The MONARCA system is another smartphone app being developed for patients with BD.4 Similar to the SIMBA app, the MONARCA app autonomously collects objective data that are used to measure changes in physical and social activity. The MONARCA app also prompts users to complete a daily questionnaire on mood symptoms, sleep, alcohol use, and activity level. Investigators evaluated the MONARCA app in 29 Danish adults with BD who had moderate to severe depressive and manic symptoms. Participants used the MONARCA app for 12 weeks and underwent biweekly clinical symptom assessments.4 The study showed mood data self-reported through the app corresponded significantly with clinical assessments of depressive and manic symptoms. More severe depressive symptoms corresponded with more “on time” of the smartphone screen, fewer outgoing and answered incoming calls, and less activity each day. More severe manic symptoms were associated with more outgoing text messages, longer phone calls overall but shorter outgoing calls, and more location changes per day.

Both studies found great potential for using objective smartphone data to discriminate between depressive and manic states in patients with BD.2,4 The MONARCA app study found the program was useful even for patients with more severe BD symptoms.4 The small size of the studies limits their results, however, and larger studies are needed to validate the findings.

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Other studies have looked exclusively at whether smartphone apps that survey patients with BD on their symptoms can be a helpful tool for research or clinical practice. Most apps involve self-generated surveys that patients initiate when convenient. One recent study looked at whether patients would accept auto-generated surveys or ecological momentary assessments (EMAs), designed to capture data on emotions and behaviors in real time.5 The goal of EMAs is to reduce the bias introduced when a patient’s mood affects whether they agree to complete a survey and possibly how they respond. The app was given to 10 individuals with BD and 10 healthy participants for 2 weeks.5 The app revealed significantly lower median mood and energy scores in the BD group compared with the healthy group. In the BD cohort, patients completed 79% of the auto-generated surveys, which suggests it offers a feasible way to collect symptom data for BD studies.

Nichols said her review identified several concerns with current smartphone apps for BD.1 “The main concerns…are evidence-based quality and data privacy or security,” Nichols said. She reported that only 25% of apps that required data input had a privacy policy that explained how users’ mental health data would be protected, stored, or shared. Authors of the MONARCA and SIMBA studies share Nichols’ privacy concerns.2,4 The MONARCA app creators acknowledged the ethical issues raised by collecting data on behavioral activities.2 “[It] requires a high degree of trust between the patient and clinician and a high degree of data security,” they wrote.

Nichols said another finding of her review was that many BD apps “were not in line with evidence-based practice or didn’t include the key elements of traditional paper and pencil resources.”1 Although few apps appeared harmful, she found that none were optimal. “Unfortunately, the major issue with mobile health resources currently is that there is no way of assuring an app will be of good quality,” Nichols said. She recommended 3 items for clinicians and patients to consider when evaluating a mobile app: “Developer background – the developer should have experience and a good reputation in mental health; privacy and security—the app should be up front in telling you how your data are used; and evidence – any claims of benefit should provide evidence.” Until new frameworks are developed for researching smartphone apps for patients with BD and for implementing them into practice, clinicians and patients should discuss the benefits and risks of any app being considered.

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1. Nicholas J, Larsen ME, Proudfoot J, Christensen H. Mobile apps for bipolar disorder: a systematic review of features and content quality. J Med Internet Res. 2015;17(8):e198.

2. Beiwinkel T, Kindermann S, Maier A, et al. Using smartphones to monitor bipolar disorder symptoms: a pilot study. JMIR Ment Health. 2016;3(1):e2.

3. Faurholt-Jepsen M, Brage S, Vinberg M, Kessing LV. State-related differences in the level of psychomotor activity in patients with bipolar disorder – continuous heart rate and movement monitoring. Psychiatry Res. 2016;237:166-174.

4. Faurholt-Jepsen M, Vinberg M, Frost M, et al. Behavioral activities collected through smartphones and the association with illness activity in bipolar disorder. Int J Methods Psychiatr Res. 2016 Apr 1. [Epub ahead of print]

5. Schwartz S, Schultz S, Reider A, Saunders EF. Daily mood monitoring of symptoms using smartphones in bipolar disorder: a pilot study assessing the feasibility of ecological momentary assessment. J Affect Disord. 2016;191:88-93.