In light of the coronavirus disease 2019 (COVID-19) pandemic, we are making an effort to speak with behavioral health professionals from diverse backgrounds and specialties to learn more about their response to the current crisis.
We recently interviewed Nancy Lau, PhD, of the department of psychiatry and behavioral sciences at the University of Washington School of Medicine in Seattle, to learn more about the state of the mobile health field before COVID-19, and how the pandemic may affect digital technologies in healthcare. Dr Lau focuses on evidence based psychosocial interventions for youths with cancer and other serious illnesses, as well as ways to improve access to health care by leveraging mobile health technology.
In March 2020, Dr Lau published an article that systematically reviewed smartphone applications (apps) for psychosocial wellness and stress management.1 After examining the “oversaturated market of publicly available mobile apps,” Dr Lau found that only 2.08% of sampled apps had published, peer-reviewed evidence. However, the majority of apps were designed for self-help interventions and did not target patients with psychological disorders.1
To share your own unique perspective on the pandemic and its effects on behavioral health, please get in touch with us via our submissions page. The following interview has been edited for length and clarity.
What made you interested in this field and why did you choose to examine the evidence for smartphone applications?
My research is primarily focused on psychosocial interventions for youths, adolescents, and young adults with chronic illnesses. One of the struggles that we face as clinical psychologists and psychosocial clinicians is that the reach of evidence based interventions is limited by access to providers. My research focuses on how we can leverage digital health technologies in order to expand the reach of interventions to patients and people who could benefit.
I wanted to learn about what types of interventions already exist and the scope of what is popular. One important challenge was trying to apply a research lens and rigorous review methods to an unregulated space that is often not researched at all.
Alongside the growth of evidence based medicine, start-up and tech culture have celebrated entrepreneurial innovation. How do you resolve the contradictions between medical science and a healthcare industry increasingly shaped by experimentation and the unknown benefits of technology?
There are advantages and mutually beneficial collaborations that can leverage expertise and training from different backgrounds. From a research perspective, I think the steps to designing and testing a digital product meant to improve mental health outcomes is very linear, stepwise, and also slow.
Digital health technologies focus more on marketing and disseminating a product that people are interested in and widely use. The inception to dissemination process tends to be on a much briefer rapid iterative cycle. When you attempt to apply the standard methods of intervention research in which a typical time frame from inception to implementation is 15 to 20 years, the research lags behind the pace of evolving digital health technologies. You may get to the point several years into data collection for a clinical trial where you’re doing the statistical analyses to see whether this is beneficial or what can be modified, but you’re working with a stagnant and potentially outdated digital product.
Only 2% of the smartphone apps you looked at had original research publications, with Headspace having the most studies.1 Is the evidence biased in favor of larger companies that can self-fund studies?
Of the studies that we identified and evaluated, we actually found that a majority of the studies were designed and conducted in academic settings. It’s unclear how much of them involved reaching out to some of these app developers vs using something that is publicly available. Some of the natural collaborations and partnerships would involve 1) using an app that already exists with a wide user base and asking what can we do to assess whether these existing mobile apps are useful vs 2) following the more traditional research approach of designing the intervention in the lab.
Sometimes apps can promise a lot to users. What are their limitations? What do you think apps should be offering and saying they can do? Are they better off as an adjunct to existing treatment?
Apps designed for psychosocial wellness, stress management, improving quality of life, or changing habits and behaviors are an unregulated market. The US Food and Drug Administration recently released a guideline focused on digital tools that can be considered a treatment, and that space is highly regulated. But all of the criteria and guidelines actually don’t apply to a majority of apps that people just download for self-help. I think that the inherent concerns and limitations relate to doing something in a self-guided capacity.
The tension comes into play when people with very serious acute mental health needs use an app as a substitute for treatment. There’s also the issue of not being able to connect with a provider if there are concerns about self-harm or suicidality. There is a lot of responsibility placed on the individual who is experiencing distress to be able to take the additional motivational step as well.
A recent study in the Journal of Affective Disorders found that users generally rated non-evidence based apps lower, indicating that users seem to have some intuition into the quality of these apps.2 How can the field involve users in improving experiences and efficacy?
In the development of apps, there is a type of research called user-centered design. Before you test the product, you involve users to get a sense of how to design digital tools to be engaging so that people continue to use it. Oftentimes, even in traditional face-to-face approaches to care, there is not a lot of information out there for patients seeking help about what types of approaches are evidence based like cognitive behavioral therapy vs meeting with a provider who may not be trained in evidence based interventions.
For engaging individuals, I think that there are a lot of new pieces that are technology specific that have not been tested. What additional treatment components can we include in order to have more signposting, self-motivation, or positive reinforcement for continuing to use this intervention? Translating face-to-face treatments to digital platforms will require engaging with users to test appropriateness and acceptability, and the identification of strategies to optimize efficacy and sustainability.
The implementation of mobile health platforms and telemedicine in psychiatric care has accelerated during the COVID-19 pandemic. How do you see the pandemic affecting this field? Do you have any concerns about the adoption of these kind of modalities during this time?
On the one hand, it is a necessity and it’s great that we have these alternative modes of delivering treatments to patients when in-person care is not an option, and I anticipate that there will be an increase in mental health concerns in the context of and after the pandemic. Research examining how telehealth modalities compare to face-to-face treatment is still in its early stages, but accessing treatment in some capacity is better than no treatment at all. There is also a lot of literature that shows that the therapeutic alliance between the patient and clinician has a big role in beneficial effects from treatment, which may be lost in the app-based medium. Being able to connect to providers in some form is important, and more research will need to be done to figure out the right balance between self-direction and therapist assistance.
As more people turn to mental health care delivered via their personal devices, what implications might this trend have for healhcare providers? We know providers can feel challenged by developments in telehealth. Do you have any advice for providers?
In conversations with colleagues, we like to think that we’re an essential part of the equation. I think it’s a balance because being able to do something that is completely self-guided is much less resource-intensive and allows you to disseminate any sort of psychosocial care on a much broader level. For telehealth, there aren’t any geographical barriers and restrictions to being able to access care in rural areas, and you can access care at any point in time.
I’m also interested in apps offering access to providers in a structured or unstructured way, such as having text messaging options that aren’t necessarily happening in real time. It is important to make sure that people are incorporating new skills when they’re experiencing distress so that it becomes a habit. Providers can check in to make sure that they’re using these skills with fidelity and having some form of accountability. Apps can offer an opportunity to do ecological momentary assessment and progress monitoring to report on symptoms.
Do you think there are generational differences in the way users approach these technologies? How might older adult patients differ from younger children and adolescents, who are highly literate and comfortable with technology?
For younger generations, it is much more intuitive and often less tech support would need to be provided. For older generations, I think that one of the things that can be done upfront is more of a tutorial, and it would also be helpful to have ongoing tech support in case they’re experiencing issues with the mode of delivery. Often when users are asked to download an app, and you’re working with youths, adolescents, or young adults who are digital natives, that is not a tall order. However this process can be very different for older generations.
What interests and questions do you have for potential future studies? On a personal level how has the pandemic affected your work? How do you see it shaping what you do as a researcher?
For current and future research directions some of the big questions that I have are 1) what is the comparative level of efficacy that we deem sufficient for use of digital self-guided interventions and 2) how do we make sure that patients continue to utilize these mobile health interventions? In our lab we’re also working on translating a face-to-face evidence based intervention for youths with health conditions onto a mobile health platform. Also, there are some barriers that mobile health overcomes, such as stigma related to seeking psychological services and a reluctance to share personal problems.
As a field, I’ve been heartened by the level of very quick adaptation of people in both clinical and research settings involving patients. In our lab, because a lot of our ongoing research requires face-to-face work with patients or dissemination of evidence based psychosocial interventions, we are working with our institutional review boards to do an e-consenting format and then also moving to video-based formats to deliver evidence based interventions.
We are also working on including measures in our studies to get a sense of the impact of the pandemic on patients’ quality of life, mental health, and material or financial hardships.
1. Lau N, O’Daffer A, Colt S, et al. Science or snake oil: systematic search of iPhone and Android mobile apps for psychosocial wellness and stress management [published online March 22, 2020]. JMIR Mhealth Uhealth. doi:10.2196/17798
2. Baumel A, Torous J, Edan S, Kane JM. There is a non-evidence-based app for that: a systematic review and mixed methods analysis of depression- and anxiety-related apps that incorporate unrecognized techniques [published online May 11, 2020]. J Affect Disord. doi:10.1016/j.jad.2020.05.011