Larry Brooks, PhD

With the widespread use of smartphones, there is an opportunity for clinicians and researchers to incorporate this technology into mental health treatment. Numerous mental health applications are available for download, but there is a limited research base to support most apps. Also, many apps are self-report and are not focused on providing and/or facilitating treatment.

Here we review 2 apps currently in development. Both use innovative technologies embedded within smartphones to capture objective data on patients to provide timely treatment and relapse prevention.

Mobilyze, an app developed by researchers at Northwestern University, is designed as a multimodal treatment for depression. It uses built-in sensors, such as GPS, ambient light, and recently made calls, in an attempt to predict the patient’s moods, emotions, and activities. It has been subject to an initial 8-person pilot study: results indicated that participants were satisfied with the app and both depressive and anxiety symptoms improved.

A machine learning approach is used: users are prompted via messages to describe their locations, activity, social context, and emotional state. The app learns to associate real-world data with those obtained via the sensors. Supplemental messages on the phone, a Web-based behavioral activation intervention, and telephone coaching were also provided as part of the initial study and contributed to the overall symptom reduction.

 Larger-scale research is being conducted at Northwestern University.

The design of the app shows promise in using passive data collection to treat a potentially debilitating psychiatric condition. Persons with depression often evidence changes in behavior, including sleeping more (or less), moving slowly, interacting less with the world, and losing interest in activities they usually enjoy. A smartphone app is well-positioned to monitor changes in behavior and can provide real-world feedback to the individual.

CrossCheck is another app currently in an NIMH-funded clinical trial that uses a range of features similar to those of Mobilyze. Unlike Mobilyze, which focuses on depression, CrossCheck’s emphasis is on re-lapse prevention in patients with schizophrenia. CrossCheck uses a combination of observational and self-report data to determine the participant’s “relapse signature.” Individualization of a relapse signature is particularly important in schizophrenia, given the heterogeneity of presentations involving positive, negative, or disorganized symptoms.

Observational data collected from sensors can model sleep patterns (eg, using light sensors, screen lock time), frequency and duration of conversations (using the microphone), traveling range (using GPS data), and movement or sedentary behaviors (from accelerometer/screen orientation data). Self-report data are collected 1 to 3 times weekly to assess symptoms, quality of life, and functioning.

Self-report responses serve as another data point in predicting a relapse signature. Marked, perhaps simultaneous, changes in the objective and subjective variables may occur before and during a relapse. Thus, active measurement of these variables can catch a relapse early. Once relapse warnings have been triggered, contact is made with both the patient and the treatment team.

There are several concerns related to the real-life practicality of the CrossCheck app. First, in a study of a self-management app for symptoms of schizophrenia also created by the developer of CrossCheck, expert mental health practitioners expressed concern that individuals with schizophrenia may sell a smartphone provided to them for treatment purposes.

 However, this was not found to be a concern of other researchers.

 Second, issues related to privacy and confidentiality need to be thoughtfully addressed in the context of HIPAA. Third, many individuals with schizophrenia have paranoia, and one can imagine that being constantly and remotely monitored may negatively affect some patients. Initial investigations by the developers found no relationship between baseline paranoia and willingness to use a smartphone for a behavioral intervention.

 Fourth, one compelling potential clinical application for this app would be for inclusion as part of a community treatment team for individuals with severe mental illness; however, there could very likely be civil rights concerns related to constant or even mandated remote monitoring of patients. Some of these issues will undoubtedly be addressed in feasibility studies and field trials.

In general, mobile apps have distinct limitations. In an e-mail correspondence, Northwestern University Professor (and director of the Center for Behavior Intervention Technology) David Mohr, PhD, wrote:

Regarding limitations, the biggest is that the vast majority of health apps that are downloaded are never used, and those that are used, are usually only used once or twice. For the few people who do use them, they are typically already engaged in the behavior. For example, someone who runs may download an app that tracks running. But that person would probably not stop running if he or she did not have the app. The people who need to start exercising aren’t usually the ones using the apps.

One [strategy to improve usability] is to embed these apps in care systems. Placing some human presence in the system can greatly increase people’s adherence. It might be data going back to a physician or coach, or learning how to optimize data flow and communications within a peer network. The other is to improve the usability-one idea being the use of sensor data.

Although Mobilyze and CrossCheck are still in the early stages of development, they are representative of the future integration of mobile health technologies in monitoring, treatment, and relapse prevention. There may be considerable generalizability beyond depression and schizophrenia-to similarly complex and often treatment-resistant disorders, such as addiction and acquired brain injury, or to chronic health conditions with episodic declines in function, such as diabetes mellitus. There is a limited research base at present, but there is significant potential for mobile technologies to serve as an adjunct to routine clinical practice for complex and treatment-resistant disorders.

Dr Brooks is a Voluntary Assistant Professor of Research in the department of physical medicine and rehabilitation at the Miller School of Medicine at the University of Miami; and he is a clinical nueropsychologist in private practice in Miami and Hollywood, Fla. He specializes in the assessment and cognitive rehabilitation of individuals with neurological disorders. Dr Brooks’s Web site is larrybrookssphd.com. Dr Schirmer is a clinical and forensic psychologist at Napa State Hospital in Napa, Calif; he is Adjunct Professor at Saybrook University in Oakland, Calif. The authors report no conflicts of interest concerning the subject matter of this article.

 Burns MN, Begale M, Duffecy J, et al. Harnessing context sensing to develop a mobile intervention for depression. 

 Mohr DC, Burns MN, Schueller SM, et al. Behavioral intervention technologies: evidence review and recommendations for future research in mental health. 

 Ben-Zeev D, Kaiser SM, Brenner CJ, et al. Development and usability testing of FOCUS: a smartphone system for self-management of schizophrenia. 

 Ben-Zeev D, Brenner CJ, Begale M, et al. Feasibility, acceptability, and preliminary efficacy of a smartphone intervention for schizophrenia. 

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Here: a look at Mobilyze and CrossCheck--2 apps currently in development that are embedded within smartphones and designed to capture objective data on patients to provide timely treatment and relapse prevention.

Mobile Apps for Mental Health

Over the past 5 years, computerized cognitive training (CT) programs have made a huge splash in the digital wellness market. These programs, usually consisting of small computer games, have capitalized on recent research that shows a previously unrecognized degree of neuroplasticity, or cognitive flexibility, in the brain.

Currently, research is moderately supportive of CT. In a 2010 

, researchers reviewed nearly 3 dozen environmental, behavioral, and biological factors believed to prevent Alzheimer disease and 

 Of these, they found evidence of preventative properties only for CT, which beat out other popular favorites, such as healthy diet and exercise.

[[{"type":"media","view_mode":"media_crop","fid":"25003","attributes":{"alt":"brain games","class":"media-image media-image-right","id":"media_crop_6839187894474","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2222","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 199px; height: 149px; float: right;","title":" ","typeof":"foaf:Image"}}]]The research on specific programs, however, is uneven. Moreover, there is an obvious profit motive for companies to make claims about their software that exceed the demonstrated benefits. Here I will explore the research to determine which computer software systems have the most empirical support. The empirical findings will be supplemented by my own clinical experiences using these programs with patients with cognitive deficits.

 describes the supportive studies of 6 different brain training companies (some companies, such as Fit Brains and Nintendo Brain Age, do not claim empirically supported cognitive benefits and have been excluded). The first category, in red, shows the total number of studies; this could include studies funded and conducted by the company itself, or a conference poster that was not peer-reviewed. The second category, in blue, indicates how many of those studies were empirical and peer-reviewed and were published in a journal.

The last category shows only those that were both peer-reviewed 

 conducted completely free of financial conflicts of interest. These studies promise the most objective and rigorous empirical evidence. I will discuss the 3 companies with the most independent supportive research-Cogmed, Posit Science, and Attention Process Training-as well as Lumosity, because of its relative dominance in the market.

With more independent, peer-reviewed research support than any other product, Cogmed claims to improve focus, attention, planning abilities, and task completion. Its training program primarily uses spatial and auditory working-memory span tasks, which work to increase the amount of information you can hold in your head and manipulate.

Span tasks might include a player listening to a list of numbers and then reentering them backwards, or a visual task similar to the popular children’s game Simon Says. Treatment programs typically last 5 weeks. Cogmed is owned by Pearson, the largest education company in the world, which charges fees for clinicians to become licensed program facilitators.

While independent studies evaluating Cogmed generally indicate that subjects improve at brain games, it is unclear whether these improvements translate into real-world functionality. Critics have cited small test sample sizes and non-replicated results as evidence that Cogmed’s claims are unsupported by research.

 Studies have also failed to show long-term, permanent gains, although with time this could change.

Perhaps most important, improving span is only one piece of working memory. The idea that improving span alone is sufficient to improve overall cognition in the face of other deficits in learning, memory, or executive function merits skepticism. Proponents of Cogmed research state that brain training shows promise, and that critics’ expectations are unrealistically high in these early stages of research.

With its bold motto, “Think Faster, Focus Better, Remember More,” Posit Science claims to enhance attention, mental processing speed, learning, memory, and even a sour mood.

In the past, Posit Science offered 2 products: an auditory package called “Brain Fitness,” and a visuospatial package called “InSight.” Both operated on the theory that enhancing perception speed and accuracy at the smallest units of auditory and visual processing will improve the entirety of these processing systems.

Recently, Posit Science created a new Internet-based platform (“Brain HQ”) that incorporates the games from both the auditory and visuospatial packages. This new platform allows the clinician to remotely monitor the frequency of use and provides limited information in terms of percentage improvements into a patient’s progress. However, “Brain HQ” lacks the degree of granularity available in the APT-3 package discussed below.

Clinically, the auditory games have strengths and weaknesses. Although the program begins with an assessment of auditory processing to establish difficulty levels, higher-functioning patients frequently find some of the games too easy and boring. This is not necessarily evidence that it does not work, but a lack of patient engagement has occasionally impeded progress in patients I have seen in clinical practice.

One of Posit Science’s visuospatial games, “Road Tour,” has more supportive evidence than any other single game by any manufacturer. Research funded by Posit Science has found that it slows cognitive decline in healthy, aging adults, and this was supported by an NIH-funded study indicating that it significantly improves mental processing speed.

 Very few interventions have been shown to increase processing speed, which makes these findings particularly unique. Processing speed is also one of the most common and devastating deficits among individuals with traumatic brain injury, so we can look forward to further studies involving this condition.

Used by cognitive rehabilitation specialists for more than a decade to treat acquired brain injury and stroke, APT-3 only recently computerized its regimen of treatment programs. It features a diverse array of exercises that target aspects of attention, such as sustaining attention, ignoring distractions, and maintaining multiple pieces of information simultaneously.

APT-3 is distinctive in that it was not originally designed for healthy people experiencing natural cognitive decline, but for treating acquired cognitive deficits. The design of the APT-3 program allows a clinician to pace the tasks and elevate their difficulty according to patient progress. Research has shown it to significantly improve attention in 

, with gains sustained for at least 6 months.

Despite its weak research base, Lumosity is currently the biggest player in the field, with over 45 million users and more than 1 billion games played. It claims to be a comprehensive solution for virtually all cognitive domains-memory, processing speed, problem solving, attention, and flexibility.

Despite its strong marketing brand, however, few independent studies have examined its claims. Its benefits have been demonstrated in independent research among very specific demographics, including post-chemotherapy cancer patients and young girls with Turner syndrome, but it is hard to say whether these results are generalizable to the population as a whole. Although Lumosity currently lacks substantial empirical support, it will likely produce interesting research in the coming years, given that its sample sizes can exceed 100,000 participants-a rarity in most research institutions.

These programs are relatively early in their development, but forthcoming research will surely optimize and refine them. In addition to the programs reviewed here, a number of other brain training programs are in relatively early phases of development. Some show a promising evidence base and have been designed by academic scientists, including “ACTIVATE” by Yale researcher Dr Bruce Wexler and “NeuroRacer” by researchers at the University of California, San Francisco. “NeuroRacer” was shown to improve cognitive control in older adults even in non-game tasks; although not available for purchase now, a commercial version by Akili Interactive Labs is in the works.

In the future, we can expect virtual reality software that mimics a work or home environment and that allows brain-injured individuals to practice office and domestic skills. Such programs will almost certainly end the debate over whether these programs actually improve real-world functioning.

Nonetheless, some programs currently have enough empirical support for use in both rehabilitation and healthy, aging populations. Their affordability, accessibility, and ease of use make them particularly attractive, and computerization allows programs to track progress and adapt to the user’s strengths and weaknesses.

For cognitive rehabilitation, they can be a useful supplement to traditional treatment by allowing patients to continue rehabilitation from the comfort of their own home. In my own practice, I use both the Posit Science and APT programs for the reasons listed above. Overall, computerized brain training games provide an exciting opportunity for aging adults and patients with acquired brain injury to improve cognitive functioning.

Computerized CT programs discussed in this article

www.lapublishing.com/apt3-attention-process-training

This article was originally posted online on 04/29/2014.

Dr Brooks is a Voluntary Assistant Professor of Research in the department of physical medicine and rehabilitation at the Miller School of Medicine, University of Miami. He is a clinical neuropsychologist in private practice in Miami and Hollywood, Fla. He specializes in the assessment and cognitive rehabilitation of individuals with neurological disorders. He currently participates in research on the development of brain training software but has no financial interest in any brain training products. Dr Brooks’ Web site is: 

 Plassman BL, Williams JW Jr, Burke JR, et al. Systematic review: factors associated with risk for and possible prevention of cognitive decline in later life. 

 Shipstead Z, Hicks KL, Engle RW. Cogmed working memory training: does the evidence support the claims? 

 Hulme C, Melby-LervÃ¥g M. Current evidence does not support the claims made for CogMed working memory training. 

 Wolinksy FD, Vander Weg MW, Howren MB, et al. A randomized controlled trial of cognitive training using a visual speed of processing intervention in middle aged and older adults. 

 Barker-Collo SL, Feigin VL, Lawes CM, et al. Reducing attention deficits after stroke using attention process training: a randomized controlled trial. 

 Anguera JA, Boccanfuso J, Rintoul JL, et al. Video game training enhances cognitive control in older adults. 

A discussion of computerized cognitive training programs with the most independent supportive research that demonstrates a previously unrecognized degree of neuroplasticity, or cognitive flexibility, in the brain.

Larry Brooks, PhD

Articles

Mobile Apps for Mental Health

Science or Sales? The Evidence and Application of Brain Training Games