As we simultaneously get close to spring and enter a phase of cautious optimism about the end of the COVID-19 pandemic, some of your clients may be thinking about starting new self-care routines or tweaking old ones. Mobile health (mHealth) apps – or in this case, mental health apps – offer opportunities for patients to add something new to their treatment plans while also allowing practitioners to track their progress. Here, we review the most effective mental health apps available and how to integrate them into your clinical practice.

Where to Start? How to Choose an Effective Mental Health App for Your Client

With estimates of more than 10,000 mHealth apps available, a high turnover rate in app stores,1 and low barriers for developers to release apps in what the Washington Post called a “chaotic world” of mental health apps,2 patients could benefit from guidance on how to choose apps that are both evidence-based and protective of their privacy. Research suggests that self-help apps can be more beneficial when used as a part of therapy rather than as monotherapy,3 so the aim is finding how to combine these to work together for clinicians and patients.

User Reviews: Provider Feedback Is Crucial

When looking for mHealth apps to recommend to clients, review sites such as PsyberGuide (from the nonprofit group One Mind) can be helpful. The American Psychiatric Association’s App Advisor4 also offers a framework that guides clinicians through the process of evaluating apps. In fact, a team of researchers recently created a database to collect reviews of apps based on those criteria.1 But because apps can be revised at any time and reviews can become outdated, the best way for mental health professionals to choose what’s best for them is to try out the app.

“Reviews are great if they cover the version you’re looking for. But they can get out-of-date quickly. If you’re buying a 2021 model car, would you want to rely on reviews from the 2015 model?” asks Steven Chan, MD, MBA, clinical assistant professor (affiliated) at the Stanford University School of Medicine and medical director for Digital Health, Addiction Consultation & Treatment at the VA Palo Alto Healthcare System.

“Review sites can only go so far in helping you choose,” says Dr. Chan, who also works nationwide on policy and on grant-funded research on mHealth apps. “They are clues that can be helpful for clinicians in determining whether the app is right for their patient and for their own clinical use, which is why clinicians need to learn not just what makes a good app but also not be afraid to try it out for themselves since the cost is so low, and in some cases, free.”

Dr. Chan gives an example of the mood-tracking app, Daylio, which he reports as easy to use and features a nice interface but, it does not offer advice or coaching. “This is why it’s helpful to try out the app for yourself before you recommend it,” he advises. “Sometimes the apps may not work for your patient’s situation if they need more structure, more interactivity, or more culturally relevant content.” (More on mental health apps for individual need and disorders below.)

Privacy and Data

Privacy and user data collection can be concerns with mHealth apps, adds Julie Kolzet, PhD, a licensed clinical psychologist and member of Psycom Pro’s Editorial Board. Dr. Kolzet favors the apps developed by the Department of Veterans Affairs (VA) because they are evidence-based, publicly funded, available to everyone, free, secure, and ensure data privacy.5

“I think that patients like to know that their data is safe,” she says. Dr. Kolzet adds that one of the “cooler” aspects of some apps is that users can interact with communities, but if there’s no guarantee of privacy, the app might not be used to its full potential.

Individual Needs

Apps can be a good complement to treatment but there’s no guarantee that an app will work for everyone. “It could be helpful to think about individual differences,” Dr. Kolzet says. She shares a few examples:

  • One patient may benefit from an app for reminders while another may prefer a calendar-based app
  • If a client struggles with paranoia and feels they are being watched online, they may not feel comfortable with an app at all, especially those that feature video
  • Age matters, too. An older patient may prefer to talk on the phone rather than something involving video chat
  • A client with depression or struggling with basic functions may not be motivated to fill out an app throughout the day, making adherence with an app’s prompts or data collection difficult

It’s important to consider how those with substance use disorders may respond to mHealth apps as well, adds Dr. Chan. “When their disease and suffering are severe, patients may forget or lose their phones.” He’s also had some patients who change their phone numbers frequently, which can make using apps more difficult.

How to Integrate Mental Health Apps into Your Practice

Establishing parameters for app use in your practice is an important consideration in terms of your time commitment and the options offered to patients.

According to Dr. Kolzet, this means establishing boundaries. Questions to consider for your professional practice:

  1. How much time are you able to devote to checking feedback from an app? For instance, daily? What if you use multiple apps for different types of client needs (eg, insomnia, PTSD)?
  2. Will you – or a member of your staff –review every chat or patient upload? Will you need to document that information elsewhere?

“If the patient is doing adjunctive work outside the session, for example, we need to remain diligent, especially when making app-related clinical recommendations,” explains Dr. Kolzet. “Once a therapist figures out how to incorporate apps into the treatment, they can make it a condition that is integral to the work or the service they provide.” In other words, you can explain to clients that, they are not just relying on you for therapy, but that the app is also part of the therapy. In this case, it’s useful to think about the extent to which app use may be optional for your clients.

“Let’s say the provider is excited to use the app but the patient doesn’t like it. What will you say as a provider? ‘You can’t work with me?’ To what extent is it optional? It’s very nuanced,” Dr. Kolzet says.

It’s a lot to consider, she says, and comes down to some basic questions:

  1. For you (the provider), how can a mental health app be of use as an adjunctive intervention to what you are already doing?
  2. For your clients, how can an app further their treatment goals?
  3. Essentially, are you and your client able to approach the app from different sides but with the same goal?

There are technical considerations as well. For instance, Dr. Chan adds that it’s important for clients and staff to feel comfortable using apps as a part of a treatment plan. This way, patients are more likely to stay engaged with the technology, and the clinician’s ability to assess the patient’s proficiency will be more valuable. 

Apps that Help Treat Specific Mental Health Disorders

Below are a selection of available health apps and digital tools from trusted sources, such as the VA, including two that are FDA approved. Noted are those which have been reviewed by the American Psychiatric Association or recommended by organizations that support mental health. This list should provide a starting point for psychiatrists and psychotherapists looking to integrate mHealth apps into their practice.

Anxiety Apps

A search for “anxiety apps” on Google Play results in a variety of approaches including mindfulness, gratitude, stress relief, journaling, yoga, and self-hypnosis. When deciding on the best tactic for your clients, Dr. Chan recommends considering the cause of the person’s anxiety. “With anxiety apps, it’s just like self-help books: The message might be similar, but it should cater to your situation.”

He says that the apps Calm, Headspace, and Daylio can be helpful trackers for people with anxiety. Calm and Headspace were also reviewed by a panel of APA experts.6 Understanding the logic behind the ratings could help you evaluate the apps’ potential for your practice.

  • Calm offers meditation help and designed to lower stress and anxiety and improve sleep. In addition to meditation exercises, the app includes sleep stories, breathing exercises along with soothing music and photos of nature.
  • Headspace focuses on guided meditation, mindfulness, and sleep and aims to reduce stress and anxiety with courses on meditation, workouts, and sleep improvement.
  • Daylio is a tracking app that helps users log moods, exercise, meals, activities and can function as a journal. Charts and stats can be reviewed for patterns or reflection. In terms of privacy, user data is stored locally, and data is not collected by the app’s creator.
  • The VA’ Mindfulness Coach introduces users to the practice of mindfulness with exercises, tracking, goal-setting, and access to support resources
  • For support during the pandemic, the VA launched its own app COVID Coach which helps users deal with the stresses of the pandemic by learning coping techniques, finding resources, and tracking moods, well-being, and symptoms of anxiety and PTSD.

Bipolar Disorder Apps

While the mental health community does not have any bipolar-specific apps in widespread use, Dr. Chan notes that mood- and sleep-tracking apps can be beneficial to this patient population. Noting that people with bipolar disorder often experience sleep disturbance, wearables such as smartwatches and fitness trackers that have built-in sleep monitors can track sleep without waking the user. While these technologies “don’t send clinical alerts and aren’t made specifically to treat bipolar disorder, [their] sensor data could be useful for tracking mood episodes,” he adds.

A study published in the International Journal of Bipolar Disorders found a lack of reliable data for consumers searching for evidence-based apps to help with bipolar disorder.7 Highlighting the need for a system that can evaluate mHealth apps in the mental health care space, the authors actually developed an assessment framework and database based on the APA’s App Advisor model for this purpose.8

One of the bipolar-centric apps reviewed by this database is eMoods, which was also recommended by bp Magazine, a publication focused on the bipolar community.

  • eMoods Bipolar Mood Tracker helps patients track moods, sleep, and medication dosages and data can be exported to share with providers. The app states that user data is not stored in the cloud and doesn’t leave the device unless prompted by the user.
  • iMoodJournal is designed to track moods and create charts for users to see patterns of their moods and experiences. This app was also recommended by bp Magazine.

Depression Apps

Mood-tracking apps can be helpful to manage depression and are a handy replacement for the pen-and-paper method of tracking behaviors, moods, and patterns on worksheets. “Apps can not only make the process come more alive, but they can give reminders to log moods and track trends over time, so those can be very helpful in describing what your days have been looking like,” Dr. Chan says.

A panel of experts at the American Psychiatric Association reviewed the following apps – perhaps even more useful to clinicians, the reviews explain how they arrived at their decisions.9

  • Sanvello is designed to help reduce stress, anxiety, and depression symptoms. Reviewers suggested this could help people with mild to moderate depression but not moderate to severe depression.
  • Mood Tools is a mood-tracking app that focuses on alleviating depression symptoms. Reviewers liked the app’s features such as the Thought Diary, activity and video suggestions, PH-9 questionnaire, and suicide safety plan.

Eating Disorder Apps

See our guide to apps for eating disorders and treatment adherence.

Post-Traumatic Stress Disorder (PTSD) Apps

The VA provides several apps aimed at managing symptoms of post-traumatic stress disorder (PTSD), including three that received favorable reviews10 by experts from the APA: PTSD Coach, CPT Coach, and PE Coach. The National Center for PTSD provides a full list11 of other VA apps that may help individuals with PTSD.

  • PTSD Coach offers education, self-assessments, and tools such as mindfulness, breathing, sleep, and grounding to help manage symptoms.
  • CPT Coach is designed to enhance Cognitive Processing Therapy treatment with a clinician.
  • PE Coach supports Prolonged Exposure therapy treatment with a clinician.
  • PTSD Family Coach provides information and support for people living with someone with PTSD

FDA approval of a digital therapeutic tool in a wearable device designed to reduce PTSD-related nightmares was announced in November 2020. The technology, called Nightware, works with an Apple Watch and iPhone to first analyze sleep patterns based on heart rate and movement (establishing the user’s baseline). If its algorithm detects that the user is having a nightmare, the watch sends vibrations that are designed to interrupt the nightmare but not awaken the person, according to the product’s website. It is available by prescription only.

Schizophrenia Apps

  • The Schizophrenia and Related Disorders Alliance of America (SARDAA) recommends SARDAA Health Storylines, a free app designed to help patients with schizophrenia and schizoaffective disorder. The app allows patients to track symptoms and moods, get reminders to take medication and for upcoming appointments, record questions for their clinician, import data from other health apps, and connect with their support team.
  • UCSF Prime, developed by the University of California San Francisco, is listed on the App Store and Google Play but is only available to research participants at this time. An email address is provided if a patient wishes to be considered as a study participant.
  • A study in Schizophrenia Research found that an app helped patients with schizophrenia upon discharge from a psychiatric hospital.12 Using the FOCUS app, patients were able to find support for their symptoms, particularly outside regular office hours. The FOCUS app is not yet available to the public but one of the researchers is hopeful that revised versions will be available in the near future.13
  • Dr. Chan says that while he has yet to come across any apps in widespread use for schizophrenia, he has seen some developments in the research phase. He gives an example of software that could help patients with schizophrenia reduce the intensity of their hallucinations by mimicking the visuals experienced by the person with a 3D representation of what they reported seeing; the software coaches them through how to reduce the hallucinations.

Sleep Disorder Apps

One-third of adults report that they get less than the recommended amount of sleep each night, according to CDC data. A lack of good sleep can not only lead to motor vehicle crashes and injuries at work, but poor sleep is also associated with chronic diseases and conditions such as type 2 diabetes, heart disease, obesity, and depression. Dr. Kolzet, who is also a behavioral sleep medicine specialist, says, “We know that helping somebody with sleep can have synergistic effects on mood and activity level…. We often think of counting sheep when it comes to sleep. Here is another image: sleep is a ‘bellwether’ or an indicator of something. Meaning, sleep disturbances can in some cases predict wellbeing and health.”

She notes that in addition to the  biological process of sleep, “We’re also dealing with environmental, behavioral, and socio-cultural processes – there are so many other factors that weigh in.”

To best capture the various aspects of patient health, Dr. Kolzet sees the future pointing to digital tools and platforms that are “made to be used in conjunction with a provider, and hopefully, they can help us understand disease overlap and comorbidity better.” With more understanding comes more opportunities to improve health, she notes.

Sleep specialists can be hard to access because there are so few providers, and it is possible that mobile apps and digital tools can help fill in these gaps when patients need help with sleep issues. “They encourage patients to take a more active role in their treatment,” Dr. Kolzet explains.

App developers have responded to the need for help at bedtime by offering apps covering every angle of sleep: tracking, meditation, white-noise and nature-sound players, hypnosis, and recorders to detect whether someone snores or talks during sleep, to name a few. But which apps are effective, evidence-based, and could provide value for people working with a clinician?

Dr. Kolzet likes the VA’s sleep apps because of their interactivity and built-in assessments; they can be used even when someone is not in treatment and are somewhat tailored to the individual. The next step, she hopes, would be to partner these evidence-based, federally funded apps with commercial products like smartwatches in order to communicate a bigger picture of overall health with providers and patients. Other noteworthy sleep apps and digital tools include:

  • The VA’s Insomnia Coach – based on CBT-I (that’s cognitive behavioral therapy specifically targeting insomnia) and provides a guided, weekly training program to track sleep, an interactive diary, and 17 tools to help improve sleep
  • The VA’s CBT-I Coach is designed to be used by people who are working with a sleep specialist in a CBT-I program. The app’s webpage notes that the app can be used on its own but it is not intended to replace therapy for those who need it. Users will learn about good sleep habits and environments, tools and techniques for relaxation, and sleep tracking.
  • Sleepio is a digital sleep improvement program that uses CBT-I techniques as well. Developed in the UK, the app is offered through the country’s national health system, and many US employers and health plans offer it as well. The company outlines access options on its website for people whose employers do not cover it.
  • Somryst (by Pear Therapeutics) is a prescription digital therapeutic that delivers CBT-I through an app and is approved by the FDA to treat insomnia. Somryst (formerly called SHUTi) features a CBT-I program of six lessons, which people can expect to spend about an hour per week to complete over the course of 6 to 9 weeks.
  • Circady Sleep Diary is designed to help people with insomnia using CBT-I with a therapist; there is a patient and provider version. Circady integrates data from a patient’s Apple’s HealthKit, Google Fit, or Fitbit while clinicians can view patient data and host telehealth sessions through the platform. (Disclosure: Dr. Kolzet consulted on the app’s development.)

Several apps mentioned elsewhere in this article relate to sleep, such as the sleep courses, sleep-friendly meditations, and breathing exercises offered by Calm and Headspace (described in the Anxiety section), and the wearable device that helps people with PTSD avoid nightmares (see the PTSD section for more details about Nightware.)

See also, how insomnia may relate to TBI and to revenge bedtime procrastination – the latter is a growing sleep trend.

Substance Use Disorder (SUD) Apps

Many apps related to substance use disorder (SUD) are focused on education, says Dr. Chan. As an example, apps from smokefree.gov give reminders to help people quit, which can be helpful when combined with coaching or medicines to reduce cravings. He also shares an example of an app that helps people when they start taking buprenorphine to treat opioid use disorder (OUD) – the app (BUP Home Induction, listed below), with input from the prescribing clinician, manages their gradual dose increases to improve adherence.

  • QuitGuide and QuitStart were created by smokefree.gov, which is produced by the Tobacco Control Research Branch at the National Cancer Institute, the FDA, smoking cessation experts, and ex-smokers. The two apps help users manage cravings with distractions like games and challenges, earn badges for milestones, share progress on social media, and get inspiration and tips.
  • The VA’s Stay Quit Coach provides information about quitting smoking, helps users tailor a plan to quit, and helps cope with cravings.
  • The VA also offers VetChange, which helps veterans and civilians learn about changing their drinking behaviors and how drinking can relate to PTSD symptoms. Education about reducing and quitting drinking and tools for managing stress are provided.
  • BUP Home Induction helps people begin their buprenorphine treatment by guiding them through the schedule of their prescription.
  • Two FDA-authorized prescription digital therapeutics were shown to improve treatment outcomes: reSET for patients with SUD and reSET-O for OUD. Both tools allow clinicians to view patient data via a dashboard and adjust the ongoing medication-assisted treatment plan.

Serious Mental Illness Apps

  • The SMI Advisor was created by SAMHSA and the American Psychiatric Association. The app features all the available resources of the SMI Adviser website, which can help clinicians find answers about treating patients with serious mental illness. The app offers educational resources to patients and families.
  • SMI Adviser also produces My Mental Health Crisis Plan, an app that enables patients to create a psychiatric advance directive.

The Expansion of Mobile Health Apps for Mental Health Services

One way that the mental health apps listed herein could further engage and benefit individuals with mental health disorders is if developers designed versions specifically for the needs of different groups of people. Dr. Chan says that the potential of mHealth apps to reach different patient populations could increase if targeted to specific cultures, languages, and sexes, for example.

“People want to feel understood when they’re using apps” he explains. “What works for college mental health, where there is pressure because of exams, is a completely different set of pressures from adult life.” Essentially, individualizing and personalizing apps could boost their effectiveness.

For instance, a team of VA researchers have proposed changes to an app that helps people manage dangerous drinking habits, called Step Away, to make the app more relatable to veterans. Their research included re-tooling the app to include veteran-specific language and imagery in a new version that they call Stand Down.14 After a successful pilot, the team proposed a larger study that would include patients across multiple VA care centers.15 (As of January 2021, they are awaiting funding.)

“It’s a very, very exciting time and we need more expertise,” Dr. Chan says. “There’s a lot of work that needs to be done to advocate so we can continue using these apps, particularly after the public health emergency ends.”

Dr. Kolzet also feels a sense of optimism for the future of apps and similar technology in mental health. “I’m excited to see how digital tools and apps, etc., will continue to be implemented into the therapeutic space,” she says. “I think technologies that can help identify patients who could benefit most from one type of therapy versus another will be the ones that are going to stand out… [such as those] that help us triage or stratify by need level or risk level.”

Additionally, she suggests that combining self-reported client data, therapist observations, and objective data from wearables (such as fitness trackers that collect biometric data) could be a promising prospect. “If we could find a way to make it all work together – the therapist, app, wearables, tools – that would be ideal,” she says.

 

See also, how digital mental health models are reshaping private practice, and our sister site Psycom’s consumer list of top mental health apps.

References
Last Updated: Sep 10, 2021