by Bernadette Rom Arjona, RN
Darvin Crisologo Jr. RN
Ma Ina Dela Rosa RN
Mary Gold Montilla RN
Roison Andro Narvaez MSN, RN, PhD (c)
Rodney Fajardo Suarez RN

St. Paul University Graduate School, Philippines

Citation: Arjona, B. R., Crisologo Jr, D., Dela Rosa, M. I., Montilla, M. G., Narvaez, R. A., & Suarez, R. F. (2023). Impact of Digital Health Apps Among Patients with Mental Health Issues: An Integrative Review. Canadian Journal of Nursing Informatics, 18(1). https://cjni.net/journal/?p=10879

Abstract

Introduction: To consider holistic well-being, one of the most important aspects we should give importance to is mental health. Due to the increasing number of mental health issues worldwide, numerous digital health applications have been developed and offered in the digital world.

Aim: This study aims to explore the present evidence and determine the impact of digital health applications for use in mental health settings.

Methods: An integrative review of the literature employing the Rating System for the Hierarchy of Evidence for Intervention and Treatment Questions by Melnyk and Fineout-Overholt (2015) was completed.

Result: 11 out of 75 articles were identified on the use of digital applications and their impact on mental health. Patients with symptoms and diagnoses of mental health illness who use various digital health applications tend to report significant improvement, high satisfaction, usability, and effectiveness in supporting their conditions.

Conclusion: Digital health apps have shown potential when it comes to improvement in monitoring and managing patients with mental health disorders. However, isolated cases of undesirable effects of these mental health applications require further research.

Implications: Digital health apps are vital tools and have the potential to support safe and effective management of a range of mental health issues and improving mental health in general.

Keywords: digital health, health apps, mental health, nursing, well-being

Contributions of this paper

What is already known about the topic?

• The use of digital health apps is not a new approach in mental health practice.
• Various digital health applications are accessible for patients with mental health issues.
• There was a relatively high usage of digital health apps in mental health during the pandemic.

What does this paper add?

• Digital health applications have grown into a viable strategy to support higher standards of mental health
• Digital health applications have diverse levels of impact in the mental health clinical practice settings.
• Digital health applications often receive promising satisfaction rates from users that show positive outcomes in reducing some mental health issues and increasing mental well-being.

What are the implications for practice?

• Digital health apps have the potential to support nursing care for safe and effective management of a range of mental health issues.
• There is a need to include digital health apps as an added tool in nursing practice to support patients in improving their mental health.
• Digital health apps have shown potential benefits when it comes to improvement in monitoring and managing patients with mental health challenges.

Background

To consider holistic well-being, one of the most important aspects we should give importance to is mental health. According to the World Health Organization (2019), mental health is a state of well-being that supports people to realize their abilities, work productively, deal with the everyday stresses of life, and contribute to their community. Mental health issues are prevalent in all workplaces irrespective of their size and level (Nielsen et al., 2012), and often put people at a disadvantage when compared to others within the general public (Huxley et al., 2003). During the COVID-19 pandemic, there was an escalation in mental issue development such as alcoholism, anxiety, and depression, and lower overall mental wellbeing (Ahmed et al., 2020; Narvaez, 2022).

Worldwide, mental and substance use disorders are leading causes of incapacity (Whiteford et al., 2013). The dimensions of the global mental health problem are extensive, with mental disease constituting an estimated 7.4% of the world’s quantifiable burden of illness (Murray et al., 2012). As well, psychological state disorders are attributable to increasing suicide (Tandon and Nathani, 2018) and eight million deaths yearly, which accounts for 14.3% of deaths worldwide (Walker et al., 2015).

Powered by access to numerous digital applications, smartphones, and high-technological gadgets, there has been a recent surge in mobile technology-based innovations (Henson et al., 2019). Developments in health mobile applications including those that target the mental health field requires adherence to concrete standards and best practices (Li et al., 2020). Since many individuals use smartphones, laptops, and other portable devices, (Moon et al., 2014) an enormous number of complex mobile apps are being developed within the mental health marketplace and are often adopted by users almost as quickly as they are developed (Luxton et al., 2011; Price et al.,2014). These technological advancements are available to patients with mental disorders and can be accessed and used virtually anywhere. Therefore, the main objective of this integrative review is to explore the present evidence and determine the impact of various digital health applications in mental health settings, implications of this impact, and suggestions for future research.

Method

Design

This research uses an integrative review design wherein the researchers study and use available articles published from 2011 up to present as data sources. An integrative review is a valid and reliable method in supporting and providing a framework for evidence-base nursing practice to provide clarity on present problems (Toronto & Remington, R., 2020). Thus, the researchers identified related scholarly studies, scanned the studies for practical applications, and summarized the findings based on medical, healthcare and nursing implications.

Search Strategy

The researchers utilized electronic resources or platforms such as Google Scholar, IEEE, SAGE, JMIR Publications, PubMed and ScienceDirect. This review was conducted using article titles and abstracts considering the exclusion criteria provided, such as duplicate, non-English, articles, not digital health apps related, not mental health-related, and articles that were not relevant to the study. Initial results yielded 85 articles, concluding with 11 articles centered on digital health apps in mental health. A direct manual search was done with the help of the keywords of Digital Health, AND Application, AND Telehealth, AND Smartphone, AND Mental Health, AND Anxiety, AND Depression, AND Schizophrenia, AND Bipolar, AND Behavioral Health (Figure 1).

Figure 1: Search Strategy Summary

Quality Assessment

This review used the Rating System for the Hierarchy of Evidence for Intervention and Treatment Questions (by Melnyk and Fineout-Overholt (2015) to determine the Level of Evidence (LOE) of each potential study. The researchers covered publications from the year 2011 up to the present. Figure 1 summarizes the researchers’ search strategy and consideration for selecting articles. All related articles that fit this study’s criteria centered on digital apps for mental health. The included studies were all assessed to be at the LOE VI, which equate to descriptive and/or qualitative designs.

Data Extraction and Analysis

Table 1 summarizes the significant parts of the research that were considered. Eleven (11) studies related to the use of digital health apps were conducted in different nations: the United States of America, the United Kingdom, Australia, Thailand, and India. All studies included in the review used a descriptive research design. The total sampling size of all studies was around 2995 participants, aged between 12 and 65 with specific mental health concerns. Service areas for each were dependent on the study’s settings. Different methods and instruments were used across the studies, such as interviews and surveys.

Table 1. Characteristics of the Sample studies

Discussion

Digital health apps for mental health

Table 1 provided a summary of the information and description of each app addressed in the 11 selected studies included in this review.   In these studies, most participants had symptoms and mental health condition diagnoses, while the participants from LINE “Friend from Heart” were undergraduate students of the faculty of education from Kasetsart University who were asked to explore basic needs for physical and mental health (Jitanan et al. 2021), and Meheli et al. (2020) looked at participants with chronic pain, but all related to the use of digital health applications to improve mental health.

The apps SOLVD, Intellicare and MoodPrism were developed to reduce signs and symptoms of anxiety and depression. SOLVOD, short for Smartphone and Online Usage-based eValuation for Depression, is a mobile daily mood self-rating app to monitor and classify depression symptoms (Moukaddam et al., 2019). IntelliCare Apps is a suite of apps that are focused on developing skills to improve mood and well-being (Mohr et al., 2011) and MoodPrism is for self-monitoring of mood and emotional well-being (Bakker et al., 2018).

The BlueIce Application also focuses on moods and emotions, but specifically for children who self-harm (Stallard et al., 2018). Similarly, LINE “Friend from Heart” focuses on depression and anxiety and helps both physical and mental health simultaneously through a chat bot and setting up appointments with a mental health counselor (Jitanan et al., 2021). These apps for anxiety and depression could augment patient care as an economical option especially for low socioeconomic groups. Moreover, it can provide ready access to care for children and adolescents, who are already large consumers of smartphones and the internet.

On the other hand, the previous studies for App4Independence (A4i), Headspace and ClinTouch showed that these apps also focus on psychosis and schizophrenia. App4Independence (A4i) is a schizophrenia-focused mobile application and a multi-feature app for illness self-management (Kidd et al., 2019), Headspace is a mindfulness app offering simple guided meditations that can be used by anyone (Mistler et al., 2017) and ClinTouch tracks psychotic symptoms (Palmier-Claus et al., 2012). The use of these apps for psychosis and schizophrenia could be incorporated by clinicians with regular therapy sessions to enhance the patient’s experience and providing real-time illness management solutions, and draw connections between triggers and symptoms, including assistance in remembering to take medications.

Research with the Open SIMPLe app that offers a psychoeducation program for people with bipolar disorder showed high satisfaction with the program with significant improvement on the SF-36 (short form health survey) and WHO-5 (The World Health Organization’s five item well-being index) (Hidalgo-Mazzei et al., 2018). The Working Well app focuses on people with serious mental illnesses who are actively working who receive community-based services to help them cope with the demands of work, tasks and expectations (Nicholson et al., 2018). Lastly, the research on the Wysa app (Meheli et al., 2022), an artificial intelligence (AI) chatbot that offers support from psychologists to address issues on mental health, pain management, and sleep concerns showed a significant improvement on both GAD-7 and PHQ-9 symptom scores after use. Open SIMPLE, Working Well and Wysa apps all provided opportunity for accessible mental health treatment for people with bipolar disorder, dealing with employment stress, chronic pain, or having sleep problems.

In summary, these digital apps include services such as self-assessments, tracking emotions and symptoms, chat bots for basic help, setting up appointments, talking to a psychologist/psychiatrist online, mental health education, information about mental issues, and ways to prevent stress and enhance mental health.

Digital health app impact on mental health

Table 2 outlines the impact of the digital apps discussed in the sample studies on participants with mental health issues. 11 mental health apps were examined and were found to differ in design, types of activities and aims. 

Table 2. Digital Health Apps and Impact on Mental Health

App4Independence (A4i) showed significant improvement in some psychiatric symptom domains with small-medium effects (Kidd et al., 2019). It is used to track recovery progress in people with schizophrenia, psychosis, and opioid use disorders. Satisfaction in using the app was high and qualitative feedback provided insights regarding feature improvements.

SOLVD was found to have the potential to serve as a basis for digital phenotyping for depression and could pave the way for interventional studies and “it helps fill a significant gap in our knowledge of the concordance between ratings obtained on the Ham-D, Ham-A, and the PHQ-9 psychometric instruments and data obtained via a smartphone app” (Moukaddam et al., 2019, p. 365).

Open SIMPLe showed helpful outcomes regarding its usability, satisfaction, and effectiveness but attrition rates were high, requiring further studies about retention factors. “Positive outcomes regarding satisfaction were found predominantly among completers” of the psychoeducation program for people with bipolar disorder over six months of use (Hidalgo-Mazzei et al., 2018, p. 436).

ClinTouch was found to potentially offer advantages over semi-structured interviews for assessing psychosis symptoms in people with schizophrenia. “Ambulant, real-time self-report assessment devices may hold advantages over interview measures, but it needs to be shown that the data thus collected are valid, and the collection method is acceptable, feasible and safe” (Palmier-Claus et al., 2012, p. 1).

MoodPrism was found to decrease symptoms of depression and anxiety and increase mental well-being by allowing people to map their mood and emotions. “Participants who had more positive and engaging experiences using MoodPrism experienced greater decreases in depression, greater decreases in anxiety, and greater increases in mental wellbeing than those who did not rate their engagement as highly. Secondly, each of these effects were mediated by increases in ESA for participants who were depressed or anxious at the time of the baseline assessment” (Bakker et al., 2018, 436).

The use of Headspace in an acute psychiatric inpatient unit was found by patients to be easy to use, which allowed them to complete a series of mindfulness meditations, and they felt it helped with anxiety, sleep, and boredom. “This is the first known study of the use of a commercially available app as an intervention on acute psychiatric inpatient units. There were no instances of an increase in psychotic symptoms reported and there were no episodes of aggression or violence noted in the record (Mistler et al., 2017, p. e34).

The BlueIce application ratings for acceptability and usefulness were high and findings suggest it can help young participants manage emotional distress and urge to self-harm (Stallard et al., 2018). “It includes a mood diary, toolbox of evidence-based techniques to reduce distress and automatic routing to emergency numbers if urges to harm continue” (Oxford Health NHS Foundation Trust, n.d., p. 1).

The LINE “Friend from Heart” app offers three types of services including Live Chat, Chatbots and calls from mental health specialists. Specialists commented that the app has interesting features with good structure that helps people with mental health issues. The appointment feature allowed users to “talk with a counselor in order to get advice on psychological problems” (Jitanan et al., 2021, p. 220) through either a live chat or online telephone call.

Substantial reductions in PHQ-9 and GAD-7 symptoms supports the IntelliCare framework of providing a suite of skills-focused features on the app that can be used to reduce symptoms of anxiety and depression (Mohr et al., 2011). “This study supports the IntelliCare framework of providing a suite of skills-focused apps that can be used frequently and briefly to reduce symptoms of depression and anxiety. The IntelliCare system is elemental, allowing individual apps to be used or not used based on their effectiveness and utility, and it is eclectic, viewing treatment strategies as elements that can be applied as needed rather than adhering to a singular, overarching, theoretical model” (p. e10).

Findings in the use of Wysa for patients with chronic pain revealed that participants look for tools that can help them address their issues related to pain management, mental health, and sleep issues (Meheli et al., 2022). “The conversational pathways frequented, and the tools used reflected the needs that clients expressed to the AI conversational agent. For instance, the users expressed their distress regarding disturbed sleep, difficulty in managing negative thoughts, difficulty in interpersonal relationships, and self-image issues. Consistent with the perceived needs and the distress that users with chronic pain reported, the tools most used and conversational pathways most frequented involved techniques and tools that address these concerns, such as exercises for cognitive reframing, thought recording, gratitude, mindful compassion, sleep and mindfulness meditations, mindful compassion meditation, and conflict resolution exercises” (Meheli et al., 2022, p. 8).

The WorkingWell mobile app has been shown to positively provide support and accessible follow-along supports for people with serious mental illness who are actively employed. (Nicholson et al., 2018). “Users begin their interactions with WorkingWell by setting up to three work-related goals each week, selected from a prepopulated list or by adding their own. They are provided a motivational quote and image and are reminded of their goals each day they access the app. Users are encouraged to choose new goals each week. Once they have chosen or reviewed their goals, users navigate to the home page, where they find the four main app components: Manage the Moment, Remind Me, Rate My Day, and My Progress. In Manage the Moment, coping skills and tips for dealing with challenges are provided, along with ideas for how to implement selected coping strategies. Remind Me provides tools that are built into the app for setting text message reminders, creating to-do lists, and making notes. In Rate My Day, users rate their effort in accomplishing their goals, from 1 to 5 stars, along with rating their success in other areas such as dealing with stress and finishing tasks. My Progress provides feedback based on users’ ratings (eg, “Way to go! Things are going fantastic! What can you do to keep it up?”) and a detailed record of their entries for the past 4 weeks, so users can track their progress and explore patterns in their work day activities and evaluations” (Nicholson et al., 2018, p. 35).

To conclude, these mental health apps provided a number of ways to manage mental health and showed promising results to address user mental and often physical needs and promote general well-being. In addition, with the help of specialists, these digital health tools play a significant role in changing the daily lives of the patients to cope better in dealing their mental health concerns and achieving satisfaction to keep them engaged in their day-to-day activities.

Implications for Practice

Digital technology is changing healthcare and nursing practice across the world. One example is the rising use of telehealth and other virtual forms of care, especially in response to the COVID-19 pandemic. Another is the development of cutting-edge technology like artificial intelligence (AI) and robotic systems, as well as the dependence of society on mobile devices, the internet, and social media.

Digital technology has already benefited healthcare practice as shown by a wide range of examples. With the help of mobile technologies, particularly smartphones and digital health applications, healthcare providers such as mental health nurses may now provide patients with remote counseling on managing their mental health. However, there are still a lot of problems to be solved such as privacy protection, ethics, access to devices and Wi-Fi, and competitive pricing.  Digital health applications can let individuals take their health into their own hands, but they should not be used alone in place of a provider visits and medical treatment.

The findings in this review have shown that digital health apps have the potential to support safe and effective management of a range of mental health issues. However, most of the apps are still lacking clinically validated evidence of efficacy. Also, issues such as big data concerns and app accessibility should be considered by future mental health app developers. It is also critical to inform the user that, like with any technology, there are advantages and disadvantages to consider before utilizing digital health applications. Digital health applications must be are concerned about data privacy. Health applications continually gather and analyze a person’s health data. The risk of a hacker accessing personal information and sharing it with third parties is a major concern. Access to the internet, the high cost of smartphones, the absence of regulatory approval, and the expensive cost of in-purchase applications are some of the other main reasons that limit the usage of digital health applications. This review then suggests that further research or studies need to be conducted to develop the safety and efficacy of these and other useful digital health apps.

Conclusion

Digital health apps have shown potential when it comes to improvement in monitoring and managing patients with mental health disorders. Most participants included in the 11 studies gathered expressed satisfaction with the apps and their functions. Although most of the studies have reported a positive impact on patients with mental health issues, from symptom recognition to being able to access healthcare assistance as needed and increasing mental well-being, there are also isolated cases of negative impact being reported. More research is needed to examine both the benefits and the drawbacks of incorporating mental health apps into patient care.

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