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Smartphone apps based psychotherapy in India: Potential benefits and pitfalls
Accepted Manuscript Title: Smartphone apps based psychotherapy in India: Potential benefits and pitfalls Author: Arpit Parmar Pragya Sharma PII: DOI: Reference:
S1876-2018(15)30118-0 http://dx.doi.org/doi:10.1016/j.ajp.2016.02.008 AJP 856
To appear in: Received date: Revised date: Accepted date:
31-12-2015 31-1-2016 13-2-2016
Please cite this article as: Parmar, A., Sharma, P.,Smartphone apps based psychotherapy in India: Potential benefits and pitfalls, Asian Journal of Psychiatry (2016), http://dx.doi.org/10.1016/j.ajp.2016.02.008 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Smartphone apps based psychotherapy in India: Potential benefits and pitfalls
Arpit Parmara*[email protected], Pragya [email protected]
Senior Resident, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
b
PhD Scholar, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India.
us
cr
ip t
a
an
Tel.: +919868410675
Ac ce p
te
d
M
Smartphones are mobile phones with the functionality of computers. There has been a recent increase in smartphone usage, especially in India. There is almost a 54% increase in smartphone ownership in 2014, which is expected to rise by 4-5 times by next 5 years (Cisco Visual Networking Index). Smartphone apps (applications) usage has also increased dramatically with new apps being added to the smartphones every day. Recently, use of smartphone has been extended to mental health which includes screening of illness, monitoring of illness and symptoms, enhancement of medication compliance, psychoeducation, skills training, tracking of treatment progress, management of subthreshold illnesses by using self-help strategies as well as for the promotion of mental health (Torous & Powell, 2015). Smartphone apps providing psychotherapy have also been developed for various psychiatric disorders including depression, anxiety, eating disorders etc. Cognitive behavioral therapies, dialectical behavior therapy, commitment therapy etc. have been applied using smartphone apps and have shown promising improvement in clinical outcomes (Lappalainen et al., 2013). Application of smartphone apps for the purpose of psychotherapy has its own benefits. Not only it helps to reach people from most remote areas, but it also reduces the cost of mental health care. It can also provide the clients with means to assess their own symptom status time to time and by which, they can track their own illness course and can act accordingly. Not only does it increase the self-efficacy of the client but it may also help the psychologist to retrieve the details of clients’ symptoms in a more accurate manner excluding the potential recall bias. It can also provide client real time help to deal with their cognitive errors which is not available in case of consulting a psychologist every time. For example, the app, Depression CBT self-help guide, provides a thorough thought diary, brief measure to assess depression (using PHQ-9), a reward system and links to relaxation audios. It also provides comprehensive and customizable checklists of the faulty emotions and irrational beliefs with necessary definitions. Such an app can also help clients from less educated backgrounds. There are also apps which can be helpful in an emergency situation when no psychotherapist help is available to the client. For e.g. an app, Operation reach out helps clients to deal with their suicidal thoughts and provides encouragement to seek help from others during such events.
Page 1 of 3
Several factors in India (like culture) may also play a significant role for this mode of psychotherapy. Countries like India where stigma related to mental illnesses is large and patients are hesitant to seek help, smartphone based approach may help to overcome this problem. Also as the mental health gap in India is large and number of psychologists for providing psychotherapy is less as compared to the west, smartphone apps may help to bridge this gap.
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M
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us
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ip t
As with other apps, the apps for psychotherapy also has potential pitfalls which are important to consider. The most important aspect is the lack of proper evidence base for their effectiveness in treating the underlying illness. A recent review reported that most of the apps used in mental health lack scientific evidence for the efficacy and longitudinal data is almost non-existent (Donker et al., 2013). Although a review found almost 1054 depression apps mostly focused on treatment and education, only few studies are published assessing its effectiveness (Shen et al., 2015). For example, a pilot RCT with depression app showed a significant improvement in depression (Watts et al., 2013) however no Indian researches on the same are available. Another important issue is the quality of apps because of minimal involvement of mental health professionals in the development of apps as most of these apps are marketed without accountability. The data on the acceptance of these apps by the general public, especially among the ones suffering from mental illnesses are scarce (Brian and Ben-Zeev, 2014). This is especially important in a country like India, where illiteracy and poverty may hamper its widespread usage among the clients. Also, majority of Indian population is non-English speaking and so the apps which are usually available in English, are less useful. One of the most important issues similar with all psychiatric treatment modalities is the confidentiality of the treatment data. Because of the unregulated use of apps along with lack of transparency in its usage might lead to inadvertent breach in the patient confidentiality (Giota and Kleftaras, 2014). As use of many apps require personal information including name, phone number, e-mail address etc. to be entered beforehand, breach in confidentiality might have grave consequences for clients using the app.
Ac ce p
Use of smartphone apps for providing psychotherapy is still in its infancy. It has a potential role for providing psychotherapy using psychoeducational material, and providing automated, tailored messages, reminders and feedback as well as live reporting of feelings, thoughts and behaviors. In the future, it may enable the psychotherapist to move some aspects of psychotherapy outside of the session and into real-life situations. However, there are still many challenges which need to be addressed before the widespread use of apps can be considered for this purpose. Involvement of mental health professionals in the development of these apps, transparency in its development, and proper data security are important steps to establish its role as an accepted option. Longitudinal data are required to demonstrate its efficacy before it can be used widely in psychiatric practice. Development of apps in native languages may help to reach illiterate population from rural background with no access to psychotherapists, especially in countries like India.
References Brian, R. M., Ben-Zeev, D. (2014). Mobile health (mHealth) for mental health in Asia: Objectives, strategies, and limitations. Asian journal of psychiatry, 10, 96-100.
Page 2 of 3
Cisco Visual Networking Index: Global mobile traffic forecast update. Available from:http://www.cisco.com/c/en/us/solutions/collateral/service-provider/visual-networking-indexvni/white_paper_c11-520862.html [Last accessed on 2015 Nov 17].
ip t
Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M. R., Christensen, H. (2013). Smartphones for smarter delivery of mental health programs: a systematic review. Journal of medical Internet research, 15(11).
cr
Giota, K. G., Kleftaras, G. (2014). Mental health apps: innovations, risks and ethical considerations. EHealth Telecommunication Systems and Networks,2014.
us
Lappalainen, P., Kaipainen, K., Lappalainen, R., Hoffrén, H., Myllymäki, T., Kinnunen, M. L., ..., Korhonen, I. (2013). Feasibility of a personal health technology-based psychological intervention for men with stress and mood problems: randomized controlled pilot trial. JMIR Research Protocols, 2(1).
an
Shen, N., Levitan, M. J., Johnson, A., Bender, J. L., Hamilton-Page, M., Jadad, A. A. R., & Wiljer, D. (2015). Finding a depression app: A review and content analysis of the depression app marketplace. JMIR mHealth and uHealth, 3(1).
M
Torous, J., & Powell, A. C. (2015). Current research and trends in the use of smartphone applications for mood disorders. Internet Interventions, 2(2), 169-173.
Ac ce p
te
d
Watts, S., Mackenzie, A., Thomas, C., Griskaitis, A., Mewton, L., Williams, A., & Andrews, G. (2013). CBT for depression: a pilot RCT comparing mobile phone vs. computer. BMC psychiatry, 13(1), 49.
Page 3 of 3
S1876-2018(15)30118-0 http://dx.doi.org/doi:10.1016/j.ajp.2016.02.008 AJP 856
To appear in: Received date: Revised date: Accepted date:
31-12-2015 31-1-2016 13-2-2016
Please cite this article as: Parmar, A., Sharma, P.,Smartphone apps based psychotherapy in India: Potential benefits and pitfalls, Asian Journal of Psychiatry (2016), http://dx.doi.org/10.1016/j.ajp.2016.02.008 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Smartphone apps based psychotherapy in India: Potential benefits and pitfalls
Arpit Parmara*[email protected], Pragya [email protected]
Senior Resident, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
b
PhD Scholar, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India.
us
cr
ip t
a
an
Tel.: +919868410675
Ac ce p
te
d
M
Smartphones are mobile phones with the functionality of computers. There has been a recent increase in smartphone usage, especially in India. There is almost a 54% increase in smartphone ownership in 2014, which is expected to rise by 4-5 times by next 5 years (Cisco Visual Networking Index). Smartphone apps (applications) usage has also increased dramatically with new apps being added to the smartphones every day. Recently, use of smartphone has been extended to mental health which includes screening of illness, monitoring of illness and symptoms, enhancement of medication compliance, psychoeducation, skills training, tracking of treatment progress, management of subthreshold illnesses by using self-help strategies as well as for the promotion of mental health (Torous & Powell, 2015). Smartphone apps providing psychotherapy have also been developed for various psychiatric disorders including depression, anxiety, eating disorders etc. Cognitive behavioral therapies, dialectical behavior therapy, commitment therapy etc. have been applied using smartphone apps and have shown promising improvement in clinical outcomes (Lappalainen et al., 2013). Application of smartphone apps for the purpose of psychotherapy has its own benefits. Not only it helps to reach people from most remote areas, but it also reduces the cost of mental health care. It can also provide the clients with means to assess their own symptom status time to time and by which, they can track their own illness course and can act accordingly. Not only does it increase the self-efficacy of the client but it may also help the psychologist to retrieve the details of clients’ symptoms in a more accurate manner excluding the potential recall bias. It can also provide client real time help to deal with their cognitive errors which is not available in case of consulting a psychologist every time. For example, the app, Depression CBT self-help guide, provides a thorough thought diary, brief measure to assess depression (using PHQ-9), a reward system and links to relaxation audios. It also provides comprehensive and customizable checklists of the faulty emotions and irrational beliefs with necessary definitions. Such an app can also help clients from less educated backgrounds. There are also apps which can be helpful in an emergency situation when no psychotherapist help is available to the client. For e.g. an app, Operation reach out helps clients to deal with their suicidal thoughts and provides encouragement to seek help from others during such events.
Page 1 of 3
Several factors in India (like culture) may also play a significant role for this mode of psychotherapy. Countries like India where stigma related to mental illnesses is large and patients are hesitant to seek help, smartphone based approach may help to overcome this problem. Also as the mental health gap in India is large and number of psychologists for providing psychotherapy is less as compared to the west, smartphone apps may help to bridge this gap.
te
d
M
an
us
cr
ip t
As with other apps, the apps for psychotherapy also has potential pitfalls which are important to consider. The most important aspect is the lack of proper evidence base for their effectiveness in treating the underlying illness. A recent review reported that most of the apps used in mental health lack scientific evidence for the efficacy and longitudinal data is almost non-existent (Donker et al., 2013). Although a review found almost 1054 depression apps mostly focused on treatment and education, only few studies are published assessing its effectiveness (Shen et al., 2015). For example, a pilot RCT with depression app showed a significant improvement in depression (Watts et al., 2013) however no Indian researches on the same are available. Another important issue is the quality of apps because of minimal involvement of mental health professionals in the development of apps as most of these apps are marketed without accountability. The data on the acceptance of these apps by the general public, especially among the ones suffering from mental illnesses are scarce (Brian and Ben-Zeev, 2014). This is especially important in a country like India, where illiteracy and poverty may hamper its widespread usage among the clients. Also, majority of Indian population is non-English speaking and so the apps which are usually available in English, are less useful. One of the most important issues similar with all psychiatric treatment modalities is the confidentiality of the treatment data. Because of the unregulated use of apps along with lack of transparency in its usage might lead to inadvertent breach in the patient confidentiality (Giota and Kleftaras, 2014). As use of many apps require personal information including name, phone number, e-mail address etc. to be entered beforehand, breach in confidentiality might have grave consequences for clients using the app.
Ac ce p
Use of smartphone apps for providing psychotherapy is still in its infancy. It has a potential role for providing psychotherapy using psychoeducational material, and providing automated, tailored messages, reminders and feedback as well as live reporting of feelings, thoughts and behaviors. In the future, it may enable the psychotherapist to move some aspects of psychotherapy outside of the session and into real-life situations. However, there are still many challenges which need to be addressed before the widespread use of apps can be considered for this purpose. Involvement of mental health professionals in the development of these apps, transparency in its development, and proper data security are important steps to establish its role as an accepted option. Longitudinal data are required to demonstrate its efficacy before it can be used widely in psychiatric practice. Development of apps in native languages may help to reach illiterate population from rural background with no access to psychotherapists, especially in countries like India.
References Brian, R. M., Ben-Zeev, D. (2014). Mobile health (mHealth) for mental health in Asia: Objectives, strategies, and limitations. Asian journal of psychiatry, 10, 96-100.
Page 2 of 3
Cisco Visual Networking Index: Global mobile traffic forecast update. Available from:http://www.cisco.com/c/en/us/solutions/collateral/service-provider/visual-networking-indexvni/white_paper_c11-520862.html [Last accessed on 2015 Nov 17].
ip t
Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M. R., Christensen, H. (2013). Smartphones for smarter delivery of mental health programs: a systematic review. Journal of medical Internet research, 15(11).
cr
Giota, K. G., Kleftaras, G. (2014). Mental health apps: innovations, risks and ethical considerations. EHealth Telecommunication Systems and Networks,2014.
us
Lappalainen, P., Kaipainen, K., Lappalainen, R., Hoffrén, H., Myllymäki, T., Kinnunen, M. L., ..., Korhonen, I. (2013). Feasibility of a personal health technology-based psychological intervention for men with stress and mood problems: randomized controlled pilot trial. JMIR Research Protocols, 2(1).
an
Shen, N., Levitan, M. J., Johnson, A., Bender, J. L., Hamilton-Page, M., Jadad, A. A. R., & Wiljer, D. (2015). Finding a depression app: A review and content analysis of the depression app marketplace. JMIR mHealth and uHealth, 3(1).
M
Torous, J., & Powell, A. C. (2015). Current research and trends in the use of smartphone applications for mood disorders. Internet Interventions, 2(2), 169-173.
Ac ce p
te
d
Watts, S., Mackenzie, A., Thomas, C., Griskaitis, A., Mewton, L., Williams, A., & Andrews, G. (2013). CBT for depression: a pilot RCT comparing mobile phone vs. computer. BMC psychiatry, 13(1), 49.
Page 3 of 3