New Framework Aids In Evaluation Of Mental Health Apps

Mental health apps provide an opportunity to address growing mental health crisis.

The flood of mental health mobile applications (apps) entering the market provides an opportunity to address the country's enormous provider shortage as well as healthcare access inequities. Yet, the vast variety of mental health app offerings coupled with inconsistent evaluation tools makes it hard to discern which digital health platforms offer true value. In addition, there is low agreement between professionals and consumers on reviews of mental health apps.

Even though thousands of mental health mobile apps are available, efficacy research is still in its infancy. Consumer guidance largely comes via popular publications or academic institutes offering their individualized recommendations, sources that patients may not necessarily consult.

AHRQ framework offers consistency, clarity

A recently-published report from the Agency for Healthcare Research and Quality (AHRQ) lays out a comprehensive framework to evaluate this fast-growing yet still largely opaque field. The goal of the new framework is to help healthcare decision makers – from patients and providers to health systems and payers—make the most informed choices, according to the technical brief. The brief is based on research from the Johns Hopkins University Evidence-Based Practice Center.

The need is critical, authors write: “There is a lack of guidance on how to choose wisely from the thousands of mental health apps without clear evidence of safety, efficacy, and consumer protection."

As mental health need grows, disparities widen

While the demand for mental health services is increasing throughout the country, access disparities are more pronounced in some communities. In fact, 25 million rural Americans live in places where there aren't enough providers to meet the demand, according to the National Alliance on Mental Illness (NAMI). 

Almost 600 U.S. counties are considered mental healthcare deserts, or places where there are no psychologists, psychiatrists or counselors, according to a media report. Still others don't access mental health services for fear of stigma, an issue that often has an outsized impact in small, interconnected rural communities.

Racial and ethnic inequities also persist nationwide. While the pandemic exacerbated mental health challenges across the board, some groups – such as Hispanic adults—fared worse than others, according to a 2021 report from the Centers for Disease Control and Prevention. During the pandemic, “persistent systemic social inequities and discrimination" compounded health problems faced by historically disadvantaged populations. These inequities included mental health, the report found.

Abundance of mental health apps target distinct needs

Mental health apps have emerged one way to increase access to care and address these widening gaps. Yet the number of options is overwhelming for both providers and consumers. As many as 20,000 mental health apps may exist, according to a 2021 report from Deloitte Insights. That report predicted global spending for mobile mental health apps will reach nearly $500 million this year, representing a 20% annual growth rate.

These apps can be used in a variety of ways, ranging from assessing mental health needs to providing wellness support like meditation. Others provide information and skill-building exercises. Some mental health mobile apps even facilitate self-managed treatment for specific mental health conditions such as depression and anxiety, with promising results.

Increasingly, certain mental health apps and digital therapeutics are being reimbursed by some insurers, making them one of the evidence-based tools providers can use in their care plans.

Yet many of these apps remain untested in terms of clinical effectiveness. During the COVID-19 pandemic, the government also eased rules for mental health and wellness tools in an effort to address the burgeoning mental health crisis. Even as the U.S. Food and Drug Administration is increasingly providing guidance and effective oversight of such tools, there is still a dearth of regulation for many direct-to-consumer wellness apps.

Mental health apps proliferate, yet hurdles remain

Many industry observers also urge caution. There is danger in adopting these new technologies without a critical eye toward privacy and risk, according to authors of a paper published in the Journal of Humanistic Psychology. Indeed, as mental health apps proliferate, providers, patients and mental health advocates have expressed concerns about their privacy as well as efficacy and safety.

Selecting which mental health app to choose amid an increasingly crowded field only adds to these challenges, the report noted: “…thus the decisional dilemma is, “How can consumers, family members and peer supports, providers, and health systems select safe and effective mental health and wellness apps best suited to their needs?"

AHRQ FASTER framework is designed to help stakeholders

That's where the new framework issued by AHRQ comes in. Through interviews with key mental health stakeholders, authors generated dozens of questions that can assess mental health apps used on smart phones and tablets.

The Framework to Assist Stakeholders in Technology Evaluation for Recovery (FASTER) is designed to help users – from providers to patients to health policy makers—better assess mental health and wellness technology. The idea is to use the three-section framework to better evaluate, compare and understand new offerings in this burgeoning new space.

Evaluating risk and safety

In the first section, the FASTER framework poses key questions to assess a mental health app's risk and safety profile. Questions in this section look at efficacy and privacy, such as whether the app provides a privacy and security agreement and whether it has been endorsed by a government agency or trusted mental health professional association.

The framework also determines whether an app has been evaluated for effectiveness through a scientifically validated study and if its approach uses evidence-based strategies such as Cognitive Behavioral Therapy.

Gauging how well a mental health app works

The second section of the FASTER framework addresses a mobile mental health app's functionality, including factors such as accessibility and cost. It also examines cultural competency, and artificial intelligence use.

Specifically, questions in this section include whether a prospective patient's phone accessibility features will work within the app; the number of reviews and ratings in places such as the Apple store and Google Play; the business model and costs; whether it works offline and if it claims to meet health privacy standards. Others look at intrusive advertising, and whether the text is well written and relevant.

The third and final section looks at the availability of specific mental health features such as journaling, mood tracking, group therapy session or live support to a coach or counselor.

Advancing digital equity and health literacy

While digital innovations such as mental health apps have the potential to expand access, it is important to address unintended barriers they may create. Some people may lack access to the technology or struggle to use and understand the information. Others might avoid digital health care for privacy concerns or the inability to evaluate the quality, according to the authors of a paper on digital health equity published in the Journal of Medical Internet Research.

To that extent, the framework is mindful of incorporating these factors in its analysis. When looking at an app's “informed consent" section, the framework questions whether the text is worded in an easy-to-understand manner, following health literacy guidelines.

Multiple questions in the framework also address whether an app reflects cultural sensitivity. In the function-oriented section, FASTER framework questions include: “Does the app report developing and testing the app for specific cultural group/s?" and “Is gender-inclusive language employed?" Diverse input matters, too, evident by questions such as: “If the app was tested in a study, what was the percentage of non-White participants?"

How the framework can be used

The AHRQ framework can be used by mental health organizations and agencies “to provide a curated list or library of safe and effective mental health apps," the report notes. That library could be used by a variety of people from consumers to health care providers interested in reviewing apps they might recommend to patients.

This framework may also be useful for public and private insurance providers as well as health system leaders to provide guidance for their members. It may be helpful to the app developers themselves to offer transparency about their products' benefits and potential risks.

What's next?

As the framework is implemented, it is essential to continue tracking and evaluating clinical benefits and evidence of mental health and wellness apps.

While FASTER provides a useful construct for evaluating these apps, creators acknowledged it will need to evolve. There is a need to test its suitability for different types of mental health conditions. And, as new technology such as artificial intelligence (AI) and gamification rapidly expand, new questions might be necessary. At the same time, the rapid proliferation of these apps may outpace the ability to evaluate the apps at scale.

It will also be useful to have a system that can train people to apply the framework in a standard and consistent way. These results could be hosted on an interactive, consumer-friendly web site, the brief notes. Having the information readily available to both consumers and healthcare providers will help identify the best mental health apps for care.

FASTER provides guidance, addresses longstanding health inequities

Amid the increasingly crowded digital health field, the FASTER framework provides much-needed guidance on evaluating the potential risks as well as benefits of mental health apps. The hope is that these guidelines will be used to better standardize the evaluation, screening and classification of these apps, giving providers, health systems and individuals clearer and more accessible information. Ultimately, these mental health tools could play an important role in addressing longstanding mental health inequities.

For more information about the advancement of healthcare technology and how programs like FASTER may be able to help your organization, learn more about RTI Health Advance's digital health capabilities.