Mobile Apps for mental health: Literature review

Gaidai Anton Sergeevich ORCID: 0000-0002-0648-1170 Senior Lecturer, Department of General Psychological Disciplines, Pacific State Medical University under the Ministry of Health of the Russian Federation 690017, Russia, Primorsky Krai, Vladivostok, Ostryakova Avenue, 2, office 12-008 Netparoley@gmail.com Kadyrov Ruslan Vasitovich PhD in Psychology Head of the Department of General Psychological Disciplines, Pacific State Medical University under the Ministry of Health of the Russian Federation 690002, Russia, Primorsky Krai, Vladivostok, Ostryakova Ave., 2 rusl-kad@yandex.ru

Kapustina Tat'yana Viktorovna ORCID: 0000-0001-9833-8963 PhD in Psychology Associate Professor, Department of General Psychological Disciplines, Pacific State Medical University under the Ministry of Health of the Russian Federation 690002, Russia, Primorsky Krai, Vladivostok, Ostryakova Ave., 2 12_archetypesplus@mail.ru

Mental health issues are becoming increasingly relevant in the modern world. According to the World Health Organization, every eighth person in the world suffers from some kind of mental disorder ^[45]. Moreover, during the COVID-19 pandemic, there was a sharp increase in the number of depressive and anxiety disorders. At the same time, existing health systems and psychological services are unable to provide assistance to all those in need, and a significant number of them are forced to cope with their ailments on their own. This determines the relevance of alternative ways of providing both medical and psychological assistance.

New technologies in the fields of telecommunications and programming can open up similar alternatives to us. One of the promising ways is mobile applications for mental health. They are programs installed and functioning on smartphones, and are designed to provide remote services in the field of mental health and can be used for communication with a specialist, self-regulation, diagnosis and treatment ^[27]. Such applications have a number of obvious advantages over traditional methods of assistance: they are available around the clock to any smartphone owner, geographically depend only on Internet access, there is no need to wait for an appointment with a specialist with them, they are inexpensive or completely free and allow you to remain anonymous ^{[21, 27, 35]}. New technologies open up prospects for a serious increase in the effectiveness of the fight against mental disorders, which has been widely discussed in recent years ^{[21, 27]}. So, from 2016 to 2018, the number of mental health applications has tripled ^[35], and at the moment their list consists of tens of thousands of names ^[23]. As for the varieties of such applications, cloud and web applications, mobile and VR applications are distinguished in the literature ^[36]. Communication with a specialist using text messages can also be singled out separately ^[38].

So, we have the sphere of mobile applications for mental health, which has emerged quite recently, is developing in an avalanche-like manner, is in demand and can bring great benefits to people. However, publications began to appear quite quickly, the authors of which pointed out the negative aspects of technological progress, among which are the insecurity of user data, lack of certification, contradictory data on efficiency and the use of approaches with unproven effectiveness in applications. All of the above makes it extremely relevant to review this area in order to find out the effectiveness of mobile applications for mental health.

The object of this study is mobile applications for mental health.

The subject is an assessment of the advantages and disadvantages of mobile applications for mental health in scientific periodicals.

Research methods

The search for publications on the subject of interest to us was carried out by searching for "mobile app" and "mobile mental health application" in the psychological sections of the databases of scientific periodicals Scopus, PubMed and in the Google Scholar search engine. The search for Russian-language publications was carried out through the request "mobile application" in the scientific electronic library eLIBRARY.RU . The publications that described the review studies of the applications were selected. That is, in order to avoid excessive expansion of the volume of this publication, we tried to consider reviews, and not reports on the use of individual applications. It was not possible to find such publications in the domestic scientific periodicals, which was reflected in the list of references. In presenting the results, we will consistently consider the advantages and disadvantages of mobile mental health applications.

Results and their discussion

The information received will be presented by a sequential enumeration and description of the advantages and disadvantages of the area of interest noted in the literature. It would be preferable to provide statistical data on the effectiveness of mobile applications, but today such an analysis seems extremely difficult, if not impossible. There are several reasons for this state of affairs, among which one can name a wide variety of applications themselves, their focus on various disorders and conditions, different target audiences and the use of all kinds of psychotherapeutic approaches, regardless of their scientific validity. All this is compounded by the fact that anyone can make a mobile application based on personal interest, commercial considerations or for other reasons. No certification system exists today and in this respect all applications are equal. Therefore, at the moment, a general overview seems to be the most appropriate.

There is a large amount of evidence in favor of the fact that mobile mental health apps improve therapeutic outcomes, including reducing the symptoms of mood disorders ^{[7, 12, 13, 15, 16, 18, 19, 22-24, 30-33, 37, 40, 44, 46]}. In one of the meta-analyses, it was revealed that intervention using mobile applications had a small or moderate effect in reducing symptoms of depression in a total sample of 3,414 adults from both clinical and preclinical populations ^[18]. One of the publications provides evidence of the usefulness of mobile applications designed to work with depression, stress, anxiety and eating disorders in students ^[22]. In another review paper, it was shown that participants experienced a reduction in stress levels and improved coping skills after three weeks of using applications ^[37]. The probable explanation is that the applications give the client the opportunity to practice new useful skills, facilitating the process of wellness changes, and thereby increase the overall effectiveness of the entire treatment.

This happens by supplementing and supporting the various stages of traditional therapy, contributing to the solution of specific tasks of each of them. Thus, it was found that mental health applications with the function of tracking and monitoring the emotional state and stress of the user, weaken the symptoms of depression, anxiety and stress ^[24]. Such applications are especially valuable due to the ability to monitor the client's condition and, as a result, promptly adjust individual recommendations. There are also frequent grateful mentions by users in reviews of applications of such functions as "reminder and notification", "logging", "visualization and data export". All these are the advantages of mental health applications, which are appreciated by people seeking help.

One of the important advantages of mobile applications is their easy accessibility if necessary. The difficulties associated with the need to wait for your turn at the reception and come to it in case of territorial remoteness are simply absent here. It is not surprising, therefore, that this advantage is one of the usual ones emphasized in the literature ^{[3, 5, 7, 12, 13, 16, 17, 23, 24, 33, 44]}. Such provision of round-the-clock access to support is important in any region, but it becomes especially important in those areas where qualified psychological assistance is not available ^[2]. In addition to the immediate benefits, this feature of applications is clearly recognized by users who see here an opportunity to relatively easily start making positive changes in their lives, which has a serious impact on the desire of customers to use this kind of help ^[13]. Another important aspect of accessibility is the more complex therapy of neglected conditions – the longer the client remains without help, the higher the risk of developing more serious disorders. And in this sense, mobile applications can also provide timely support and prevention ^{[2, 3, 21]}. The comprehensive flexibility of mobile applications is also emphasized, which allows users to overcome organizational, social and individual barriers to receive psychological assistance ^[6]. As for applications operating on the principles of scientifically-based areas of psychotherapy, they often assume a choice – you can use them yourself, receive specialist support through the application, and also be used as an addition to traditional sessions with a specialist ^[29].

Another group of factors of the usefulness of mobile applications for mental health can be characterized as economic. Thus, the sources indicate the relative ease of finding information about psychological assistance that would suit a particular user from a financial point of view ^{[1, 5, 7, 12, 24, 33, 44]}. In one of the publications devoted to the use of mobile applications for mental health by students with attention deficit hyperactivity disorder, it was shown that the need for only a symbolic fee had a decisive role in getting help for people in need of it, whereas they could not afford to turn to specialists in the traditional way. Indeed, the average cost of paid applications is about $ 5, which is 20-40 times cheaper than the cost of one appointment with a specialized specialist ^[7].

The literature emphasizes that anonymity when using mobile applications avoids stigmatization, which, despite the spread of scientific knowledge about mental health, continues to be a problem. ^{[7, 12, 16, 17]}. If we talk about cultures where traditional ideas about shame persist, then seeking help can have the opposite effect and even worsen the client's condition ^[34]. In addition, one of the reviews claims that applications can serve as a kind of entrance into the field of psychological assistance and ultimately lead the client to a specialist ^[44]. In general, mobile mental health applications allow users to overcome obstacles when seeking help arising from a negative attitude to traditional psychological and psychiatric care ^[39].

The above shows the undoubted benefits of mobile applications in combination with traditional therapy. However, certain problems of this tool have also been identified, which we will now turn to.

A common problem for mobile apps is the low percentage of user retention ^{[19, 30, 32, 42, 46]}. One of the reviews indicates that the share of lost users exceeds 20% ^[19]. In another study, the percentage of participants who fully completed the course of therapy on mobile devices was characterized by a wide spread depending on the study: from 29.4% to 87.5%. Among the reasons for the departure of users are factors such as unsatisfactory functionality and difficulties in using applications ^[42]. Also, the use of mobile applications implies a lack of confidence that the proposed impacts are used in accordance with the developer's intention ^[25]. And indeed, today there are only a small number of objective ways to ensure the correct execution of tasks by the user, so in this case everything depends solely on the motivation of the client.

The next reason for concern implies applications designed to accompany people with a high risk of suicide. According to available data, such applications are not yet highly effective in preventing suicide ^{[28, 42]}. So, none of these applications corresponds to the best practice of providing information about crisis support inside the application, that is, there are no clear and clear instructions for the user about behavior in a critical case ^[28]. Most applications are not yet able to effectively help during situations involving suicide or self-harm, especially to predict the onset of such situations in advance ^[42]. As a result, people with a high suicide risk have not yet found adequate support through mobile mental health applications.

Among the problems with confidentiality, two main drawbacks stand out: third-party access to confidential information and the absence of a privacy policy ^{[1, 9, 13, 17, 28, 42, 44]}. Thus, users often voice concerns that information about them is used without appropriate consent for marketing purposes ^{[9, 13, 17, 42, 44]}. Even more concern is associated with thoughts about getting personal information into the public domain with subsequent problems in personal, professional and other spheres of life ^[44]. Judging by the user reviews, they were dissatisfied with the lack of the need to enter a password to access confidential information ^[1].

As for privacy policy, only 22% of apps focused on bipolar disorder and 29% of apps focused on suicide or self-harming behavior provided a clear privacy policy that would inform users about how their data is being used ^{[1, 28]}. That is, when using a part of mental health applications, there is a real risk of being identified and facing a number of problems in various spheres of life, which destroys users' trust in these applications.

The Effectiveness of Mobile Apps for Mental Health

As already mentioned, there is information about the effectiveness of mobile applications ^{[4, 12, 15, 24, 31, 32, 37, 42, 44]}. But upon closer examination, it turns out that the correct methods of impact assessment were not always used in the studies under consideration, and if they were still used, then it was about a small number of participants ^[15]. As for short–term effectiveness, we can only talk about it with respect to two applications, while there is no evidence of long-term effectiveness from using applications yet - most of the studies provide information about periods of application use lasting less than six months ^[12]. In one of the review studies, which examined 11 randomized controlled trials of the results of using applications, the authors conclude that the long-term benefits of applications are not confirmed by empirical data, therefore those in need of appropriate assistance should not rely entirely on this tool ^[31]. Summing up, we can say that the evidence base indicates a lack of high-quality, useful, convenient applications, and despite the rapid growth of their number, the evidence of their usefulness remains quite modest ^{[4, 8, 10, 20, 43]}.

Also, a number of authors point to the dubious theoretical basis of some mental health applications ^{[24, 37, 42, 44]}. For example, in one of the reviews it is noted that only a small part of the reviewed works provided a clear justification for the proposed impacts ^[37]. In another review, 2 out of 14 applications under consideration turned out to be such unfounded applications ^[24]. Needless to say, untested practices can harm users who, like specialists, should be aware of similar problems in this area.

Conclusion

We have received somewhat contradictory information about the usefulness of mobile applications for mental health. They undoubtedly have great potential to help people with mental disorders, but they also have noticeable drawbacks that are difficult to call irremediable, but which, nevertheless, should be known to all interested parties. Of course, some of the ambiguities are caused by the broad nature of this review. Undoubtedly, the picture associated with the consideration of one of the trends in this area associated with a particular disorder or sample may differ markedly from the one presented. Based on the above, we consider it necessary to draw some conclusions about the prospects for future research of mobile applications for mental health.

The lack of standardized ways to evaluate mental health applications necessitates the development of appropriate guidelines for patients and specialists, as well as certification systems. The recognition of the application as qualitative may be based on its development based on a sound approach, scientific evaluation of effectiveness and the availability of communication with emergency services.

The problems of user engagement can be largely solved with the help of interactive elements, gamification and integration with social networks ^[14]. Indeed, the problems of user engagement in mobile mental health applications can be effectively solved using various approaches. One of these approaches involves the use of interactive elements. Interactive elements can help users feel like active participants in the process of improving their mental health. For example, users can take various tests or surveys to assess their mental state, and then receive recommendations and advice depending on the results. It gives people a sense of control and participation. Another stimulating approach is gamification. Gamification allows you to turn the process of improving mental health into a game or competition, which can be very motivating for users. For example, a mobile app may offer achievements for achieving certain goals, using app features, or participating in certain tasks. Users can compete with friends or other users of the application, which will also help to maintain their interest and motivation. Integration with social networks can also be a useful tool to increase user engagement. Users can share their achievements, progress, or experiences via social media if they deem it necessary, which will allow them to receive support from other people. This will create additional motivation and a sense of belonging to a community of people with similar difficulties. However, in order to effectively address the problems of user engagement in mobile mental health applications, various factors must be taken into account, such as individual user needs, content quality, usability and data privacy. It is important to complement these approaches with further research and analysis in order to develop more effective strategies to increase engagement and improve the mental health of users.

Wider use of the capabilities of mobile devices, taking into account the user's state with reference to place and time, can provide a personalized, context-sensitive approach in interacting with the application. When combining a mobile application with traditional therapy, it is possible for a specialist to access some of the information about the client, if it seems necessary and desirable ^{[9, 11, 18]}.

One of the promising areas is the assessment of the effectiveness and attractiveness of mobile applications for the older generation. Since most of the studies were conducted among young people, the results for people who are less familiar with modern technologies and do not treat them so favorably may differ markedly from the available ones ^{[31, 35, 41]}.

             Based on the results of the review, we can say that mobile mental health applications have such advantages as accessibility, cost-effectiveness and confidentiality. Another important advantage is the improvement of treatment results. Above, we have already had the opportunity to see that these advantages are not always fully realized, which is due to the fairly widespread prevalence of disadvantages such as a high percentage of outgoing users, difficulties with data protection and the use of questionable psychotherapeutic approaches as the basis of applications. These shortcomings, as well as the often insufficient disclosure of advantages, are not surprising if we take into account only the recent emergence of this area. The listed shortcomings are hardly critical and today we can talk about new rich opportunities opening up for psychology in the field of mobile applications for mental health.