APA App Advisor: Working With Patients to Use Apps

This series features members of APA’s App Advisor Expert Panel who discuss the general use of mental health apps and answer APA members’ questions. This group is composed of APA members and other subject matter experts in mental health from related professions (for example, social work, psychology, nurse practitioners, informaticists) and patients with lived experience of mental illness. The purpose of this panel is to maintain APA’s App Evaluation Model and to provide resources for professionals and patients to give them tools they can use when deciding what app is appropriate. The articles will also explore clinical, research, and policy interests of the panelists around mHealth (mobile health).

This month’s panelist is Darlene King, M.D. Dr. King works with APA’s App Advisor Expert Panel and is a member of APA’s Committee on Mental Health Information Technology. She is a fourth-year psychiatry resident at the University of Texas Southwestern Medical Center in Dallas. As a physician with an engineering background, Dr. King thinks in ways that link engineering, medicine, and information technology. She earned a biomedical informatics certificate from the University of Texas School of Biomedical Informatics at Houston in 2019.

Q: One part of APA’s Evaluation Model prompts the user to consider whether the app comes from a “trusted source.” What are some ways we can tell if an app is from a trusted source?

A: First, it’s important to look at the developer’s profile in the app store and see if you recognize the company and to look for a few key pieces of information. Does the developer fall into any of the following categories: government, academic institution, or private company? A private company may be more likely to sell information or be held to different standards from those for a government agency or academic institution.

You should also review other information available in the app store, including the privacy policy, to see how information collected by the app is handled. You also should consider what type of app it is—for example, is it categorized as a wellness app or a medical app? This is important, because medical apps must adhere to the Health Insurance Portability and Accountability Act (HIPAA).

Q: When patients approach you about using an app, what important information do you discuss with them?

A: It’s a good idea to approach discussing apps with patients similar to how you would approach talking about medication: Go over the risks and benefits, certainly, and let them know that the app use is voluntary and that they are not being expected to adhere to app usage.

Using apps also prompts a different kind of risk/benefit conversation. In terms of risks, for the most part, apps do not have the same confidentiality restrictions and don’t have to adhere to HIPAA. Personal information that patients share in the app and with others could be sold to third parties or not be as protected at the same stringent level as their medical information. Also, unlike medications, most apps are not FDA approved, and many are not evidence based. We still don’t know how helpful many apps may be. Finally, the information collected by apps that offer peer support may not be confidential, and some apps do not have built-in safety or crisis features.

However, there are some benefits to using many types of apps. For example, apps that are used regularly could help with mood tracking; journaling; or a targeted symptom, such as poor sleep, with a CBTi (cognitive-behavioral therapy for insomnia) app. Also, patients may have greater access to resources or help through an app than otherwise easily possible. Apps can be a convenient way to engage with a specific type of intervention.

Q: Once you and a patient have decided to use an app together, what are some strategies to get the patient to engage with that app as a part of therapeutic treatment goals?

A: As the research suggests, an app’s effectiveness depends on consistent and appropriate use. So, it’s important to help patients think about the benefits of using the app and consistently remind them to use it during check-ins. That said, you might also suggest that they set a timer or notification (another app available to them on their phone) to remind them to engage with the app.  You might also consider having patients plan to reward themselves for using the app daily for the first week and then repeat that reward if it seems to be successful. Depending on the app and specific type of treatment, patients might also want to tell friends about it, engage with the app as a group, or ask for accountability from friends and family to check whether they are using the app regularly.

Q: Glancing at the app store shows that there are some apps that are specifically created for children. What questions might parents ask when you recommend using an app as a part of a child’s treatment?

A: Of course, the first question parents are certain to ask is whether the app is safe for their child to use. A conversation about safety goes back to issues around risks and benefits (as we talked about earlier), but also some are related to basic usability: Is this an app specifically for children or one primarily for adults? Both? Will my child be talking to other children of the same age on the app or is there a peer or community chat aspect to the app that might include adults? Can I monitor my child’s usage of the app? How will this app help my child? How often should my child use the app? Do we need to bring screenshots of results or exercises that are generated when using the app?

Q: Should psychiatrists obtain written informed consent from patients for the use of an app?

A: This may be a good idea in terms of providing patients with all the information they need to decide whether or not they want to use an app, but there are some downsides as well. As this area continues to evolve, there are a number of factors that a clinician should consider and discuss fully with patients in an informed consent process before engaging in the use of a mental health app in treatment. Several such factors are identified in opinion number 32 of The Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, posted here. ■