Tom’s digital health disruptors: mental health apps

The rise of tablet computers and smartphones is leading to an influx of tools to improve all aspects of mental health, from sleeping problems to anxiety.

Activity and mood trackers are particularly popular: it can sometimes feel as if a press release for a new mood tracker arrives every week.

Despite this, getting an accurate figure for how many mental health apps are available – never mind how many actually ‘work’ – is an impossible task.

The area is still a relative green-field of start-ups and small companies. This may be why some of the first efforts to support doctors and patients have been made in this area.

These efforts include the launch of the NHS Choices Health Apps Library last year, which recommends 27 apps for mental health – by far the most for any condition in the library.

This was followed in March this year by what NHS England called the ‘mental health app library’, although the commissioning board now refers to this as ‘a library of online mental health services’ to better reflect the tools it contains.

Lots of enthusiasm

Geraldine Strathdee, NHS England’s clinical director for mental health, said at the launch of the app library in March this year: “Mental health care can be enhanced by technology and its ability to connect us with the right treatment in a more personalised and accessible way.”

Unsurprisingly, this view is backed by the developers of some of the tools recommended by the NHS. Big White Wall – available as an app and via a browser – is an online community that allows people to anonymously discuss their anxieties and depression around the clock.

Speaking to Digital Health News, a spokesperson said: “Digital services can help overcome some of the barriers to access, such as unwillingness to take time off work, a lack of suitable transport or childcare.”

It is a similar sentiment from another company featured in the library, Ieso Digital Health, which is not yet available as an app but offers live, confidential one-to-one cognitive behavioural therapy with a therapist via secure instant messaging.

The company’s clinical lead Sarah Bateup told Digital Health News: “Online services are great for people who struggle to get out the house or are embarrassed about a face-to-face service with a GP.”

More can be done

Momentum for these tools appears to be building, particularly among younger people who are no strangers to technology – and who may well have used website forums and social media to find support from peers for many years.

There remains “huge untapped potential” though, says Mark Brown, a prominent online advocate for mental health support and founder of mental health magazine One in Four.

“There’s no reason why the kinds of mechanisms that we’ve seen applied to other chronic conditions can’t be utilised in helping people to get on with their lives, mitigate symptoms or work toward therapeutic ends,” says Brown, who now works as development director for social enterprise Social Spider CIC.

Brown highlights one of the significant challenges in the uptake of apps on the NHS: the cost of bringing an app to market that has the measurable and tested clinical outcomes that would make a doctor recommend it.

“This is further confused in some respects by a lack of clarity as to the NHS stance on the development of such apps,” says Brown. “Will the NHS accept commercial development of medical apps? How will it manage the process of accrediting and testing and, as importantly, how much will this cost?”

Burden of evidence

It’s worth drawing a comparison to the pharmaceutical industry, which has a well-established model for bringing new medicines to the market, with European approval before a national assessment of cost-effectiveness.

Of course, this is done by established companies with billion dollar revenues, which can afford the expansive clinical trials and gruelling market access process required to demonstrate that a drug has a positive effect, and should be funded on the NHS.

While some apps for mental health issues, such as insomnia support tool Sleepio, have demonstrated their ability to help patients in randomised trials, most app developers are small start-ups who just don’t have the resources to prove the effectiveness of their technology on this kind of scale.

A new way of working needs to be developed for medical apps says Jen Martin, programme manager at MindTech, one of the National Institute for Health Research’s eight Healthcare Technology Co-operatives that is focused supporting the development of new technologies for mental health and dementia.

“We need to develop methods to demonstrate evidence that are quick and proportional and are able to provide evaluation so much quicker,” she adds. “Medicine evaluation is so expensive and slow with lots of follow-ups, but with apps you can collect data on the fly.”

One of her organisation’s main projects is a collaboration with Leeds and York NHS Foundation Trust and The University of Leeds to develop a set of criteria for evaluating digital mental health tools such as apps and mobile websites.

The work has led to the creation of a framework for mental health digital products that takes into account the need for a proportionate approach when evaluating mental health apps as well as the wide range of apps available.

The need for guidance

The need to support smaller companies has also been advocated by Rachel Dunscombe, chief information officer at Bolton NHS Foundation Trust.

With the Greater Manchester Academic Health Science Network, it recently held an event called ‘Mobilise the NHS’ to bring together clinicians and SMEs to discuss what sort of app can most benefit the health service.

Speaking to Digital Health News after the event she said: “SMEs needed help to understand and navigate the NHS – how to hit the right spoke and make an idea appealing for clinicians. It’s different for them as NHS usually procures from large companies.”

Specific support for developers has been published by The British Standards Institution in the form of PAS 277, which outlines a set of principles to follow in order to build a tool that can be trusted by healthcare professionals.

NHS England is also expanding on its existing libraries with the creation of an endorsement model for medical apps one of the goals for this year outlined in the ‘Personalised Health and Care 2020’ IT and information framework.

At the National Information Board meeting, the first signs of a four step model emerged. Developers will go from self-assessing their own apps, to getting the support of a ‘crowd sourcing panel’, to getting academic evidence of effectiveness and value, to getting a full-scale endorsement from national bodies.

New guidance has brought with it its own confusion though. The Royal College of Physicians recently put out guidelines recommending that doctors should only use medical apps with a CE mark. Barely any have this – the EHI Awards winning Mersey Burns app that helps clinicians determine how much fluid to give a burns victim – is one of the very few that do.

The proposition was lambasted by Charles Lowe, managing director of the Digital Health and Care Alliance, who argued that it would be a “disaster” if useful apps were abandoned by medical staff.

On the other hand, he advocates the safety checking of apps using accepted international standards; and a cut-off after which only CE-approved apps should be used.

An industry in infancy

It’s not surprising that these kinds of disputes are emerging; the medical app industry is one that is still in its infancy and people are struggling to define its limits and what constitutes best practice.

However, mental health may have some advantages when it comes to apps. It already has well-defined requirements to create paper treatment plans, and the idea of users tracking their activities and mood in diaries is well established.

CBT tools and support communities already have official backing and are helping people with anxiety and depression. Hopefully, it should not be too great a leap to transfer these ideas to a native app that a doctor can recommend on a regular basis.