is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire, area, and a clinical assistant professor and program director of the Psychiatric-Mental Health Nurse Practitioner Programs, Department of Nursing, University of New Hampshire, Durham.

Sara Robinson, MSN, RN, PMHNP-BC

In this series, Scariest in Psychiatry, we asked clinicians about the scariest topic in mental health. What’s frightening, worrisome, or concerning in psychiatry? Here’s how they answered.

During my first year working at a community mental health center (CMHC) in New Hampshire, there was a moratorium on prior authorizations for patients with state Medicaid insurance. This was due to strong advocacy efforts with state legislature by one of my psychiatrist colleagues at the CMHC, and other dedicated stakeholders. This was great… until it ended.

My nurse practitioner program prepared well me for many facets of patient care, but an area that was not addressed was the concept of prior authorizations and the potential challenges faced by insurance formularies. My first experiences left me thinking, 

What do you mean I went through all of this training to select the best possible medication for my patient, and now I am being told I cannot prescribe that? 

The idea of someone who has never met or assessed the patient making these judgment calls is difficult to sit with, especially when medications that have proven to be efficacious for a patient when nothing else has are no longer covered or the coverage is declined.

Although this is incredibly frustrating and discouraging for me as a clinician, ultimately the patient is suffering the burden of these systems. The timeline for prior authorization reviews can further cause impairment and harm to patients. Often, for what most of us would consider a reasonable and timely review, one must request what is called an “expedited” review. That, of course, has a particular process as well. In a survey of physicians collected by the American Medical Association (AMA) in 2021, it was noted that 93% of patient treatments requiring prior authorization were delayed.

 This survey noted as well that treatments that required prior authorization were felt to have had a negative impact on care 91% of the time.

 Inefficiencies of the existing prior authorization systems has reached a level of national political priority, and this has resulted in legislative efforts to support an electronic prior authorization process for Medicare Advantage plans.

Although I have not solved this large-scale barrier and systemic challenge faced by clinicians and patients all over the country, I have found some value in figuring out how to best approach these situations when otherwise I might feel powerless. As an educator training 

psychiatric-mental health nurse practitioners

 (PMHNPs), I have worked to integrate the knowledge of this issue into our curriculum so that graduates are prepared for the possibility of the medication determined to be best for their patient not being covered or initially declined. It is challenging for a clinician entering the field to reconcile this fact. I found that to be a very hard pill to swallow, if you will. It was so hard to swallow that I would have requested a sublingual formulation—but that would have been denied, I’m sure.

Here are some of the recommendations that I have found to be useful in these situations:

1. Obtain a comprehensive psychiatric medication history. This is imperative to incorporate within 

 to ensure we are providing safe and high-quality care. However, documenting a highly detailed medication history can provide incredible value when faced with denial of a medication. Take note of the specific medications that the patients took and the dosing if known, along with any benefits, adverse effects, and reasons for discontinuation. I make sure that this is documented clearly and reviewed periodically. Including the date that the medication history list was obtained is helpful for the clinician because, depending on the records system, it may not be clear when it was last reviewed and updated. It is helpful to keep the list up to date and to revisit with any changes or new information from the patient, previous records, or other sources. See examples in 

. There have been times when a medication has been denied and the formulary suggestions letter comes back, only to recommend medications that the patient 

 in fact already tried and failed. Having this documented to send with consideration for appeal has helped to overturn several medication denials.

2. Though this does not directly impact the result of the authorization, I find it to be very helpful to have a transparent conversation with patients about prior authorizations and what to expect. It may feel like precious appointment time spent discussing “what-ifs,” but this facilitates patient self-efficacy, and they may be better able to advocate for themselves when they are aware of these systemic processes. Communication gaps are inevitable, and if the clinician does not receive notification of prior authorization requirement—which does happen frequently—having the patient as a conduit to ensure that all involved parties are aware of what is happening is quite beneficial. This can help to minimize delays with the approval process as well. Patients can contact their insurance companies as well to address denials or other coverage issues. It may help the patient to better understand the source of these delays as well, and to utilize their valuable time accordingly.

3. Consider writing an appeal to the insurance company or request a peer-to-peer review. There is some variability in the peer-to-peer review request process depending on the state where care is taking place, along with the patient’s insurance. Typically, the information for facilitating the next step should be documented on the notification of the denial of medication coverage. These letters are often sent to the clinician’s office and to the patient’s home address.

 appeal letters and requested peer-to-peer reviews. Some have been successful, and others have not. I have yet to uncover a magic formula for this, but I find that documenting a comprehensive review of medication history and trials, rationale for medication selection, and presentation of risks of not having that medication are all quite helpful to include. I have pulled in literature support and clinical guidelines to validate my requests in the past. As someone who has shifted to primarily academic work in recent years, I have more of an appreciation for this now than I did when I was exclusively working in clinical practice! Granted, I have access to an extensive online library database through my university, but there are many accessible and free resources available for clinicians, not to mention health care agency subscriptions. This can even be a helpful rationale to support a request to your employer for access to some of these materials to support prior authorizations.

Even if the appeal is then denied, I find that patients are appreciative of this additional effort and recognize the challenges of going up against a powerful system. One patient case stands out in my mind, as I had a patient with severe, chronic, 

 who finally began to respond to a combination of treatments with significant improvement of symptoms. We initiated this regimen with samples, and upon seeking to continue this via the pharmacy, insurance coverage denied it. This inspired the patient’s passion for advocacy and led them to become an active political participant at a state level. It was incredible to see someone who had suffered for so long and lacked motivation and a sense of purpose become invigorated by the idea of making a larger impact difference and helping others.

Requesting a peer-to-peer review is an option in many cases as well, although sometimes the peer that is offered for the call is not in fact an intraprofessional colleague, but may be a colleague from another discipline. Unfortunately, I had a particularly negative interaction during a peer-to-peer review several years ago, which I wrote about in my previous piece, “

.” This person chose to criticize my training and background, even though I was practicing legally within my scope and congruently with regulations in my state. That individual used his own bias and opinions about my training as his rationale for denying the patient’s medications. I remained calm throughout the interaction and sought out support from a psychiatrist colleague, and ultimately, we went to the insurance company to file a complaint about the issue. As it turns out, the entire call was recorded, and their brazen lack of professionalism was clear. The individual was held accountable—and most importantly, the patient’s medication ended up being covered.

In this case, the patient had many changes as far as living situation and transitions of care, which made gathering comprehensive previous records challenging. Some records were obtained, but not all treatment records were available, which is not uncommon. This patient had previously been quite unstable for a period of time, with multiple psychiatric inpatient hospitalizations and medication changes, but more recently had maintained a prolonged period of stability on the current medication regimen. By collecting a comprehensive medication history at intake and ongoing, along with collecting previous records whenever possible, having that supportive documentation to justify the continuation of the regimen was imperative and well-documented.

4. Familiarize yourself with your state laws and guidelines around prior authorizations, and review formularies for the primary insurance companies that you see patients within periodically. There are some smart phone apps that can facilitate formulary checking as well. Additionally, the AMA compiled a Prior Authorization State Law Chart, which provides specific regulations for each US state.

Prior authorization reform has been pursued on a national level, but so far there has been minimal progress.

 In New Hampshire, the moratorium on prior authorizations was evaluated for extension and had substantial support, although the opposition was fierce and ultimately it did not continue.

As psychiatric clinicians, we know that these authorizations are not only impactful on medication prescribing, but also on inpatient psychiatric hospitalization lengths of stay and justification of levels of care. Services, facilities, and clinicians are all limited, which negatively impacts access to care. Of further concern is when these services are justifiably accessed and there is an external decisionmaker dictating length of stay appropriateness.

I find solace in discussing these situations with my colleagues and peers, and I look to continue working with other passionate advocates for mental health treatment access and equity to address these treatment-interfering systemic barriers to optimal care.

1. 2021 AMA prior authorization (PA) physician survey. American Medical Association. 2022. 

https://www.ama-assn.org/system/files/prior-authorization-survey.pdf

2. King R. House committee advances bill to install new prior authorization reforms for Medicare Advantage. 

. July 27, 2022. Accessed October 6, 2022. 

https://www.fiercehealthcare.com/payers/house-committee-advances-bill-install-new-prior-authorization-reforms-medicare-advantage#:~:text=The%20legislation%20would%20require%20the,for%20newer%20and%20pricier%20treatments

3. 2021 Prior Authorization State Law Chart. American Medical Association. 2021. Accessed October 6, 2022. 

https://www.ama-assn.org/system/files/2021-04/pa-state-chart.pdf

Changing the game of prior authorization: the patient perspective.

5. Mara D. Prior authorization for drugs to treat mental illness is a public safety problem. 

. April 26, 2016. Accessed October 6, 2022. 

https://www.seacoastonline.com/story/news/local/portsmouth-herald/2016/04/29/prior-authorization-for-drugs-to/31067409007/

Articles

Denial of coverage can be frustrating. Here’s how you as a clinician can handle these situations. 

Prior Authorizations and (Micro)managed Care

In this episode of The Big Q, Sara Robinson, MSN, RN, PMHNP-BC, shares how she introduces new medications to patients, from discussing possible adverse effects to letting them know when they can expect to feel some relief from their symptoms.

is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire, area, and a clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham.

What is the first thing you share with your patient when you are about to prescribe a new medication?

Managing Patient Expectations

 is common for US adults and even more pervasive for patients presenting in psychiatric settings. Estimates of previous experience of traumatic events is 51% to 84% in the general adult population and 76% to 91% in those seen in psychiatric settings.

 The most prevalent comorbid disorders among adults with 

 (SMI) are substance use disorders (SUDs).

 Despite trauma symptoms often being underreported, 30% to 60% of individuals seeking treatment for SUD also meet criteria for 

 Acknowledgment of “dual diagnosis dates back decades, into the early 1980s; however, the classification of PTSD and SUD as 

 is inadequate to capture the range of symptoms and impairments of this diverse patient population.

 Greater understanding of approaches to SUD and related support services may help psychiatric providers provide multifaceted, comprehensive support to patients with SMI, PTSD, and SUD.

A Simple Concept With Complex Implications

Daniel C. McFarland, DO; Luigi Grassi, MD; Michelle Riba, MD, MS, DFAPA, FAPM

Helping Patients With Attentional Difficulties and Maladaptive Use of Psychoactive Substances

New Directions for Insomnia and Bipolar Disorder

Research Roundup: Psychiatric Comorbidities in the News 

Evidence-based treatments exist for both PTSD and SUD; however, the approaches are rarely integrated, despite recognition of frequent cooccurrence. There are trends to further integrate 

 (TIC) in both SUD and psychiatric settings,

 but these services are seldom cohesive. To combat the SUD epidemic, availability of medication-assisted treatment/recovery has focused on primary care and the treatment of SUD as a chronic health condition. There is also greater opportunity for psychiatric providers to strengthen their care of patients with comorbid SMI, PTSD, and SUD by continually linking emergent evidence with clinical care. As the SUD epidemic has further intensified during the 

 the need for trauma-informed psychiatric care addressing SMI and SUD is even greater.

Treatment of SMI-related distress or symptomatology in isolation from SUD fails to address the whole person and is likely to result in suboptimal outcomes.

 Without integration of SUD and SMI care, providers risk inappropriately generalizing diagnoses without recognizing the context and lens of SMI symptoms. Addressing an epidemic requires the responsiveness of all providers.

 As SUD services, treatment, and research have advanced, we highlight 5 practices that are useful in supporting psychiatric clinicians as they effectively integrate trauma-informed SUD and SMI treatment.

There is substantial evidence that clinicians do not routinely ask patients about trauma history in clinical settings.

 Despite growing recognition of the impact of adverse childhood experiences on individuals and awareness of trauma prevalence, both institutional and intrinsic barriers interfere with provider inquiries about 

 Although a psychiatric history often includes inquiries about traumatic experiences, TIC requires routine attention to symptomatology and reactions to trauma. Documentation of a single question within an initial evaluation is inconsistent with TIC, but consistently attending to previous experiences with and responses to trauma throughout care is imperative.

 Trauma assessments at initial visits may underreport traumatic experiences, as patients may not feel comfortable disclosing these at a first-time appointment.

Similarly, inquiring about substance use and recurrence of substance use must be an ongoing practice. Patients may not disclose substance use right away for a multitude of reasons. As the provider learns this information, the trajectory of care may change, much like when we are asking about trauma. Assessment around SUD also requires being trauma-informed, as increased 

 Patient omission of disclosing a substance use recurrence is common in psychiatric care, often related to fears of losing care or prescription medication. To mitigate this risk and develop space for honest disclosure, clinicians can share their policies or practices related to substance use and foster open discussions—discussions that acknowledge cravings and recurrence are likely to increase with stress and trauma.

Recognize Trauma as a Primary Pathway to Substance Use

For decades, the pervasive narrative around 

 was the “gateway hypothesis,” which has now been widely refuted. The gateway hypothesis—that consumption of a particular substance will lead to or increase the likelihood of progressive substance use—came to prominence after publication by Kandel in 1975. The 4-stage sequence of drug consumption—from beer and wine, to tobacco and hard liquor, to cannabis, to other illicit drugs—indicates that only individuals who use 1 drug have a chance of progressing through the sequence.

 Although substance use is associated with use of other substances, a causal relationship where alcohol and/or cannabis are gateway drugs has been disproven.

 Conversely, marijuana use has been associated with reductions in 

Drug use sequences and initiation vary based on cultural context and on unmeasured common causes that are understood to be more impactful on subsequent drug use than initial use of a particular substance.

 There is clearly an association between experiences of trauma and 

, as patients meeting criteria for PTSD are 14 times more likely to have a comorbid SUD when compared with patients without PTSD.

 Both initiation of opioid use and transition to injection opioid use from other routes may be related to experiences of trauma.

One notable evidence-based approach is integrated treatment for cooccurring disorders (ITCOD). Integrating treatment approaches for mental illness and SUDs requires looking at combining efficacious existing treatments while modifying interventions that may be outdated or lack reliable benefit.

 ITCOD is a multifaceted approach to treatment and care that captures the importance of individual therapy, assertive outreach, social support interventions, and long-range perspective via a patient-centered framework.

As we unlearn the non–evidence-based “gateway hypothesis,” a deeper dive into traumatic experiences and their relation to substance use is likely to serve both provider and patient. Often, substance use initiation is related to seeking relief from pain as well as traumatic events and symptoms.

 Providers can more fully explore events preceding substance use initiation or transition to nonprescribed medication with compassionate understanding, recognizing that 

 may have been the only accessible and available coping tool at that time.

When we sit in the office with a 40-year-old patient, for example, imagine, as they are sharing memories of their traumatic upbringing with you, that they are 12 years old and not in your office, but in their home—terrified of the trauma there. They have no resources or outlets. A substance is introduced, and it temporarily provides some relief of the awful feelings that they are experiencing. That is not a moral weakness or deficiency. One can imagine what one would do in that situation, but the context and the patient’s experience are of utmost importance, and we need to remove our own opinions from the equation. Intergenerational trauma is another prevalent reality, and the cycle perpetuates. When someone comes to see us for help, it is our job to use our expertise and understanding to facilitate their healing and 

Partner With Patients Across Multiple Pathways to Recovery

Substance-specific 12-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous are often considered synonymous with peer-led recovery. These programs have benefited millions of people over the course of decades. However, these models are based on an abstinence-only philosophy with religious/spiritual elements, wherein sobriety is the explicit goal for group members. These programs have provided effective support for countless individuals and families, but they do not fit all people seeking or maintaining recovery.

Abstinence-only models are not a panacea. Many individuals suffering from SUD are not able or ready to totally discontinue use or are turned off by the religious basis of these groups, resulting in disengagement from these services.

 Alternatives to spiritually based and abstinence-only peer-led mutual support groups exist and should be considered viable recovery pathways for patients. They include SMART Recovery, Secular Organizations for Sobriety, Moderation Management, LifeRing, Women for Sobriety, and Celebrate Recovery, among others.

 In addition to these peer-led groups, harm reduction services—including peer-led groups and/or syringe services programs—can be a critical low-barrier access point to engage patients with SUD who are not interested in abstinence. Abstinence and 

 are often conceptualized as diametrically opposed; in reality, they serve as different engagement points on a continuum. Appropriate service or program recommendations are dynamic, contingent upon individual differences in needs and desires surrounding treatment and recovery.

Instead of referring patients to treatments that are not well suited to the individual, acknowledging the multiple pathways to treatment and recovery is imperative. We have heard of the challenging routes patients have faced on their journey to treatment and recovery, such as a provider telling them they could not be seen “until they go to AA and stop drinking.” This advice is as good as telling your patient to leave your office and never come back again. Supporting multiple pathways helps meet patients where they are, learn where patients are in their willingness to engage in treatment, and determine which modalities may be the best fit for them. It is important to engage in a shared decision-making process and provide options, rather than providing a paternalistic recommendation that does not take patient preference or prior experiences into consideration.

Approach With Unconditional Positive Regard

When assessing patients, the longstanding OLDCARTS (onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity) acronym utilized in general medicine can be adapted for psychiatric evaluation and assessment. Information gathering in a psychiatric evaluation is not a rigid, linear, “checking off the boxes” process—there is, of course, an 

art to facilitating an informative interview

. Asking our patients when the symptom or trauma started or occurred and ascertaining what was going on in their life around the time that they started using substances are crucial to assembling the pieces of the puzzle each of our patients presents. Often, a silent “Aha!” moment occurs when these connections are made, relating the timing of trauma to the onset of substance use or to an increase in one’s patterns of use. This is important to recognize upon evaluation, and it is important to keep that context for ongoing treatment, especially as individuals who have experienced trauma are likely to experience trauma again in their lives. This can make individuals in recovery more susceptible to recurrence of substance use.

Approaching our patients from a place of unconditional positive regard, a concept expanded upon by Carl Rogers, is central to facilitating a safe space for our patients to share with us what is going on without judgment, and without fear of disappointing us as providers. Our interactions with patients are timebound, limited, and within a physical space most often that is “our” home turf: our office space.

Ongoing self-reflection and assessing areas of one’s own implicit biases are imperative. A systematic review looking at health care professionals’ attitudes toward patients with SUDs found negative attitudes toward this patient population, which impacted patient outcomes unfavorably.

 There are often inciting events for these views, and the outward expression is likely most often unintentional. As lifelong learners, we are well served to recognize when inaccurate conceptualizations (eg, the gateway hypothesis) have led us astray in oversimplifying substance use within our visits.

Engage in Ongoing Knowledge and Skill Development

A systematic review of negative provider views impacting patient outcomes identifies needs for education, training, and improved structure to better support complex patients.

 Formal educational opportunities including fellowships in 

, addiction certification, and Suboxone waiver training are increasing in availability and accessibility.

 All health care providers practicing clinically are required to participate in continuing education. Due to the 

, many states have specifically added requirements for continuing education related to opioid prescribing and opioid use disorders. It is quite beneficial to seek out and take advantage of learning opportunities in areas that are not necessarily our daily focus or in those we studied quite a while ago.

There are peer-facilitated learning opportunities, as well as the PACT-MAT ECHO model,

 which is an all-teach, all-learn approach. These sessions have many benefits, especially since comorbidity of a psychiatric disorder along with a SUD is often an area where clinicians appreciate feedback and recommendations for ongoing care. It is also an excellent opportunity to network and for clinicians to become familiar with other area resources and referral locations.

As psychiatric care providers amid a challenging health care landscape and a global pandemic, we are tasked with providing optimal care to our patients and meeting their needs. The evidence, as we have noted, continues to evolve, and this provides all of us with the opportunity to self-reflect and continue adapting in our own practice and methods. Opportunities for collaboration and growing our knowledge base abound, and within the field we are lucky to have colleagues and mentors to support us along this journey.

serves as the project manager for the Harm Reduction Education and Technical Assistance project, a multiorganization collaboration dedicated to reducing drug-related harms, based at the Department of Nursing, University of New Hampshire. She is also an adjunct professor in the university’s Department of Social Work.

is a family nurse practitioner in community health and an assistant professor of nursing at the University of New Hampshire. Dr Nolte’s research focus is reducing drug-related harms.

Does trauma-related training have a relationship with, or impact on, mental health professionals’ frequency of asking about, or detection of, trauma history? A systematic literature review.

2. Integrated treatment for co-occurring disorders. Substance Abuse and Mental Health Services Administration. 2009. Accessed January 7, 2022. 

https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf

3. Rasmussen IS, Arefjord K, Winje D, Dovran A.

 Childhood maltreatment trauma: a comparison between patients in treatment for substance use disorders and patients in mental health treatment.

Trauma-informed care for individuals with serious mental illness: an avenue for community psychology’s involvement in community mental health.

5. Beckett P, Holmes D, Phipps M, et al. 

Trauma-informed care and practice: practice improvement strategies in an inpatient mental health ward.

Untreated posttraumatic stress among persons with severe mental illness despite marked trauma and symptomatology.

8. Brunette MF, Oslin DW, Dixon LB, et al. 

The opioid epidemic and psychiatry: the time for action is now.

9. McCauley JL, Killeen T, Gros DF, et al. 

Posttraumatic stress disorder and co-occurring substance use disorders: advances in assessment and treatment.

10. Nöel W, Wang J. Is cannabis a gateway drug? Key findings and literature review. National Institute of Justice. 2018. Accessed January 7, 2022. 

https://www.ojp.gov/pdffiles1/nij/252950.pdf

11. Bradford AC, Bradford WD, Abraham A, Bagwell Adams G. 

Association between US state medical cannabis laws and opioid prescribing in the Medicare part D population.

12. Degenhardt L, Dierker L, Chiu WT, et al. 

Evaluating the drug use “gateway” theory using cross-national data: consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys.

13. Nolte K, Drew AL, Friedmann PD, et al. 

Opioid initiation and injection transition in rural northern New England: a mixed-methods approach.

14. Lederhos Smith C, Severtsen B, Vandermause R, et al. 

Seeking chronic pain relief: a hermeneutic exploration.

15. Henwood BF, Padgett DK, Tiderington E. 

Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults.

Broadening the base of addiction mutual-help organizations.

17. Carver H, Ring N, Miler J, Parkes T. 

What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography.

18. van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. 

Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review.

The development of fellowship training in addiction psychiatry.

20. Salvador J, Bhatt S, Fowler R, et al. 

Engagement with Project ECHO to increase medication-assisted treatment in rural primary care.

30% to 60% of individuals seeking treatment for SUD also meet criteria for PTSD.

Supporting Patients With Serious Mental Illness and Comorbid Substance Use Disorder and Posttraumatic Stress Disorder

In the previous 2 parts of this series on mHealth apps, we examined the barriers in access to care and what apps are available to assist in treatment of depression and 

. In this installment, we will cover the potential challenges and unintended consequences of utilizing this technology.

Unintended Consequences: Inaccurate Information and Self-Diagnosis

Apps of all kinds in the Android Google Play and Apple Store calculate ratings based on independent user feedback. User feedback is subjective and does not involve a review process or other rigor. An app may have a 5-star rating based on user feedback; however, this rating does not require any third-party verification of the quality, security, efficacy, or validity of the app.

 Given the lack of consistent oversight or regulation, there is no penalty for mHealth apps providing non-evidence-based and/or inaccurate information.

 A lack of reliable oversight means there is no verification of information quality. A study by Stawarz et al

 found that many of the apps with high user ratings had an inconsistent evidence base, demonstrating that priorities to the user that would translate to a higher app rating do not indicate solid validity and sound evidence.

Part 1: mHealth Apps for Depression: Overcoming Challenges

Part 2: Treating Depression and Preventing Suicide: The Impact of mHealth Apps

Another potential challenge specifically with mHealth apps for 

 is that of patient self-diagnosis. Patients may self-identify that they are depressed, but in the absence of a full psychiatric evaluation by a trained mental health professional, they could very well meet criteria for a different condition that would require specific intervention and treatment tailored to that disorder. This can lead to negative treatment outcomes and misdirection of efforts supporting treatment of a condition that may not apply to a given consumer.

The clinical utility and efficacy of the data provided within these apps is an important consideration. Currently there is no formal review process for mHealth apps, and that has been an 

. The existing medical research on apps is not very robust, and it is quite far behind relative to how widely mHealth apps are utilized.

 With the existing research being so limited, another factor to consider is that the studies that exist often include very small sample sizes.

 Research conducted on these apps also tends to be short in duration, without longer-range follow-up to evaluate outcomes.

Security of patient data is an important consideration within the context of using mHealth apps for depression. Protected Health Information (PHI) breaches are reported on the news nationally and worldwide every day. All breaches, whether large or small, have the potential for significant impact for individuals, communities, and larger populations. An in-depth study of some mHealth apps found that there was transmission of medical data via unsecured processes, and that privacy policies were lacking relative to the kind of information being obtained from individuals.

The aim of a cross-sectional study by Tangari et al was to evaluate the collection of user data within mHealth apps, and to review the privacy practices of apps and potential risks to customer information.

 It was noted that amongst the top mHealth apps, privacy disclosures to the app user was consistently inadequate. The evaluation of privacy and security of these apps is complex and multifactorial. See the 

 for an overview of the components addressed in the security review of apps.

Security Areas Addressed in Review Completed by Tangari et al

In the study by Tangari et al, 665 different third parties were identified as being able to access patient information contained within the apps.

 It was noted that a list of some specific third parties had accessed the most data—more when compared with the rest of the third parties obtaining this information. The vast majority of the apps reviewed were able to obtain and share personal information of the apps’ users. The review found that many privacy policy links did not work or were not reliable.

There is significant concern related to patient safety, especially when one’s symptoms are severe and amidst the presence of suicidal thoughts or actions. In the Martinengo et al

 review of suicide prevention apps, the findings demonstrated that none of the apps assessed patient risk or protective factors, or triggers; only one of the evaluated apps inquired about prior history of 

. Individuals with a history of previous self-harm are at a substantially increased risk of suicide when compared with the general population.

 are important, complex processes conducted by highly trained, skilled clinicians in psychiatry and related fields. Evaluating patient risk is complex, even for the most skilled and experienced provider with years of training and expertise in the field. There are numerous risk factors for suicide, and yet the reality of the outcomes of suicide is far more nuanced and complex beyond a list of these potential contributing factors. Significant risk factors for suicide include but are not limited to: prior history of self-harm or suicide attempt,

 family history, psychiatric illness, recent personal loss, and 

, along with other demographic and social factors.

Safety planning is an important tool used by mental health clinicians to work with patients who are dealing with suicidality when these patients are not at an acute phase of requiring inpatient hospitalization. In the review of suicide prevention apps, only 10% the depression apps and only 52% of suicide prevention apps that were reviewed utilized templates to support development of a safety plan for the app’s users.

 Only 4 of the apps reviewed allowed users to share the safety plan with a trusted member of their support system.

Of the 46 suicide prevention apps, only 20% provided users with emergency access to trained mental health care professionals via the app.

 Of the depression management apps reviewed, 24% provided app users with direct access to a crisis line through the app. However, when the crisis contact information was verified during the review process, 9% of the crisis contact information in these apps was incorrect.

Some of the suicide prevention apps utilize chatbots.

 work by identifying key words and phrases to trigger subsequent responses based on various algorithms. In the apps utilizing chatbots, a very concerning statement from a patient stating that they are “sad” and “hopeless” did not prompt a follow-up question that would be triggered by a “worrying statement,” when, in fact, the aforementioned statement is quite concerning and would warrant further evaluation and clinical intervention.

There are unintended consequences of mHealth apps for depression as they exist currently. A lack of external validity measures and exclusive use of user review ratings does not provide patients with information regarding the evidence base or efficacy of content provided within the app. As health care providers, our role is to translate evidence base into terms that patients can understand; the provider may be tasked with trying to do this, but given the aforementioned concerns, providers may be reluctant to do so. A potential opportunity to improve upon this would be facilitating collaboration and partnerships between academic and medical institutions for app development. With the knowledge base and the intimate awareness of security and privacy, these collaborations would be able to facilitate creation of an app that is evidence-based, externally validated, and suitable for use as a tool in collaboration with the 

Privacy of collected data is an additional concern that is not unique to mHealth apps. There is a noted lack of transparency on the part of apps to provide a clear explanation to app users regarding how their data is collected and potentially shared.

 Ideally, the accountability for these policies should be placed on the individual app companies, with some standards and regulation by the app stores that are publishing the tools.

Best Practices to Support Care Using Patient-Facing Technology

To continue to facilitate mHealth apps that are effective, safe, and useful for patients, there are actions that can be taken to strengthen the aforementioned factors and to address some of the concerns outlined previously within this series.

A standardized, external review tool to validate apps would be a helpful framework to provide some added accountability and verification of app content. A tool discussed in one of the reviewed papers is the 

 (MARS), which seeks to confirm interrater reliability and consistency using 2 expert raters to evaluate based on a 23-item scale.

 This scale, like others that have been explored, lacks clear validity and has not been widely utilized to further evaluate its validity and efficacy. Including quality measures in App Store ratings or reviews that have been conducted by field experts, in addition to the existing system of exclusively customer review ratings, would be another way to potentially increase the accountability required for mHealth apps.

As the sheer number of mHealth apps being used to treat depression is expansive and potentially overwhelming to health care providers, further research and review may help guide the 

 and support those who choose to recommend or discuss app use with tehir patients as an adjunct to professional care. Using an evaluative tool such as MARs would provide health care providers with a more efficient way to be able to further encourage or perhaps redirect patients from the use of certain apps to support their mental health.

Ensuring that patients are informed consumers and aware of how their information is being used is imperative. App developers should be transparent in the writing and sharing of privacy policies, and further oversight regarding third-party sharing should be prioritized on a higher national level to remove some of the onus from the individual and to ensure that developers and corporations are accountable.

A best practice would be for supportive app tools to be encouraged when clinically appropriate, with clear guidelines that they are not a replacement or substitution for clinical care. This would be something for the patient and provider to approach as part of collaborative, patient-centered care. There are disclaimers that app users need to acknowledge in order to use these apps, but there should be ongoing check points and redirection to a trained mental health care professional beyond just an initial acknowledgment when first using the app.

With the rapid influx of new technologies, there are many benefits and unintended consequences in the use of mHealth apps in mental health care, there is also a potential role and benefit for well-done mHealth apps to address mental health, and specifically depression and suicidality. However, as a standalone intervention, mHealth tools are not reliable for managing these complex and potentially life-threatening conditions.

 The treatment of depressed and suicidal patients requires a collaborative, team-based approach including the patient, family, friends and a skilled mental healthcare provider in the utilization of different treatment modalities.

There are aspects of existing mHealth apps that may be ineffective, but more importantly there are components that can be potentially harmful. For example, almost 10% of the crisis hotline phone numbers in the apps reviewed by Martinengo et al

 were incorrect. Without a more comprehensive review process or verification mechanism, that kind of error can have potentially serious consequences. Additionally, this lack of oversight or guidance places the onus on individual health care providers and patients/app users. This may further impede the ability to make progress in this modality. Health care providers may be fearful of 

, which may steer providers away from considering the incorporation of app use into their practice.

There are significant and seemingly endless opportunities for how these apps can potentially be utilized to benefit patients and providers, provided this occurs in a safe and evidence-based manner with consideration for privacy of patient information. Ongoing research is needed, along with policy to encourage and promote safe app development and use, and clear, realistic outcomes associated with the app.

is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire area, and a clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham.

Learn what potential challenges come with mHealth apps and how to overcome them to best fit patient needs. 

Sara Robinson, MSN, RN, PMHNP-BC

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