Separating the Good From the Bad in a Wild West Landscape of Apps, Wearables and Websites

Healthcare professionals and their clients/patients are faced with questions about how to choose the most reliable and effective tools, how to decide what is real or fake on the internet, and how to avoid the snake oil. How do you answer?

Mental health care is an area in need of transformation. One in five Canadians will have mental health problems this year, yet many struggle to access care. According to one study (Patten, S., et al. (2016) Major Depression in Canada: What has changed over the past 10 years? The Canadian Journal of Psychiatry, 61(2), 80–85.) only 13% of people with depression had any therapy or adequate care.

Mobile health apps aimed towards patients are an emerging field of mHealth. Their potential for improving self-management of chronic conditions is significant. Just as technology has transformed other aspects of our lives, people are increasingly tapping it for health needs.

Experts believe that technology has a lot of potential for clients and clinicians alike. A few of the advantages of mobile care include:

• convenience
• anonymity
• lower cost
• services available to more people (e.g. rural areas)
• engagement (technology-supported treatment is sometimes more appealing than traditional methods).
• 24/7 availability
• support (technology can complement traditional therapy by extending an in-person session, reinforcing new skills, and providing support and monitoring.

A Wild West

The number of smartphones worldwide is predicted to reach 5.8 billion by 2020 and there are 6 million multimedia applications (apps) available for download in the app stores. According to the latest report from Institute for Human Data Sciences 318,000 of these are mHealth apps.

Since there are no formally adopted national standards for evaluating the effectiveness of the hundreds of mental health apps, wearables, websites, and related health technologies that are available, consumers should be cautious about trusting a product. However, there are a few suggestions that can help you choose wisely.

Always remember “caveat emptor” (buyer beware) and that no one is in charge of protecting your well-being in a mobile and online world, except you.

Note: Some of these guidelines may be better suited to apps than wearables or websites.

Authority. Is the information from a credible source?

Developer. Check the company behind the product. Who is funding the app or website, for example? What is their experience producing mental health technologies?

Bias. Who is paying for the development of the technology? Are there ads? Is the solution sponsored?

Advertising. Who is paying for the development of the technology? Are there ads and if so, is there a clear distinction between editorial content and advertising content?

Qualifications. Are the editors and contributors identified and their professional qualifications stated? (e.g. the Mayo Clinic online states “specialty medical editors work with our editorial staff to bring you timely, relevant and accurate information and tools.”)

Protect your privacy. Consider:

• Is there a privacy policy?
• What data are collected? Shared? With whom?
• Can you opt-out of data collection or delete it?
• Are cookies placed on your device?
• Are data maintained on the device or the web (i.e., “the cloud”)? Both?
• What security measures are in place?
• Is the technology HIPAA compliant (legislation that provides data privacy and security provisions for safeguarding medical information)?

Be vigilant about what you are asked to provide or do. For example, are you being asked to log-in using Facebook? Are you asked for permission to connect to your camera or GPS for your location? These kinds of request should raise suspicion and further investigation.

Is there support? If it is important to you, check if there is live, 24/7 support available for technical problems or for clinical support from a trained professional (if you want personal contact).

Is there evidence for effectiveness? Developers often make many claims even though there is currently little clinical evidence to support them. This does not mean that apps, wearables, and online mental health sites don’t work, but rather that there is much we still do not know. If there is no information about the effectiveness, check to see if it is based on a treatment that has been tested. For example, research has shown that Internet-based Cognitive Behaviour therapy (CBT) is as effective as conventional in-person CBT for certain disorders.

Is the therapist licensed? If the technology connects you to a therapist or counsellor, ensure that they are licensed. Licensing protects you. “Therapist” is not a legally protected word in most provinces and states, meaning anyone can claim to be a therapist and offer services that may appear as therapy. It may not always be easy to know that you are receiving evidenced-based psychotherapy.

Updates. Find out how often the information is updated. In many cases, twice-yearly updates to the information may suffice.

Check reviews. Search for independent user reviews (not necessarily those published by the app developer). Also, check for reviews and recommendations from PsychCentral (psychcentral.com), Anxiety and Depression Association of America (https://adaa.org/finding-help/mobile-apps) or the National Health Services (UK) Apps Library (https://www.nhs.uk/apps-library/).

Beware of misleading logos on websites and apps. The National Institute of Mental Health (NIMH) has not developed and does not endorse any apps. However, some app developers have unlawfully used the NIMH logo to market their products.

How will you pay for the service? Some insurance companies cover treatment that includes in-person therapy. But online therapy or web therapy services are often not covered or reimbursable by many insurance providers. If you plan to be reimbursed, check with your insurance company first.

Ease of use. An app, wearable, or website is only effective if it is easy-to-use and you like it. Consider:

• Would it be easy to use on a long-term basis?
• Are any features customizable?
• Do you need an active internet connection for the device or solution to work?
• For apps, what platforms does it work on (Android, iOS).
• Is it accessible for those with impaired vision or other disabilities?
• Is it culturally relevant?

Try it. If you’re interested in something, test it for a few days and decide if it’s easy to use, holds your attention, and if you want to continue using it. An app or mobile sensor or website is only effective if it keeps you engaged on a consistent basis…long enough to resolve the issues that brought you to it in the first place.

The need for mental health apps is clearly there. The need for new apps to be both effective and trustworthy is the current clinical shortcoming and the strategic opportunity.

Hopefully these guidelines will empower you as a consumer to make informed decisions about the mental health information, treatment, and support that you choose. If you cannot find answers to these questions, or if you are in any way doubtful of what you are being offered or asked to do, it may be best to move on.