The future is in our hands: The role of mobile phones in the prevention and management of mental disorders

Mobile phones lend themselves to mental health care. Widely used across ages, incomes and cultures, they are also personal, location independent, carried on the person, usually turned on, and often connected to the Internet. As such, they offer unique opportunities for accessing health information, monitoring progress, receiving personalised prompts and support, collecting ecologically valid data, and using self-management interventions when and where they are needed. Furthermore, entry barriers associated with other forms of technology are minimised, enhancing the potential to reach underserved populations. A small but rapidly growing literature supports their use in the prevention and management of mental health disorders.

In this Viewpoint, I provide a brief overview of the current state of mobile mental health, a specialised section of the larger field of mHealth (health care delivered on mobile communication devices such as mobile phones, smartphones and tablets). I also discuss riorities for mobile mental health into the future.

Ecological momentary assessment

Mobile phones, smartphones and tablets are particularly suited to ecological momentary assessment (EMA): monitoring and assessment in real-time and real-world conditions. Many dimensions of symptoms, affect and functioning, particularly those that change frequently, are not well captured by self-report or clinical interviews. Relying on retrospective recall or compliance with paper diaries can be problematic and validity is often compromised. (Stone et al., 2003). With mobile phones, by comparison, information can be collected in real-time, multiple times a day, as people go about their everyday activities. SMS reminders can be sent as memory prompts to enhance adherence. Situational information can be easily gathered to aid identification of triggers and patterns in moods or behaviours. Progress can be monitored. The unique ability of mobile devices to collect ecologically valid information, and to contribute to large-scale prevention and management initiatives, are yet to be fully realised.

Ecological momentary interventions

Mobile phones are also successfully deployed in therapeutic situations. Extensive global networks enable users to access psychotherapeutic strategies and support in real-time, where and when they need them. Broadly, these ‘ecological momentary interventions’ (EMI) can be categorised in three groups:

Automated, tailored programs: delivered via downloadable ‘apps’ or via the Internet on smartphones, these programs are used with and without clinician support for prevention, early intervention and treatment, and to assist with the completion of therapy-related skills practice. Typically, users are prompted to enter information about their situation or internal states, and the program provides personalised information, support or therapy in real-time. An example is ‘myCompass’, an interactive program tailored to individual users with depression, anxiety and stress (Harrison et al., 2011). The program provides self-monitoring assistance, prompts and reminders, graphical feedback with contextual information, motivational messages, and brief self-help modules based on cognitive-behavioural therapy, interpersonal therapy and positive psychology techniques.

Context-aware programs: the new smartphones contain many in-built sensors such as GPS, ambient light and movement, and they are also capable of connecting to external sensors. The harnessed data can be linked to user-reported information to facilitate an understanding of individual patterns of responding in specific situations, and to deliver real-time information, support and feedback in those situations. Already, a small number of prototype mental health programs have been developed to detect when individuals need assistance and to provide real-time therapeutic interventions – see, for example, the Mobilyze program for people with depression (Burns et al., 2011). Context-sensitive treatment is an area of mHealth that holds much promise. It is likely that future work will focus on sensors built into smartphones, as preliminary data indicate lower compliance rates when users need to wear or carry sensor devices in addition to their mobile phone (Prociow et al., 2012).

SMS programs: low-end technology, such as the short message service (SMS), which is available on all mobile phones, is being used to reach large populations directly for mental health promotion, and also to provide psychotherapeutic interventions for specific patient groups. An example of the latter is Mobile Assessment and Treatment for Schizophrenia (MATS), a program targeting auditory hallucinations, medication adherence and social interaction (Granholm et al., 2012).

Public attitudes towards the use of mobile phones in mental health care are positive across different age groups, and for different types and severity of mental health conditions (Ben-Zeev et al., 2012; Proudfoot et al., 2010; Whittaker et al., 2012) and they are likely to continue into the future. There are now over 700 consumer applications for mental health conditions in the Apple App Store alone (MobiHealthNews, 2012), in addition to applications running on other operating systems and programs delivered via the Internet or SMS. The field is growing at an exponential rate. Applications are available for clinical assessment, symptom monitoring, psycho-education, psychological therapy (guided and unguided), psychotherapeutic skills training and support – and for a range of mental disorders including depression, bipolar disorder, anxiety, addictions, psychosis, eating disorders as well as comorbid conditions (Luxton et al., 2011).

However, only a minority of applications are supported by data indicating their efficacy and usability. At the end of 2010, our team conducted a search of the research literature and found only six papers describing mobile mental health programs with some form of evaluation involved (Harrison et al., 2011). We repeated the search in September 2012 and found 39 papers with data about the effectiveness of programs. Of note had been the increase in therapeutic programs for severe mental illnesses. Predominantly, however, the published research consisted of pilot studies utilising one-group pretest–posttest designs, with only a handful of randomised controlled trials reported. Although limited, the evidence to date points to mHealth programs being acceptable and assisting individuals to effectively monitor and manage their mental health, leading to improved outcomes.

The future

So where will the field of mHealth be in the next 10–15 years? It is clear that with advances in technology, the rate of program development will continue to accelerate. The next generation of mobile mental health programs will incorporate technologies and techniques such as dynamic personalization, semantic processing, speech pattern recognition and intelligent reminding. We will also see more disciplines working together in the field, including computer science, engineering, neuroscience, health informatics, educational methodology and public health.

With growth and development will come increasing competition and the need for evidence of program quality. The ‘market’ (consumers, policy makers, health services and funders) will demand robust evaluations involving a combination of short-term studies, including acceptability and usage, as well as longer-term randomised controlled trials. The latter will have sufficient follow-up periods to ascertain whether preliminary gains are maintained and whether the effects are clinically relevant. Currently, the precise mechanisms for improvements in symptoms and functioning are unclear (only one study to date: Kauer et al., 2012), but this too will become a priority, and concomitantly will facilitate the development of theories of change specific to mHealth. Future trials will also include a cost-effectiveness component. It will not only factor in program development costs, but also the costs of the actual mobile devices (if the program is restricted to particular handsets which must be issued or acquired separately by users), network connections and any preliminary training or clinician time. Evidence will also be needed on whether the mobile programs actually improve access to services, particularly by individuals who do not otherwise use mental health services.

For mHealth to become truly scalable and sustainable in the future, however, an ecosystem approach is required. Applications will be interoperable (instead of the siloed approach that currently exists), able to be connected to electronic health records, and integrated within the broader healthcare system (Estrin and Sim, 2010). Standards for security of data collection, transfer and storage, user confidentiality and privacy will be taken into account. Progress is underway. A first set of guidelines for mobile health applications has recently been disseminated for public comment as part of a proposed ‘App Certification Program’ (Happtique Mobile Health Source, 2012). Preliminary solutions are also being proposed for data sharing between different mHealth applications and with electronic health records, and for making sense of the vast amounts of multi-level data generated by EMA/EMI programs in order to improve health outcomes (Chen et al., 2012). Data mining and standards will continue to be of importance for mobile mental health to flourish in the future.

Today, there are almost 6 billion mobile phone subscriptions worldwide: 75% of the mobiles in use are in developing countries, penetration has reached saturation in some developed countries and costs are continuing to fall (International Telecommunication Union, 2011). Mobile devices are not only helping to bridge the digital divide for socioeconomic groups who cannot afford to own computers, but, within the next 10 years, they will help to bridge the health divide for underserved and hard-to-reach populations. Clinicians will see the advantages of incorporating mobile mental health into their clinical assessment and care, and the public will access evidence-based interventions at the most useful times in their day-to-day lives.