I’ll be honest again, I haven’t used any of these very much apart from some failed attempts to complete MoodGym. Feel free to comment if you have.
We could all use a little help keeping our New Year's resolutions and if you're already, like me, beginning to falter here are some resources that might lend a helping hand. These are some apps and websites that I've personally found interesting and relevant but it doesn't mean that they are secure. Whenever you give someone your data there is a possibility that it will end up in the hands of a third party. Also, just because these are interesting to me doesn't mean they'll work for everyone and I suggest you read through their websites to assess whether it's something that might cause you distress personally.
1. I will try to keep on top of my physical wellbeing. Be Active! One thing I find very interesting is that even though we know how important the five ways to wellbeing can be there are very few apps. One that I beta tested from Somerset Public Health still appears to be available on Google Play but not the App Store. Instead I would draw your attention to the large numbers of ‘lifeloggers’ out there and especially SuperBetter. I like it because it has suggestions about what to do, fun and whimsical activities with the important purpose of helping you build resilience. Jane McGonigal, the brains behind it, is enthusiastic and anyone who equates games to a better world is ok in my book!
2. I will try to connect with people. It all really depends on what you find best because there are a lot of options out there. Going to meetups or doing some local volunteering are great ways to meet people. Obviously Buddyapp is a firm favourite for anyone currently in therapy, letting you plan appointments and share your diary. Big White Wall is a peer support forum but requires you to be in the right neighbourhood – my postcode doesn’t give me access. If you want to connect to people online there are lots of forums for specific issues or alternatively you could try one like 7 Cups that offers free anonymous trained listeners. There’s been quite a bit of chatter about Koko lately, developed by an MIT student and supposedly “a social network that actually helps you feel better” – I haven’t tried it yet so can’t say whether it’s any different to the more established 7 Cups.
3. I will try to be more mindful. I’ve been asked a lot about mindfulness apps, people looking for suggestions about which ones are best. As a person who is naturally averse to being told what to do I sometimes find them a little too prescriptive for me so I might not be the best judge. But I really enjoyed playing around with buddhify, I like that idea of using mindfulness for specific times rather than it being a course. But if you’d like to learn about it people with far more experience than me typically recommend Headspace. If your pockets can’t handle signing up for it you could try the U.S. Veteran Association’s Mindfulness Coach app or there are some apps that offer guided diaphragmatic breathing such as MyCalmBeat, Tactical Breather, Breathe2Relax or a favourite of mine (it has an Apple Watch app) Breathe. For young people I came across Stop, Breathe & Think – I’m sure you’re allowed to use it if you’re an adult and it actually is quite informative.
4. I will try to understand myself better. How do we go about understanding ourselves better? One way is to communicate with people but I’ve covered that in number 2. Perhaps you could use some kind of measure or tracker to begin tracing a pattern of your behaviours and thoughts. WhatsMyM3 is used in the U.S. to diagnose certain mental health issues but as there is no research yet to identify whether using these measures outside of a therapeutic environment helps people in any way I would suggest trackers that look at more aspects of your life. One of the first I came across was Optimism, it’s free and lets you edit what you measure, similar to T2 Mood Tracker (another VA app). People often want a tracking app that lets them tag, save, post photos, and iMoodJournal is the best I’ve found for doing all those things. You can then see how your sleep, friends, family, food, exercise, etc. all interact with your moods. Moodscope is also a nice way of measuring and tracking your moods and recording your thoughts.
5. I will try to be more reflective. Sometimes it can be useful to reflect on your thoughts, and that’s where CBT and DBT come in. MoodKit includes a thought checker, journal, tracker, etc. and was in fact developed by professionals. MoodGym is a free online CBT course with research behind it. DBT Diary Card has been recommended as a great way to track behaviours and emotions.
I’ll be honest again, I haven’t used any of these very much apart from some failed attempts to complete MoodGym. Feel free to comment if you have.
6. I will try to sleep better. We all know how important a good night’s sleep is for our mental health. I’ve used Sleep Cycle in the past but found that whilst there was a sort of morbid curiousity with how little sleep I was getting, it didn’t really make a difference to how I slept. Possibly it meant I woke up a little fresher but it's hard to tell - I don't like waking up, fresh or not! Another app that’s similar is Pillow. I tried Dream:On but again, whilst it was interesting to reflect on my dreams and the possible link with music I didn’t find it worthwhile in improving my sleep. In fact the one app that seems to help the most, and is especially useful when I’m staying in London and can’t sleep with the sounds of sirens, is Relax Melodies (another I haven’t tried yet but which doesn’t have ads is Dormio). It’s just a noise machine for your phone. If you’d like to work on your sleep Sleepio and CBT-I Coach offer CBT-based interventions to help you sleep better. I tried using Sleepio for a bit but found it hard to remember to set it up before bed. They do seem to have been met with a lot of approval by people. CBT-I Coach is another VA app and is more about learning than tracking.
7. I will try to be happier and enjoy life more. One of my favourite sayings is “there is no way to happiness, happiness is the way” but why not get a little help? People are talking about Happify a lot but I have yet to explore it in any great detail. It does seem fun with some interesting games, activities, videos, etc. Speaking of fun, how about some good games to play that supposedly also help your mental health? First up is Personal Zen – research found playing it for 25 mins reduced anxiety – but I find it a bit boring. If you want to reduce anxiety you could try Flowy, no research but it uses gamified breathing exercises to help you relax. Or perhaps you’d like to overcome your fear of spiders with increasingly realistic games with spiders on Phobia Free? Quite a few apps include games similar to e-Catch the Feeling, the idea being along the lines of Personal Zen’s attention bias modification. One of my other favourites is BrainyApp from Alzheimer’s Australia that actually has some pretty challenging ‘brain’ games along with activities that can help you keep your brain and heart healthy.
8. I will reach out if I need to. Sometimes, no matter how well we’ve followed our resolutions, we end up needing help. There are a few apps out there for supporting those who are suicidal – the Irish SOS app, the American Operation Reach Out, Australian Operation Life, and the UK Stay Alive app. There are a number of websites that offer online chat or phone numbers, for these you would be best going to this private wiki as there are a links for websites worldwide. If you or someone you know are in crisis it’s important to contact emergency services.
I was recently asked to be on a panel alongside experts on data protection and regulation. My position was ethics. The audience was mostly made up of digital health companies, business not usually being an area where ethics is a priority. In the medical community there has long been a tradition of maintaining ethics (albeit sometimes not very well) whilst in technology the major consideration has been beneficence. So on the one hand the idea is to reduce harm and on the other is to do good. The problem with doing good, or even doing no evil, is that you are relying on your own judgement of what that is. It makes people forget about informed consent and focus on autonomy. We make presumptions about people. After all, the road to hell is paved with good intentions.
I wrote an introduction that I didn't have time to say and so I thought it would be appropriate to post it here. It was written knowing that whilst data protection and regulation may be taken seriously, considering there are repercussions for those who don't comply (even if it is only a slap on the wrist), ethics is yet to be something high on the list of priorities. I tried to argue that it is something very important, even if it isn't mandatory.
Consumerisation of digital health is obvious by how often we use the word 'consumer' to describe the people using digital health products and resources. I believe ethics is as consumer facing as you can get. Before today I thought about ethics in terms of what happens with consumer data from an organisational perspective but with all the research potentially being done with people's data I think research ethics is increasingly relevant.
This is a post I was asked to write for Victoria Betton's wonderful blog on all things Digital Mental Health. We managed to get a chance to speak at the King's Fund Digital Health and Care Congress where she was speaking and I was chairing. I was lucky enough to also attend the People Driven Digital Health and Wellbeing event in Leeds, which I found incredibly inspiring, and this is a kind of response/plug of my research :)
Technology and Mental Wellbeing Research
I have to admit that I wish I had thought of the words ‘people-driven’ when I first started my research. Instead I chose the much more difficult to explain concept of ‘autonomous’ – it’s also one of those terribly academic words that no one really knows the meaning of. Oh to go back in time! In fact the title of my research, “a constructive grounded theory study of the experiences of autonomous users of digital mental health” is quite a mouthful, so much so that I had to set up a website just to explain it!
People-driven really does explain my research quite well though. I’m inviting people to tell me about their experiences of digital mental health, of using technology for their mental wellbeing. After spending the past 3 or 4 years digging deep into the world of digital mental health, looking at everything from computerised CBT to gaming apps for anxiety, I realised that there was something really significant going on. On the one hand you had all this research looking at the efficacy and acceptability of various digital tools and activities and on the other you had people using them. Lots of new stuff was being created, tested and rolled out with less than perfect results (few people actually used them) and it seemed like nobody was listening to the people who knew best. That is, the users. It’s much better now with organisations like mHealth Habitat, but the research is still thin on the ground.
So that was the start to my research. I chose the word ‘autonomous’ because I wanted to ask the people who were already using websites, apps, social media etc for their mental health. They weren’t told by their doctor to go online and find this information. They weren’t given an app by a researcher and told to use it. It was their decision to use them and I think that is pretty important.
It was also important for me to actually hear what people had to say about their experience. I could easily have imposed what I thought I’d find, formed hypotheses, and tested them. But it would have meant that I completely missed the complexity of digital mental health, where one person’s trigger is another’s support and the technology itself could cause the very problems it’s trying to help (think sleep apps and the finding that looking at screens before bed can disrupt your sleep). So with questions left purposefully broad I can sit in an interview and actually listen to what people have to say, I’m not looking for a right or wrong answer, and I don’t need to tick any boxes.
In a PhD you’re always asked what your contribution will be. My contribution isn’t just for academics; it’s for people too. Without toolkits, regulations or prescription we have been using digital for our mental health, and there are lessons and experiences aplenty. I’m incredibly self-conscious, always have been, and I’ve found social media great because I can now tell everyone what I’m going to do and it forces me to do it. Apps are a great way to distract me from worrying about what everyone thinks of me, worrying about how they see me. I feel that I’ve gained confidence. There’s a complexity there that people need to know about. Whether they are a developer, a user or a policy maker, the experience of digital mental health is worth knowing about.
If you are interested in hearing more about my research feel free to contact me or visit the website, where you can also let me know if you are interested in telling me your story.
I recently presented a talk on the area of Mental Health Apps at WONCA Rural Health 2015. It was a real honour to have the opportunity, and to speak alongside Drs Michael Jong, Peter Berggren and Phil Wilson. Each spoke of some wonderful work they were engaged in and I would urge you to check them out.
When I was asked to do this by my supervisor, Prof Patrick Pietroni, I was a little intimidated. My experience of rural health comes mainly from growing up in rural Ireland – and it became clear over the course of the conference that this is not really considered rural, especially by those in Australia! But I do know my way around technology for mental health and there are some universals in rural health that it was clear to me could potentially be tackled by an app.
Mobile devices are incredibly exciting for a geek like me. Even though I am old enough to remember a world that could survive without smartphones I’m not really sure how the adult world worked without them. They fill a niche that we never even knew we had – I check my bank balance in the queue, do my shopping on the train home. In the past 20 years ownership of both mobiles and smartphones have grown exponentially, in rural and urban areas (albeit at different rates). Cost has always been a significant factor but as coverage widens, need increases and the inbuilt accessibility and privacy of a smartphone make them a good alternative to the more complicated, costly computers. It often provides a direct link to populations who had never previously used technology. Including babies.
A study that I often like to quote is the result of a World Health Organisation Mental Health Survey (Andrade et al, 2014). In it they addressed the barriers to treatment in a global population of people with diagnosable mental health conditions. 63.8% wanted to handle their mental health on their own. Whilst the authors saw this as a barrier I see this as an opportunity. If something both acceptable and appropriate can be found it could be a significant game changer.
The thing with mental health apps is there is so much potential:
- Provide information in the right place at the right time
- Provide non-invasive, real-time communication and delivery
- Provide increased reach through ubiquity and accessibility options
- Provide motivation through notifications and gamification techniques
On my iPhone I have over 200 apps in the area of mental health and this is but a drop in the ocean. Whilst various numbers have been suggested it is probable that the number of mental health apps available number near to 100,000 by now (Donker et al., 2013; Kamerow, 2013). They can do so much… What’s My M3 offers assessments, Bipolar Connect offers access to an online forum, Recovery Record for monitoring eating disorders, Phobia Free to provide systematic desensitization for arachnaphobia (with augmented reality!) and Joining Forces providing targeted mental health information. The functionality is impressive.
That is key with the smartphone. Functionality is only limited by imagination. StudentLife is an app developed by a Dartmouth Professor to track and correlate mood with activities ( Wang, Chen, Chen, & Li, 2014) . Not only could it use the GPS but it picked up audio in conversations as well. One day an app like this could alert you when your stress levels increased and perhaps you could use a biofeedback device, like BellyBio, to regain composure – prevention in real time.
Best of all, certain types of smartphone apps can work without network coverage or internet. In rural health this lack of connectivity is often a barrier to providing real-time help. But as the algorithms get better, and the battery life too, it may be possible that continuous monitoring and timely prevention could become a reality.
If you are interested in my thoughts about Regulations – Intended Use and Unintended Consequences or on ResearchKit they will be linked to once I have time to post.
Should we be worried that fitness devices are not very accurate? In this article from MobiHealthNews activity tracker companies explain that it is the engagement that’s important. I have to say from my own experience that the inaccuracy acts as a driver to engage more.
After a 10km walk when my Health app said I did only 6789 steps I then proceeded to walk more that week just so I could up my daily average. Yeah, it sucks for doctors who were hoping to tap into this data but let’s be honest here. Most of the time we rely on self-reported data – did you go for a walk today? Yes of course I did (not). Even if it were accurate what’s to stop someone giving their iPhone to their more active friend for an hour. I can see it now – people jogging down the road with iPhones, FitBits and various strapped to themselves, cards in newsagents offering their activity to others. If we don’t trust humans (and when it comes to health it’s usually best to be at least a little skeptical) why should we trust technology? Surely it is better to have inaccurate data than to have data that actively lies? That day I walked around 12500 steps (according to Google). I knew it (kind of) but my phone didn’t. But how could I blame it? I couldn’t, no… Instead I had to prove it wrong. I was placed in a position where I wanted to also be more truthful to myself – I am inactive (the downside of a PhD) and the one time I did a 10km walk it was important enough that the data rewarded me that I changed my behaviour. Brilliant! Let’s keep measuring steps wrong, let’s keep challenging our technology, because the day that it’s more accurate than we are is the day we stop trying to best it.
The published review can be found in the March 2015 edition of The Psychologist magazine (available here). It's a shortened version of my previous app review for SAM. Here it is with the references included.
SAM App Review
The Self-Help for Anxiety Management (SAM for short) app aims “to help you understand and manage anxiety”. From the perspective of someone with experience of mental health apps and websites through my research I believe this is one of the better ones. The usability aspect is often overlooked in favour of replicating an established intervention. This can often lead to low levels of adherence, especially when there is minimal therapist contact (Newman, Szkodny, Llera, & Przeworski, 2011). The app is easy to use and intuitive, moving the user from information about using the app to information about their anxiety. The self-help aspect is clear, with the toolkit allowing tailoring of preferred techniques, and the concept of tracking anxiety useful (Klasnja & Pratt, 2012). My only concern is there needs to be more clarity about the function and use of the ‘Social Cloud’ for users, especially emphasising that it is an unmoderated peer-to-peer network.
For more information visit their website: http://sam-app.org.uk/
Klasnja, P., & Pratt, W. (2012). Healthcare in the pocket: mapping the space of mobile-phone health interventions. Journal of Biomedical Informatics, 45(1). doi:10.1016/j.jbi.2011.08.017
Newman, M. G., Szkodny, L. E., Llera, S. J., & Przeworski, A. (2011). A review of technology-assisted self-help and minimal contact therapies for anxiety and depression: is human contact necessary for therapeutic efficacy? Clinical Psychology Review, 31(1), 89–103. doi:10.1016/j.cpr.2010.09.008
A recent app review written for the Journal of Psychological Therapies in Primary Care, due out this summer. Many thanks to Phil Topham, Praminda Caleb-Solly and Paul Matthews from the University of the West of England.
App Review: SAM
The Self-Help Anxiety Management app is a good example of an app that has been designed for and by the people who are going to use it. Using the concept of self-help Phil Topham, Praminda Caleb-Solly and Paul Matthews of the University of the West of England spent 5 long years and £100,000 working with students and staff to develop an app that delivers anxiety management techniques and information from your smartphone. With over a quarter of a million users by the end of 2014 it is fair to say that this app is not only useful but extremely well-used too.
This is certainly an app that has been developed to be picked up and used immediately, the design as a whole being very intuitive. The interface is uncomplicated and efficient, benefitting from personalisable features. For instance My Anxiety Toolkit allows you to save certain ‘self-help tools’ that you find effective so they are easily accessible when you return to the app. The tools themselves are quite engaging and interesting – one lets you listen back to your voice whilst another invites you to ‘clean the screen’ to reveal a picture. These elements of Attention Bias Modification twinned with gamification (i.e. ‘fun’) have demonstrated mixed results in recent studies using smartphone apps (Dennis & O’Toole, 2014; Enock, Hofmann, & McNally, 2014) but the role of mobile distraction within self-help for anxiety will, I’m sure, be an interesting area of research in the future.
Security and Safety 3/5
The security and safety of any app can be difficult to ascertain. The backend of the app would appear to be secure considering it was developed by both an app development company and computer scientists. At the frontend whilst it doesn’t have the option to secure it with a passcode, the innocuous name ‘SAM’ would be unlikely to invoke comment at its appearance on your phone. It is also clear how to report an issue. The Social Cloud aspect would, I feel, cause concern. It is essentially an unmoderated forum – people are able to chat anonymously with each other and the only oversight comes from within this user-community. It is true that online forums have often functioned as a result of both this anonymity and beneficence of self-moderation (Ryan, 2010). However, these aspects are also often considered attributable to some of the more negative behaviours online (Joinson, 2002). The likelihood of harm resulting from an online forum is very low (Eysenbach, Powell, Englesakis, Rizo, & Stern, 2004) but there is a need for this risk to be considered and I feel it would benefit from it being more explicit. The discussion around online forums in areas of mental health is certainly one wrought with ethical and clinical dilemmas, ones that need to be addressed in more depth than can be provided here.
Phil is a counselling psychologist and much of SAM reflects this. It is well-researched and sits within a number of self-help and behaviour change frameworks such as psychoeducation and transtheoretical model of change (Abraham & Michie, 2008). The qualitative response (assessed through online reviews, blogs and vlogs) appears to be overwhelmingly positive and many individuals find this a useful and appropriate app. Overall the app presents itself well but I am not convinced as to the therapeutic benefit of the Social Cloud. Whilst peer-to-peer online support is often cited as advantageous for many reasons (Lal & Adair, 2014; Proudfoot et al., 2012) research suggests that it may not provide any significant additional benefit to an intervention (Freeman, Barker, & Pistrang, 2008). For this reason, and paired with the additional ethical concerns that an unmoderated forum may present, I feel the SAM app must lose a point.
This app really is a wonderful app and very enjoyable to use. Feedback from others who have used it is always positive. I feel it would be useful as an adjunct to therapy as well as for those who prefer to self-manage their anxiety.
I had the opportunity to speak with Phil via Skype and he filled me on some more details about the app and its development.
This is the first post in what will hopefully become a regular introduction to Digital Mental Health. I have had the good fortune of being the one to introduce a number of different groups to the topic and these posts are in a similar form to what I have presented to them. If you have any suggestions or questions please feel free to ask.
It begins with an explanation of devices.
This is an app review I wrote for the Journal of Psychological Therapies in Primary Care, Vol 3(2), available now. I'd like to thank Syed and James for their time and everyone at Buddy for a wonderful example of digital mental health at its best!
I've been trying to do a poster for a Diversity Festival at the University and thought the first step would be to write down some ideas. Turned into a rather long blog post so, whilst it is completely unsuitable for a poster, I have decided to finally update with something new! It definitely made me think a lot and I really enjoyed writing this (in stream of consciousness format). Still don't know what the poster will be though!