Depression is a serious, common, and recurring disorder linked to diminished functioning, quality of life, medical morbidity, and mortality. There has been a 37.5% increase in health life years lost to depression over the past two decades. Depression was the third-leading cause of global burden of disease in 2004 and the leading cause of burden of disease in high- and middle-income countries. It is projected to be the leading cause globally in 2030. While effective treatments for depression are available, they are underused. Barriers to treatment include geography, socioeconomic status, system capacity, treatment costs (direct and indirect), low mental health literacy, cultural beliefs, and stigma. A 2010 study found that 75% of primary care patients with depression in urban areas could identify more than one structural, psychological, cultural, or emotional barrier to accessing behavioral treatments. The rate was substantially higher in rural areas.

So begins a new paper that considers an old problem – the difficulty of patients accessing mental health care.

But this paper is different. It considers a modern approach to access: smartphone and tablet applications (or apps) for depression. And it’s not just the topic that is so modern with this week’s Reading. Consider: the paper was published in a new journal, JMIR mHealth and uHealth, available only on-line, and focused on the very modern topic of mobile health. (This journal is a spin-off of JMIR, the Journal of Medical Internet Research, itself a relatively new journal, which boasts an impact factor of 4.7 in 2013.)

This week’s Reading: “Finding a Depression App: A Review and Content Analysis of the Depression App Marketplace” by Nelson Shen et al. In it, the authors seek to shed light on a poorly studied area. As they note early in the paper, despite the incredible popularity of apps, only one recent systemic review looked at depression apps, and included just 4 papers. And so, Shen et al. consider apps for depression, drawing out common characteristics and purposes.

This is, then, an important topic. The potential here is great: with so many of our patients empowering themselves with apps, those with depression could potentially access good information, screening tools and even treatments such as CBT.

What did Shen et al. find in their paper? It’s best summarized by the old Roman phrase caveat emptor (let the buyer beware).

Here’s the link:

What they did:

· The review involved 5 major app stores: Apple (iTunes), Android (Google Play), BlackBerry (AppWorld), Nokia/Symbian (Ovi), and Windows Mobile (Marketplace).

· Apps were searched for in all 5 stores using the term “depression.”

· Based on app titles, store description and screenshots, apps were divided into “potentially relevant” and “not relevant” by two reviewers. To be “potentially relevant,” apps had to have “depression” in the title or store description; they needed to be for health consumers (not professionals) and were in English.

· Testing was done to ensure that reviewers choices were reproducible (that is, there was “interrater reliability”).

· After choosing the apps, reviewers “extracted the data” – that is, using a coding system, they classified and described the apps. Again, efforts were made to ensure interrater reliability.

What they found:

· The initial search yielded 1,054 apps, but only 243 met the inclusion criteria. (!)

· The majority of apps were Google (53.5%) and Apple (37.0%). Nokia, Windows and Blackberry represented under 10% of included apps. (!)

· The apps were found in 32 different store categories; “health and fitness” was the most common one (41.2%). Most apps carried a small price tag (on average $3.15). A third of the apps were downloaded in about 100-5000 computers; one app was downloaded in the 1 million to 5 million range.

· Apps could be categorized under several themes: therapeutic treatment, psychoeducation, medical assessment, symptom management, supportive resources, multipurpose. (See below for a graphical description of app content.)

· Apps were heterogeneous in quality. For example, 2 e-books (under psychoeducation) were fiction; only 15% of symptom management apps actually reported the source of their content.

The authors conclude:

This study found that finding an appropriate depression app may be challenging due to the large quantity available. The search results yielded non-depression-specific apps to depression apps at a ratio of 3:1. Over one-quarter of the apps excluded from the study failed to even mention depression in their description or title and exemplify the role of metadata in populating the search results. The lack of reporting of organizational affiliation and content source brings the credibility into question. Whether the content is evidence-based is a whole other issue.

They continue:

As the app phenomenon and health consumerism continue to grow, the user’s ability to find a reliable and credible app may become increasingly difficult.

Moody Me, an iTunes app, allows users to track their mood over time

A few thoughts:

1. You may not use apps – but your patients often do. For this reason, the paper is relevant.

2. But as patients seek out resources, this paper shows that the depression app world is something of a jungle – many apps, collectively of lower quality, and, yes, there are more than a few snake pits.

3. To continue the analogy: people need a good guide to get anywhere in a jungle. But the app world lacks basic standards. Shen et al. note an effort by the Greater New York Hospital Association to develop a certification system for health-care apps, though it seems to have fallen apart. But across the pond, there’s a promising experiment: the U.K.’s National Health Services recently released the Mental Health App Library – a list recommending specific apps – seeking to help guide patients in their journeys. That said, in Canada, there is no equivalent list… so far.

Further Reading

For more on the NHS Mental Health App Library, see:

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.