Mental Health Smartphone Apps: Review and Evidence-Based Recommendations for Future Developments

<jats:sec>             <jats:title>Background</jats:title>             <jats:p>The number of mental health apps (MHapps) developed and now available to smartphone users has increased in recent years. MHapps and other technology-based solutions have the potential to play an important part in the future of mental health care; however, there is no single guide for the development of evidence-based MHapps. Many currently available MHapps lack features that would greatly improve their functionality, or include features that are not optimized. Furthermore, MHapp developers rarely conduct or publish trial-based experimental validation of their apps. Indeed, a previous systematic review revealed a complete lack of trial-based evidence for many of the hundreds of MHapps available.</jats:p>           </jats:sec>           <jats:sec>             <jats:title>Objective</jats:title>             <jats:p>To guide future MHapp development, a set of clear, practical, evidence-based recommendations is presented for MHapp developers to create better, more rigorous apps.</jats:p>           </jats:sec>           <jats:sec>             <jats:title>Methods</jats:title>             <jats:p>A literature review was conducted, scrutinizing research across diverse fields, including mental health interventions, preventative health, mobile health, and mobile app design.</jats:p>           </jats:sec>           <jats:sec>             <jats:title>Results</jats:title>             <jats:p>Sixteen recommendations were formulated. Evidence for each recommendation is discussed, and guidance on how these recommendations might be integrated into the overall design of an MHapp is offered. Each recommendation is rated on the basis of the strength of associated evidence. It is important to design an MHapp using a behavioral plan and interactive framework that encourages the user to engage with the app; thus, it may not be possible to incorporate all 16 recommendations into a single MHapp.</jats:p>           </jats:sec>           <jats:sec>             <jats:title>Conclusions</jats:title>             <jats:p>Randomized controlled trials are required to validate future MHapps and the principles upon which they are designed, and to further investigate the recommendations presented in this review. Effective MHapps are required to help prevent mental health problems and to ease the burden on health systems.</jats:p>           </jats:sec>

section_content: In collaboration with SuperBetter Labs, LLC This bulletin describes our scientific study of a tool called SuperBetter, which reduced users' depression and anxiety symptoms and increased their well-being. 

Scientists have developed good treatments for depression, but many people who need help do not get it. Therapy can be costly, unavailable, or just too stigmatizing. The rise of smartphones and web-based programs has opened the door for new ways to support people who are striving to overcome depression and improve their well-being. 

SuperBetter is a web-based and smartphonebased application that provides people with engaging, interactive content designed to help them achieve wellness goals. In this study, the University of Pennsylvania teamed up with SuperBetter Labs to test whether this application can help people overcome symptoms of depression. 

In this study, two versions of SuperBetter were compared to a waiting list (control group). One version of SuperBetter targeted depression symptoms using strategies from cognitive-behavioral therapy (Beck, 1979) and positive psychotherapy (Seligman, Rashid, & Parks, 2006). The other version did not specifically target depression; It used quick and easy feel-good activities that had been popular with previous SuperBetter users. 

This bulletin describes how the team conducted this rigorous trial, and then it outlines and explains the main findings. It focuses on the following questions:

 Does SuperBetter relieve depression?  Does it also decrease anxiety and/or improve life satisfaction, social support, and self-efficacy?  Which version of SB works best?
section_name: The University of Pennsylvania

section_content: Participants became less depressed and anxious.
section_name: SuperBetter provides relief.

section_content: One version of SB provided the most relief.
section_name: Specific SB content works especially well.

section_content: Participants became more satisfied with their lives.
section_name: SuperBetter improves well-being.

section_content: How was the study done? DESIGN This study was a randomized controlled trial. All participants had an equal chance of being assigned to one of three groups:

 A group that used a version of SuperBetter based on cognitive-behavioral therapy and positive psychotherapy ("CBT/PPT SuperBetter");  A group that used a version of SuperBetter based on simple, easy, feelgood activities ("Being Awesome SuperBetter");  A group that waited for their turn to use SuperBetter ("Waiting List").
section_name: Method

section_content: Participants were recruited from two websites:  Authentic Happiness (www. authentichappiness. upenn. edu), which is affiliated with the University of Pennsylvania Positive Psychology Center  Craigslist (www. craigslist. org), an online community bulletin board Participant characteristics: The average age was 40. 72% of participants were female, and 82% were White. 39% were currently using therapy or coaching, and 22% had tried these in the past. 42% were currently using antidepressant medication, and 64% had tried it in the past. 

At pre-test participants were depressed, with average scores of 32. LIFE SATISFACTION was measured with the Satisfaction with Life Scale (SWLS).
section_name: PARTICIPANTS

section_content: was measured with the New General Self-Efficacy Scale (NGSE). 

SOCIAL SUPPORT was measured with the Multidimensional Scale of Perceived Social Support (MSPSS).
section_name: SELF-EFFICACY

section_content: Potential participants completed a screening questionnaire, and those who were eligible enrolled in the study and completed a pre-test (including all the measures listed above). Then, they were randomly assigned to one of the three groups: CBT/PPT SuperBetter, Being Awesome SuperBetter, or the Waiting List control group. The SuperBetter groups were asked to use the app daily for one month. Every two weeks, all participants were asked to complete a survey about their depression and well-being. 

When all data had been collected, the data were analyzed using hierarchical linear modeling (HLM) with the statistical program SAS. HLM is a good way to analyze data when some participants drop out and so data is missing (Nich & Carroll, 1997). 

Use SuperBetter for 10 minutes daily
section_name: PROCEDURE

section_content: What was discovered?

The most important question in the study was this: Do SuperBetter players become less depressed in one month, compared to people on a waiting list?
section_name: Results

section_content: At the 1-month post-test, SB players' depression scores decreased by 11. 3 points. In comparison, waiting list participants' scores only decreased by 4. 3 points. 

How big is this change? Do 11. 3 points on a depression scale matter? This change is equivalent to the following: After one month, a SB player reports that 5 symptoms that used to bother her 3-4 days per week are no longer a problem-while a waiting list participant reports that only about 2 symptoms have improved that much.
section_name: POST-TEST ANALYSES

section_content: By follow-up (six weeks pre-test), SB players' scores were 17 points lower than at pretest (compared to a 6 point decrease for waiting list participants). This is equivalent to eliminating about 8 symptoms that used to bother a SB player 3-4 days per week (compared to eliminating about 3 symptoms for waiting list participants). Waiting List SuperBetter
section_name: FOLLOW-UP ANALYSES

section_name: ANXIETY

section_content: At the one-month post-test, SB players' anxiety scores decreased by 3. 5 points. Waiting list participants' anxiety scores only decreased by 1 point.
section_name: ANXIETY

section_content: At the one-month post-test, SB players' life satisfaction increased by 3. 1 points. . Waiting list participants' life satisfaction only increased by 0. 5 points.
section_name: LIFE SATISFACTION

section_content: At the one-month post-test, SB players' social support increased by 3. 5 points. Waiting list participants' social support only increased by 0. 1 points.
section_name: SOCIAL SUPPORT

section_content: At the one-month post-test, SB players' self-efficacy increased by 3. 4 points. Waiting list participants' self-efficacy only increased by 0. 5 points.
section_name: SELF-EFFICACY

section_name: SECONDARY

section_name: OUTCOMES

section_name: Results

section_content: Which version of SuperBetter worked best? The hypothesis was that the CBT/PPT version of SuperBetter would work best, because it uses strategies from effective therapies (cognitive behavioral therapy and positive psychotherapy).
section_name: Continued

section_content: At the one-month post-test, using CBT/PPT SuperBetter were slightly better off than waiting list participants: Their depression scores fell by 9. 3 points compared to 4. 5 points, but the difference was not statistically significant.
section_name: CBT/PPT SUPERBETTER (VS. WAITING LIST)

section_content: At the one-month post-test, participants using Being Awesome SuperBetter were significantly better off than waiting list participants: Their depression scores fell by 13. 0 points compared to 4. 5 points (p <. 0001). By follow-up, the participants using Being Awesome SuperBetter saw their depression scores fall by a total of 19. 7 points.
section_name: BEING AWESOME SUPERBETTER (VS. WAITING LIST)

section_content: Overall, the Being Awesome version of SuperBetter performed better than the CBT/PPT version of SuperBetter, as seen in the graph below. There are several possible explanations. One is that it may be hard to master CBT skills without more guidance. Another is that not all the CBT/PPT participants downloaded/used all the content they were offered, so they did not receive their full "dose" of SuperBetter. More research is needed to understand what specific kinds of SB content work well.
section_name: COMPARISON OF 2 VERSIONS OF SUPERBETTER