The expanding use of mobile health technologies is “unprecedented in the history of medicine.”1 Apps have “transformed many aspects of clinical practice” because apps “provide many benefits for health care practitioners, perhaps most significantly increased access to point-of-care tools, which has been shown to support better clinical decision-making and improved patient outcomes.”2 Psychiatrists, clinical psychologists, psychotherapists, and other mental health clinicians are increasingly faced with questions regarding the efficacy and risks of mobile and online apps.2 The American Psychiatric Association (APA)’s Expert Panel on apps notes that apps can be “appropriate and useful” in the care of patients with psychiatric conditions but delineates several potential dangers in apps that mental health practitioners might be using in the course of their practice and highlights concerns and questions that practitioners should consider before using an app.2
One of the uses of an app in clinical practice—including the practice of psychiatrists—is to assist in the screening, diagnosis, and monitoring of depression.3 A study of physicians and patients found that both were interested in such an app and were seeking tools that would be “easy and intuitive” to use and would offer “personalized content.”4
To offer insight into such apps, we spoke with 2 experts involved in researching and developing apps to be used by psychiatrists and other physicians to screen for depression and diagnose and manage patients with the condition. The apps address different needs and use different technologies, but taken together, they shed light on the manifold ways that apps can be used for depression management in clinical practice.
We interviewed Ravi N. Shah MD, MBA, chief innovation officer, Department of Psychiatry, assistant professor of Psychiatry, Columbia University Irving Medical Center New York, New York.
How did you develop the treatment approach used in your app?
Dr Shah: I teamed up with John Mann, MD, who is a professor of Translational Neuroscience and a former vice chair for research in the Department of Psychiatry at Columbia University. He is also the director of research and director of molecular imaging in the Neuropathology Division of the New York State Psychiatric Institute.
Dr Mann had written a review in the New England Journal containing a treatment algorithm for medical management of depression.10 Many psychiatrists regard the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study11 as a treatment algorithm, but although it was an instructive and helpful clinical trial to teach us about depression and medication, it is not necessarily the most optimal way to treat depression today.
How does your approach differ from that of the STAR*D?
Dr Shah: Here are a few examples. The STAR*D studied improvement in symptoms every 4 weeks, but we think the data suggest it is better to check for improvement every 2 weeks. The STAR*D suggest that if 1 selective serotonin reuptake inhibitor (SSRI) does not work, the patient should switch to another SSRI.11 In our treatment algorithm, if people do not improve on one SSRI, they can switch to a serotonin and norepinephrine reuptake inhibitor (SNRI).
What else does the app offer?
Dr Shah: The app offers clinical pearls for depression treatment in a stepwise fashion; titration protocols for the 7 essential generic medications used to treat depression; build-in calculators for the PHQ-9 and the Columbia Depression Scale Suicide Risk Assessment (C-SSRS), and safety planning.
The tool suggests “gateway” screening questions that, if the patient responds by saying “yes,” more formal tools are suggested. For example, if the patient indicates that they have needed much less sleep, it is recommended that the patient has a longer, more formal bipolar screening scale, which is also included in the app.
If a patient presents and you think they have depression, you can open the app. It will remind you of the diagnostic criteria for depression. You can select whether the patient is presenting for an initial or a follow-up visit. The app prompts you to ask important question about suicide risks as well as questions to see if the patient might have bipolar disorder rather than unipolar depression. When a medication is suggested, there is information about how to initiate and titrate the medication, the most common side effects, and the full FDA prescribing information if you want to do further reading about the medication.
The app will also help as the patient comes up for follow-up to ascertain if the patient is improving, has not changed, or is in remission, and will suggest options, based on those results. Should you change the medication? Change the dose? How soon should the patient be seen again? This tool can help you longitudinally in managing the patient.
It sounds a little like a “cookbook” approach. Where does clinical judgment fit into the picture?
Dr Shah: Even in the kitchen, you need to combine use of a cookbook with your own judgment. That’s certainly the case in a clinical setting. You are treating human beings and you are a trained clinician. No app can be applied in a robotic manner or replace clinical judgment. Rather, it is another tool in the toolkit and a way to help you incorporate the latest research into practice. No matter what algorithm we create, it can never recreate every scenario in humankind, but it is likely to cover much of what is seen in routine clinical practice. We expect clinicians to use their judgment, just as they would with any clinical tool.
And does information automatically get transferred to the patient’s electronic medical records (EMR)?
Dr Shah: The app is downloadable via the web onto a smartphone or computer and has exportable PDFs. We do not currently collect any data that is on your own computer or smartphone. We are in the process of developing a system of integrating the information with the patient’s EMR, and of course once we do that, any transmission mode will be HIPAA-compliant. In addition, we have an automatically generated text to document the clinician’s decision-making process and the clinician can add that to the patient’s notes.
How can your app be accessed?
It is available on our website:App Access
We also interviewed Hari Prasad, MS, cofounder and CEO of Yosi Health.
What is Yosi Health?
Mr Prasad: Yosi Health is a patient engagement platform that offers a suite of solutions to engage patients before, during, and after their visit. This creates maximum efficiency for physicians and other health care providers.
How did you come to found Yosi Health? What was the impetus behind it?
Mr Prasad: In my background, I worked for large payers and provider organization and what I noticed in my professional experience as well as my experience as a consumer and patient, is that there were not enough tools to help health care providers understand their patients’ medical needs.
Typically, information is collected from patients via pages on a clipboard in the waiting room. Patients sit next to each other and fill out these forms. Everyone is pressed for time. Handwriting can be illegible. Some people have difficulty reading the forms. During the pandemic, the extra time spent in the waiting room can lay some patients open to the potential of COVID-19 contagion.
Additionally, we have noticed that large amounts of vital information are often lost in the clipboards. And the questions on the preprinted forms don’t always capture what is most relevant and important to a given provider, based on his or her approaches to the medical conditions for which the patient is coming.
The proverbial camel’s back broke for me when I was trying to fill out my patient paperwork with a dislocated shoulder in the emergency room. It was both annoying and painful. I had to rummage through my things to find my insurance card, remember all the medications I was taking, sign a bunch of consent forms, and do all of this while in serious pain. Having worked for hospitals and insurers and having an academic background in health informatics, finance, and data analytics, I knew there had to be a better way.
To develop this “better way,” I assembled a team of respected physicians in a number of disciplines, including psychiatry, to weigh in on developing a platform that could help improve waiting room productivity and allow physicians to get a sense ahead of time what complaints their patients were presenting with and any salient information having to do with that complaint, so the platform had to be customized to the needs of every physician. To save the physicians effort and time, we wanted to streamline the platform with the industry’s leading EMR/EHR [electronic health record] providers so that the information could directly be entered into the patient’s record.
How does your tool work?
Mr Prasad: We offer a convenient web-based tool that patients can fill out in the convenience of their homes. We use a combination of available standardized questionnaires and augment these with other evidence-based questions that each clinician would like to ask. The questions included are selected by each provider, so it is highly customized and individualized, based on the unique set of priorities approaches of the physician. We really feel that one-size-fits-all doesn’t work in behavioral health, because each psychiatrist or other clinician will have his or her own set of questions. After we have collected the information, we score the assessments from the patient and provide it to the clinician before the patient arrives at the appointment.
We are not only cognizant of each provider’s unique set of questions but also the workflow and structure of the medical practice. A large group practice isn’t the same as a solo practice, or an outpatient clinic, for example.
Our software is cloud-based and works on a subscription basis and all of the workflow is fully automated. Once an appointment has been booked, we instantly contact the patients in a simple, seamless, engaging way via a HIPAA-compliant platform that’s fully web-based, can be used on any smartphone or computer, and serve a wide range of demographics.
One of the most common and major problems in the treatment of patients in general and especially those with mental health disorders is poor engagement. And yet physician surveys have found that a growing number of providers are interested in adopting digital clinical tools. A significant population of patients with psychiatric disorders, including severe mental illness, are comfortable using digital devices and tools when they are tailored to this population.5 Since many of these patients don’t readily adapt to digital tools, we make it very simple and patient centric. We don’t ask them to download apps or create logins or passwords and we collect all the information we need, ranging from past medical history to allergies, family history, current medications, review of symptoms, and history of the present complaint. As mentioned, we use recognized, established, evidence-based depression and anxiety screening tools and then we transfer the information directly into the patient’s EMR, thus removing all of the documentation time that a provider spends and wastes.
Can you please speak more to the screening questionnaires you use for depression and anxiety?
Mr Prasad: As mentioned, our technology automates the sending of screening questionnaires that flag depression, anxiety, or at risk addiction patients based on criteria supplied by the providers and care centers. We offer a wide range of standardized, evidence-based screening tools such as the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GaD-7), the Alcohol Use Disorders Identification Test (AUDIT), the Screen for Child Anxiety Related Disorders (SCARED), and many others, together with personalized input from the clinician.
By automating these screeners prior to the patient’s visit, not only will every appropriate person/patient have a secure and easy private method of answering the questions safely, remotely, and accurately, but the providers will also have the ability to deliver to and/or flag a greater number of at risk patients significantly faster than the traditional point of care in person at the office, over the phone, or via video.
Is psychiatry the only specialty you work with?
Mr Prasad: While we work with 22 specialties across the country with customers in all 50 States, we focus largely on psychiatry/behavioral health, pediatrics, pain management, and women’s health. Within psychiatry, we work with an array of mental health conditions, of which depression is only one example.
How can clinicians access your app?
Mr Prasad: You can visit us at: https://yosi.health/patient-intake/
Table 1: Potential Perils and Pitfalls of Mental Health Apps
| ● Offering incorrect or misleading information to patients. |
● Claiming to offer therapeutic interventions or services but actually be ineffective, leading to belief the patient is treatment refractory.
● Not being secure, or improperly disclosing or allowing access to the personal health data.
● Selling patient collected data but not obviously disclosing this information to users.
● Not actually collecting clinically useful or actionable data.
● Being a new technology whose use in a clinical setting is still not fully understood.
Table 2: Evaluating an App: Questions to Ask
| ● On which platforms/operating systems does the app work? |
● Does it also work on a desktop computer?
● Has the app been updated in the last 180 days?
● Does the app collect, use, and/or transmit sensitive data?
● If yes, does it claim to do so securely?
● Is there evidence of specific benefit from academic institutions, end use feedback, or research studies?
● Does the app have a clinical/recovery foundation relevant to your intended use?
● Does the app seem easy to use?
● Can data be easily shared and interpreted in a way that’s consistent with the stated purpose of the app?
● What are the main engagement styles of the app?
● Do the app and its features align with your needs and priorities?
● Is it customizable?
● Does the app clearly define functional scope?
● Does the app seem easy to use?
● Can the app share data with EMR?
1. App Advisor. American Psychiatric Association. Accessed: January 28, 2022. https://www.psychiatry.org/psychiatrists/practice/mental-health-apps.
2. Ventola CL. Mobile devices and apps for health care professionals: uses and benefits. P T. 2014;39(5):356-364.
3. BinDhim NF, Shaman AM, Trevena L, Basyouni MH, Pont LG, Alhawassi TM. Depression screening via a smartphone app: cross-country user characteristics and feasibility. J Am Med Inform Assoc. 2015 Jan;22(1):29-34. doi:10.1136/amiajnl-2014-002840. doi:10.1186/s12888-021-03064-x
4. Patoz MC, Hidalgo-Mazzei D, Blanc O, et al. Patient and physician perspectives of a smartphone application for depression: a qualitative study. BMC Psychiatry. 2021 Jan 29;21(1):65. doi:10.1186/s12888-021-03064-x
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6. Depression. World Health Organization. Published September 13, 2021. Accessed: January 20, 2022. https://www.who.int/news-room/fact-sheets/detail/depression.
7. Ettman CK, Cohen GH, Abdalla SM, et al. Persistent depressive symptoms during COVID-19: a national, population-representative, longitudinal study of U.S. adults. Lancet Reg Health Am. 2022 Jan;5:100091. doi.org:10.1016/j.lana.2021.100091
8. Depression. National Institute of Mental Health. Updated: January 2022. Accessed: January 20, 2022. https://www.nimh.nih.gov/health/statistics/major-depression
9. Park LT, Zarate CA Jr. Depression in the primary care setting. N Engl J Med. 2019;380(6):559-568. doi:10.1056/NEJMcp1712493
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11. Sequenced treatment alternatives to relieve depression (STAR*D) study. National Institute of Mental Health. Accessed: January 19, 2022. https://www.nimh.nih.gov/funding/clinical-research/practical/stard.
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