A research review of 18 randomised controlled trials confirms that smartphone apps are an effective treatment option for mild to moderate depression, but no evidence to suggest that apps alone can outperform standard psychological therapies, or reduce the need for antidepressant medications.
Depression is the most prevalent mental disorder and a leading cause of global disability, with mental health services worldwide struggling to meet the demand for treatment. In an effort to tackle this rising challenge, researchers from Australia’s National Institute of Complementary Medicine (NICM), Harvard Medical School, The University of Manchester, and the Black Dog Institute in Australia examined the efficacy of smartphone-based treatments for depression.
The researchers systematically reviewed 18 randomised controlled trials which examined a total of 22 different smartphone-delivered mental health interventions. The studies involved more than 3,400 male and female participants between the ages of 18-59 with a range of mental health symptoms and conditions including major depression, mild to moderate depression, bipolar disorder, anxiety and insomnia.
The first of its kind research found that overall smartphone apps significantly reduced people’s depressive symptoms, suggesting these new digital therapies can be useful for managing the condition.
Lead author of the paper, NICM postdoctoral research fellow Joseph Firth says this was an important finding which presented a new opportunity for providing accessible and affordable care for patients who might not otherwise have access to treatment. “The majority of people in developed countries own smartphones, including younger people who are increasingly affected by depression,” said Firth. “Combined with the rapid technological advances in this area, these devices may ultimately be capable of providing instantly accessible and highly effective treatments for depression, reducing the societal and economic burden of this condition worldwide.”
Co-author, NICM deputy director, Professor Jerome Sarris highlighted the importance of the findings for opening up non-stigmatising and self-managing avenues of care. “The data shows us that smartphones can help people monitor, understand and manage their own mental health. Using apps as part of an ‘integrative medicine’ approach for depression has been demonstrated to be particularly useful for improving mood and tackling symptoms in these patients,” said Sarris.
When it comes to the question of “Which app is best?” and “For who?,” the results suggested these interventions so far may be most applicable to those with mild to moderate depression, as the benefits in major depression have not been widely studied as of yet.
The researchers found no difference in apps which apply principles of mindfulness compared to cognitive behavioural therapy or mood monitoring programmes.
However, interventions that used entirely ‘self-contained’ apps – meaning the app did not reply on other aspects such as clinician and computer feedback – were found to be significantly more effective than ‘non-self-contained’ apps. The authors suggested this might be due to the comprehensiveness of these particular stand-alone apps rather than the combination of therapies.
Despite the promising early results, there is currently no evidence to suggest that using apps alone can outperform standard psychological therapies, or reduce the need for antidepressant medications.
According to co-author and co-director of the digital psychiatry programme at Beth Israel Deaconess Medical Centre and a clinical fellow in the department of psychiatry at Harvard Medical School, Dr John Torous, the research is a timely and promising step forward in the use of smartphones in mental health.
“Patients and doctors are faced with a vast array of mental health apps these days, and knowing which ones are actually helpful is imperative,” said Torous. “This research provides much needed information on the effectiveness of apps for depression, and offers important clues into the types of apps which can help patients manage their condition.”
Jennifer Nicholas, a PhD Candidate at Black Dog Institute and co-author of the paper says with the knowledge that apps can be effective for managing depression, future research must now investigate which features produce these beneficial effects.
“Given the multitude of apps available – manyof them unregulated – it’s critical that we now unlock which specific app attributes reap the greatest benefits, to help ensure that all apps available to people with depression are effective.”
The rapid advances and adoption of smartphone technology presents a novel opportunity for delivering mental health interventions on a population scale. Despite multi-sector investment along with wide-scale advertising and availability to the general population, the evidence supporting the use of smartphone apps in the treatment of depression has not been empirically evaluated. Thus, we conducted the first meta-analysis of smartphone apps for depressive symptoms. An electronic database search in May 2017 identified 18 eligible randomized controlled trials of 22 smartphone apps, with outcome data from 3,414 participants. Depressive symptoms were reduced significantly more from smartphone apps than control conditions (g=0.38, 95% CI: 0.24-0.52, p<0.001), with no evidence of publication bias. Smartphone interventions had a moderate positive effect in comparison to inactive controls (g=0.56, 95% CI: 0.38-0.74), but only a small effect in comparison to active control conditions (g=0.22, 95% CI: 0.10-0.33). Effects from smartphone-only interventions were greater than from interventions which incorporated other human/computerized aspects along the smartphone component, although the difference was not statistically significant. The studies of cognitive training apps had a significantly smaller effect size on depression outcomes (p=0.004) than those of apps focusing on mental health. The use of mood monitoring softwares, or interventions based on cognitive behavioral therapy, or apps incorporating aspects of mindfulness training, did not affect significantly study effect sizes. Overall, these results indicate that smartphone devices are a promising self-management tool for depression. Future research should aim to distil which aspects of these technologies produce beneficial effects, and for which populations.
Joseph Firth, John Torous, Jennifer Nicholas, Rebekah Carney, Abhishek Pratap, Simon Rosenbaum, Jerome Sarris