Do All Those Mental Health Apps Actually Work?
Examining the evidence for mental health apps targeting depression and anxiety
In recent years, mobile applications (apps) for mental health have emerged as an increasingly popular tool for managing stress and conditions like depression and anxiety. The World Health Organization estimates around 5% of the global population suffers from depression. In the United States, estimates suggest that anxiety disorders will affect 34% of people in their lifetime. Recent global events like Covid-19 and war likely further increase these numbers. Therefore, the demand for accessible mental healthcare solutions continues to grow. Mental health apps represent a promising avenue for expanding access to psychological support and interventions.
In 2020, a colleague and I wrote a review article on mental health apps for stress, anxiety, and depression with the following general conclusion:
“But are the claims about the efficacy of these apps supported by evidence? We identified 19 published articles on PubMed of peer-reviewed randomized clinical trials of mental health apps focused on stress, anxiety, and depression. Despite some evidence for the effectiveness of mental health apps, it remains unclear how effective these apps are compared with standard of care. Populations studied so far also lack diversity, making it difficult to generalize any benefits to racial minorities and low-income individuals—the very people who have been most negatively impacted by the COVID-19 pandemic and traditionally have higher barriers to mental health services.”
Since then, far more studies have emerged on mental health apps across a wide variety of conditions, intended uses, and intervention strategies. This article will explore the interventions used and the efficacy of these technologies.
The Growing Landscape of Mental Health Apps
The mental health app marketplace has experienced explosive growth. These apps leverage the ubiquity of smartphones and mobile technology to deliver psychological interventions in an accessible, private format. The increasing affordability and accessibility of smartphones has made mobile apps a central component of many innovative mental wellness and clinical care interventions. There are hundreds of these applications available on the app stores. Each app uses different strategies to affect mental wellbeing.
One study examined 1,435 mental health apps from Google Play and iTunes stores, focusing on apps related to depression, self-harm, substance use, anxiety, and schizophrenia. After a screening process, the researchers analyzed 73 consumer-focused mental health apps that were top-ranked in the stores. The research found that the majority of these apps (81%) offered a single mental health-related functionality, with the most common features being information/psychoeducation (36%), therapy/treatment (32%), and symptom/mood monitoring (25%).
The analysis of app store descriptions revealed that 81% of apps made positive claims, with 64% specifically claiming effectiveness at either diagnosing mental health conditions or improving symptoms, mood, or self-management. Scientific language was the most frequently used method to support these claims (44% of apps), though notably only two apps (2.7%) provided direct evidence from studies using the app itself, and only one app (1.4%) included an actual citation to published literature.
When researchers examined the scientific techniques mentioned by apps, they found that a third (33%) referenced methods that had no evidence in the scientific literature. Only 14% of apps described any design or development involving lived experience, and none referenced formal certification or accreditation processes. These findings suggest a significant gap between the scientific claims made by mental health apps and the actual evidence supporting their use.
However, navigating this rapidly expanding landscape can be challenging for both healthcare providers and consumers. Most applications marketed on app stores do not have any real clinical validation for their claims as indicated in the study referenced above. However, among those applications that have performed studies and published results, the evidence is positive. In some cases, application developers have gone to far as seeking FDA clearance for their applications. These are commonly referred to as digital therapeutics. Mental health apps broadly fall into two categories: consumer-grade wellness apps and prescription digital therapeutics (PDTs). The majority of applications are consumer-grade, unsubstantiated apps, but there are a growing number producing good clinical evidence.
Consumer Apps vs. Prescription Digital Therapeutics
Consumer-Grade Mental Health Apps
Consumer mental health apps are generally available for direct download from app stores without requiring a prescription. These apps typically offer features such as:
Mood tracking and journaling
Guided meditation and mindfulness exercises
Basic cognitive behavioral therapy (CBT) concepts and exercises
Relaxation techniques and breathing exercises
Community support features
General mental wellness education
While these apps can provide helpful tools for mental wellness, they often lack rigorous clinical validation. Many do not have peer-reviewed research supporting their effectiveness, and some may even contain potentially harmful content.
Prescription Digital Therapeutics (PDTs)
In contrast, prescription digital therapeutics represent a new category of regulated, evidence-based digital interventions. Key characteristics of PDTs include:
FDA clearance as medical devices
Prescription requirement from healthcare providers
Rigorous clinical trials demonstrating safety and efficacy
Integration with traditional medical care
Coverage by some health insurance plans
Adherence to strict data security and privacy standards
PDTs undergo extensive testing and validation before receiving regulatory approval, similar to traditional pharmaceuticals. They are designed to deliver evidence-based therapeutic interventions for specific conditions under medical supervision.
Pear Therapeutics and Akili Interactive are good examples of companies with these applications, however issues with reimbursement have led to significant business headwinds. A new application, Rejoyn, is FDA approved for depression.
What Functions and Features May Make Mental Health Apps Effective?
The effectiveness of mental health apps depends heavily on their design and implementation. Research has identified several key characteristics that contribute to their observed effects.
The foundation of an effective mental health app lies in its ability to maintain high patient engagement and provide an intuitive user experience. Successful apps incorporate features like real-time engagement capabilities, strategic usage reminders, and gamified interactions to keep users motivated. Additionally, they employ simple, clean user interfaces that reduce cognitive load – particularly important for users experiencing depression or anxiety who may have impaired working memory. This includes using visual elements over text, keeping written content concise, and utilizing inclusive, non-clinical language that resonates with users.
Perhaps most importantly, effective mental health apps incorporate both transdiagnostic capabilities and robust self-monitoring features. Given the high comorbidity of psychological disorders, apps that can address multiple related conditions through similar intervention approaches tend to be more engaging and effective. Self-monitoring features, which allow users to track their thoughts, behaviors, and emotions, play a crucial role in building emotional self-awareness (ESA). Research has shown that enhanced ESA can lead to reduced symptoms and improved coping skills across various mental health conditions, including anxiety, depression, and substance abuse. Many applications allow people to track their daily mood, feelings, and experiences to link how they feel to certain events or triggers. In some circumstances these applications can transmit this information to clinicians to allow for better medication dosing or treatment planning.
Research Evidence on App-Based Interventions
Two recent systematic reviews have examined the effectiveness of mental health apps for depression and anxiety. Here are their key findings:
Children and Youth Services Review Study (2021)
A systematic review by Leech et al. examined randomized controlled trials of mental health apps specifically for adolescents and young adults. The analysis included 11 trials with 1,706 participants aged 10-35 years.
Key findings:
Apps demonstrated significant effectiveness for anxiety symptom reduction
Evidence for depression symptom improvement was mixed
Study quality was generally sound, with no trials rated as high risk of bias
Longer-term benefits beyond the intervention period were unclear
Age was not identified as a significant moderator of effectiveness
The review concluded that smartphone apps show promise as standalone self-management tools for mental health, particularly for anxiety. However, more controlled trials with follow-up data are needed to confirm these findings and determine factors affecting engagement and effectiveness.
JMIR Mental Health Study (2022)
A more recent systematic review and meta-analysis by Lu et al. evaluated 15 randomized controlled trials involving 2,627 participants, focusing on both effectiveness and minimum effective "dose" of app-based interventions.
Key findings:
Apps have a small but significant positive effect on anxiety symptoms
No statistically significant effect on depression symptoms
Interventions lasting at least 7 weeks showed larger effects for anxiety
Effects tended to diminish during follow-up periods
Most studies used cognitive behavioral therapy (CBT) as the theoretical foundation
Study quality concerns were noted in several trials
The authors concluded that while there is some evidence supporting app-based interventions, particularly for anxiety, current evidence is insufficient to recommend clinical use due to small effect sizes and study quality limitations.
Implications and Future Directions
These systematic reviews highlight both the potential and limitations of mental health apps. While apps show promise for anxiety management, particularly with longer intervention periods, evidence for depression management remains mixed. Several key considerations emerge:
Intervention Design: Future research should focus on determining optimal intervention length and intensity ("dose") for maximum effectiveness.
Quality Standards: There is a need for improved reporting and study quality in app-based intervention research.
Long-term Effects: More studies with extended follow-up periods are needed to understand the sustainability of benefits.
User Engagement: Research should examine factors affecting user adherence and engagement with mental health apps.
Integration with Care: Studies should explore how apps can best complement traditional mental healthcare.
Effects Compared to Standard of Care: It is unclear how the effects of mental health apps compare to standard of care like psychotherapy or SSRI-drugs.
Integration into Electronic Health Records: The data generated from these applications can help supplement in-clinic EHR systems.
Conclusion
Mental health apps represent a promising tool for expanding access to psychological support, particularly for anxiety management. They are very accessible especially in areas where there are limited health resources or for patients where the cost of traditional treatment methods are prohibitive. However, more high-quality research is needed to establish optimal intervention characteristics and determine their role in clinical care. As the field continues to evolve, maintaining a balance between innovation and evidence-based practice will be crucial for realizing the potential of digital mental health interventions.
Health care providers and consumers should approach mental health apps with informed optimism, recognizing both their potential benefits and limitations. Prescription digital therapeutics may offer a more rigorous alternative to consumer apps for those requiring clinical-grade interventions, while wellness apps may serve as helpful tools for general mental health maintenance and support.
Thanks for putting this out into the ecosystem, again.
I’m not sure the community would agree, however, that a digital mental health platform granted marketing clearance by this FDA, is any indication of potential real world effectiveness above and beyond that purported by options available OTC.
And, as you mentioned herein, the commercial success of firms like Click, Pear and Akili have all been lackluster, and I know their C-suites personally, but in digital mental health, unlike in neuropsychiatric drug commercialization, there is no correlation between clinical efficacy in a trial and real-world effectiveness in the actual world.
Perhaps instead of asking what additional evidence is needed, which rarely changes the clinical picture for the person with lived experience, we should ask instead how to tailor existing interventions to those in need and determine what needs those who are suffering continue to have that remain unaddressed.