Multi-App Package Provides Tailored Behavioral Care

Mental health apps have been touted as a cost-effective way of increasing access to mental health care for those in need. But while many apps targeting depression or anxiety have shown promise in controlled trials, their real-world effectiveness has been limited due to poor user engagement; after one or two weeks most users get bored and move on to something else.

“One of the core symptoms of depression is a lack of motivation, so it’s asking a lot of depressed individuals to have them spend 30 minutes on their phone reading educational modules,” said David Mohr, Ph.D., the director of the Center for Behavioral Intervention Technologies at Northwestern University.

“A common thread of successful apps that people engage with repeatedly is that they typically do one thing and can be used for about 30 seconds at a time,” continued Mohr, who has spent more than two decades researching the use of digital tools for mental health. So why not try this tactic with mental health apps?

Mohr and his colleagues at Northwestern did just that; they developed and tested a multi-app mobile health platform called IntelliCare in primary care patients with depression and anxiety. Not only did the patients show high engagement with the apps over an eight-week period, but also they reported greater improvement from depression and anxiety than those who were not using IntelliCare. The findings were reported in JAMA Psychiatry.

IntelliCare consists of multiple brief, interactive apps that each focus on a specific skill, such as setting goals or learning self-affirmation. The apps can be downloaded through the IntelliCare Hub page, which also lets users track their mood and well-being. The Hub makes app recommendations for users based on how they rate their mood.

For the trial, users had access to five apps through the Hub page: Daily Feats (goal setting), Day-to-Day (positive psychology), MyMantra (self-affirmation), Thought Challenger (reframing one’s mindest), and WorryKnot (regulating emotions). Coaches were also available to answer participants’ questions, provide encouragement, and make app suggestions via text messages.

Working with colleagues at the University of Arkansas Medical Center, the Northwestern team recruited 146 adults with depression and/or anxiety from primary care clinics in the Fayetteville region. The study participants included people of diverse racial/ethnic backgrounds and socioeconomic status, thus reflecting a real-world population that might have limited access to mental health services. Half of the participants were given access to IntelliCare for eight weeks, while the others were on a wait list and received the software after eight weeks.

The authors defined recovery from depression and/or anxiety as a 50% or greater reduction in symptom scores on the nine-item Patient Health Questionnaire (PHQ-9) and/or seven-item Generalized Disorder scale for anxiety (GAD-7) or an absolute PHQ-9/GAD-7 score of less than 5.

After eight weeks, 59% of the participants using IntelliCare achieved depression recovery compared with 31% of those on the wait list. Similarly, 57% of participants using IntelliCare achieved recovery from anxiety compared with 38% of those on the wait list. The average improvements were higher than those reported in previous studies testing a single mood app and on par with improvements seen in studies of internet-based psychotherapy, the authors noted.

User engagement was also high. On average, the participants used the app about 100 times over the course of six weeks.

“We’re facing an unprecedented time of stress and anxiety around the world, and having research-grade tools like IntelliCare can help greatly,” said Steven Chan, M.D., M.B.A., a clinical assistant professor at Stanford University School of Medicine and co-chair of APA’s Committee on Innovation. Chan, who is also a member of the Psychiatric News Editorial Advisory Board, was not involved with the IntelliCare study.

“The strategy of deploying multiple apps makes sense,” he continued. “Multiple icons on your home screen will boost the number of opportunities you have to tap on those icons.” Chan, who is also the medical director for addiction consultation and treatment at the Palo Alto VA Health System, noted that the Department of Veterans Affairs is trying something similar by creating collections of health apps for easy access and download by patients.

Chan said that he believed that the IntelliCare coaches were instrumental to study participants. Coaches on average initiated contact with the study participants at least two times a week and responded to participants’ messages, Mohr and colleagues reported.

“Letting patients fend for themselves in the online jungle is insufficient,” Chan said, noting that highly regarded companies like Apple make customer service an integral part of their mission. At Palo Alto’s VA addiction treatments services, for instance, he and other staff guide patients as to how to download, install, and launch apps. “We have dedicated helplines, too, to help patients set up their mobile phones and devices,” he said.

Additionally, connecting coaches with patients can increase engagement with the apps, said Liza Hoffman, M.S.W., the director of behavioral health at Bicycle Health, a telemedicine startup that provides confidential online treatment for people with substance use disorders.

Before joining Bicycle Health, Hoffman worked at Cambridge Health Alliance (CHA), a large safety net health system in Boston. She led a study testing the feasibility of integrating mental health apps into primary care across CHA’s 12 clinics. The principle was similar to IntelliCare but rather than having the patient choose apps from a dashboard themselves, the care manager (staff member who helps patients with complex health problems navigate the health system) and patient would discuss the app options and create the patient’s app suite together.

“Getting the patient involved and setting up a specific plan increases their motivation to use these apps,” she said.

Hoffman’s feasibility study found that patients generally viewed their mental health apps favorably and used them; getting care managers or primary physicians to offer apps in the first place was a more challenging endeavor.

“While we should focus on what patients want from an app first, we cannot forget clinician buy-in, which is not guaranteed outside of a controlled trial setting,” she said. At CHA, she developed a “smartphrase” that care managers or others could type into a patient’s electronic health record that would bring up the online app toolkit, which made the process of discussing and downloading apps as seamless as possible.

Mohr believes that many care managers and other health care professionals would find IntelliCare very useful since it has built-in text features. “Care managers spend a lot of time trying to reach patients over the phone for follow-up assessments, and we know that no one answers the phone anymore. With text messaging, managers can reach patients directly through the app.”

“The field of digital mental health is crowded, but I’m optimistic about IntelliCare since it’s a modular system that can be integrated into a range of health care settings,” Mohr continued. He noted his team is currently planning a larger-scale rollout of IntelliCare at nearby Rush University Medical Center in Chicago, which has an established collaborative care program.

The IntelliCare study was supported by grants from the National Institute of Mental Health, National Institute of Diabetes and Digestive and Kidney Diseases, and National Center for Advancing Translational Sciences. Mohr has an ownership interest in Adaptive Health Inc., which has a license from Northwestern University to commercialize IntelliCare. ■