TECHNOLOGY IN PSYCHIATRY
Dr Lemon is a graduate of the School of Medicine, Sydney University of Notre Dame Australia, currently working at St Vincent’s Hospital, Sydney, New South Wales, Australia.
The evidence for using digital technologies to improve outcomes in mental health care is growing at a rapid rate. Already, studies have highlighted how technology can be used to effectively provide well-established treatments, such as cognitive behavioral therapy.1 The unique capabilities of some technologies are also allowing the development of new therapies, such using virtual reality-based exposure therapy for PTSD.2 Furthermore, with ownership levels at more than 92 per 100 inhabitants in developing nations, the ubiquity of mobile phones has enabled the delivery of mental health care on a scale larger than ever before, particularly in areas with high demand and limited local resources.3,4
There are an enormous number of smartphone apps that claim to help with mental health problems, with many being free for download. However, their potential for positive impact remains unclear. Few have had their effects on outcomes rigorously evaluated. Their availability is also sporadic, often downloadable from app stores one month, then absent the next.5,6 Although research indicates patients are keen to use them, of the apps currently available, most are deleted after only a few uses.7–9
Building knowledge of the effect of apps on clinical outcomes is key to defining their true role in care. However, to ensure positive effects are realized, we need also to consider how best to design and implement them for patients with mental health conditions. To do this, greater understanding of the user experience (UX) of mental health apps is needed.
UX fundamentally refers to the dynamic, subjective and context-dependent way in which a user engages with a product or system.10,11 In the case of mental health apps, investigating UX can help us understand the knowledge and expectations of technology that patients have developed from their own personal use. Through this, we can begin to understand why current apps are so readily deleted despite persistent interest in using them, and determine the key characteristics of successful alternatives.
Psychiatrists are already interested in understanding and applying knowledge about UX. In the American Psychiatric Association’s (APA) App Evaluation Model, practitioners are advised to assess their own and their patients’ views on the “ease of use” of apps before endorsing their inclusion in treatment regimens. This involves examining a range of characteristics that relate to UX, including accessibility and whether or not features can be customised by the user.12 Some recent research has also begun trying to understand patient preferences and needs by assessing patterns in publically available feedback for certain mental health apps.8
Although such approaches are a good, pragmatic starting point for understanding the UX of apps, psychiatrists and their patients could benefit from greater use of more rigorous alternatives. Across the eHealth literature, approaches to assessing UX range from simply asking for user opinions about design and functionality to construct-based measures like “user-satisfaction” that feature prominently in other fields, such as marketing.13 Many, however, lack standardized definitions and sound methodologies. This makes the data they provide difficult to interpret and apply in evaluating, designing and implementing health technologies.
Only recently have other strategies built on robust definitions and methodologies begun to emerge in eHealth. Construct-based approaches such as usability provide a clear lens through which to assess and utilize information about parts of UX, as well as simple data interpretation tools for stakeholders with an interest in user-centric design, but limited expertise in the area.14–18
The bottom line
Rigorous approaches for understanding UX in relation to mental health apps are still emerging. However, as interest continues to grow in using apps, psychiatrists should expect not only that their impact on clinical outcomes has been carefully assessed, but also that their design and implementation is built around scrupulous testing of the UX. Tools for determining the role of apps, such as the APA’s App Evaluation Model can lead in guiding psychiatrists towards this by encouraging them to ask developers for data on UX evaluation. Furthermore, with greater expertise in UX, psychiatrists can position themselves to more strongly guide technology companies in building and implementing better apps in the same way that knowledge of patients’ experiences of certain drugs can be used to advocate for better pharmacotherapies.
Smartphone apps have the potential to greatly enhance the delivery and impact of mental health care in many ways. Realizing this requires all aspects of their use to be rigorously assessed, not just their effects on clinical outcomes. Assessing and applying knowledge about UX in relation to apps is a fundamental part of this, and a key step in exploring and defining their role in mental heath care.
1. Olthuis JV, Watt MC, Bailey K, et al. Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database Syst Rev. 2016;3:CD011565.
2. Gonçalves R, Pedrozo AL, Coutinho ES, et al. Efficacy of virtual reality exposure therapy in the treatment of PTSD: a systematic review. PLoS One. 2012;7:e48469.
3. World Health Organization. Global diffusion of eHealth: Making universal health coverage achievable. Report of the third global survey on eHealth. 2016. http://who.int/goe/publications/global_diffusion/en. Accessed January 29, 2018.
4. World Health Organization. Mental Health Action Plan 2013-2020. 2013. http://www.who.int/mental_health/publications/action_plan/en. Accessed January 29, 2018.
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