide-safety-planning

Virtual Hope Box - https://onemindpsyberguide.org/apps/virtual-hope-box-review/

Recent meta-analysis looking at studies of apps for depression and anxiety - https://www.nature.com/articles/s41746-021-00386-8

Standford University’s B.J Fogg - https://en.wikipedia.org/wiki/B._J._Fogg

Interesting article about gamification - https://mental.jmir.org/2019/6/e13717

Head to Health website - https://www.headtohealth.gov.au/

Tools and apps page of the Reach Out website - https://au.reachout.com/tools-and-apps