Exploring the role of health apps in supporting young people with depression: a mixed methods study

• Main Author: Martinengo, Laura Beatriz
• Other Authors: Josip Car
• Format: Thesis-Doctor of Philosophy
• Language: English
• Published: Nanyang Technological University 2022
• Subjects: Science::Medicine::Computer applications
• Online Access: https://hdl.handle.net/10356/157124
• Institution: Nanyang Technological University

Depression affects individuals across the lifespan and is a leading cause of disability worldwide. Despite effective therapies, less than half of individuals with depression are treated, both in high- and low- and middle-income countries, due among many to a shortage of specialised care providers, high costs of treatments, lack of awareness about depression, a desire to handle symptoms by oneself, and stigma. Digital health offers a feasible alternative to support depression management. Despite this promise, most apps available in leading commercial app stores are not evidence-based and lack essential privacy and security functionalities, undermining individuals' trust. The overarching aim of this doctoral research project is to assess the role of mental health apps in supporting depression self-management in younger adults. Three aspects of depression management – patient education, self-guided cognitive behavioural therapy (CBT), and suicide prevention – were included in this project. Therefore, I used mixed methods research methodology, consisting of a systematic evaluation of apps targeting the three areas of depression management addressed in this project; and qualitative analysis of conversations between a simulated app user with a typical presentation of depression and a conversational agent, defined as a computer program mimicking human conversations using verbal or written interfaces. For all the systematic app assessments, comprehensive assessment criteria were developed using relevant evidence-based clinical guidelines or intervention manuals from the United States, United Kingdom, Australia, Singapore, and the World Health Organization, which resulted in checklists including 38 educational topics (assessment of education on depression offered by mental health apps), six evidence-based techniques (self-guided CBT-based app assessments) and six suicide prevention strategies (suicide prevention app assessments). The search was performed in Apple’s App Store and Google Play using a third-party database (42matters), followed by two rounds of screening against predefined inclusion and exclusion criteria. Eligible apps were thoroughly evaluated, and the data were tabulated and analysed using descriptive statistics. Subsequently, the dialogues between a simulated user based on standardized case scenarios of someone with depression and the conversational agents identified in the three app assessment projects were analysed using qualitative content analysis. A total of 199 individual apps (100 iOS and 99 Android) were assessed, of which 16 apps were included in two app assessments and five apps were included in all three. There were 58 apps offering depression education, 98 apps offering self-guided CBT, and 69 apps conveying suicide prevention advice. Eight of these apps included a conversational agent, either standalone or as part of a more comprehensive app. In general, only 40 apps (20%) presented comprehensive information on depression (7/58, 12%), self-guided CBT programs (28/98, 29%) or suicide prevention strategies (5/69, 7%) to support self-management for individuals with depression, unable or unwilling to seek help through traditional channels. Education on depression offered by mental health apps was scant and consisted mainly of lists of symptoms or treatments. A total of 12 apps (21%) included non-evidence-based information and only 30 apps (52%) included references for their content. Self-guided CBT-based techniques were included in wellbeing apps (n=20), mental health apps targeting 2 or more conditions (n=65) and depression apps (n=13). Depression apps presented the most comprehensive interventions, with 8 apps (62%) including at least four evidence-based interventions. Cognitive restructuring was the most common technique, offered by 77 apps (79%). The privacy policies of 74 apps stated sharing data with third-party service providers. Suicide prevention advice was offered by depression management and suicide prevention apps, including eight conversational agents. Most apps (40 apps, 58%) included up to three suicide prevention strategies. Six apps (9%) provided erroneous crisis helpline phone numbers. To fulfil their potential, mental health apps must adhere to evidence-based clinical guidelines, be patient-centred, and offer enhanced and transparent data security measures. A multidisciplinary team comprising government regulatory agencies, the app development industry, healthcare providers, and the public should be set up to address this issue.