Guide to build an engaging and evidence-based mental health App
I would like to dedicate my first hack mental health article to Jong Hyun Park, who recently passed away due to mental health issues. I hope that we will eventually live in a world where no one will take their life with their own hands.
Mental health startups are beginning to receive significant attention from investors, as the impact of depression is beginning to take a toll on people’s lives and the global economy. According to the World Health Organization (WHO), depression is the leading cause of disability in the world and is a major contributor to the overall global burden of disease. Economically, researchers have estimated the global direct and indirect financial cost of mental disorders to be $2.5 trillion US dollars in 2011, a number which is expected to grow to $16 trillion US dollars by 2030. These numbers show that the opportunity for technology to make a significant impact on mental health is present — but at the same time, considering the possible risks is also critical.
Furthermore, mental health services tend to be expensive and time-intensive (a full treatment averages 16.54 sessions), which accounts for the high rate of premature dropout for patients. On top of these issues, 80% of youths in US do not receive the treatment they need. Mobile health apps for the masses may be a way to expand and improve care in an unprecedented way. Hence, this article will provide an overview of the current literature at the intersection of depression and technology and highlight what to watch out for when building apps for the mental health community.
Firstly, we should consider whether the app offers habit forming behaviors to the users. As Nir Eyal puts it, habits have a short half life. In fact, they have been shown to work like a queue with a “last in, first out” structure. The newly acquired habits (last ones in the “queue”) are the ones most likely to disappear. This difficulty is no different for mental health patients. Apps without habit forming behaviors may have low use and retention rates in the long run. We can’t rely on the best medical practices for forming habits either, as the study by Torous shows that patients exhibit low rates of engagement in their natural settings away from the clinics when using current mobile health apps, even if it is specifically designed for their cause.
One thing to consider is that receiving mental health treatment is new to many users, which makes engagement with mobile health apps even harder. App makers can’t simply rely on the users to stick with the app and find the right self-care, as users usually have a mountain to climb if they are to form a new habit of consistently using a new mobile health app.
Hence, it is important that the app considers how it will assist the user in coming back to the app time and time again. One method is to ask what negative emotions the app helps eradicate for the user. Literature shows that compared to positive emotions, negative emotions have stronger influences on human behavior. Thus, analyzing what problems the app could alleviate through behavioral change could help the users stick with the app and receive the treatment they need.
Secondly, the app must be intuitive for the user. The app makers must consider whether the content makes sense to the user base who is engaging with the app and should aim to avoid overwhelming the user. This aspect is important because a study this year has shown that cognitive behavioral therapy seldom helps children, with almost half of cognitive behavioral therapies not contributing to recovery from primary anxiety diagnoses. These authors believe that this inefficacy may be due to children not learning and practicing cognitive behavioral skills beyond therapy sessions, which is attributable to lack of motivation, forgetfulness, and unclear understanding of cognitive behavioral therapy skills.
One method to address this problem of meeting users where they are is to incorporate gamification, which integrates game mechanics to motivate users to go out of their way to achieve their goal. Gamification in healthcare is not a novel idea, with Global Healthcare Gamification Market expected to exceed $3.7 trillion by 2022. Mango Health, Mindbloom, and Hemocraft are just a few of the many mobile healthcare apps that strives to alter patient behavior through games.
Hence, addressing mental illnesses through gamification could empower therapies. In Pramana’s study, researchers saw increase in the efficacy of cognitive behavioral therapy skills amongst children through gamification in their apps. While this study is a promising starting point, another point to consider is that the children of this generation are “digital natives,” more at ease in the digital space than the “digital immigrants.” Thus, considering the incorporation of gamification for different age groups, demographics and cultures could improve the success rate of these mental health therapies.
Thirdly, the app must address how the user data will be protected against the misuse of clinicians, since many apps fall under the wellness section to avoid the scrutiny of the HIPAA (Health Insurance Portability and Accountability Act). This way, app creators can write their own privacy policies. But as the user is unaware of this law, they may share sensitive data without knowing how the data is harvested. Studies have shown that patients share more suicidal thoughts on mobile apps than on paper in clinics. While these studies reveal the power of mobile health apps to encourage users to be more authentic and share more, users also become more vulnerable to the breach of privacy.
The mobile health apps could also collect more data, such as the location, physical activity, ambience, camera, touch speed, proximity sensor, voice and the heart rate of the user to get an accurate real time understanding of the patient. However, such sensitive data raises the responsibility of the app makers to refrain from misusing the user’s data. If the mobile health apps lose the users’ trust, people will avoid these apps, even if they prove to be effective in treating mental health.
With data breaches becoming more common, the app makers must either refrain from collecting sensitive data or inform the users how their private data is protected. This step also entails ensuring that the privacy policies meet the literacy level of the public, as the average reading level of the current privacy policies of popular mental health apps is at the college freshman. Apps must go beyond having the privacy policy to educate the users how their data will be used.
Lastly, the apps must reconsider metrics for measuring success. The current app store has a misaligned incentive model for mobile health apps, as it doesn’t favor apps that provide the users with honest evaluations. The reason is that the ratings are written by non-professionals who often share their subjective feelings instead of the accuracy of the app’s assessment.
Studies have shown that the apps that reinforce positivity more often result in better ratings. Since the app store does not discriminate between the professionals and laymen, the user may base their decision not on the app’s efficacy, but the frequency of positive feedback. Hence, the fourth challenge will be to incorporate professional voices and ensure that the app is not giving wrong feedback to the user, such as having a different score system for the users that gives more weight to professionals.
These points can provide the foundation for designing apps for the mental health community. While the need for apps that can save lives is urgent, it is also imperative that we get the first steps right so that these apps can go mainstream. As they become more accepted and trusted, I am sure that the mental health apps will protect, enrich, and save many more lives.
