The Use of Mobile Apps and Technologies in Child and Adolescent Mental Health (Preprint)
Authors: PUNUKOLLU Mallika 
Published: March 2019

BACKGROUND

This review will aim to critically evaluate the current available literature concerning the use of online and mobile-based applications and interventions in the detection, management and maintenance of children and young peoples mental health and wellbeing. More specifically, to determine if this type of intervention is yet effective and appropriate enough to be comprehensively utilised by CAMHS clinicians to support their delivery of the service.
In addition Case Studies will demonstrate examples of current applications of this type of intervention in a typical Tier 3 CAMHS service within NHS Greater Glasgow and Clyde.

OBJECTIVE

To determine if digital mental health interventions are effective and appropriate enough to be comprehensively utilised by CAMHS clinicians to support their delivery of care.

METHODS

A structured literature search of 7 electronic databases was conducted for relevant publications between January 2007 and November 2017. Databases searched included; MEDLINE, PsychINFO, EMBASE, AMED (Allied and Complementary Medicine), Health Technology Assessment Guide, Cochrane Database of Systematic Reviews and the Cochrane Register of Controlled Trials. Searches were conducted with keywords pertaining to mental health, wellbeing and problems, age of the study population and words pertaining to mobile or Internet apps or interventions (see Table 1).
Database specific filters of Human Population and English language were applied where available. Following the database search reference lists of identified studies were screened to ensure an exhaustive search.

RESULTS

Study Inclusion
Initial database searching with the filters of Human Population, English Language and 2007-2017 publication date identified 1013 results with 3 additional results identified through screening of appropriate reference lists. Duplicate results were removed yielding a total of 692 records for screening. The titles and abstracts of these unique citations were assessed for eligibility. After this process the remaining 92 full-text articles were assessed against the inclusion and exclusion criteria with a total of 6 included in the final review.

Study Characteristics
Characteristics of the studies are detailed in Table 3. The 6 publications included in this review consisted of, 4 randomised controlled trials reporting mental health outcomes [36–39], 1 RCT reporting health service outcomes and 1 study of cross-sectional design reporting on a screening app [40]. Of the trials that reported RCT results, 3 described results from the same data set [37,38,41]. Publication dates ranged from 2011 to 2017. 4 studies were conducted in the anitpodean region [37–39,41], one was carried out in Sweden [36] and one primarily in South Korea, however the app was available worldwide but was published in the Korean Language so primarily only accessible to Korean speakers [40]. Affective (mood) disorders and related co-morbid conditions were the primary psychiatric conditions of interest in 5 of the studies [37–41].

Study Risk of Bias
All studies were assessed for quality and risk of bias using a tool adapted from the widely accepted Cochrane Risk Of Bias Tool [35]. The studies were assessed to be of varying quality, with only one assessed as being of high quality [39]. In general, performance bias due to difficulties in blinding participants and personnel was an issue as well as difficulty in assessing the use of selective reporting. Full results of the Risk of Bias assessment can be seen in Table 4.

Study Participants
All included studies involved participants under the age of 18 years, age of those involved ranged from 10 years up. Only 2 sampled exclusively from the traditionally thought of paediatric population, involving only participants between the ages of 13 and 17 years [36,39]. 81.4% of participants in the Jang et al. (2017) study were aged 10 to 29 years but no further breakdown of the groups composition in terms of ages was provided [40]. It should also be noted that the sum mean age of participants involved in the mobiletype trial was 18.1 years [37,38,41]. Additional demographic data of participants was recorded in all studies, with none reporting any statistically significant differences between the intervention and attention comparison groups, however in all included studies the number of female participants was disproportionately greater than the number of male participants [36–41].
4 of the included studies were exclusively comprised of data from participants with mild to severe emotional or mental health difficulties, either formally diagnosed [36] or indicated by scores on a validated scale [37,38,41]. As the aim of the MEMO trial was to evaluate the effectiveness of the intervention in preventing the onset of depression, prospective participants scoring in the clinical range as having mental health difficulties on several validated scales were excluded from participation [39].

Incentives to Participate
Incentives to participation were employed in the design of many of the studies. The mobiletype studies offered $30 phone credit to reimburse the young participants and participating GPs received quality assurance points toward their continuing personal development [37,38,41], while the MEMO trial offered ringtones and games as rewards for participation [39].

Mobile Technology Characteristics and Mobile Phone Ownership
Of the 6 studies included in this review, 5 utilised asynchronous features of mobile phones (including apps and multimedia messaging) [37–41], the remaining study concerned the use of a mobile phone based interactive voice response system [36]. Studies evaluated the effect of use the mobiletype app [37,38,41], the MEMO-CBT multimedia mobile phone program [39], an unnamed depression and suicide screening app [40] and the Interactive Voice Response follow up system for reporting mood post discharge from inpatient care[36]. With the exception of the unnamed app described by Jang et al. [40], all technologies utilised were designed specifically for the paediatric and young adult population [36–39,41]. At the time of writing, none of the technology or apps used is currently available for public consumption, either on Google Play or the App Store.
Mobile phones were required for participation in all included studies, some studies relied on participant personal mobile phone ownership [39,40], other research teams worked in conjunction with mobile technology companies including Sony Ericsson, Telstra Corporation and Vodafone, to provide participants with mobile phones and pre-paid SIM cards in order to take part [37,38,41]. The MEMO trial research team provided free internet access to allow participants to easily view content [39].

Mental Health Outcomes
As evident in table 3 the main area of interest for mobile technology intervention was depression, anxiety and suicide. 5 studies reported mental health outcome data [36–40]. Whittaker reported that use of the multimedia mobile messages with CBT content had no significant effect on depression scores when compared to non-CBT delivered content. It was found that both the intervention and the control groups experienced slight improvements in scores on the Child-Depression Rating Scale –Revised immediately post-intervention (mean increase 0.61 in intervention group and 1.07 in control group) but then scores for both groups worsened when assessed at 12 months, with no significant difference when adjusted for baseline score (p=.27).
The only other mobile app to have undergone an RCT included in this review was the mobiletype app [37,38,41]. The trial analysed the depression, anxiety, stress and emotional self awareness scores of 114 participants aged between14 and 24 years with emotional or mental health problems, who were randomised to use either the mobiletype app, which monitored mental health or an abbreviated version with no mental health self monitoring. It was found that there was no significant difference between groups in the post-intervention depression (p=.69, d=0.09), anxiety (p=.76, d=0.07) or stress (p=.32, d=0.22) scores. Regardless of group, significant decreases in score were observed on the depression, anxiety and stress scale with the effect of time [34,37]. Emotional self-awareness was found to undergone significantly greater increases in the intervention group using the full mobiletype app than the attention-comparison group. The increase in emotional self-awareness was discovered, through regression analyses, to have significantly decreased depressive symptoms. The mobiletype intervention itself was not directly responsible for the decrease in depressive symptoms [38].
Johansson assessed the used of a mobile Interactive Voice Response system in the immediate post-discharge follow up of paediatric psychiatric in-patients. It was found that participants found the call acceptable, responding with high frequency. No significant differences in mood levels were reported between the groups that were randomised to receive IVR calls every second or forth day and that no interaction between age, sex diagnosis or treatment period existed [36].
Only one app was designed for population screening purposes. Jang found that positive self-reported depression scores from screening tools on the app were positively correlated with increased risk of scoring as high risk on suicide screening tools [40].

Health Care Service Outcomes
Only one study reported health service outcomes data [41]. The mobiletype RCT [37,38,41] assessed the use of the mobiletype app as a clinical assistant tool for GPs, as an aid in the development of doctor-patient rapport and its effect on pathways to care. The study found that GPs felt the mobiletype intervention significantly assisted them in gaining a picture of their patient’s current level of functioning (p=.023, effect size [d]=0.48), was significantly more helpful in making decisions about medication (p=.013, d=0.55) and referrals (p=.012, d=0.55) than the control program. However, the use of the mobiletype program had no significant effect on doctor-patient rapport from the paediatric patient perspective or on pathways to care [41].

Mobile Technology Usage
Few of the included studies reported data on the technology usage by participants. Of those that did, Whittaker found that on 19% of participants viewed more than half of the multimedia messages sent to them and reported that participants greatly overestimated the proportion of messages they viewed [39]. The mobiletype trial reported that only 52.6% of participants in the intervention group received what they researchers considered to be the minimum effective dose with the remainder of participants not active enough on the app to reach this dose level [37]. Johansson reported 71% of participants achieved an answering IVR call frequency of 100% [36].

Child, Adolescent and Young Person Feedback
Although not the aim or primary outcome measure of any of the included studies, results of the MEMO-CBT included reports from the majority participants that they found the program to be helpful, with a slightly higher proportion (84%) of the intervention group giving positive reports than the control group (82%) this difference was however, non-significant (p=.46). There were also non-significant differences between the intervention and groups in sharing of messages with others (37.9% and 40.0% shared messages respectively).

CONCLUSIONS

The aim of this report was to critically evaluate the available literature regarding the use of mobile apps and technologies in the maintenance and management of child and adolescent mental health. In doing so it was found that despite promising initial reports, there is not yet sufficient evidence for widespread adoption of these technologies in the child and adolescent mental health service and further research must be done to determine their clinical benefit (if any). There must also be development of a validated tool to assess the quality of apps and clinical guidelines should be agreed upon for their use and oversight. This is a promising and important area of study, which should be at the forefront of health technology and mental health research.