Received: 19 December 2016 Revised: 4 April 2017 Accepted: 9 April 2017

DOI: 10.1002/da.22657

REVIEW

There is an app for that! The current state of mobile

applications (apps) for DSM-5 obsessive-compulsive disorder,
posttraumatic stress disorder, anxiety and mood disorders

Michael Van Ameringen MD, FRCPC1,2,4 Jasmine Turna BSc, PhD(c)2,3

Zahra Khalesi BSc2 Katrina Pullia BSc2 Beth Patterson BScN, MSc1,2

1 Department of Psychiatry and Behavioural

Neurosciences, McMaster University, Hamilton,
ON, USA
2 MacAnxiety Research Centre, McMaster
University, Hamilton, ON, USA
3 MiNDS Neuroscience Graduate Program,
McMaster University, Hamilton, ON, USA
4 Hamilton Health Sciences, Hamilton, ON, USA
Correspondence
Dr. Michael Van Ameringen, McMaster
University, MacAnxiety Research Centre, 1057
Main St. W, L02, Hamilton, ON L8S 1B7.
Email: vanamer@mcmaster.ca
Mental health apps are viewed as a promising modality to extend the reach of mental health care
beyond the clinic. They do so by providing a means of assessment, tracking, and treatment through
a smartphone. Given that nearly 2/3 of the American population owns a smartphone, mental
health apps offer the possibility of overcoming treatment barriers such as geographic location or
financial barriers. Unfortunately, the excitement surrounding mental health apps may be prema-
ture as the current supporting literature regarding their efficacy is limited. The app marketplace is
littered with apps claiming to treat or assess symptoms, but even those created by reputable orga-
nizations or those incorporating components of evidence-based treatments have not yet been val-
idated in terms of their efficacy. This review aims to provide a comprehensive review of the cur-
rent state of the mental health app literature by examining published reports of apps designed for
DSM-5 anxiety and mood disorders, OCD, and PTSD. The breadth of apps reviewed includes those
oriented around assessment, symptom tracking, and treatment as well as “multipurpose” apps,
which incorporate several of these components. This review will also present some of the most
popular mental health apps which may have clinical utility and could be prescribed to clients. While
we discuss many potential benefits of mental health apps, we focus on a number of issues that
the current state of the app literature presents. Overall there is a significant disconnect between
app developers, the scientific community and health care, leaving the utility of existing apps
questionable.

KEYWORDS
anxiety, depression, eHealth, mHealth, mobile apps, OCD, PTSD, smartphones

1 INTRODUCTION
Mental illness affects approximately one in five individuals in the
United States (Centre for Behavioral Health Statistics and Quality,
2015) yet access to reliable treatment options is limited within exist-
ing health care systems. Lack of available facilities and trained profes-
sionals (Gulliver, Griffiths, & Christensen, 2010), financial costs, stigma,
structural barriers, and lack of perceived need for treatment (Mojtabai
et al., 2011) have all been outlined as potential barriers to treatment.
As a result, treatment modalities that supersede such obstacles are
necessary. The widespread adoption and use of mobile technologies
represents a new and innovative way to improve health care delivery
using smartphone apps. Mobile apps refer to any software program
designed to run on smartphone or tablet platforms. In turn, this allows
for mobile technologies to support fields related to medicine and pub-
lic health, ultimately furthering the reach of health care beyond the
clinic. According to the Pew Research Centre (2012), one in five smart-
phone owners reported having a health-related app downloaded to
their phone, with the most popular being those related to diet, weight,
and exercise (Fox & Duggan, 2012). Moreover, 52.7% of primary care
patients report using such apps (Carras, Mojtabai, Furr-Holden, Eaton,
& Cullen, 2014) further supporting their utility in health care. The
app marketplace has recently exploded, exceeding the 165,000 health-
related apps released for both Android and iOS platforms in 2015, of
which approximately 7% targeted mental health issues (mental health
mobile health applications or mHealth apps) (Aitken & Lyle, 2015).
While the mHealth app literature is limited, several review
papers have been published on the topic (Donker et al., 2013; Gee,
Griffiths, & Gulliver, 2016; Huguet et al., 2016; Olff, 2015; Singh et al.,
2016; Torous & Powell, 2015; Turvey & Roberts, 2015). Unlike these

Depress Anxiety. 2017;1–14. wileyonlinelibrary.com/journal/da 

c 2017 Wiley Periodicals, Inc. 1
2 VAN AMERINGEN ET AL .
previously published papers that focus on a sole disorder or class of
disorders, the current review aims to provide a comprehensive review
of the mHealth app literature targeting anxiety, mood, and related dis-
orders. The breadth of apps reviewed include those oriented around
assessment, symptom tracking, and treatment, as well as “multipur-
pose” apps, which incorporate several of these components. Given
the small number of randomized controlled trials (RCTs) evaluating
mHealth apps in clinical populations, all published trials were included.
The mHealth app literature has been reviewed in terms of the validity
and efficacy of the apps related to mental health, regardless of public
availability. Examples of apps in each category that are most frequently
utilized by the public will also be presented, paired with a short sum-
mary of the supporting evidence (or lack thereof). It should be noted
that the apps discussed for this purpose are not to be interpreted as an
endorsement, but rather serve as examples of apps that are currently
available for download and fall under the categories of apps presented
in this review. Finally, potential issues with mHealth apps extend-
ing to validity, limitations, and future directions for this field will be
examined.
2 SEARCH METHOD
For the purpose of this review, only articles assessing Smartphone
apps, defined as a specific application developed for download onto
the smartphone through its respective store (e.g. GooglePlay, App
store, etc.), were reviewed. Although many articles exist which evalu-
ate mHealth devices such as computers, web-based tools that can be
opened on a smartphone or other devices and personal digital assis-
tants (PDAs), far less have been published using smartphone apps.
For example, in a systematic review conducted by Faurholt-Jepsen,
Munkholm, Frost, Bardram, and Kessing (2016) assessing the evidence
of electronic self-monitoring for adults with bipolar disorder, only one
of the 13 articles reviewed incorporated a smartphone app as defined
in this paper.
The following electronic databases were used to conduct searches
for empirical work assessing mHealth apps: PubMed, MEDLINE,
PsychINFO, and Google Scholar. A combination of search terms was
used to locate articles: “mHealth” “Mobile health” “app*” “Smart-
phone” “Anxiety” “Social Anxiety Disorder” “Posttraumatic Stress Dis-
order” “Obsessive-Compulsive Disorder” “Major Depressive Disorder”
“Depression” and “Bipolar.”
Popular apps mentioned in this paper were found by searching sim-
ilar key terms mentioned above in Apple iTunes (iOS) and Google Play
(Android). Other apps were also found based on recommendations of
users and health professionals (e.g., Psych Central, the Anxiety and
Depression Association of America, and Buzzfeed). A selection of these
popular apps, categorized by type of apps discussed in this review,
are presented to familiarize clinicians with existing mHealth apps that
patients may already be using (Tables 1–4). The published evidence
evaluating these popular apps is also summarized, providing a concise
figure differentiating mHealth apps with evidence, from those without.
Given that over one-third of health care providers are recommending
apps (Aitken & Lyle, 2015) these tables may help guide patients and
clinicians in search of mHealth apps.
3 CURRENT mHEALTH APPS
3.1 Assessment apps
Assessment apps can be programmed with preset algorithms whereby
participants respond to a series of questions based on their sub-
jectively reported symptoms in order to receive potential diagnoses
(Labrique, Vasudevan, Kochi, Fabricant, & Mehl, 2013). These apps
can also provide suggestions for potential pharmacological treatment
options, which may assist clinicians with minimal psychiatric training
(Labrique et al., 2013; Torous & Powell, 2015). Some popular assess-
ment apps that are frequently downloaded are described in Table 1.
While, there are no studies validating assessment apps for anx-
iety disorders, bipolar disorder (BD), or OCD, the app marketplace
remains littered with screening tools claiming to do so. For exam-
ple, the Anxiety Test and Y-BOCS Test apps assess generalized anxi-
ety disorder (GAD) and OCD, respectively, but are not supported by
research evidence. Further, WhatsMyM3 is a paper-based screening
tool developed to screen for major depressive disorder (MDD), bipo-
lar disorder, posttraumatic stress disorder (PTSD), and anxiety dis-
orders (Gaynes et al., 2010). Although it has been validated against
the MINI, the publicly available app version has not (Gaynes et al.,
2010). In theory, previously validated assessment tools should remain
valid in app-format, however many scales require reformatting to fit
the smartphone modality. Just as changes to the formats of paper
and pencil or computer-based scales (including different translations
or changes in the wording) require revalidation, so too, should app
versions. Validation provides the user with more confidence in the
measure.
3.1.1 Major depressive disorder
The Patient Health Questionnaire (PHQ-9), a validated paper and com-
puter measure, is one of few assessment tools that have been vali-
dated as a smartphone app (Fann et al., 2009). The smartphone PHQ-
9 (iPhone test-retest: ICC(95% CI) = 0.93 [0.9–0.97] and the Revised
Suicidal Ideation Scale (RSI-S) (iPhone test-retest: ICC(95% CI) = 0.85
[0.78–0.93] have also been found as equivalent to traditional meth-
ods of delivery (iPhone vs. Paper: PHQ-9, ICC (95% CI) = 0.92 [0.87–
0.96]; RSI-S ICC(95% CI) = 0.86 [0.79–0.94] (Bush, Skopp, Smolenski,
Crumpton, & Fairall, 2013).
3.1.2 Post-traumatic stress disorder
The mobile version of the PTSD Checklist (PCL)-Civilian has been
found to be comparable to paper and computer formats, demon-
strating high internal consistency (Cronbach’s 𝛼, 0.95–0.96) and test-
retest reliability (ICC, 0.91 [0.87–0.96]) (Bush et al., 2013). The PCL
is utilized by numerous apps in the public domain as a general PTSD
screener.
VAN AMERINGEN ET AL . 3

TA B L E 1 Examples of existing popular assessment mHealth apps for anxiety, mood, and related disorders

App marketplace
Condition Name (price [USD]) Evidence Description of app functionality
Published evidence
MDD Depression iTunes (free) Mobile PHQ-9 validated against • Mobile use of validated PHQ-9, score of
monitor (also available in paper-based iPhone vs. Paper: PHQ-9, ≥11 has been used to suggest high risk
(BinDhim et al., MoodTools app) ICC (95%CI) = 0.92 [0.87–0.96] (Fann (BinDhim et al., 2015).
2015) et al., 2009 ; Bush et al., 2013) • Many additional mobile PHQ-9 apps are
available.

Multiple WhatsMyM3 iTunes (free) Paper version of scale validated against the • 27-item tool to screen for PTSD, MDD,
conditions MINI (n = 647) (as screen for any BD, and anxiety disorders.
psychiatric disorder: sensitivity = 0.83;
specificity = 0.76) (Gaynes et al., 2010)

PTSD PCL iTunes (free) iPhone version is comparable to paper and • Mobile PSTD Checklist
(also available in computer formats (Cronbach’s 𝛼 = • Used in PTSD Coach and PE Coach to
PTSD/PE Coach 0.95–0.96) (Bush et al., 2013). monitor symptom change.
apps)

Lack of evidence
OCD Y-BOCS OCD test iTunes (free) None, mobile Y-BOCS has not been • Self-test using clinician-rated Y-BOCS. In
validated. app purchase required to view results.

SAD Social phobia test iTunes (free) None, mobile SPIN has not been validated. • Self-test using SPIN, unknown cut-off
scores to “diagnose” SAD.

GAD Anxiety test • iTunes (free) None, mobile GAD-7 has not been validated. • Self-test using GAD-7, also used in many
• GooglePlay (free) “anxiety screening apps.” No defined
cut-off, uses score to rate anxiety from
minimal to severe.

BD, bipolar disorder; GAD, generalized anxiety disorder; MDD, major depressive disorder; MINI, Mini International Neuropsychiatric Interview; OCD, obses-
sive compulsive disorder; PE, prolonged exposure; PHQ-9, Patient Health Questionnaire; PTSD, posttraumatic stress disorder; SAD, Social Anxiety Disorder;
SPIN, Social Phobia Inventory; Y-BOCS, Yale-Brown Obsessive Compulsive Scale.

TA B L E 2 Examples of existing popular tracking mHealth apps for anxiety, mood, and related disorders

App marketplace
Condition Name (price [USD]) Evidence Description of app functionality
Published evidence
MDD MindfulMoods iTunes (free) Mobile PHQ-9 monitored symptoms • Independent sample of three
(Torous et al., 2015) over 1-month versus paper (n = 13) questions from the PHQ-9.
(r = 0.84) (Torous et al., 2015)
Purple Robot (Saeb GooglePlay (free) Passive data collection, predicted • App collects passive data from
et al., 2015) depressive states with 65–86% sensors in phone; however, the
accuracy (n = 28) (Saeb et al., 2015) existing app does not provide
interpretations of mood states.

BD MONARCA N/A, in beta-testing Two trials (3- and 6-months; n = 17 and Uses passively collected data to predict
61, respectively). Passive sensor data user’s mood state:
correlated with reported clinical
measures (Bardram et al., 2013; • Patients can view personal data,
Faurholt-Jepsen et al., 2014, 2015) manage triggers and early warning
signs.
• Clinicians can receive an overview of
patient’s mood, activity, sleep, and
medication adherence.

Lack of evidence
Multiple conditions T2 Mood Tracker • iTunes (free) None • Several preloaded visual analogue
• GooglePlay (free) scales (anxiety, depression, general
well-being, head injury, posttraumatic
stress and stress).
• Can incorporate own customized
scales on any issue.
• Make notes about daily events that
may affect rating.

BD, bipolar disorder; MDD, major depressive disorder; N/A, not applicable; PHQ-9, Patient Health Questionnaire; MONARCA, MONitoring, treAtment, and
pRediCtion of bipolAr disorder episodes.
4 VAN AMERINGEN ET AL .

TA B L E 3 Examples of popular existing treatment-based mHealth apps for anxiety, mood and related disorders

App marketplace
Condition Name (Price [USD]) Evidence Description of app functionality
Published evidence
MDD Mobilyze! Previously available; • 8-week trial (n = 7), significant decreases • Passive data collection of: location, activity, social
group now studying in depressive context, mood, emotions and cognitive/ emotional
Intellicare suite ((t13 = 7.02, betaweek = –.82, P < .001) states.
(reviewed below— and anxiety symptoms (t13 = 4.59, • Supported by a website with access to lessons, tools
BoostMe/Worry betaweek = –.71, P < .001) (Burns et al., and feedback; telephone coaching with the purpose
Knot) (free) 2011). of enhancing adherence.

BoostMe (part GooglePlay (free) • Suite of apps used for 8 weeks (when “Boost Me” specifically attempts to reverse a reported
of Intellicare paired with coaching) significantly drop in mood by providing users with positive
App Suite) reduced PHQ-9 and GAD-7 scores activities.
(P < .001) (Mohr et al., 2017). Features:
• Built-in list of suggestions including those that have
previously improved the user’s mood.
It is a part of a 13 app suite, each designed to support a
skill or instructional style to support acquisition of
skills for depression and anxiety.
PD Flowy iTunes (free) • 4-week clinical trial; not clinically Breathing retraining using a series of mini-games to
GooglePlay (free) effective (n = 63) (Pham et al., 2016) reduce anxiety.
Features:
• In-game movements controlled by breathing.
• Users touch screen and inhale, remove finger as they
exhale.
• A breathing indicator visually displays a full breath,
with the goal of the game being to complete each
breath fully.

PTSD PTSD Coach iTunes (free) • Developed by US Dept. of Veterans To learn about and manage PTSD symptoms.
GooglePlay (free) Affairs. Features:
• Qualitative feasibility studies support • Self-assessment using PCL for screening/tracking
participant satisfaction and perceive it as symptoms.
"moderately" to "very helpful" with • Coping skills and assistance for common PTSD
symptoms (n = 45) (Kuhn et al., 2014; symptoms.
Miner et al., 2016).
• Psychoeducation regarding symptoms and
• 8-week pilot RCT self-guided vs treatments.
clinician-supported PTSD Coach (38% vs.
70% report sig. decrease in PCL); both
groups effective, between-groups diff. not
sig. (n = 20) (Possemato et al., 2016).
• 1-month, crossover, RCT = sig. drop in
PCL-C of 39.1% of those assigned to app.
No sig. effect of app over watlist was
observed (n = 49)(Miner et al., 2016).

PE Coach iTunes (free) • Developed by the US Dept. of Veterans Created to support clinicians/patients during
GooglePlay (free) Affairs. prolonged exposure therapy.
• Within-subjects, crossover; 4 sessions PE Features:
Coach and 4-sessions traditional PE • Voice recording (to record PE sessions)
assessing usability and app satisfaction • Assessment of treatment outcome every other
(Reger et al., 2015) session, using the PCL.
• Breathing retraining tool.
• Hierarchy accessible outside of sessions.

Anxiety Worry Knot GooglePlay (free) • Suite of apps used for 8 weeks (when “Worry Knot” teaches the user to manage worry with
(part of paired with coaching) significantly lessons, distractions and worry management tool.
Intellicare reduced PHQ-9 and GAD-7 scores (P < Features:
App Suite) .001) (Mohr et al., 2017). • guided tool to address specific problems user cannot
stop thinking about and provides
• written text about how to cope with “tangled
thinking.”
• Presents statistics about progress, gives daily tips
and tricks about managing worry.
It is a part of a 13 app suite, each designed to support a
skill or instructional style to support acquisition of
skills for depression and anxiety.

(Continues)
VAN AMERINGEN ET AL .
TA B L E 3 (Continued)
App marketplace
Condition Name (Price [USD]) Evidence
Personal Zen iTunes (free) • A single session of gamified delivery
method for ABM reduced subjective
levels of anxiety (Dennis & O’Toole,
2014).
Lack of evidence
OCD Live OCD free iTunes ($34.99) • None, based on principles of exposure
and response prevention (ERP).
MDD, major depressive disorder; ABM, attention bias modification; OCD, obsessive compulsive disorder; PCL, PTSD checklist; PD, panic disorder; PE, pro-
longed exposure; PTSD, posttraumatic stress disorder.
3.2 Tracking apps
Tracking apps provide healthcare professionals and patients with the
possibility of remote monitoring of symptoms through active and pas-
sive data collection. Active data collection requires users to physically
enter information, usually in the form of questionnaires, diaries, or sub-
jective mood and anxiety ratings (Torous & Powell, 2015). While pas-
sive data are collected automatically by the many sensors embedded
in smartphones including GPS to monitor location, accelerometers to
record movement and physical activity as well as phone calls, text activ-
ity, and microphones to detect social engagement (Torous & Powell,
2015).
To our knowledge, there are currently no studies evaluating the
accuracy of tracking apps for anxiety disorders, OCD or PTSD. How-
ever, there are numerous apps which claim to do so in app market-
places; some popular apps are listed in Table 2.
3.2.1 Major depressive disorder
Self-report data on an app have been used to track symptom progres-
sion through a trial evaluating adjunctive quetiapine-XR in refractory
MDD (Schaffer, Kreindler, Reis, & Levitt, 2013). In addition to reg-
ular study visits, participants completed daily self-reports of symp-
toms on the QIDS-self report and Hospital Anxiety and Depression
Scale-Anxiety subscale (neither scale has been validated in the mobile-
format). This self-report data permitted earlier detection of improve-
ment in depressive symptoms at day 7 compared to clinical evalua-
tion, and early detection was predictive of responder status at week
6 (P = .03) (Schaffer et al., 2013). Mindful Moods, an app incorporat-
ing an independent sample of three questions from the PHQ-9, was
administered daily for 1 month and paper PHQ-9 scores were also
collected before and after app use (Torous et al., 2015). While results
of both modalities were strongly correlated (r = 0.84), scores from
5
Description of app functionality
Users are presented with "angry" sprites and "friendly"
sprites.They must trace the path of the friendly
sprite as accurately as possible, ignoring the angry
sprite.This game aims to train users to focus on the
positive stimulus, rather than the negative and
ultimately reduce anxiety through principles of ABM.
Guides users through ERP for OCD.
Features:
• Create an exposure hierarchy.
• Set goals and rewards for practicing exposures.
• Loop tape: allow users to record personal loop tapes
for exposure.
• Real-time help with obsessions.
• Generates detailed reports.
• Children’s version available.
• Currently being studied at Brown University.
the app were higher than those reported on paper, suggesting that
participants may feel more comfortable reporting symptoms on their
smartphone device than to a clinician (Torous et al., 2015).
The ecological momentary assessment (EMA) app iHOPE was eval-
uated in individuals with mild-to-moderate depression for 8 weeks
(Hung et al., 2016). EMA involves repeated measuring of an individual’s
current behaviors and experiences in real time, in their natural environ-
ment (Shiffman, Stone, & Hufford, 2008). The app included measures
of days of active iHOPE use, EMA of emotion, sleep and cognition, and
PHQ-9. These daily app EMA responses were significantly associated
with baseline HAM-D (PHQ-9 (𝛽 = 0.5, P = .005); EMA depression
items (𝛽 = 0.4, P = .003); anxiety (𝛽 = 0.53, P < .001) and poor sleep (𝛽 =
0.41, 0.023) demonstrating validity as an assessment app for Chinese
participants (Hung et al., 2016).
Passive data recording through a smartphone app have also been
utilized to monitor mood over time (Asselbergs et al., 2016; Canzian
& Mirco, 2015; Hung et al., 2016; Saeb et al., 2015; Schwartz, Schultz,
Reider, & Saunders, 2016). For instance, Saeb, Zhang, Kwasny, Karr,
Kording, and Mohr (2015) investigated whether depressed behav-
iors could be predicted through participant movements, using the app
Purple Robot. The app recorded participant GPS location every 5
min, circadian movements, as well as smartphone usage (duration and
frequency) passively through the phone’s sensors. An algorithm was
used to correlate collected passive data with reported PHQ-9 depres-
sive symptoms. Depressive symptoms correlated with movement (r =
−.58, P = .012), location variance (r = −.58, P = .012), phone usage
duration (r = .54, P = .011), and frequency (r = .52, P = .015), as
well as circadian movement (r = −.63, P = .005). Consequently, those
endorsing depressive symptoms visited fewer locations, were more
likely to visit the same locations, had higher levels of phone use,
and more irregular circadian movements. The algorithm was able to
predict depressive states with 65–86% accuracy (Saeb et al., 2015).
6 VAN AMERINGEN ET AL .

TA B L E 4 Examples of popular existing Multipurpose mHealth Apps for anxiety, mood and related disorders

App Marketplace
Condition Name (Price [USD]) Evidence Description of App Functionality
Published evidence
Anxiety AnxietyCoach iTunes ($6.99) • Developed by the Mayo Clinic Offers assessment, tracking, psychoeducation and
disorders, • Used in 2 pediatric case reports; treatment
OCD and suggested utility in instance Features:
PTSD where therapist contact is • Self-test to assess severity of fears and worries.
disrupted. (Whiteside et al., 2014) • Tracks progress graphically.
• Psychoeducation—Information about anxiety
disorders, explanations of CBT, and guidance for
accessing other forms of treatment.
• Extensive library of exposures targeting each
disorder.

Lack of evidence
MDD MoodTools iTunes • Based on “research-supported To be used as support during formal treatment.
(free)GooglePlay(free) tools.” Features:
• Mobile PHQ-9 has been validated • Psychoeducation - provide basic information on
(Bush et al., 2013). causes, symptoms and treatments of MDD.
• PHQ-9 for symptom tracking
• “Thought Diary”—to identify negative/distorted
thinking patterns (developers state that this is
based on CBT principles).
• Suggested “Activities” to reduce isolation and
avoidance (based on principles of behavioral
activation).

Anxiety (non Pacifica iTunes • Said to be “based on CBT Daily tools to help anxiety, stress, and worry using
specific) (free)GooglePlay principles.” quick, simple activities.
(free)(with in app Features:
purchases) • Tracking mood or health activities (i.e. sleep and
exercise)
• Daily goals and thought diary (identify and
replace distorted thoughts).
• Relaxation techniques (i.e. progressive muscle
relaxation, mindfulness meditation, etc.)
Pacifica is currently being studied at the University
of Minnesota.
*Pacifica for clinicians is also available and includes
functions such as client monitoring, assessments,
and direct messaging capabilities.
Anxiety MindShift iTunes • None, developed by AnxietyBC Targets anxiety and fears relevant to teen and
(adolescents) (free)GooglePlay (nonprofit organization) young adults.
(free) Features:
• Strategies to deal with everyday anxiety
• Specific tools for test anxiety, perfectionism,
social and performance anxiety, worry, panic and
conflict.
• List of active coping strategies.
• “Chill Out” tools include breathing exercises,
mental imagery and mindfulness strategies (can
favourite preferred strategy).
• “Quick Tips” assist with real-time anxiety.

Anxiety Self-Help Anxiety iTunes • None, developed in collaboration Developed to help users understand, monitor and
Management (free)GooglePlay with research team at UWE change anxiety through self-help exercises and
(SAM App) (free) private reflection.
Features:
• Techniques to manage anxiety: interactive
breathing exercises and guided imagery.
• “Social Cloud” is a closed anonymous social
network for SAM users.

CBT, cognitive behavioral therapy; MDD, major depressive disorder; OCD, obsessive compulsive disorder; PHQ-9, Patient Health Questionnaire; PTSD,
posttraumatic stress disorder; UWE, University of Western England.
VAN AMERINGEN ET AL .
Although the Purple Robot app is currently available on Android, it col-
lects passive data but does not provide interpretations about mood
states.
3.2.2 Bipolar disorder (BD)
Tracking apps evaluated in BD have predominantly employed passive
data to predict mood shifts and manic states (Beiwinkel et al., 2016;
Faurholt-Jepsen, Vinberg et al., 2015). While these apps seem promis-
ing, they are not available to the public. Studies using active data col-
lection methods are less represented in the literature, however, this
modality appears feasible with up to 95% completion rates (Schwartz
et al., 2016).
MONARCA (MONitoring, treAtment, and pRediCtion of bipolAr
Disorder Episodes) is a self-monitoring app assessing illness activity
(mood, sleep length, activity level, medicine intake). MONARCA col-
lects passive data related to behavioral activities (e.g., the number and
duration of incoming and outgoing of phone calls and text messages
(social activities); accelerometer data (physical activity); the amount
of movement between cell tower IDs (mobility); and phone usage)
(Bardram et al., 2013). Studies using MONARCA in BD patients have
shown that passive data correlates with self-report data, and sever-
ity of clinically rated depressive and manic symptoms, as rated by the
Hamilton Depression Rating Scale-17 items (HDRS-17) and the Young
Mania Rating Scale (YMRS). Following 3 months of use, significant cor-
relations have been noted between self-reported mood and HDRS-17
(B = −0.051, P < .001); decreased movement was also correlated with
a higher score on the HDRS-17 (B = −0.48, P = .020) (Faurholt-Jepsen
et al., 2014). A later 6-month trial with 61 BD patients (Faurholt-
Jepsen, Frost et al., 2015) revealed that self-reported mood was cor-
related with HDRS-17 (B = −0.058, P < .001) as was decreased activ-
ity level (B = −0.042, P < .001) and increased self-monitored stress
level (B = 0.047, P > .001). An increase in self-reported mood was cor-
related with YMRS scores (B = −0.039, P < .001) as was increased
activity level (B = 0.047, P < .001) and decreased sleep length (B =
0.047, P = .026). The results indicated that active and passive data col-
lected using MONARCA correlated with clinician-rated depressive and
manic symptoms (Faurholt-Jepsen, Frost et al., 2015). MONARCA has
also been effectively able to predict affective states using voice fea-
tures extracted from naturalistic app use (Faurholt-Jepsen, Busk et al.,
2016). However, daily self-monitoring does not reduce BD symptoms
over a 6-month period (Faurholt-Jepsen, Frost et al., 2015).
SIMBA (Social Information Monitoring for Patients with Bipolar
Affective Disorder) has been evaluated in 133 BD patients (Beiwinkel
et al., 2016). The app was used for 12 months and clinical assess-
ments were completed at 8-week intervals using the German YMRS
and the German HAM-D. Participants rated their mood and energy on
a 10-point scale and passive data including distance travelled, location
changes, and device activity were simultaneously recorded and paired
to self-reports. Lower self-reported mood, decreased social communi-
cation, and a decline in physical activity predicted higher overall lev-
els of depressive symptoms (B = −0.56, P < .001; B = −0.28, P < .001;
B = −0.11, P = .03). Higher levels of manic symptoms were predicted
by decreased smartphone activity (B = −0.17, P < .001), less distance
7
travelled (B = −0.37, P < .001), and higher social communication (B =
0.48, P = .03) (Beiwinkel et al., 2016).
Passive data have also been used to predict state changes (e.g.,
normal to manic or depressed to normal) in BD. In a 10-month trial,
10 BD patients used a smartphone which collected passive informa-
tion, paired with clinician-rated HAM-D and YMRS conducted every
3 weeks (Grunerbl et al., 2015). The app detected state changes with
76% recognition accuracy and 97% perfect recall and precision. The
state change recognition function of the app also alerted the primary
physician and scheduled appointments when appropriate (Grunerbl
et al., 2015).
A relationship between self-reported social rhythm metric (SRM)
data and passive data from smartphones has also been reported
(Abdullah et al., 2016). Location, distance traveled, conversation fre-
quency, and nonstationary duration as inputs, were able to predict sta-
ble (SRM score ≥ 3.5) and unstable (SRM score < 3.5) states with high
accuracy (precision: 0.85 and recall: 0.86), suggesting that automated
sensing can be used to infer a SRM score Abdullah et al., 2016.
3.3 Treatment apps
Limited access to specialized mental health care is often cited as a
primary barrier to treatment (Gulliver et al., 2010). Accordingly, digi-
tally distributable treatments such as mHealth apps create an oppor-
tunity to increase patient access to evidence-based mental health
treatments and most mHealth apps employ treatment methodologies
already established in face-to-face psychological treatments, such as
cognitive-behavioral therapy (CBT). Theoretically, these apps may be
utilized as a discrete form of treatment or as an adjunct to formal treat-
ment. To date, several meta-analyses have shown that computer-based
therapies are an effective means of treatment for anxiety and depres-
sive disorders (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010;
Davies, Morriss, & Glazebrook, 2014; Richards & Richardson, 2012);
however, the translation of such techniques to the smartphone inter-
face is only beginning to be explored. The app marketplace is littered
with apps claiming to treat symptoms of a plethora of psychiatric con-
ditions some of which are described in Table 3.
3.3.1 Major depressive disorder
Over one-third of depression apps in the public domain are endorsed
as therapeutic treatment interventions (Shen et al., 2015). These apps
provide therapy using hypnosis, brainwave entrainment, music ther-
apy, or nature sounds. Almost 90% of these apps also cite a layper-
son as the source of information (Shen et al., 2015). Other types of
therapeutic apps include spiritual/faith-based, entertainment, positive
affirmation, behavior training, light/visual, exercise-based therapy, and
diet and activity suggestions. Only ten apps provide CBT, however
they were classified as multipurpose as they also incorporate com-
ponents of assessment, tracking and psychoeducation (Shen et al.,
2015).
There are five studies exploring the efficacy of a treatment-based
smartphone app targeting MDD symptoms (Burns et al., 2011; Ly
et al., 2014; Mohr et al., 2017; Wahle, Kowatsch, Fleisch, Rufer, &
Weidt, 2016; Watts et al., 2013). One examined the efficacy of an
8 VAN AMERINGEN ET AL .
8-week behavioral activation smartphone program, compared to a
mindfulness program of similar length (Ly et al., 2014). Both treatment
conditions involved minimal therapist contact, restricting interaction
to <20 min each week. At posttreatment, 73.5% of the behavioral
activation group no longer met criteria for DSM-IV MDD; while, 53.1%
of the mindfulness group was deemed recovered. At the 6-month
follow-up, 88.2% of the behavioral activation group and 81.3% of
the mindfulness group were deemed recovered. When stratified
based on depression severity, a larger proportion of the severely
depressed group (≥10 on PHQ-9) responded to behavioral activation
(73.9 vs. 50%); while a larger proportion of the less severe depressed
patients (<10 on PHQ-9) responded to mindfulness (92.3 vs. 82.4%)
(Ly et al., 2014). Watts et al. (2013) evaluated the efficacy of the mobile
version (The Get Happy Program) of a previously evaluated 6-lesson
clinician-assisted CBT program (The Sadness Program) for depression
(Johansson & Andersson, 2014; Perini, Titov, & Andrews, 2009).
In both groups, significant reductions in PHQ-9, Beck Depression
Inventory-II, and Kessler Psychological Distress Scale scores pre- to
posttreatment and pretreatment to 3-month follow-up were noted.
Moreover, at posttreatment only 45% of the sample met PHQ-9
criteria for depression (Watts et al., 2013). Ecological momentary
interventions have also been evaluated for their therapeutic poten-
tial. These interventions aim to deliver interactive tools, when an
immediate need (such as decreased mood or increased anxiety) is
identified in real-time resultant of passive data collection (reviewed
in Gee et al., 2016). Prior to beginning an 8-week trial with Mobilyze!,
contextual passive data was collected (i.e., text’s, GPS, etc.). Partici-
pants were also periodically prompted to self-report current mood
states, data which were then paired with simultaneously recorded
sensor data. This process produced machine-learned algorithms to
help derive a “standard deviation of mood.” Within the situation, if
self-reported mood was outside of this range, they were prompted
to use a behavioral activation-based tool. By week 8, only one of the
seven completers continued to meet MINI criteria for depression
(Z = 2.15, betaweek = –.65, P = .03) and the intent-to-treat analyses
revealed that depressive symptoms decreased significantly over time
(t13 = 7.02, betaweek = –.82, P < .001) as did GAD-7 scores (t13 = 4.59,
betaweek = –.71, P < .001) (Burns et al., 2011). The Mobile Sensing
and Support (MOSS) app is a context-sensitive intervention that
constructs context based on time of day, location, smartphone usage,
and physical/social behavior (Wahle et al., 2016). The "recommender"
function of the app presented potential CBT-based interventions (i.e.,
activity scheduling, cognitive restructuring, etc.) to the user depending
on the constructed context and subject preferences. In a clinically
depressed sample (PHQ-9 score ≥ 11) regular use of the app demon-
strated significant decreases in PHQ-9 scores (P = .01) (Wahle et al.,
2016).
The Intellicare suite of apps is an evidence-based, group of apps cur-
rently available for public download. Each of the 13 apps support a sin-
gle skill or instructional style to support acquisition of a set of skills
related to depression and anxiety (i.e., “Boost Me” based on behav-
ioral activation; “Move Me” exercise for mood) (Mohr et al., 2017). In
a single-arm pilot study, they evaluated change in depression and anx-
iety during 8 weeks of Intellicare supported by low-intensity coach-
ing. The coaching protocol involved a 30- to 45-minute engagement
phone call explaining how to use the tools and build rapport; thereafter
participants received 1–2 texts/week for support, encouragement, and
reinforcement of app use. Over the 8 weeks, participants used the
apps an average of 195.4 (SD 141) times, for 1.1 (SD 2.1) min. Signifi-
cant reductions at endpoint were noted in both the PHQ-9 and GAD-
7 (P ≤ .001); 37% met criteria for full remission/no depressive symp-
toms and 42% for full remission/no symptoms of anxiety (Mohr et al.,
2017).
SuperBetter (SB) is an existing smartphone/internet-based gami-
fied tool designed to increase user drive to accomplish challenging
goals. Roepke, Jaffee, Riffle, McGonigal, Broome, and Maxwell (2015)
evaluated the effects of a version of SB incorporating CBT and positive
psychotherapy (CBT-PPT SB) to specifically target depressive symp-
toms, compared to general SB (focusing on self-esteem and accep-
tance) and a waitlist control (WL) over 6 weeks. The authors noted
a significant main effect of time on depression (Centre for Epidemio-
logical Studies Depression questionnaire [CES-D]. While all SB users
(General SB: Condition coefficient = −6.13, t(276) = −3.90, P < .001;
CBT-PPT SB: Condition coefficient = −3.92, t(275) = −2.06, P = .04)
achieved greater relief from depressive symptoms than WL, the CBT-
PPT SB group did not show any added benefit over general SB users
(Roepke et al., 2015). Adherence rates were also noted to be lower in
this study than other mHealth app studies which the authors suggested
may be more representative of actual app use as no incentives were
provided (Roepke et al., 2015).
While the studies above show some promise in relieving symptoms
of depression through use of mHealth apps, only one study has evalu-
ated the effectiveness of such interventions (Arean et al., 2016). This
study utilized a cognitive control app (Project: EVO), problem-solving
therapy app (iPST), and an information (control) app. Over the 12-week
period, no significant differences were observed in PHQ-9 score or
remission (Project: EVO 45% vs. iPST 46% vs. control 34%; 𝜒2 = 3.36,
P = .19). However, when stratified by depression severity, depression
was significantly lower at week 12 for the iPST condition (difference
= 1.79, SE 0.76, t201 = –2.36, P = .02) but not Project: EVO (P = .19)
compared to controls. Further, mild disability (as per Sheehan Disabil-
ity Score ≤ 15) yielded higher rates of recovery at 4 weeks for both
Project: EVO (𝜒 2 1 = 5.36, P = .02) and iPST (𝜒 2 1 = 0.72, P = .40) over
control (Arean et al., 2016).
3.3.2 Panic disorder
A recent RCT evaluated the effectiveness of “Flowy” a gamified
mHealth app operationalizing breathing retraining (Pham, Khatib,
Stansfeld, Fox, & Green, 2016). In this study, feasibility and clinical
response following 4 weeks of treatment were evaluated. Enrolled
participants (n = 63) all demonstrated moderate levels of anxiety at
baseline and no statistically significant decreases in clinical measures
were noted at endpoint. The authors reported that the true effects of
“Flowy” on clinical symptomatology may not have been demonstrated
as a result of the low sample size and the limited 4-week time frame for
treatment (Pham et al., 2016).
VAN AMERINGEN ET AL . 9

3.3.3 Social anxiety disorder (SAD) to regular therapy (Possemato et al., 2016). However, the lack of a
treatment as usual group prohibits the exclusion of treatment effects
Dagoo et al. (2014) evaluated a mobile adaptation of a 9-week
due simply to usual primary care.
internet-CBT program for SAD (Andersson et al., 2006). This mobile-
A more recent crossover RCT compared 1 month of PTSD Coach or
CBT (mCBT, n = 27) treatment program was compared to a guided self-
WL condition, revealing a clinically significant drop in PCL-C in 39.1%
help treatment program based on interpersonal psychotherapy (mIPT,
of those assigned to PTSD Coach from baseline to the postcondition
n = 25). The mCBT was comprised of several modules focusing on cog-
assessment (Miner et al., 2016). However, a significant effect of PTSD
nitive interventions, exposures and social skills. Weekly measurements
Coach over the WL control condition was not apparent which authors
were completed online (Leibowitz Social Anxiety Scale (LSAS-SR)) and
attributed to low statistical power as modest effect sizes were seen
both treatment programs showed significant improvements pre- to
for both the ITT (d = −0.25) and completer sample (d = −0.33) (Miner
posttreatment (mCBT:t(24) = 6.18, P ≤ .001; mIPT:t(21) = 2.75, P =
et al., 2016). These findings led to a more rigorous RCT where partici-
.01); with a large within groups effect size in the mCBT group (d = 0.99)
pants (n = 120) were instructed to use the app as desired 3 months, the
versus a small effect found for mIPT (d = 0.43). A larger proportion of
goal being to mimic real-life app use (Kuhn et al., 2017). At posttreat-
the mCBT group was also classified as responders (55.6%) as compared
ment, participants assigned to PTSD Coach had significantly greater
to the mIPT groups (8.0%). However, due to technical issues with the
improvements in PTSD symptoms (P < .035), depressive symptoms (P
smartphone interface, 50.05% of this sample accessed the treatment
< .005), and psychosocial functioning (P < .007) than did WL partic-
platform using a computer (Dagoo et al., 2014), leaving the true effects
ipants. While a larger portion of PTSD Coach users revealed signifi-
of the mobile version unconfirmed.
cant improvements in their symptoms over WL (46.8 vs. 25.9%, P =
Attention bias modification (ABM) using smartphones has also
.018), there were no significant mean differences in outcomes between
been evaluated in SAD (Enock, Hofmann, & McNally, 2014). ABM,
conditions at posttreatment. Although improvements appeared to be
also known as cognitive bias modification of attention, attempts to
maintained at the 3-month follow-up, the design precluded testing of
divert attention from negative expressions that anxious individuals are
between-group effects at this timepoint (Kuhn et al., 2017).
believed to have a bias toward. In this RCT, participants performed a
PE Coach, also developed by the VA, is designed to support both
variant of dot-probe training with neutral or threatening based facial
patients and treatment providers during prolonged exposure (PE) ther-
expressions three times daily, over a 4-week period (Enock et al., 2014).
apy, an evidence-based form of CBT for PTSD. While PE Coach has
LSAS-SR scores decreased from pre- to postassessment in the two
not yet been evaluated for efficacy, a case series with two active
training groups (active condition [t(157) = −9.13, P < .001, d = −0.71]
duty soldiers was published assessing usability and app satisfaction. In
and control group [t(140) = −9.04, P < .001, d = −0.60]) but not signif-
a within-subjects crossover design, both patient’s reported improve-
icantly in the WL group (t(26) = −1.18, P = .25, d = −0.17). While both
ments in psychiatric symptomatology posttreatment, viewed the app
conditions proved to be more effective than the WL group, the ABM
positively, reporting preference for PE Coach over traditional PE
group did not show any additional gains over the control group (Enock
(Reger, Skopp, Edwards-Stewert, & Lemus, 2015).
et al., 2014). Similarly, a single session of a gamified delivery method for
ABM has also been shown to reduce subjective anxiety and observed
stress reactivity in highly trait anxious undergraduate students 3.3.5 Obsessive-compulsive disorder
(Dennis & O’Toole, 2014).
A single case report discussed the utility of a GPS-based app which pro-
vided audio feedback to the patient if a certain amount of time passed
without moving a predefined distance outdoors (Olbrich, Stengler, &
3.3.4 Posttraumatic stress disorder
Olbrich, 2016). The patient, with excessive outdoor checking behav-
PTSD Coach is an app developed by the US Department of Veteran iors which often led to missed/late appointments, chose to use per-
Affairs (VA). Findings of a qualitative feasibility study described partic- sonal voice recordings to reduce the amount of time spent in a given
ipants as very satisfied with the app and perceived it as moderately to location. During the first two trials, the time taken to get to appoint-
very helpful with their PTSD symptoms (Kuhn et al., 2014; Miner et al., ments reduced to 1 hr (previously took 2 hr) and eventually 20 min.
2016). The effectiveness and feasibility of PTSD Coach have been However, the patient stated that the impact of the application was not
evaluated in a pilot RCT (n = 20) as a self-managed (SM-PTSD Coach) on the voice recording but rather that he did not want to attract atten-
or clinician-supported (CM-PTSD Coach) approach (Possemato et al., tion of individuals in his proximity (Olbrich et al., 2016).
2016). The SM-PTSD Coach group received a 10-min handout guided
session detailing app functionality while the CM-PTSD Coach group
3.4 Multipurpose apps
received four, 20 min sessions over 8 weeks focusing on app use,
setting PTSD symptom reduction goals and assigning specific app Multipurpose apps seem to be the most popular for all age cate-
activities. Thirty-eight percent of the SM-PTSD group (d = 0.41, P = gories and typically target several symptoms of anxiety or mood dis-
.02) and 70% of the CM-PTSD group (d = 1.4, P < .01) presented statis- orders. Their functionality can be customized to the user’s symptoms
tically significant declines in PCL-specific scores pre- to posttreatment. and some of the most downloaded options are shown in Table 4.
The between-groups difference was not statistically significant, leav- A feasibility study for a BD multipurpose app (psychoeducation and
ing the possibility that the app may be useful as self-help or adjunct tracking) (SIMPLe) reported participant satisfaction with usability and
10
acceptability of the app, with 74% of users continuing use 3 months
later (Hidalgo-Mazzei et al., 2016).
4 CURRENT STATE OF MHEALTH APPS
The mHealth app literature has grown extensively in the past year,
attesting to the mounting interest in evaluating their clinical utility.
However, it should be noted that an overwhelming majority of these
empirically supported apps are not yet available for public download,
leaving clinicians and mHealth app users unequipped to navigate the
extensive existing app marketplace. The extant mHealth app litera-
ture does however support app use in mood disorders. For instance,
the mobile PHQ-9 is one of few validated assessment apps (Bush
et al., 2013) that has been shown to effectively screen for depression
(BinDhim et al., 2015) and motivate treatment-seeking behavior
(BinDhim et al., 2016). Both active and passive data collected from
apps can also reliably portray a user’s depressive symptoms (Schaf-
fer et al., 2013; Torous et al., 2015) which may prove beneficial to
clinicians when used as part of regular treatment. MDD treatment
apps have suggested efficacy in controlled settings (Burns et al., 2011;
Ly et al., 2014; Mohr et al., 2017; Wahle et al., 2016; Watts et al.,
2013). Although these results are promising, it should be noted that
continued participation is often incentivized and some studies incor-
porate therapist contact, making it difficult to isolate the effects of
the app. Further, when evaluated in a naturalistic setting or without
incentives (more representative of real-life app use), both adherence
and treatment effects become less pronounced (Arean et al., 2016;
Roepke et al., 2015). BD tracking apps such as MONARCA and SIMBA
also show promise (Bardram et al., 2013; Faurholt-Jepsen et al., 2014;
Faurholt-Jepsen, Vinberg et al., 2015; Faurholt-Jepsen, Frost et al.,
2015; Faurholt-Jepsen, 2016; Beiwinkel et al., 2016) and further illumi-
nate the benefits such apps offer to regular treatment (Grunerbl et al.,
2015). Finally, the mHealth app literature targeting anxiety disorders,
PTSD and OCD provides limited empirical support and must be eval-
uated further. Overall, the treatment effects of apps are much smaller
than other evidence-based treatments. However, they possess much
potential to reach sizable populations of individuals without access to
mental health care.
4.1 Potential benefits
The potential benefits of mHealth apps have been attributed to their
accessibility and portable nature. For example, tracking apps utilizing
active data collection allow for self-monitoring of symptoms in real
time, reducing the possibility of recall bias. While passive data elimi-
nate the issue of recall bias and subjectivity altogether by continuously
monitoring user activity. The potential benefits of any app however, are
contingent upon its role in treatment, as a self-help tool or adjunct to
formal treatment.
There are unique benefits to using apps in conjunction with regu-
lar treatment. For instance, validated assessment apps can equip less
experienced mental health professionals or primary care workers with
VAN AMERINGEN ET AL .
tools to educate patients about presenting symptoms by specifying
diagnoses or relevant treatments. Additionally, tracking apps can pro-
vide clinicians with detailed information regarding a patient’s symp-
toms between appointments. Tracking information may also allow
clinicians to optimize course of treatment based on accurate reports
outlining symptom change between appointments. Multipurpose or
treatment apps may also reduce the need for in-person appointments
with clinicians, thereby limiting the inconvenience of geographical bar-
riers, time or financial costs for the patient, and alleviating the work-
load of a clinician. Apps such as AnxietyCoach have been shown to
improve treatment engagement when therapist contact is disrupted
(Whiteside, Ale, Vickers Douglas, Tiede, & Dammann, 2014) as they
have built-in exposure recommendations and provide an alternate line
of patient-therapist communication. Treatment apps may also rein-
force what is learned in therapy between treatment sessions. In the
case of pharmacotherapy, medication reminders may also improve
treatment compliance. Moreover, if benefit of treatment apps was
demonstrated, they could be given to patients while waiting for access
to specialized care to help manage their symptoms until formal treat-
ment became available.
Apps have the ability to transcend usual barriers to treatment and
offer care to those without access to conventional treatment methods.
They may serve as an attractive option for underserviced groups, like
those of low socioeconomic status, as individuals with low household
incomes and minimal education tend to rely more heavily on smart-
phones than their wealthier counterparts (Smith, 2015). With the cost
of apps being significantly less than that of traditional care, they could
provide some form of aid to populations where help may not be afford-
able or available. Apps could also alleviate the burden on the health
care system by providing a self-help option for those with mild psychi-
atric symptoms, as self-help tools have been shown to be more effec-
tive in such populations (Newman, Szkodny, Llera, & Przeworski, 2011).
This would reserve the limited and specialized services for more severe
and partially refractory cases. Apps may also effectively be incorpo-
rated into a stepped care model and be used to lessen the burden of for-
mal treatment by eliminating the need to take time off work. Moreover,
individuals who have already undergone treatment could continue to
monitor their symptoms or engage in treatment exercises to minimize
the risk of relapse.
Using a smartphone for mental health purposes is not only conve-
nient but also private. Individuals can engage with their apps at any
point of the day without worrying about self-stigmatization, whereby
the individual actively applies stereotypes to oneself (Corrigan,
Larson, & Ruesch, 2009). Mental health services may become more
accessible and easier, rendering people more likely to participate in
these activities, through the use of apps. Further, lack of perceived
need of treatment is often cited as a treatment barrier (Mojtabai et al.,
2011) and apps may have ability to motivate users to seek diagnosis or
treatment as demonstrated by a depression assessment app (BinDhim
et al., 2016). Assessment apps through psychoeducation can help both
patients and inexperienced health professionals better categorize anx-
iety and mood symptoms and identify the need for treatment earlier to
minimize the suffering associated with such illnesses.
VAN AMERINGEN ET AL .
4.2 Potential disadvantages and unresolved issues
Despite their tremendous potential to extend the reach of mental
health care, the existing limited literature does not sufficiently support
the purported benefits of mHealth apps. The lack of studies and low
quality of the scientific literature demonstrate that app development
has severely outpaced research. For instance, anxiety and depression
apps each comprise 18% of the disease specific app space, respec-
tively (Aitken & Lyle, 2015); however, the evidence for anxiety apps
is far behind those targeting depression. These extensive libraries of
mHealth apps are difficult to navigate and the lack of evidence makes
it difficult for clinicians to appropriately guide patients away from apps
with irrelevant or falsely endorsed therapeutic abilities. Even those
created by reputable organizations are not currently supported by
empirical evidence; while apps supported by empirical evidence are
not actually available for public download. A primary driving factor for
this may be that mHealth app developers lack the necessary exper-
tise to produce validated apps, and only 5% include a medical specialist
in their team (Research2guidance, 2015). For this reason, millions of
dollars are being invested into an app market where minimal scientific
evidence has been used in development.
Many apps are also premised upon evidence-based treatments;
however, transferring a treatment from one modality to another typ-
ically requires validation prior to being deemed effective. For example,
manualized or internet-based CBT programs often incorporate large
bodies of text which cannot be directly transferred to the smartphone
platform due to the difficulty of reading lengthy texts on such devices.
As such, text is shortened (Dagoo et al., 2014) potentially altering the
psychometric properties of the program and reducing the previously
established validity. Similar limitations are also seen in assessment
and tracking apps where many utilize validated clinical measures that
have not been evaluated on smartphone devices. Relatedly, assess-
ment tools must also be revalidated when changed into a different for-
mat. A study developed a smartphone app in order to assess preva-
lence rates of bipolar spectrum disorder in a Korean sample (Woo et al.,
2015). Although their use of a smartphone app permitted the quick dis-
semination of assessment, the app had not been validated against the
paper and pencil version.
It has been suggested that apps would be most prized as a stan-
dalone, self-help treatment. Yet, no studies actually evaluate apps in
this context, instead many focus on them as an adjunct to therapy. To
promote the issue, pure self-help treatments are also accompanied
by a number of limitations. For one, self-help treatments have been
described to offer the most benefit for specific phobia and have been
described as no more effective than WL controls for OCD or PD.
Furthermore, benefits are typically limited to populations presenting
mild symptomology (Newman et al., 2011). Drop-out rates are also
higher in guided self-help conditions, when compared to face-to-face
treatment (Cuijpers, Donker, van Straten, Li, & Andersson, 2010) a
relationship that may be facilitated by reduced patient accountability.
Overall, apps may hold the potential to significantly alter the treat-
ment landscape but their clinical application may be more limited than
previously thought.
11
Apps hold promise to reduce the effects of certain treatment bar-
riers, but maintain others. Pessimism regarding treatment efficacy
is a frequently cited barrier to treatment in psychiatric populations
(Mojtabai et al., 2011). Apps have been rated as the lowest in regards
to appeal, helpfulness, personal support, motivation, and credibility
when compared to face-to-face interventions, self-help books, and
web-based information (Musiat, Goldstone, & Tarrier, 2014). Unless
addressed, such perceptions hold the potential to diminish the role
of mHealth apps further. Even 70% of mental health professionals
who regularly use apps themselves, forego supplementing their usual
care with apps and 54% further believe that none of their colleagues
are incorporating apps into treatment either (Grossman Kaplan et al.,
2015). Psychiatric outpatient populations have expressed interest in
using apps to track and treat symptoms (Torous et al., 2015; Erbes et al.,
2014); however, despite the interest, mHealth apps are underutilized.
Presently, five mHealth apps account for 15% of all downloads in the
health care category and over 50% of apps have less than 500 down-
loads (Becker et al., 2014). While there seems to be much theoretical
value to mHealth apps, whether they work and whether people will
actually use them remains elusive.
5 FUTURE DIRECTIONS AND
CONCLUSION
The majority of mHealth apps available have not been examined criti-
cally, are not supported scientifically, and the few existing studies eval-
uate apps that are rarely available for download to the public. More-
over, the apps available within the app market are in constant flux,
with apps being removed almost every 2.9 days (Larsen, Nicholas, &
Christensen, 2016). This poses a great limitation for both individuals
seeking self-help tools and clinicians trying to choose an app for their
clients. With only the support of sparse, low-quality studies, clinicians
may be guilty of becoming overly enthusiastic about the clinical role
of mHealth apps and their potential utility. In two studies by Schueller,
Washburn, and Price (2016), 81% of surveyed clinicians reported rec-
ommending some form of technology to patients, although the rec-
ommendations were primarily information/education -based websites.
Despite the eagerness of clinicians to incorporate apps into clinical
practice, many factors must first be resolved. In order for apps to
achieve the level of utility that is expected of them, more resources
need to be put toward researching existing apps for their proposed
uses (Schueller et al., 2016). Alternatively, existing apps designed for
purposes other than mental health could also be further explored,
as suggested by Roepke et al.’s (2015) use of SB. For instance, apps
such as Pokémon Go may have unintended behavioral activation and
exposure-based benefits which could be explored in clinical popu-
lations. Effectiveness studies targeting populations facing treatment
barriers may be a reasonable next step for app research, as these pop-
ulations may be more motivated to use such tools. Passive data col-
lection represents a promising modality for tracking and predicting
changes in mood states. It may also be used to examine behavioral
12
biomarkers of psychiatric illnesses, such as data from such sources as
accelerometry, actigraphy, paralingustic monitoring, and many others
(Adams et al., 2017). The future direction of this field should include
enhancements of passive data collection as an important tool for clini-
cians to enhance patient care.
It is essential that clinicians are involved in the development and
integration of apps. In addition, regulating authorities need to delin-
eate laws to protect the privacy of both patients and clinicians. Future
directions for this field include utilizing developing technologies, such
as wearable tracking devices, for increased circulation of apps beyond
the smartphone interface. It is only upon the development of safe,
evidence-based, validated apps, that the proposed benefits of apps
may become evident.
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How to cite this article: Van Ameringen M, Turna J,
Khalesi Z, Pullia K, Patterson B. There’s an app for that!
The current state of mobile applications (apps) for DSM-5
obsessive-compulsive disorder, posttraumatic stress disorder,
anxiety and mood disorders. Depress Anxiety. 2017,00,1–14.
https://doi.org/10.1002/da.22657